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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.

 
At its meetings on 31 March and 23 June, 2017, 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. 

A patient was referred to a consultant for investigation of fatigue. She alleged that the consultant failed to provide a complete assessment. In response, the physician asserted that there were many possible causes for persistent fatigue and he had only investigated the matter within his sphere of expertise. Those investigations were negative. In reviewing the matter, the Committee could find no fault with the care provided. The Committee noted that the patient appeared to have high expectations for the benefit of the referral in question.

A physician became upset with a nurse regarding an equipment issue at a specialty clinic. He continued to berate that nurse, and another, in a loud and hostile way. The episode was heard by many individuals, including a group of high school students. In response, the physician acknowledged and apologized for the inappropriate behavior. Nevertheless, the Committee felt that the episode was so extreme, and could present a risk to patient care, that a Censure was in order.

A physician hired a new assistant who was, unfortunately, involved in complicated interpersonal relationships with some of the physician’s patients. It was alleged that the physician was denying access to some of these patients as a consequence. In reviewing the matter, the Committee noted that the behavior of all involved had become increasingly hostile and threatening. The Committee did not feel the physician had any choice for his own safety, and that of his staff, than to deny further access to certain individuals.

A patient underwent major surgery and suffered a significant complication. It was alleged that the surgery was performed improperly. The surgeon asserted that, following appropriate informed consent, and considerable discussion, he proceeded with the surgery, but the patient suffered an unfortunate complication, resulting in long-term disability. In reviewing the matter, the Committee could find no evidence that the surgery was performed improperly or that informed consent was not obtained.

A patient underwent a procedure which she alleged caused her significant pain. She further alleged that the physician appeared to be indifferent to her discomfort. The physician responded that he had followed appropriate standard procedures regarding sedation and anesthesia and had been unaware that the patient was having any difficulty. While the Committee agreed that there were no deficiencies in the specific care provided, it felt that the physician should have made an effort to be more aware of any difficulties which may be arising.

A patient had a consultation for elective surgery and was waiting for information regarding the booking. Several months went by without information. Attempts to clarify the situation through the physician’s office were unsuccessful. In response, the physician asserted that booking difficulties with the hospital created some uncertainty. The Committee, nevertheless, felt that the office staff, for whom the physician is responsible, should have been able to provide clearer information to the patient. The Committee felt a Counsel was warranted.

A patient was seen by a family physician for a number of health issues. However, the patient subsequently developed lung cancer and died very quickly. The patient’s wife alleged the physician had failed to provide proper care for her husband in failing to reach the diagnosis earlier. In reviewing the matter, the Committee noted that a number of physicians had been involved in the patient’s care and there had been no symptoms warranting more investigation than had already been conducted. From all the information available, it appeared that the cancer had appeared and progressed very quickly, likely precluding a diagnosis much earlier than had occurred.

A patient underwent a procedure which did not produce satisfactory results in her opinion. She alleged that she had consented to a completely different procedure than the one performed. In reviewing the matter, the Committee noted that all documentation at the hospital and in the physician’s notes made it clear that the patient was not misled as to what procedure was being done. Nevertheless, the Committee did note that the physician had not produced an operative report until receiving the complaint. This was approximately a year and a half after the procedure. The Committee felt that this lack of proper documentation warranted a Caution.

A physician followed a patient for a number of months for a particular problem. An initial attempt at a diagnostic procedure was unsuccessful. Nevertheless, this was not repeated for a further four months. By that time, it was clear the patient had a significant life threatening issue which the physician had failed to diagnose in a timely fashion. The Committee felt a Censure was warranted.

A patient stopped in to see his physician during an afternoon when patients were allowed to do so. Nevertheless, the physician had instructed his staff that he did not wish to see this patient due to a dispute regarding a prescription. This was explained to the patient in front of the rest of the waiting room. In response, the physician discussed the difficulties regarding the prescription and his wish to avoid a confrontation. The Committee, nevertheless, felt that instead of addressing the issue so publicly, the patient should have been offered another appointment so the physician could deal with the patient directly and privately.

A complaint was received similar to several which have arisen in recent years. The circumstance involves the physician becoming ill, leaving a practice for a period of time. Because there is uncertainty up until this point, patients have usually not taken significant action regarding seeking alternative care. After some absence, the physician determined that a return to practice was not possible, unfortunately, then creating some difficulties for the patients. The burden of closing a practice, including dealing with notifying patients and dealing with charts, can be significant when personal issues are overwhelming. In many ways, the circumstance cannot be avoided. The only suggestion may be to inform patients by whatever means possible, including the possibility of social media, regarding issues which may be relevant. 

 Opioids

In follow-up to the guideline sent out last year, some physicians have taken initiatives regarding patients who they feel are receiving excessive opioids.  In many cases, these patients were inherited from another physician.  Physicians are reminded that the fairly strict limits suggested by the guidelines are to be considered a goal to be pursued once the Prescription Monitoring Program is fully functional.  On their own, they should not cause a physician to arbitrarily initiate changes in a patient’s treatment.  This is not to obviate from the physician’s ongoing obligation to pursue harm reduction strategies when appropriate for a particular patient.  In any case, the first initiative of the Program will pay particular attention to initial prescriptions for opioids.  In other words, is the initial choice and duration of opioid therapy for a particular problem appropriate?

 Telephone Access

The inability of patients to access many physicians’ offices by telephone remains an ongoing problem.  Evidence is strong that a majority of calls to some offices likely are unanswered.  There are many reasons for this.  To assist physicians, the New Brunswick Medical Society has prepared management advice on this specific issue.  Physicians are encouraged to review such and make changes as appropriate to their office processes.