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
President - Dr. Lachelle V. Noftall, Fredericton
Vice-President - Dr. Lisa Sutherland, Rothesay
Dr. Eric J.Y. Basque, Pointe-des-Robichaud
Dr. Stephen R. Bent, Miramichi
Dr. Zeljko Bolesnikov, Fredericton
Dr. Robert J. Fisher, Hampton
Mr. Donald Higgins, Rothesay
Mr. Paul Leger, Rothesay
Mr. Edward L.D. McLean, Saint John
Dr. Marcel Mallet, Moncton
Registrar - Dr. Ed Schollenberg
Dr. Nicole Matthews, Campbellton
Dr. Mamoun Meddoun, Edmundston
Ms. Patricia l. O'Dell, Riverview
Dr. Stéphane Paulin, Fredericton
Dr. Susan E. Skanes, Dieppe
Dr. James Stephenson, Saint John
Dr. Julie Whalen, Moncton
At its meeting of 4 April, 2014, Council considered the following matters.
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.
In two separate complaints, elderly patients were sent home from the Emergency Department only to each return at least twice before they were admitted. By then they developed significant symptoms. It was alleged that the initial assessments were incomplete. These matters always turn on the specific facts. Sometimes, as in one of these complaints, it is noted that a patient had been sent home before a particular lab result had been received. This could call into question the physician’s decision. At other times, patients are often demonstrating only the initial appearance of significant pathology. As always, care to appropriately document decision making can be critical in assessing the matter later.
A patient had a procedure, which resulted in significant ongoing complications, requiring further intervention. On attending another surgeon, he was advised that he had had a previously noted “carcinoma”. He alleged the initial surgeon had failed to advise him of this. In response, the surgeon stated that he thought he had made that comment, but was unsure. In any case, it was generally agreed that the finding was insignificant from a clinical point of view. However, the Committee noted that, regardless of the significance, this is the kind of information which patients will likely want to know. Such findings, even if not determinative of the clinical course, should be disclosed to the patient.
Following an injury, a patient underwent a procedure some years later. The results were almost immediately unsatisfactory and she complained about a significant amount of pain. She revisited the surgeon several times without satisfaction. In the end, she eventually sought the assistance of her family physician who determined that, during the course of the original procedure, the patient had suffered a major complication. In reviewing the matter, and based on the surgeon’s own response, it was clear that the communication with the patient had been minimal. She was not advised as to what procedure she had had. Any attempts at attention for the complication were dismissed. The Committee felt it appropriate to warn the physician, through a formal Caution, on the importance of sharing information with patients.
A patient was undergoing minor surgery and had antiplatelet therapy discontinued for a short period of time. Following this, she immediately suffered a significant thromboembolic event. It was alleged that the Plavix had not been appropriately managed. In reviewing the matter with a number of experts, it became clear that there was a wide range of approaches to the issue for essentially the same surgery. In some cases, there was no interruption in therapy, in some cases it was briefer, and in some cases it was longer. In that light, the Committee did not feel it could be critical of the physician for taking any particular approach. However, physicians in similar situations are expected to follow the latest and prevailing guidelines regarding anticoagulation therapy during surgery.
A family physician complained a consultant was not treating a referred patient appropriately. There was a disagreement regarding the benefits of a particular therapy for this particular patient. Without the consultant’s approval, the therapy was not available except at another centre. The Committee acknowledged the general right of any physician to decline to provideany therapy which is not believed in the patient’s best interest. In addition, physicians are expected to acknowledge opinions from colleagues and consider their approach in that light. Without determining the merits of the argument in question, the Committee felt this matter is best approached on the basis of informed consent with the patient or their family.
There was a complaint that an infant was injured from an immunization that was given by a non-professional employee of a physician. The physician asserted that the employee had been appropriately trained and untoward events can always occur. In reviewing the matter, the Committee noted that immunizations and other injections can be given by non-professional staff. However, the physician must take complete responsibility for their training and be able to assert that they have the appropriate competence to provide that service.
As most physicians know, there are significant changes to the process by which patients can access medical marijuana. These came into effect April 1st, 2014. There has also been significant confusion about the impact on physicians when patients request prescriptions for such. Council expects that this process will take some time for physicians to become familiar with in terms of the drug itself and the procedures for prescribing it. As a very initial step, Council has adopted the attached guideline, which will hopefully give physicians some background on the matter. A significant provision of this is that any such prescribing should either be done by the patient’s own physician or one to whom they have been referred. It is inappropriate for such prescribing to be done by a physician otherwise not involved in the patient’s care. This includes entities which will provide this service from out of province. If a physician becomes aware that a patient has accessed such a service, they should contact the College office. In any case, this guideline should be, in many ways, considered preliminary. As matters clarify, further amendments are likely.
Physicians have received guidance from many sources on the issue of informed consent. These have tended to be focused on discussing the legal requirements such as which facts or concerns must be raised with which patient and in what circumstance. Council has chosen to adopt a guideline recently developed by medical regulators in Maine which articulate this process in a different way. Such is enclosed for your interest.
Telephone Access to Physicians
Patients often complain that they find it difficult to access their physician’s office by telephone. The phenomenon is hard to explain. Practice sizes appear to be much smaller than they were in years past, but telephone access appears to be more difficult. There are, of course, a wide range of reasons for this. Nevertheless, the fact is that many patients may find it almost impossible to telephone their family physician for an appointment. This is likely in no one’s best interest. For that reason, Council would appreciate hearing any ideas from physicians regarding approaches they have adopted which appear to make such communication easier.
In recent months, Council has become aware of a variety of situations regarding members. These included questions of impairment, questions of competence, and questions of unprofessional behavior. In none of these situations was the College advised as required under the Medical Act as follows:
52.3(1) If a member or associate member has information concerning another member, associate member, or former member, from whatever source which suggests, if the information is true, that the other member, associate member, or former member, may be guilty of professional misconduct under this Act or the regulations, or may be incapacitated or unfit to practise under this Act or the regulations, the member or associate member shall report such information to the Registrar without delay.
Further discussion on this will be forwarded to the Regional Health Authorities shortly. Nevertheless, by brief explanation, it should be noted that this provision applies to all physicians, residents, and medical students, without exception. It refers to knowledge which comes to the physician’s attention by whatever means. Furthermore, it does not require that any of the facts alleged have been proven, but only that an allegation has been raised. It should also be noted that any such reports which are provided to the College remain anonymous. They themselves do not initiate an investigation without further information.
A more detailed discussion of this issue is provided in the guideline available on the College website.