Bulletins

April 1995



This Bulletin is forwarded to every medical practitioner in the province. Decisions of the College on matters of standards, amendments to Regulations, By-Laws, 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 1994-1995
President - Dr. L.M. Higgins, Saint John
Vice-President - Dr. Michael Perley, Woodstock

Dr. David Beaudin, Saint John
Dr. Ludger Blier, Edmundston
Dr. Christine Davies, Saint John
Dr. Beatriz Sainz, Oromocto
Dr. Matthew Swan, Campbellton
Dr. Georges D. Surette, Moncton
Registrar - Dr. Ed Schollenberg

Dr. William Martin, Newcastle
Dr. David Olmstead, Fredericton
Dr. Nataraj Chettiar, Bathurst
Ms. Suzanne Toole, Saint John
Dr. Pamela Walsh, Riverview

Council Report:

At its meeting of April 7, 1995 the Council considered the following matters:

Complaints and Registrations:

A patient presented to a family physician with a neurological problem. She alleged that he immediately chastised her for attending his busy office with such a problem. No examination was done. After reviewing the matter extensively, the Committee concluded that the actions were quite inappropriate. The patient was entitled to a more caring attitude. It was equally unacceptable to fail to perform even a brief examination, given that this could determine the most appropriate avenue of referral. A letter advising the physician of his obligations was approved.

A complaint concerned the emergency room management of an adolescent with mononucleosis. The parents alleged that the assessment was inadequate and their son should have been admitted. He was discharged home, improved briefly, but subsequently died of aspiration pneumonia. In reviewing the matter, the Committee could not find any deficiencies in care such as would constitute professional misconduct, nor could they find any evidence that admitting the patient would have prevented this outcome. A letter stating same was approved.

There was an allegation by a patient regarding the surgical management of a bowel obstruction. She alleged the management was inappropriate and that repeated requests to be transferred to another hospital were ignored. On reviewing the matter with expert opinion, the Committee concluded that the surgical management was appropriate. The patient had also been incorrectly told that she had a malignancy. This, at best, seemed ill-advised. Furthermore, while there was no direct evidence that the patient had specifically requested the transfer, it is clear that a physician has no right to continue to provide treatment without the on-going consent of the patient. While this was not definitely the case here, it should be clear that it is the physician's obligation to accede to the patient's wishes for alternative arrangements if such are requested and available.

There was a complaint from a patient regarding a physician who had made an inappropriate response when she attempted to discuss more than one matter at an office visit. This can be a difficult problem in a busy office. It should be clear that physicians should consider what is best for the patient in such a situation. Significant problems may require a further visit, but minor ones can be dealt with. A policy telling the patient that only a single problem may be dealt with on a particular visit may not be compatible with comprehensive patient care.

There was a complaint regarding an assessment done by a physician at the request of an insurance company. Initially, there was some difficulty for the patient to obtain the report. This matter is addressed below. More particularly, it did seem that certain comments in the report were misinterpreted by the insurance company in a way adverse to the patient. The physician clarified these comments in a follow-up report. Physicians are reminded that, in producing such reports, they should respond as carefully as possible to the specific questions which have been asked.

There was a complaint against two physicians regarding the management of a patient who presented with a hip injury. The original x-ray was somewhat inadequate, and the patient was encouraged to be mobile. It eventually was discovered that the patient had a pathological fracture of a hip due to a tumour. The diagnosis was unusual and no fault could be found with the physicians for originally not considering it. However, the appropriate treatment was delayed somewhat by the premature conclusion that a significant injury was not present.

A complaint came from a family which had been discharged from a physician's care when the wife of the patient attempted to provide information to the physician regarding her husband's condition. A dispute with the receptionist staff arose, and the family was advised to find another physician. While no specific allegation of professional misconduct was possible, the Committee felt that the approach taken by the physician and his staff was not appropriate. Physicians are to consider first the well-being of the patient and, as well, are obligated under the Code of Ethics to cooperate with family members in a patient's interest.

In addition, the Committee recommended several matters be referred to a Board of Inquiry. These included three allegations of sexual impropriety, two allegations of misuse of the authority to prescribe, and one allegation of refusal to treat.

Access to Third Party Reports:

As most physicians are aware, since 1992, physicians have had an obligation to provide to their patients copies of all information in the patient's file, unless it can be shown that provision of same would harm the patient or another. This was the case regardless of the source of the information.

One area which has not yet been addressed concerns access to reports provided at the request of a third party, such as an insurance company. The general advice given to physicians was that there was no obligation to provide such reports.

On reviewing the matter, it is clear that the reasons behind the Supreme Court decision of 1992 can still apply to this situation. The patient, when presenting for such an assessment, will provide confidential information, will submit to a physical examination, and may provide body fluids for analysis. The physician's obligation to competence and confidentiality are the same. To clarify the issue, Council has resolved that examinations provided at the request of another party shall, for purposes of access to records, be considered in the same light as all other records. Such reports shall be provided at the patient's request, subject to the conditions above.

In addition, reports of this nature may be submitted to family physicians. Occasionally, there will be instructions that they are not to be provided to the patient. It should be clear that once any report becomes part of the patient's record, the patient has full right of access to it, notwithstanding the wishes of the provider of such reports.

Difficulties With Receptionist Staff:

From time to time, complaints concern difficulties patients may have with receptionist staff. In recent years, literally all complaints of this nature have involved situations where the spouse of a physician was employed as the receptionist.

The reasons why such a situation might make complaints more likely is unclear. Nevertheless, the situation seems to exist elsewhere. As a consequence, the following comments, from the College of Physicians and Surgeons of Alberta, are provided for interest. This also deals with the question of physicians who hire former patients for their staff:

Employing Patients and Relatives:

"From time to time physicians employ office staff who are or have been their own patients, or who are relatives or spouses. In the best interest of all possible worlds this may work extremely well for everyone concerned.

The difficulty is that the medical world may not always be the best of all possible worlds. What this means is that the College sometimes hears of significant difficulties when such people are employed by a physician.

Such individuals may be more difficult for the physician to deal with in a way which calls for controls or discipline, because both physician and employee may be less able to be completely objective about each other as employer and employee than would be the case where there is no relationship outside of that one.

The presence of such an employee within a group of employees may be more disruptive or intimidating, for real or imagined reasons, than one who has no relationship with the physician outside of employment.

In the group practice situation, other physicians in a practice may find such employment inappropriate. That is a conflict which needs careful consideration and delicate negotiation. The fact is that in many medical groups, and indeed in many other work settings, such employment is absolutely forbidden for all of the reasons above, and perhaps others.

The difficulties may be even greater where the employee in question holds a position of authority over other employees within the office, and where he or she may have direct contact with patients coming to the office.

The purpose in doing a column on this subject is not to suggest that such individuals must never be employed by a physician, but to strike a cautionary note and urge careful thought before establishing such a relationship. This may be especially relevant where the employee is a spouse."

Annual Announcement:

The 1995 Annual Announcement is currently being mailed. Additional copies are available to members for a fee of $10. The only change from last year is the addition of Fax numbers. Physicians who have not provided the office with a Fax number are encouraged to do so. Physicians should also advise us of any other omissions or changes as soon as possible.

ES/jm