Bulletins

November 2002

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.

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Officers and Councillors 2001-2002

President - Dr. Ludger Blier, Edmundston
Vice-President - Dr. Marc Panneton, Campbellton

Ms. Barbara Bender, Saint John
Dr. Zeljko Bolesnikov, Fredericton
Dr. Marc Bourcier, Moncton
Dr. Douglas Brien, Saint John
Dr. Christine Davies, Saint John
Dr. Paula M. Keating, Miramichi
Mr. Stanley Knowles, Miramichi
Mr. Eugene LeBlanc, Dalhousie

Registrar - Dr. Ed Schollenberg


Dr. John McCrea, Moncton
Dr. Robert E. Rae, Saint John
Dr. Beatriz Sainz, Oromocto
Dr. Malcolm Smith, Tracadie-Sheila
Dr. Rudolph Stocek, Hartland
Dr. Pamela Walsh, Riverview
Dr. Claudia Whalen (PhD), Fredericton




At its meeting on 4 October, 2002, Council considered the following matters:

COMPLAINTS
An elderly patient underwent an abdominal procedure, but succumbed afterwards to a heart attack. On reviewing the matter, the Committee could not find any deficiencies in the care provided. There was a question as to whether the preoperative ECG showed any evidence of developing pathology. In retrospect, this may have been the case. However, the automated interpretation of the ECG failed to detect such. There was no evidence that the physicians relied on this. However, members are cautioned that such automated interpretation has the potential to mislead physicians. In all circumstances, specific visual interpretation of the ECG is warranted.


An Emergency Room physician prescribed an antibiotic to a child despite a documented allergy. The child suffered no significant ill effects. It was the Committee's conclusion that the error was inadvertent and possibly due to a moment of inattention related to an interruption in the assessment of the child. Members can only be conscious of the distractions which may occur in a busy department.


There was an allegation that a physician had failed to report to the relevant authorities an allegation of child abuse. The physician responded that he was not sure the allegation was credible. On reviewing the matter, the Committee did note that it had been reported by another physician. Nevertheless, members are reminded that the legal obligation to report such matters applies to all professionals involved in a child's care. The Committee chose to remind the member firmly of this obligation.


There was an allegation from a patient regarding excessive pain during an anesthetic procedure. A review of records of the matter demonstrated no objective evidence of such pain. It appeared most likely that the patient's recollection was the result of the effects of certain premedication used.


A patient underwent a procedure and alleged that it was performed improperly. In reviewing the matter, the Committee could find no evidence of deficient care. However, the Committee was significantly concerned that the patient was first assessed by another physician who recommended the procedure. The physician who actually performed the procedure had no discussion with the patient. It was noted that this was an established scheduling approach taken by these physicians. In the Committee and Council's view, such is unacceptable. Any physician performing an invasive procedure is responsible for assessing the patient directly, discussing the matter with the patient, and obtaining appropriate informed consent. Patients who have not met the physician performing the procedure cannot give properly informed consent. While it is understood that, in exceptional circumstances, such as vacation or scheduling difficulties, such may be acceptable, it is Council's view that such should not be routine practice.


There was an allegation that a patient had suffered a significant complication following an operative procedure. On reviewing the matter, the Committee noted that the procedure involved was complicated, delicate, and known to frequently result in nerve damage. This patient had suffered such, and furthermore, had been unable to have the results ameliorated despite many attempts. Nevertheless, the Committee felt there was no evidence that the initial procedure was performed deficiently.

The mother of an adolescent patient complained that a physician had refused to assess her daughter unless the patient removed her shirt. The physician had stated that, unless a complete assessment was possible, he would not proceed at all. Under the circumstances, the Committee felt the patient could still be appropriately assessed and, at the same time, have her privacy concerns respected. Despite the physician's concerns about liability, the Committee felt that the care provided would be judged based on the best that can be done under the circumstances.

There was an allegation that a physician had inappropriately provided care to a patient with whom she had a preexisting relationship. The patient had recently relocated to the area and the physician was unable to find alternative care. When the patient became ill, she provided, in the Committee's view, a minimal amount of assistance prior to transferring the patient to a consultant. Physicians are reminded that it is unethical to provide treatment for themselves or family members except in emergencies and minor circumstances. In the Committee's view, the same concerns apply to individuals with whom the physician may have an intimate relationship. In this case, the Committee did not feel the physician had provided any treatment more than was necessary under the circumstances. However, it would have been preferable for care to be provided by another.


