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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.

 Officers and Councillors 2013-2014 

Council Update

At its meetings on 20 June and 3 October 2014, Council considered the following matters.

 COMPLAINTS

A Counsel is advice as to how to improve the physician’s conduct or practice.

 A Caution is intended to express the dissatisfaction of the Committee and to forewarn the physician that if the conduct recurs, more serious disciplinary action may be considered. 

 A Censure is the expression of strong disapproval or harsh criticism. 

There were two unrelated complaints regarding similar complications from gynecological surgery.  Such complications are relatively common and can occur despite the best of care.  In response to the complaints, the Committee noted that, with appropriate informed consent, the patients had accepted the risks involved in the particular procedure.  Furthermore, in both cases, once the complication was recognized, both surgeons immediately referred the patients to appropriate colleagues for definitive treatment.  The Committee could find no fault with the care provided in either case.

A pregnant patient presented with acute symptoms.  The attending physician felt it appropriate to discuss the matter with a medical consultant.  After some discussion, it was determined that the patient could be released without being specifically seen by the consultant.  The patient was subsequently diagnosed with a significant issue and complained that she should have been seen at the time in question.  In response, the consultant asserted that he provided appropriate advice, recognizing the possibility of a significant problem.  He did not come in to see the patient as he was not requested to do so.  In reviewing the matter, the Committee acknowledged the benefit of telephone advice in many situations.  It is not necessary for every patient, in all situations, to be seen by the consultant who may be called on a matter.  Nevertheless, if there is a decision not to see a patient, the physician must accept responsibility of failing to directly assess the patient.  In other words, the physician should consider the totality of the issue in order to determine whether to assess the patient directly.  This could relate to the severity of the symptoms, potential risks of a particular diagnosis, or the experience of the referring physician.  If a review of these issues suggests the patient should be seen, the consultant should consider doing so, notwithstanding the lack of an initial specific request for such.

There was a complaint from a patient who attended the Emergency Department and allegedly overheard a resident physician making mocking remarks about the patient.  In response, the physician asserted that no such remarks were made and the patient must have misinterpreted anything she heard.  The Committee could find no evidence one way or another on the matter, but felt it appropriate to remind physicians of the importance of using extreme care with any conversation that might be overheard.

There was a complaint regarding the management of a patient’s labour.  It was alleged that the attending physician failed to intervene in a timely fashion, resulting in the baby being born with significant difficulties.  The Committee first noted that the relationship of cause and effect in such circumstances may not always be clear cut.  In this case, evidence prior to the onset of labour might have suggested earlier problems.  Nevertheless, on specifically reviewing the information available regarding the physician’s response to the labour and the monitoring as it progressed, the Committee could find no point where it was clear that a different approach was appropriate.  In other words, no fault could be found with the care provided.

The patient attended her family physician believing she had developed a specific chronic illness which could affect her livelihood.  The family physician disagreed with the diagnosis.  Over several visits the disagreement persisted.  The patient requested a referral to a consultant which the physician refused to do.  Subsequently, the patient arranged a referral by her own means and had the diagnosis confirmed.  Her family physician was initially disparaging to that conclusion.  In response, the physician asserted that a referral was not made because a further investigation should have been done first.  While the Committee noted that there are situations where more complete investigations should be done before a referral is considered, patients have a basic right to another opinion when they request.  The physician was Counselled that such a fact should be recognized

A patient was seen by a surgeon in consultation.  After an examination, the surgeon determined that there was not an organic reason for the patient’s difficulties.  The patient subsequently claimed that the assessment was inadequate and unnecessarily painful.  A second consultant subsequently came to same conclusion.  In this case, the Committee determined that the surgeon’s assessment was appropriate.  The issue may have been how the possibility of a non-organic cause had been raised to such a patient.  It is unclear whether a different approach would have avoided a complaint in this matter.

A child was to be seen by a consultant.  Due to the child’s condition, a lengthy wait in the waiting room would be far from ideal.  However, after such a wait, the mother found out that the physician had been in the office doing personal things.  She felt this was inappropriate care.  In response, the physician noted the appointment was at a clinic where the physician did not directly employ the staff.  Due to miscommunication by the staff, the physician was not informed of the child’s arrival.  Physicians do have responsibility for the conduct of those working for them.  However, in this case, the physician had limited ability to influence the behavior involved.  The physician was encouraged to take whatever measures necessary to initiate change in procedure.

The patient was seen in consultation by a physician.  Both before and after the visit the patient noticed interactions between the physician and staff suggesting the physician was in a hurry to go elsewhere.  The patient alleged that the visit itself was unnecessarily brief with minimal examination.  The physician asserted that appropriate care had been provided.  In reviewing the matter, the Committee had some concerns over the quality of the assessment.  They also felt it appropriate to Counsel the physician on behavior which may be perceived by patients and lead them to believe the physician was not directing appropriate attention at the patient.

