Bulletins

September 2000

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 1999-2000

President - Dr. Beatriz Sainz, Oromocto
Vice-President - Dr. Christine Davies, Saint John

Dr. Pamela Walsh, Riverview
Dr. Bill Martin, Miramichi
Dr. Ludger Blier, Edmundston
Dr. Marc Panneton, Campbellton
Dr. Marc Bourcier, Moncton
Dr. Gordon Mockler, Westfield
Dr. Zeljko Bolesnikov, Fredericton
Registrar - Dr. Ed Schollenberg


Dr. Nataraj Chettiar, Beresford
Dr. Rudolph Stocek, Hartland
Dr. Douglas Brien, Saint John
Mr. Eugene LeBlanc, Dalhousie
Mr. Fernand Rioux, Caraquet
Dr. Claudia Whalen (PhD), Fredericton
Ms Janet McIntosh, Moncton




At its meeting on 15 September 2000, Council considered the following matters:

Complaints:
A patient complained that a physician had failed to report to the College an allegation of sexual abuse against another physician. On review of this specific aspect, the Committee could not determine that a specific credible allegation had been communicated to the physician. It was also noted that he had advised the patient that he was an "acquaintance" of the alleged perpetrator. Under these circumstances, the perception that the treatment provided may be compromised should be acknowledged. It was also noted that, to avoid such a potential conflict, the physician had attempted unsuccessfully to arrange alternate care.

A patient complained that a family physician had failed to provide appropriate documentation, investigation and referral following several injuries. In response, the physician noted that appropriate referrals had been made. All relevant documentation had been completed, but that the patient had been dissatisfied with the contents of such reports. In reviewing the matter, the Committee determined that the physician had taken all reasonable steps necessary. No fault was found with the care provided.

There was a complaint that a physician who saw two children in an Emergency Department had failed to undertake proper assessments. Both children subsequently became gravely ill. On reviewing the matter, the Committee determined that the assessments provided were acceptable under the circumstances and, in any case, the subsequent illnesses were unusual, as were their presentations. In short, no fault was found with the care provided.

There was a complaint that a family physician had failed to provide a patient with appropriate information regarding mammography results. The patient was seen over several years and had regular mammograms. The studies showed a lesion which was not changing and likely benign. Repeated follow-up was recommended. The patient was only advised that the studies were "normal".. The patient subsequently developed cancer and, on reviewing the record, discovered the previously noted changes. The patient alleged that the denial of any information precluded her from making appropriate decisions. The Committee first of all noted that the standard of care regarding the particular mammography findings had evidently changed. Such findings would now more likely result in intervention than they would have several years ago. In addition, the Committee did feel that the standard of care as to what information should be disclosed to patients under these circumstances may have also evolved. For that reason, the Committee could find no fault with the approach taken by this physician. Nevertheless, it would appear to be good practice to fully acquaint the patient with all results, including benign findings.

A complaint arose regarding the care provided to an infant in a community hospital. The child developed increasing respiratory distress, eventually requiring referral to a regional hospital. On reviewing the matter, the Committee concluded that this was a viral infection which was following its expected course. Considering that the infection was at its early stages, the care provided by the physician was found to be acceptable.

There was a complaint from a patient regarding the management of a retained placenta. The allegation was that improper analgesia had been provided and that she had received an inadequate explanation of the procedure. On reviewing the matter, it was felt that the physician had provided all appropriate explanation and support. A subsequent meeting of the parties had evidently resolved the issue.

Two children were seen in an Emergency Department and recommended to be followed up by their family physician. Appointments were made. After the assessments were complete, the physician's office subsequently billed the family for complete examinations. In response, the physician stated that, in his opinion, the medical conditions had resolved and, as a consequence, he had performed a complete examination as an uninsured service. The Committee felt that the approach taken was improper for several reasons. First of all, the physician's specific notes suggested that there were entrance complaints. As a consequence, any service provided was medically indicated and, consequently, insured. The type of such an assessment would depend on the circumstances. In any case, it is also required for any fees charged to a patient to be fully disclosed in advance. In these circumstances, there was no evidence that they were. Finally, physicians are obligated to be prepared to discuss any fees with patients. The Committee felt there were several shortcomings in the approach taken, but, in the end, determined that the comments provided would be sufficient education.