There was an allegation from a physician in a community hospital that a consultant in a regional centre repeatedly resisted transfer of patients. It was alleged that the consultant either refused to take phone calls or hung up during them. In reviewing the matter, the Committee felt that, first of all, the need to transfer the patients was reasonably clear. Under those circumstances, the consultant should have respected the opinion of the attending physician. In one case, it did appear possible to avoid transferring the patient. In those circumstances, the consultant should have provided appropriate advice and assistance to the attending physician to allow him to manage the case appropriately. A belligerent, judgmental approach to dealing with a colleague is never acceptable. It was also noted that the consultant had frequently refused to complete a consultative report in these circumstances. Such is also unacceptable. Furthermore, it would be improper to bill for a consultation unless the report had been completed.

A patient suffered damage to the ear drum as the result of a syringing by a physician. This was likely due to a preexisting injury. It did not appear that the physician could have anticipated such.

A patient had not seen a physician for a number of years and, when attempting to make an appointment, was advised that, since it was assumed she had obtained care elsewhere, she could not be accepted back into the practice. The Committee notes that this issue continues to arise, especially when a physician takes over a practice and does not see all of the original patients within a certain period of time. While the patients may reasonably expect that they continue to have a family physician, the physician may also reasonably expect that the patient is obtaining care elsewhere. The question arises as to whether a physician could establish a specific policy such that after a particular number of years the patient can be considered to have left the practice and there would be no obligation to accept them back. The Committee feels that physicians could take such an approach, but in order for them to do so fairly, all patients would have to have a clear understanding of the policy. Furthermore, it would seem necessary that each patient be advised at the point that they are about to be discharged from the practice for non-attendance. Unfortunately, this approach may simply cause patients to present for otherwise unnecessary visits. For that reason, the Committee feels it is quite reasonable for physicians to consider some patients to have left their practice after a particular period of time. However, physicians should be prepared to reconsider the matter based on the particular circumstances. In other words, the patient could provide some information, through a letter, such that the physician could determine each matter on a case by case basis. This would allow the physician to identify those circumstances wherein the patient, for whatever reason, simply did not attend a family physician. The Committee also wanted to point out that this situation was aggravated by the fact that the patient was seen on a monthly basis by a consultant who, at no time, had provided any information back to the family physician. If such had been the case, the family physician would have been in a position to note the patient's expectations for ongoing care.


There was a complaint that a consultant had refused to accept a phone call from a physician in another region. The patient at issue was actually a patient who was from the region that the consultant was covering. In response, the consultant acknowledged the error. The Committee felt this was an appropriate conclusion. The Committee notes that there can be few, if any, situations where it is acceptable to refuse to take a call from another physician. It is only under those circumstances that the complete facts can be known. Any obligations, if any, for further care can only be determined by those facts.


A patient allegedly succumbed after receiving an excessive dose of an intravenous medication. It was alleged that the physician had prescribed too high a dose, but the physician asserted that the error was on the part of the nurse transcribing the order. The precise facts could never be determined. Nevertheless, given that such errors can occur, it is expected that systems to correct such would be in place. Under these circumstances, there was evidence that the nurse involved had questions regarding the order, but there was no evidence that any effort was made to check the dose with this physician or any other. In any case, there was no direct evidence that the medication error actually caused the patients death.

Council also referred a matter, concerning an allegedly fraudulent prescription, to the Board of Inquiry.

PHYSICIANS AND THE
PHARMACEUTICAL INDUSTRY

Concerns continue to be raised about the relationship between physicians and the pharmaceutical industry and the potential effect on patient care. Council would like comment from members regarding one specific aspect of this, namely physician participation in industry sponsored post-marketing studies.

Such studies involve drugs which are already approved and available. In exchange for enrolling patients receiving the drug into a study to monitor some aspects of their use, physicians will be compensated for their time, either based on a specific fee per patient enrolled, in the form of some equipment, or in the form of travel to meetings to discuss the findings. The scientific benefits of these studies have been questioned. Results are seldom published and other means of surveillance are available. Council, and others, are concerned that these initiatives are simply designed to encourage the prescribing of a particular drug. While most physicians will assert their independence from such influence, the fact that these initiatives continue to be offered seems to present evidence that they are effective in their intent.

To that end, Council wonders whether it should continue to be acceptable for physicians to enter such arrangements where they are compensated based on the number of patients who are prescribed and continue to receive a particular preparation. Council also wonders whether it is acceptable to participate in such initiatives when physicians are induced with vacation trips. Members are encouraged to respond in any fashion they wish.

