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 June 15^th and September 28^th, 2018, 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 physician performed a diagnostic test and provided the patient with a diagnosis which could require an intervention. However, when the test was repeated, both locally and at a major referral centre, there was no evidence of this condition. Nevertheless, the physician persisted with his view causing unnecessary stress according to the patient. The Committee noted that there were possible explanations for the different results and felt the physician could have been more informative to the patient of the reasons for such. The Committee did not feel it was appropriate to insist on a diagnosis which could not be generally supported.

A pregnant patient alleged that her physician had failed to provide a timely report regarding a result from prenatal screening. It was noted that the situation was complicated by the fact that part of the testing was done in another province. Furthermore, the physician had been on vacation, which was unexpectedly extended for personal reasons. The physician had made arrangements for most, but not all, laboratory results to be reviewed by a colleague. The Committee acknowledged that some of the issues were beyond the physician’s control, but it was felt appropriate to issue a Counsel regarding the importance of having a system in place, during absences, to avoid any significant results being missed.

A patient raised a number of issues regarding a family physician. She objected to his approach to scheduling, which often had patients arriving when he did not intend to be in the office. She also had concerns regarding his approach to an appointment where he provided her with a significant diagnosis, without additional information.

Regarding the latter aspect, the Committee did note that providing a patient with a diagnosis, such as a malignancy, can be fraught with difficulties. A physician is often not able to provide any additional information. The Committee was concerned about the physician’s approach with scheduling and recommended that the physician access the advice provided by the New Brunswick Medical Society to assist physicians with avoiding difficulties in this area.

A family complained regarding a physician’s management of an elderly patient with dementia. They alleged the physician asserted that the patient’s condition was declining quickly, but failed to remove the patient’s driving privileges. In response, the physician noted that most of the decisions regarding the patient’s care were actually made by others. He did acknowledge, in hindsight, that he should have acted on the patient’s driver’s license sooner. In reviewing the matter, the Committee noted that the family did not seem to have clear insight as to the difficulties this patient was having. There was an ongoing dispute with the physician, and others, regarding the patient’s true status. In any case, the Committee did note that the physician was obligated to report this patient regarding his driving privileges, and issued a Counsel in that regard.

A patient attended a student health clinic seeking a refill of an antidepressant prescription. She objected to the questions that the physician raised regarding her background and other stresses related to her studies. The physician responded that simply renewing the prescription would not have been appropriate. He felt it was necessary to review all stressors which the patient might be subject to. In reviewing the matter, it was clear to the Committee that the patient was quite sensitive regarding the discussion of certain aspects. The Committee felt that the physician had acted appropriately in assessing her condition in a broader context. Ideally, such should be done in a way which minimizes any discomfort for the patient. Beyond stating such, the Committee could find no fault with the care provided.

A patient had a chronic, but rare, condition and was managed by a local specialist. The family claimed they had requested a referral to another centre several times, but this was rejected. When the patient subsequently was referred, he died suddenly of an unrelated cause. The family alleged that the initial treatment, and failure to refer, caused the patient harm. In reviewing the matter, it seemed unlikely that the course of events could have been any different. The patient’s death was unpredictable and not clearly related to the chronic issue. The physician responded that the patient himself had made no request for a referral. In any case, the local physician was in contact with the distant consultants. The Committee could find no fault with the care provided.

A patient with dementia fell twice over the course of two weeks and was seen by the same Emergency physician on each occasion. The family alleged that his assessment was inadequate and he was resistant to admitting the patient. Upon reviewing the response of the physician, and the available records, the Committee could find no evidence that the assessment was insufficient. The Committee felt there were communication difficulties between the family and the physician, but the Committee felt no further action need to be taken.

A patient attended an after-hours clinic. It was alleged that the assessment by the physician was insufficient. In reviewing the matter, it was noted that the patient’s entrance complaint was somewhat unclear, but possibly a sore ear. The physician asserted that he assessed the patient appropriately and made a referral. In reviewing the matter, the Committee could not find any specific fault with the care provided except that the patient was significantly unsatisfied with the encounter. The physician appeared to have become frustrated with the patient as a historian. The Committee felt that he could have made a greater effort to clarify her issues and guide her accordingly. The Committee felt a Counsel was appropriate.

It was alleged that a physician was charging patients directly for medical assessments even though such were covered by a government program. In response, the physician asserted that these were errors on the part of his staff. In reviewing the matter, the Committee was skeptical that such should occur given the nature of the process. It was inappropriate to charge patients directly when the physician was otherwise being appropriately compensated. A Caution was considered appropriate.