A consultant was providing treatment to a patient. Due to circumstances, specifically lack of certain equipment, the consultant reluctantly could not provide further treatment. The patient requested a direct referral so the treatment could be continued elsewhere. This was refused, requiring the patient to arrange such through her family doctor, and resulting in a significant delay in treatment. Under these circumstances, the Committee felt there was an obligation to provide a direct referral in order to expedite access.

BENZODIAZEPINES
Federal regulation of benzodiazepines has recently been changed. They are now given a special classification as a "targeted substance". New provisions, somewhat similar to those in place for narcotics, have been adopted. Many of these changes concern pharmacy practice regarding storage, record keeping, and transfer of prescriptions, but some may have impact on physicians. Firstly, it is now explicitly mandated that prescriptions for benzodiazepines be dated. Secondly, it is required that physicians keep record of benzodiazepines stored in their offices or at other sites. This includes a record of the receipt of any of these drugs, as well as their destruction. It is not required to record all dispensing or distribution to patients, unless such is in an amount exceeding five times the usual daily dose. Furthermore, thefts or other losses must now be reported. It is hoped that more specific advice on this aspect will be available later.

In addition, the regulations allow that the Federal Minister of Health can revoke a physician's right to prescribe all benzodiazepines. This could occur as a result of a provincial disciplinary finding. It can also occur if the physician has, on more than one occasion, prescribed benzodiazepines to themselves, or improperly done so to a family member. It should be noted that College rules already make such prescribing improper. Finally, physicians can also voluntarily relinquish the right to prescribe these drugs.

OTHER BUSINESS
Council also considered the following matters:

Professional Corporations
About a third of New Brunswick physicians are currently practising under professional corporations. The following information is provided for the benefit of others that may be considering such.

Physicians usually choose to practice in professional corporations for tax and management reasons. The decision to do so is an individual one and usually follows discussions with an accountant or tax lawyer. If the conclusion is favorable, then the first step is to set up a corporate structure and register the Corporation under the Business Corporation Act. Again, such is usually done with the assistance of a lawyer or accountant.

Such a registered corporation is considered a legal "person". It can purchase property, sign contracts or leases, sue or be sued. However, for a corporation to practice medicine there are certain additional elements.

For example, there are restrictions on the acceptable names available for professional corporations. They generally must include the term "Professional Corporation" or "P. C." or otherwise reflect that they are practising medicine. Corporations should include the physician's name, or initials, or the geographical area in which they practice.

Day to day affairs of a corporation are run by "directors". Two thirds of the directors of the professional corporation must be physicians. As most professional corporations are only set up by a single physician, this usually means that he or she is the only director.

It is common in a corporate structure for there to be different classes of shares. Some shareholders have the right to vote and, hence, oversee the corporation's affairs. For Professional Corporations, such voting shares must be held by licensed physicians or by corporations controlled by licensed physicians. In addition, the corporate structure may establish shares which do not have the right to vote, but only share in any financial benefits. There is no restriction on the ownership of these shares; they can be owned by anyone.

Once a corporation has been established that meets the above criteria, it can be registered with the College. This involves a brief application process and registration fee of $100. The annual fee for professional corporation is fifty dollars. Upon registration, the College advises Medicare that the Corporation is licensed to practice medicine and which physician or physicians are practicing through that corporation.

It is sometimes asked whether such a corporation can participate in activities outside the practice of medicine. This may be restricted by "articles" under which the corporation is established. From the College's point of view, the corporation is no different from an individual physician who may persue other ventures beside medicine.

The question also arises as to the impact on liability issues of practising in a corporation. Generally, under corporate law, if an activity occurs through the corporation only the corporation can be sued. Such still would apply to professional corporations in regards to such business matters as contracts or occupier's liability. On the other hand, if the matter is related to the practice of medicine, whether as a malpractice suit or as disciplinary matter, the fact that the physician is practising through a corporation is ignored.

More detailed information on registering Professional Corporations is available on the College website or from the College office.

ES/jm