NEONATAL CIRCUMCISION
Questions have recently been raised regarding the continued acceptability of neonatal circumcision. A death in one province and a policy decision against such in another have resulted in the Council reviewing this issue. Based on information currently available, Council feels that physicians should continue to be guided by prevailing medical standards, best illustrated by the Canadian Pediatric Society, which concludes:

The overall evidence of the benefits and harms of circumcision is so evenly balanced it does not support recommending circumcision as a routine procedure for newborns. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. The decision may ultimately be based on personal, religious, or cultural factors.

REPORTING OF ADVERSE EVENTS

The Colleges in several other provinces have mandated, or are considering, specific policies which mandate physicians to disclose adverse events and errors which occur in the course of patient care.

Council considered whether such an initiative was necessary here. It was concluded that it was not. This is because it is Council's view that this was already an existing obligation on the part of physicians. In other words, patients remain entitled to have complete information regarding their care, including any adverse events. Council was furthermore of the view that it is improper for such an obligation to be interfered with by other parties. It is Council's view that early, candid, and full disclosure of adverse events to patients, and their families, will be of benefit to all concerned.

TERMINATION OF CARE
In response to feedback requested from physicians, Council wishes to confirm that there has been no policy change regarding physicians' ethical obligations, should they wish to terminate the care provided to a patient. Physicians retain the right to decide to provide no further treatment to a patient provided the patient is not in need of immediate care.

Council notes that the decision to terminate care is, and should be, a difficult one. Council also acknowledges additional pressures that the lack of alternatives can create for physicians and patients.

Under these circumstances, Council encourages members to consider the gravity of any such decisions. There are, indeed, some circumstances which clearly warrant the termination of care. This includes fraud for purposes of obtaining narcotics and other drugs, violent or aggressive behaviour, and double doctoring. (Members should note that "double doctoring" has a very specific meaning under the Controlled Drugs and Substances Act. It refers to attempting to obtain a narcotic or controlled drug without disclosing that such had been prescribed by another physician within the previous thirty days.)

There are other circumstances where Council feels physicians should use significant caution. The Code of Ethics advises physicians to respect the right of patients to make reasonable requests for second opinions, consultations, or simple information. Council also notes that physicians should judge each circumstance according to the particular patient. If one member of a family voluntarily or involuntarily leaves a practice, it may be inappropriate to discharge other members as a consequence.

In any case, Council does note that there is no evidence that this is a significant problem in terms of patient access. The majority of patients without physicians are obviously in that situation for other reasons.

Some years ago, the College published a guideline from the College of Physicians and Surgeons of Ontario. While it is not completely appropriate to the New Brunswick situation, it is reproduced here to assist members.

TERMINATION OF CARE - FROM THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO

As far back as anyone can remember, the ethics of the profession have defined the physician/patient relationship as an ongoing one in which the doctor accepts responsibility for the patient's care and will not end the relationship with a patient without good reason, proper notice and an opportunity to obtain another doctor's services. The Canadian Medical Association Code of Ethics prohibits discontinuing necessary medical services unless the patient requests the discontinuance, alternative services are arranged or the patient is given a reasonable opportunity to arrange for those alternative services.

Here are some suggestions for ways to proceed when your judgement tells you that it will be in the patient's best interest to terminate your physician/patient relationship.

1. Communicate your decision to the patient as compassionately, as supportively, but as clearly as possible.

2. Give the patient a reasonable amount of time to find a new physician. This time would be that which it would take a reasonable person, using reasonable effort, to find a new doctor. This time may vary from community to community.
[In New Brunswick there will usually be considerable delay in a patient finding another physician. In these circumstances, it is generally considered reasonable that the original physician continue to provide service to the patient for a period of two to three months. When alternate care can be arranged directly, then the patient can be transferred immediately.]

3. Be helpful to the patient in finding a new doctor and transferring records.

4. Document the process you choose to use. In some cases, you may wish to consider sending a registered letter with a return receipt requested. Place a copy of the letter with the postal receipt in the patient's chart along with the termination entry recording your actions.

5. Be sure your staff is aware of your decision so that further calls from the patient may be responded to appropriately.

6. Where the patient has ongoing dealings with other health care providers, (e.g., pharmacists, hospitals, physiotherapists) let those providers know that you are no longer caring for the patient.

7. If you are of the opinion that ongoing care is necessary, make sure you convey this clearly to the patient.

The following is a sample of a letter you might wish to consider in conveying your decision to patients. This letter, must, of course, be customized to fit your particular circumstances. The need to terminate your relationship with a patient can be most comfortable for you and the patient if a caring and rational explanation is given.