A patient,in a terminal state, was being cared for in hospital by his local physician. His family was pressing that he be transferred to another centre for care by a specialist. They went so far as to arrange this independently of the local physician who expressed some dissatisfaction with the process. She felt it inappropriate that a transfer was made without her involvement. She further asserted that the patient himself, as opposed to his family, did not wish such a transfer to take place. In reviewing the matter, the Committee noted the stresses that are placed on families in such circumstances and the potential for miscommunication to be high. They did not feel that further action was necessary.

A patient attended the Emergency Department with complications of a surgical procedure from some days earlier. He was referred to the appropriate surgeon who, because the original procedure was not done locally, declined to provide any assistance to the patient. It was alleged by the family physician, who had done the original procedure, and sought the referral, that the surgeon was unnecessarily abusive in the discussion. In reviewing the matter, the Committee could find no justification for refusing to assist the patient simply because the original procedure was done in another location. Regardless of how the patient arrived at the hospital, the surgeon was obligated to offer such assistance as appropriate unless the patient wished otherwise. Furthermore, to belittle the referring physician in an unprofessional way was similarly unacceptable. The Committee felt that a Censure was the appropriate response.

A patient attended the Emergency Department with abdominal pain. He had symptoms which were not specific. The assessment by the Emergency physician did not suggest a specific cause. Two weeks later, the patient was seen again and this time diagnosed with gallstones. It was alleged that the initial assessment was independent. In reviewing the matter, the Committee could find no objective evidence that the initial assessment was insufficient. The course of the patient’s disease had evidently not progressed to the point where a clear diagnosis could be made.

A young patient suicided. The family alleged that a mental health assessment done the previous year was insufficient to detect the risks to this patient. In response, the physician noted that the process was designed to screen for significant problems and was not meant to be a comprehensive assessment. In reviewing the matter, the Committee wondered if the physician could come to any conclusions based on the rather limited assessment which he undertook. There were hints of significant issues which were not noted in the course of this assessment. The Committee felt that a Caution was appropriate in this circumstance. The Committee did not feel there was any evidence of cause and effect between the physician’s assessment and the patient’s ultimate suicide.

A patient needed a refill on medication prior to some travel. She attempted to arrange this through her family physician, but the office was persistently closed at the time in question. When the office reopened, she called back and made comments to the staff following which the physician called her back and an angry discussion followed. In response, the physician noted that he was called away on a family matter unexpectedly and, upon return, was in the process of dealing with matters that had arisen. He regretted the direct communication with the patient, as the discussion could have occurred at another point. In reviewing the matter, the Committee did note that the patient had somewhat created difficulties for herself by delaying accessing a refill. The situation was further aggravated by the absence of any communication from the physician’s office while he was away. There was no one in attendance and no message available regarding his absence. The Committee felt this could have been handled better, but did not feel further comment need be made.

A very elderly patient presented with unusual abdominal and chest pain. The initial assessment by the physician did not point to any particular factor. He read the ECG as negative and noted the troponin level increase from 8 to 40 over the course of two hours. The patient was sent home and returned the next day with similar symptoms, but now with a troponin level of 42,000. The family alleges that that physician should have responded to the rising level and recognize such as evidence of cardiac disease. In reviewing the matter, the Committee noted a range of opinions on the basic issue as to what level would warrant further action in this type of patient. In some views, any doubling of the troponin level could be an indicator. In others, especially with elderly patients, this standard could result in false positives. In the end, the Committee did not feel they could comment further on the matter.

An elderly patient fell at home and suffered significant head trauma including both swelling and bleeding in the brain. He was admitted for observation with an uncertain prognosis. At that time, the family expressed the patient’s previous stated wishes regarding resuscitation. The physician ordered a level for such which allowed medication, fluids, and feeding if necessary. Subsequently, when the family was absent, a feeding tube was inserted. They were adamant that they did not authorize such, but the physician felt that they had. This was as noted in the record. He also noted that the order for the feeding tube was, in fact, provided by a colleague over a weekend. The Committee felt that there appeared to be uncertainty regarding the resuscitation status and which measures would be allowed on the part of the family. This created the situation where the family had to deliberately choose to have the tube removed which resulted in the patient’s demise within a few days. It was felt appropriate to Counsel the physician to clarify as much as possible what would be the response to any particular situation.

Other Business

• Among other issues Council considered the following matters:
• Progress on the Prescription Monitoring Program. Physicians are reminded to obtain access to the provincial Electronic Health Record if they wish to prescribe monitored drugs.
• Reviewed proposed revisions to the Canadian Medical Association Code of Ethics and determined to defer the consideration of adoption of such.
• Confirmed no change in licensing fees for 2018-2019.
• Confirmed that future applications for licensure in New Brunswick will be through the national application process, Physiciansapply.ca
• Reviewed pending legal action against a number of Naturopaths for alleged misleading advertising.
• Confirmed the following as Executive for 2018-2019: