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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.

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Officers and Councillors 2008-2009

Council Update
At its meeting on 27 March, 2009, Council considered the following matters:

COMPLAINTS

A patient attended an Emergency Department several times with back pain.  He alleges that during those visits, the physicians failed to make a timely diagnosis of Cauda Equina Syndrome.  The patient subsequently required surgery, but suffered neurological sequelae.  In reviewing the matter, the Committee felt that the physicians involved had appropriately assessed the patient in terms of signs and symptoms which would have suggested the eventual pathology. 

A patient was referred to a consultant.  An investigation was ordered which, for a variety of reasons, was very difficult to schedule.  Eventually, the test was done and the patient was asked to come in for a return appointment.  However, the physician was away from the office for personal reasons.  This was not disclosed to the patient, who complained that the physician had been inattentive and failed to respond to her clinical situation.  In response, the physician noted that he had instructed his staff to provide no information regarding the reason for his absence.  In reviewing the matter, the Committee noted the increasing anxiety on the part of the patient relating to the previous scheduling difficulties, which were compounded with the inability to further discuss the matter with the physician.  Physicians are clearly entitled to privacy regarding their personal matters.  In this instance, it is possible that a minimal amount of information passed to the patient would have increased her understanding of the situation. 

In two unrelated complaints, the issue involved patients who moved from elsewhere.  Both patients had significant medical difficulties and a treatment plan with which their new physicians did not agree.  Under these circumstances, patients will often expect that the previous approach will simply continue.  However, while physicians are expected to give appropriate heed to the patient’s past treatment, they remain ultimately responsible for their own therapeutic decisions. 

In three separate complaints, there was an allegation that the patient was improperly discharged from a practice.  In reviewing each matter, it was clear to the Committee that the relationship between the patient and the physician had likely broken down beyond repair.  However, in all cases, the physician had not given the patient appropriate warning that they risked being discharged from the practice.  Physicians are reminded of the College guideline, which requires that, except in exceptional circumstances, there be communication between the physician and the patient regarding any difficulties which might result in the termination of the relationship.  Ideally this would be with a direct discussion, but in some circumstances, a letter may be sufficient.   The guideline is available on the College website or from the College office.

A patient was being followed by two consultants.  He complained that one consultant failed to provide appropriate ongoing information to his family physician.  In reviewing the matter, the Committee noted that the patient had an unusual presentation of a relatively rare condition.  This did create some uncertainty as to the best course of action.  Nevertheless, it was noted that all correspondence was copied to the family physician, who appeared to be appropriately apprised of the situation. 

The administration of a personal care home complained that a physician covering the Emergency Department had refused to accept the transfer of a patient who had fallen.  The physician asserted that, absent significant symptoms, the patient could be best monitored in her own environment.  The Committee agreed that this could be an appropriate response, but was unable to determine the precise role of the physician regarding patients in the personal care home.  In other words, it could not be clearly determined whether he had the authority to make orders regarding these patients.

A patient was in hospital for recovery from an injury.  Her own family physician was away and she was covered by his colleague.  The patient complained that, at no time during the admission was she attended by this physician.  In reviewing the matter, it was not clear that there were any specific medical reasons for the patient to be seen by the physician, but the Committee felt it was still necessary for the physician to meet the patient directly regarding discharge plans and other issues, if not on the basis of common courtesy.  Relying solely on interaction through the nursing staff may not always be sufficient.

Two separate complaints questioned a patient’s urgent access to their family physician’s practice.   In one case, the patient had been advised that, when circumstances warranted, she could attend the office without an appointment.  However, when she did so several times, this created difficulties for the staff.  In the second case, the patient made repeated demands for urgent appointments, which were usually met.  However, following another acute situation, the physician was not able to see her.  The patient felt this was inappropriate care.  While physicians want to respond to the needs of their patients, it is often necessary to set limits as to how such might occur.  In these cases, the initial ambiguity regarding the approach to take created further difficulties for all concerned.

A patient was to undergo a procedure.  She requested it be done under general anesthetic, but conscious sedation was used instead.  During this process, the patient became increasingly uncomfortable and attempted to have the procedure stopped.  In response, the physician felt that, all considered, the approach taken was the best for the patient.  The Committee noted that the physician had failed to consider the patient’s ongoing medications, which involved significant doses of both narcotics and benzodiazepines, thus modifying her response to the usual effects of the medication he used during the procedure. 

Following a work injury, a patient requested that a physician complete a form for the employer regarding specific limitations on her activity.  She alleged that the physician declined to provide the information and made disparaging comments regarding all workers employed by the same entity.  The Committee noted the difficulties involved in physicians being requested to provide specific information on which they may not feel able to comment.  Nevertheless, the Committee also noted that the physician’s comments to the patient could well create the impression that the physician was not responding to her specific clinical situation. 

In a follow-up visit to a consultant, the patient arrived, but evidently at the wrong clinic.  The consultant appeared very annoyed at this, as records and diagnostic studies were not available.  The patient questioned whether the physician provided an appropriately objective assessment in this context.  The Committee noted that the error regarding the appointment was not the fault of the patient.  While the physician may have felt some frustration at the situation, every effort should have been made to avoid any suggestion that the patient did not subsequently get an appropriate assessment.

 OTHER BUSINESS

In other business, Council:

• Reviewed the recommendations and follow-up to the recent inquiry on pathology services at the Miramichi Regional Health Authority.  Council determined to work with all parties to implement the recommendations. 

• Coincident with the pathology inquiry, reviewed ongoing discussions with the Department of Health regarding amendments to the Medical Act.  Once these have been approved by the Department, copies of the proposals will be available to the members on request.  It is expected the amendments will be introduced later in the year.

• Gave final approval to the previous draft on “Closing a Practice”.  A copy of the guideline is available on the College website or by contacting the College office.

• Considered tentative proposals to license Physician Assistants under the Medical Act.  Council determined to work with all parties once the decision is made to go ahead with this initiative. 

• Reviewed recent policies on criminal records checks.  All applicants are subject to such.  Available Canadian resources allow a search for individuals who have been convicted of an indictable offense.  In addition, applicants from outside Canada are checked with Interpol. 

•  Reviewed recent financial statements, showing the College suffered an expected loss of approximately $400,000 in 2008.  College reserves now appear to be sufficient to cover one year’s operating costs.
  
  

 FROM THE ARCHIVES

One hundred years ago

In 1909, the Council determined that they did not want to be considered a “College”, as was the case in other provinces, and expressed concern that a new Medical Act would allow the practice of osteopathy.

Seventy-five years ago

In 1934, Council continued to refuse to consider registration of Jewish refugees from Germany.  They also continued an ongoing dispute with Dalhousie University regarding the necessity of licensing medical students.

 Fifty years ago

In 1959, Council set up its first Specialists Register, including provisions which allowed registration of physicians without certification who graduated before 1945.  Council also determined to increase the annual fees, with $57 going to the Medical Society and $8 to the Council.  The Registrar’s salary was increased to $2400 per year.

Twenty-five years ago

In 1984, Council noted the first federal and provincial initiatives at controlling physician numbers, affirmed a requirement that all specialists undergo a rotating internship and began to consider the possibility of a full-time registrar.  There were 882 physicians licensed.