Bulletins

July 1997



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 1996-1997

President - Dr. David Beaudin, Saint John
Vice-President - Dr. William Martin, Miramichi

Dr. Leonard M. Higgins, Saint John
Dr. Ludger Blier, Edmundston
Dr. Christine Davies, Saint John
Dr. Beatriz Sainz, Oromocto
Dr. Marc Panneton, Campbellton
Dr. Georges D. Surette, Moncton
Registrar - Dr. Ed Schollenberg

Dr. Michael Perley, Woodstock
Dr. David Olmstead, Harvey Station
Dr. Nataraj Chettiar, Bathurst
Ms. Suzanne Toole, Saint John
Dr. Pamela Walsh, Riverview
Mr. Eugene LeBlanc, Dalhousie


At its meeting on 6 June 1997, Council considered the following matters:

Complaints

There was a complaint from a family regarding the care provided to an elderly relative by a physician. The patient, who was not previously known to the physician, was admitted for back pain. The appropriate investigations were done, but the results were delayed in reaching the physician and there was further delay in advising the family. This created a great deal of adverse feelings and distrust. In reviewing the matter, the Committee could find no fault with the care provided. Such communication difficulties, particularly involving extended families, are a recurrent source of complaints. As the Code of Ethics advises, "Be considerate of the patient's family and significant others and cooperate with them in the patient's interest."

A patient complained regarding the care provided by an ophthalmologist in prescribing corrective lenses following cataract surgery. He eventually sought care from other practitioners, and later sought redress from the ophthalmologist for the expense involved. In reviewing the matter, the Committee felt that the care provided was appropriate. The complainant had become impatient and as a result of seeing other practitioners, had made it impossible for the ophthalmologist to assist in reaching an accommodation with the dispensing optician.

There was a complaint from a lawyer regarding a report provided by a physician. The physician charged $500 for a report which consisted of approximately half a page of hand-written notes. The physician provided no justification for the time or effort involved in the producing of the report. In reviewing the matter, the Committee noted that the College's regulations require that fees charged be "fair and reasonable". Determination of reasonableness is based on recommendations from the New Brunswick Medical Society. Fairness is determined by reference to the effort involved, and the value of the opinion. In the absence of any justification from the physician, the Committee felt that the charge for the report was excessive and advised that a reduced amount would be appropriate under the circumstances.

There was a complaint from a widow against an emergency physician concerning the care provided to her husband, who had collapsed at home, and been taken to the hospital where resuscitation was unsuccessful. The complainant stated that the physician had not properly discussed the events with the family and that there had been further dispute regarding the availability of an autopsy to determine the cause of death. In reviewing the matter, the Committee felt that the physician could have been more available to the family to discuss such matters, specifically to discuss the circumstances of the death, at least in a preliminary way. When nothing further could be done for the patient, the physician has a responsibility to be respectful of the needs of family members in such situations. The Committee also noted that the question of autopsy availability is an on-going one which is currently under review.

A small child fell on her wrist and was presented to her family physician. On examination, it was concluded that a fracture was unlikely. The child was seen again the next day, with a story of failing to use the arm normally, but with no obvious discomfort. The family eventually took the child to another physician who did an x-ray and diagnosed a fracture. In reviewing the matter, the Committee could not be certain exactly what information was passed to the physician during the second visit. Nevertheless, the fact that the patient was brought in a second time, with continuing concerns, suggested that an x-ray may have been warranted at that point. Reliance on tenderness, or obvious discomfort, will not be sufficient in children of that age. Nevertheless, it was also clear that, given the nature of the fracture and the age of the child, the clinical recovery was not compromised with the delay in diagnosis.

There was a complaint from a patient that an invasive procedure had been done without consent while she was heavily sedated. After reviewing the matter, and the response from the physician, the Committee recommended that matter be referred to a Board of Inquiry.

Compulsory Physicals
In response to a concern expressed by a patient, Council became aware that certain physicians were requiring patients to submit to complete physical examination, at their own expense, as a pre-condition for prescription renewal. Prescriptions for long-standing medications were not renewed unless the patient complied.

This is to advise members that Council has considerable concerns regarding this approach. First of all, it is completely correct for a physician to require some periodic assessment as a condition of patients continuing to receive treatment, such as prescription renewals. Whether this reassessment consists of a simple office visit or requires a complete physical examination would, obviously, depend on the circumstances. If a complete examination is required for monitoring of the condition, in the physician's opinion, then it is clearly medically necessary, as defined by Medicare, and should be billed as a Code 7. It is improper, in Council's opinion, to require such a physical, and then deem it to be medically unnecessary, and, as a consequence, not covered by Medicare.

There was also the question of whether the service could be provided on an "opted-out" basis. It is Council's opinion that the ability to provide the service on this basis seemed highly questionable. For example, Medicare rules require that a patient treated in an opted-out manner for a particular condition cannot be treated in an opted-in manner subsequently. Thus, if a complete physical is provided for a patient, on an opted-out basis, it would be necessary that all subsequent care, including subsequent office visits for that condition, be provided on an opted-out basis as well.

It was also noted that in order for a service to be provided on an opted-out basis, such service must be available from another physician who would be willing to provide it on an opted-in basis. In many locales there is little or no access to alternative family physicians. Thus, the ability for patients to obtain the service from another practitioner appeared theoretical only. Finally, Council noted that where the need for a complete examination may be less certain, the physician can ethically provide the required reassessment as an office visit and then offer, on a completely voluntary basis, the possibility to the patient that a complete physical would be available, but only as a direct charge to them. Thus, patients who wish to have this service provided can request same, but it cannot be a strict condition of continuing care.

After Hours and Vacation Availability
In light of the on-going debate within the profession regarding physicians' respective obligations to be available after regular hours, or during vacations, the Council of the College wishes to hear from members regarding their attitudes to this issue. To that end, with this Newsletter is enclosed a brief document highlighting those concerns, along with a policy statement from the College of Physicians and Surgeons of Alberta, which focuses on relevant issues.

Address Changes Enclosed with this mailing is an update to the Annual Announcement, previously distributed to members. Many addresses in New Brunswick, especially in the rural areas, are being changed. Physicians are encouraged to provide the College with notice of changes as soon as they take effect.

ES/jm