In a somewhat complicated matter, the Committee had to review the impact of a personal relationship between a physician and a patient.  In most circumstances, such is strictly forbidden and can result in significant penalties.  In this case, the physician and the complainant commenced a relationship before there was any professional contact.  There was no evidence of duress or coercion in how matters progressed.  At this point, the Committee felt these were individuals engaging in consensual activity.  The physician did see the patient on one occasion in a professional capacity, but for a minor matter.  The relationship ended shortly thereafter.  On that basis, the most the Committee noted it could be critical of the physician was for treating patients with whom they have a personal relationship, similar to the advice against treating family members.  However, due to some unusual factors in this manner, which cannot be disclosed, the physician would have known, as the relationship commenced, that there was a significant possibility that there could be a professional encounter at some point.  The Committee felt that the physician had been reckless in allowing a relationship to develop knowing this possibility.  Such circumstances can, and did, create additional difficulties for the patient.  For these reasons, recognizing the unusual situation, the Committee felt it appropriate to Caution the physician regarding the entire matter. 

A physician had been offering assistance to a couple with their plans to adopt a baby.  Eventually, a baby was found for the couple. Until the matter was finalized, the baby was under the care of another physician in the community.  Subsequently, with their own doctor, the family made an appointment for the child who had become ill.  The physician’s staff made the arrangements.  However, when the patient presented the physician became upset that he had not formally accepted the child as transferred from the other physician.  The family complained that the entire response was inappropriate and particularly so because some comments could be heard by others in the office.  The Committee could find no acceptable explanation for the physician’s behavior and issued a Caution regarding such.

While a physician was providing locum consulting services he was the subject of two complaints.  Both alleged inadequate assessments.  In one case, the patient had a significant problem which was diagnosed, but the physician failed to take immediate action on the matter.  In another case, the physician spent most of the visit reviewing records and then told the patient to return later for an examination.  The Committee could not find any acceptable reason for the approach taken in either matter and considered a Caution on both matters to be an appropriate outcome. 

Two complaints against a physician alleging an unnecessarily hostile approach to patients were referred to the Review Committee. 

Twenty-six complaints against a physician alleging professional misconduct were referred to a Board of Inquiry for a hearing.

Consultations  

Some years ago Council adopted guidelines dealing with the “Consultation/Referral” process, as well as “Preventing Follow-up Care Failures”.  Despite these guidelines, issues continue to arise regarding the communication between referring physicians and consultants.  This can create significant risks for patient safety, as well as potential legal risks for the physicians involved.  As a consequence, Council has determined to clarify the respective obligations of physicians in this matter. 

Physicians are encouraged to review the full guidelines on the College website.  More specifically the amended guideline on “Consultation/Referrals” requires consultants to acknowledge receipt of any consultation requests.  This should include information regarding the actual or expected appointment time as well as confirmation that the patient has been notified.  The guideline also expects the offices of both physicians involved to assist the patient with any inquiries regarding the status of the matter. 

In addition, the guideline on “Preventing Follow-Up Care Failures” has been amended to require that a physician who refers a matter to another health professional must have a system in place to track and ensure that a referral letter has been received by the consultant. 

Sample templates to assist with these processes will be available on the College website.

Annual Fees

Council has approved an increase in annual fees of $60.  This will result in a fee of $580 for those physicians who pay by pre-authorized debit and $600 for those who pay by cheque.  All other fees remain unchanged.  Invoices will be sent out in November.

Electronic Medical Records

At present, the College has no position on the format of physician’s records.  However, after many years of discussion, and much controversy about its actual implementation, Council now feels it appropriate to suggest that a comprehensive, functional, integrated electronic medical records system may eventually become the expected standard for appropriate medical care.  Such a point may yet be some time in the future, but Council urges physicians to consider such an eventuality in making their own decisions on this matter. 

Medical Directories

All physicians in New Brunswick now receive two copies of this directory.  The question arises as to whether there remains any value in continuing to offer a printed directory.  Some organizations have discontinued such in favor of online access only.  To that end, the College would appreciate hearing by any means from physicians with any view on the issue.  It would be particularly interesting to know whether, notwithstanding online access, there remains any value to a printed directory for physicians or their staff.  Such information will help determine whether directories will be published in the future. 

From The Archives

100 years ago

In 1914, Council began allowing physicians to make a single $20 payment, which would grant them licensure "in perpetuity" instead of paying the $1 annual registration fee. Council also approved increasing the Registrar's salary to $100 annually. There were 265 physicians registered. 

Seventy-five years ago

In 1939, Council determined to resist pressure from several communities which wished to recruit Jewish refugee physicians, decided that all new registrants would have to be born in Canada, and decided to take no action against a physician convicted of driving while intoxicated.

Fifty years ago

In 1964, Council agreed with the Medical Council of Canada to discontinue any questions in psychiatry as part of their examinations.  Council also became the first in Canada to acknowledge certified general practitioners in the directory, upon application and payment of a fee. 

Twenty-five years ago

In 1989, Council agreed to work towards requiring 24 months of postgraduate training. By 1992, agreed to work towards developing a Peer Review process, and determined to publish the names of all certified family physicians, without charge, in order to clarify that they were not specialists.