Dear (Patient's name)

For the reasons we discussed recently, I do not believe that it will be in your interest for me to continue as your physician. I regret to inform you that I will not be in a position to provide you with medical services after (fill in the date, which will vary with your circumstances).

I urge you to obtain the services of another physician satisfactory to you.

When you have had an opportunity to see your new physician, please ask him or her to contact me and I will be pleased to provide a full summary of my care while you have been my patient and to transfer a copy of your medical record.

Yours very truly,
(your name and signature)

MORAL OBJECTIONS
In response to feedback generated from physicians and others at Council's request in a recent Bulletin, Council has approved the following comment:

One of the most difficult dilemmas in the patient/physician relationship occurs when the physician has a personal moral objection to a procedure or treatment that the patient may request or inquire about. Such issues create a conflict between the recognized autonomy of a competent patient to make their own decisions regarding health care and the autonomy of physicians to practice according to their own knowledge, experience, and conscience.

It is Council's view that the autonomy of both patients and physicians can be respected, on the basis of physicians following the principles of good medical practice, the Code of Ethics, and College Regulations.

To that end, it is a basic obligation under the Code of Ethics and College Regulations for physicians to advise patients when their personal morality would influence any recommendation or practice they may make regarding a patient. In other words, it would be improper to refuse a patient's request without stating such. The basic requirement is that patients should be informed as to why a physician is declining to provide the service or treatment requested.

Council also feels that, while it is not an obligation to do so, it is preferred practice for physicians who have such objections to refer the patient to another where such objections may not arise. Nevertheless, if the physician feels even that is unacceptable, Council does view it as an acceptable alternative for the physician to provide information, upon the patient's request, regarding resources which may be directly accessible to the patient.

In any case, any discussions, should these issues arise, should be dealt with in a manner which is neither judgmental, nor intimidating.

Physicians are also reminded that other factors may have some influence here. In addition to the Code of Ethics and College Regulations, the Human Rights Act prevents physicians discriminating in access to care based on a number of factors, including specifically "race, colour, religion, national origin, ancestry, place of origin, age, physical disability, mental disability, marital status, sexual orientation, or sex".

Finally, physicians are reminded that, should a complaint arise, any care offered will be judged according to accepted medical and scientific standards.

OTHER BUSINESS

Council accepted a guilty plea from a physician to a charge of failing to meet the standard of the profession regarding the prescribing of controlled drugs. As a consequence, Council issued a reprimand without publication of the physician's name.

Council acknowledged with appreciation the contributions of Drs. Christine Davies, Beatriz Sainz and Pamela Walsh, who had completed the maximum term of nine years on Council.

Council received a report of the Review Committee. The Committee had reviewed the scope of practice of a specialist. The Committee has also recommended that two physicians undergo office inspections. The Committee also reviewed a number of complaints which had arisen against a single physician. While the number of complaints was high, they did not suggest a particular pattern. As a consequence, the Committee determined to take no further action.

Council decided to reduce the initial registration fee for licensure from $200. to $100. It was hoped this would have a modest benefit for Locum recruiting.

Council requested more information regarding a proposal for a national service to review the credentials of all physicians seeking licensure in any province.

In response to an allegation of improper abandoning of a medical practice, Council passed a resolution of criticism.

COMMITTEES

Executive Committee
The Executive Committee generally handles matters which arise between Council meetings. They also are responsible for reviewing the performance and the contract of the Registrar.

President: Dr. Marc Panneton
Vice President: Dr. Rudolph Stocek
Past President: Dr. Ludger Blier
Public Member: Mr. Eugene LeBlanc
Member at large: Dr. Douglas Brien

Complaints Committee
The Complaints Committee is responsible for the initial investigation of complaints and making recommendations regarding disposition.

Dr. Douglas Brien
Ms. Ellen C. Desmond
Mr. Gordon Foster
Ms. Judy Glennie
Dr. Leonard Higgins
Dr. Douglas Keeling
Dr. Perry Spencer

Review Committee
Matters may be referred to the Review Committee by the Complaints Committee or Council. They generally deal with issues requiring more extensive investigation or ongoing monitoring, including questions of physician performance and competence and incapacity due to illness or substance abuse. The Committee also handles appeals from decisions of Council.

Dr. Rudolph Stocek
Dr. Odette P. Albert
Ms. Barbara Bender
Dr. Gordon Mockler
Dr. Beatriz Sainz
Dr. Patrick D. Sullivan
Dr. Georges Surette

ANNUAL DUES
This mailing includes invoices for annual dues for 2003. Members will note that fees remain the same as they have been for the last several years. Where available, members are encouraged to take advantage of pre-authorized payment, which will reduce fees by $20.