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. Douglas Brien, Saint John
Registrar - Dr. Ed Schollenberg
At its meeting on 8 April, 2005, Council considered the following matters:
A patient complained that a procedure was performed in an insensitive manner. In response, the physician reviewed his technique, and noted that a nurse attended throughout. In reviewing the matter, the Committee could find no indication of improper behavior. Physicians should always attempt to be sensitive to anxiety or discomfort on the part of patients.
A patient had a urological procedure and presented to the Emergency Department several times with poor urine flow. His principal complaint appeared to be difficulty voiding, which responded to catheterization on several occasions. A urologist was involved throughout. The patient subsequently presented with renal failure due to ureteric obstruction. A further procedure was necessary. In reviewing the matter, the Committee could not find evidence that the physicians involved had failed to properly assess the situation. Based on the information available, and in consideration of the consultant's opinion, the care provided appeared to be appropriate.
A patient raised a number of issues against a family physician. One complaint dealt with well baby care to her infant son. It was alleged that the physician failed to properly assess the child on each visit. The physician responded that the child was already being weighed by another service and, in any case, repeated examinations would fail to disclose any abnormalities. In responding to the complaint, the Committee reminded the physician of the appropriate standards for well baby care.
A family complained that a physician failed to properly assess a patient with uterine cancer. In reviewing the matter, the Committee agreed that investigations had been done in an appropriate and timely fashion under most circumstances. However, the patient had a rare, and very aggressive, tumor to which she succumbed quickly.
A patient attended the Emergency Department with a friend. The attending physician complained that the friend smelled strongly of cigarette smoke. The patient complained that, as a result, the physician failed to properly assess her. The physician responded that, even after the companion left, the odor was so strong it was difficult to proceed. In reviewing the matter, the Committee also noted that the physician had made a number of comments which were overheard by the patient. These caused the patient to question the adequacy of the care provided. The Committee noted that the patient in this case had not done anything which would have warranted the physician's reaction. The physician was reminded to respond more appropriately to similar situations.
A patient had been discharged from a psychiatric ward where a medical condition was uncovered. He presented to his family physician with a note from the hospital, but the family physician could not determine what the issue was. As a consequence, it was alleged that the patient's care was delayed. In reviewing the matter, the Committee did not feel the physician had responded appropriately to the circumstances. If he could not obtain direct information from the patient, or could not read the discharge note, he should have made greater effort to contact the physicians involved in treating the patient previously.
There was an allegation from a patient that a disability assessment was improperly performed. It was alleged that the physician's conclusions were not supported by the evidence. In reviewing the matter, the Committee noted that the observations the physician provided were similar to those done at the same time by other physicians. The principal difficulty appeared to be in the conclusion. The Committee felt this difference of opinion did not represent deficient care.
A patient had been seeing another physician whose practice was taken over. He had been well and had not had a reason to see the new physician. Nevertheless, after some time, he did make two appointments solely for the purpose of getting acquainted. However, he had to cancel these. He subsequently became ill, and was granted another appointment. Before he could attend, he was advised that the physician had now closed the practice. The Committee noted that similar circumstances had arisen on several other occasions when practices have been taken over and not all the patients were seen within a period of time. The Committee feels there is some responsibility to communicate with patients regarding the possibility that they may not all be accepted by the new physician and should begin to make alternate arrangements. Ideally, this could be communicated by the departing physician. The new physician could also make some effort to determine which patients could continue to expect to be seen, notwithstanding that they have not yet attended the office. To some extent, this may also assist in identifying patients who have already chosen to see other physicians.
There were two separate complaints regarding confidentiality. In one case, a family physician communicated with a company physician regarding the patient's work environment. In another case, a physician communicated with a school regarding a child's behavior problems. In reviewing these matters, the Committee could find no evidence of ill intent, but felt the physicians did not have clear authority to communicate with others. While, in many circumstances, verbal consent for such is acceptable, in both cases here, there were reasons to believe that the patient or family may not have wished such communication to take place. Under those circumstances, physicians may be wise to obtain written consent to avoid questions arising later.
In other provinces there have been circulating suggestions regarding the value of prescribing generic hydromorphone as opposed to Dilaudid. Apparently the solubility of Dilaudid makes it advantageous for misuse in intervenous form. In contrast, the generic preparation is insoluble and cannot be so easily taken improperly. For that reason, it is being suggested that, where possible, patients be offered the generic preparation. It is noted, however, that because of these characteristics, even bona fide patients may need a higher dose. For that reason, this advice may be principally for patients receiving an initial prescription for hydromorphone.
In other business, Council:
- Noted that the College of Physicians and Surgeons of Ontario had agreed to limit their onsite evaluation for foreign-trained physicians applying for licensure in Ontario. Such should no longer involve direct patient contact by the assessor.
- Reviewed recently audited financial statements for 2004 which showed the College continued to produce a surplus. This will likely preclude the need for a fee increase. Council considered various options for the surplus funds.
- Noted new guidelines from the pharmaceutical industry designed to reduce the inducements offered to physicians.
- Received reports that some family physicians were still being asked to sign consultation requests which they themselves had not initiated. Council determined to review whether signing such a request could be considered "falsifying a record" and possibly a form of misconduct.
CODE OF ETHICS
The Canadian Medical Association's Code of Ethics has been adopted by the Council of the College and is now binding on New Brunswick physicians. One new provision concerning clinical research states the following:
39. Inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of your participation including any compensation.
A plain reading of this provision suggests that physicians are now obligated to disclose to patients involved in research whether the physician is being compensated for such, and the amount of same. Before advising members as to its interpretation, Council wishes to hear any comments regarding this. It is assumed the major impact would be on those situations where the physician is compensated specifically for each patient enrolled in a study.
If physicians have any views on this issue, please forward them to the College by any appropriate means.
FROM THE ARCHIVES
Ninety years ago
In 1915, Council granted emergency examinations for physicians who were going overseas with the military, advised a hospital in Woodstock to quit employing an unlicensed physician, and declined to refund the registration fee of a physician who had decided to become a priest. There were two hundred and fifty three physicians registered.
Sixty years ago
In 1945, Council determined that no physicians from outside New Brunswick would be granted licensure until all local physicians had returned from the war, and determined to grant free licensure for two years for any such returning physicians.
Thirty years ago
In 1975, Council discussed the legality of acupuncture, noted the opposition of the Medical Society to Council's request for billing profiles from Medicare, and determined to increase the annual fee to $42.