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 2014-2015

Council Update
At its meetings on 28 November, 2014, Council considered the following matters:

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. 

COMPLAINTS

There were two unrelated complaints relating to failure to diagnose in the Emergency Department.  In the first case, the patient was brought in by ambulance after collapsing, and complaining about a sore hip.  The physician immediately assumed the patient was drug seeking, did a minimal assessment, and sent the patient away.  The patient subsequently was determined to have a fractured hip.  The Committee concluded that the assessment of both the reason for the fall, as well as the source of the pain, was minimal and issued a Caution.

In another case, it was alleged that the physician failed to make a diagnosis of intussusception in a child.  The child was subsequently seen at another hospital where the diagnosis was made.  The Committee could find no fault with the care provided by the initial physician.  The child did not have any of the typical symptoms or signs.  The child did not appear uncomfortable, there was no blood in the stool, and there was no mass on examination.  At the second hospital the findings were the same, but an x-ray had suggested a bowel obstruction, which had pointed the second physician in the appropriate direction.

Three unrelated complaints arose as the result of initial comments made to patients when seen at after-hours clinics.  In the first case, the patient, who arrived with depressive symptoms likely secondary to benzodiazepines, was immediately advised that she should not have come to the clinic.  The physician asserted that such a clinic had no obligation to provide her with care.  While the subsequent outcome of the encounter did meet the patient’s needs, it was felt appropriate to issue a Counsel to the physician regarding the notion that there was less obligation to assess a patient in the setting of an after-hours or walk-in clinic. 

In a second complaint, a mother was advised by the physician that the clinic preferred not to see young children.  The mother immediately concluded that any subsequent assessment would be insufficient.  The Committee could find no reason that a child with conjunctivitis could not be seen in such a clinic and issued a Counsel to the physician for his unhelpful remarks.

Finally, an infant with a fever was seen in a clinic.  The physician began by admonishing the mother for failure to treat the fever adequately, even before any assessment of the patient was done.  While the rest of the encounter was appropriate, the Committee felt, again, that such comments will not contribute to the reassurance that a parent will be seeking when they bring a child for such an assessment. 

An older child, but with special needs, was brought by her mother to the Emergency Department.  She had been seen in two other centres over the previous days with an undiagnosed fever.  At the very beginning of the encounter with

the Emergency physician, he admonished the mother for seeking a further opinion regarding her child.  He asserted it would be unlikely that he would find anything after she had already been seen elsewhere.  The Committee felt that the subsequent assessment was appropriate and the child was discharged.  The child was later admitted to a regional centre for a period of time.  The Committee felt that a Counsel was appropriate regarding the unnecessary remarks which could only help to undermine any opinion the physician subsequently gave.  The approach failed to acknowledge that, in many patients, infections can progress and any subsequent assessment may come to a different conclusion than an earlier one.

A pregnant patient was seen by a new family physician who had raised the question of a possible herpes infection.  Without knowing that the diagnosis was definite, the physician raised issues regarding the impact on the delivery of the baby, as well as questions regarding the faithfulness of the patient’s partner.  The entire encounter caused considerable distress to the patient.  The diagnosis was subsequently not confirmed.  In response, the physician acknowledged that she had handled the matter poorly and caused unnecessary distress to the patient.  The Committee determined to take no further action on the matter.

An elderly patient developed pancreatitis, a known complication to a procedure.  She alleged that the complication should not have occurred and that the subsequent management was inappropriate.  In response, the physician asserted that there had been fully informed consent and any subsequent management was appropriate.  However, he noted that there were significant language difficulties and all communication was through an interpreter.  The Committee could only note the importance of adequate informed consent and the particular challenges that are faced when dealing with a language issue.  All that physicians can do is to make all reasonable efforts to make sure that all communication with the patient is as well understood as possible. 

A physician was subject to a Counsel regarding the adequacy of informed consent.  The patient suffered a complication as the result of a procedure, on her eye.  The physician asserted that there had been appropriate informed consent following a lengthy discussion about possible treatment options.  However, such discussion occurred immediately prior to the procedure, rather than at an earlier appointment.  The Committee felt that this was not an appropriate situation for the patient to understand complex information in order to make such decisions.

A patient complained regarding the accuracy of the diagnosis of schizophrenia made eight years previously.  He alleged that the diagnosis was incorrect and it had adversely affected his subsequent care.  In reviewing the matter, the Committee noted the patient had initially presented with complicated symptoms and the physician had come to a tentative diagnosis after consultation with colleagues.  The Committee could find no fault with the care provided at that point.  It was felt that the patient’s current mental state had unnecessarily focused him on past events.

A patient had an intrauterine contraceptive device inserted which subsequently perforated the uterus and migrated into the pelvis.  She acknowledges that she had been given appropriate warning regarding this complication, but, nevertheless, complained regarding the physician’s response.  In reviewing the matter, the Committee, so far as they could determine, noted that the physician had responded appropriately to the clinical situation, although some investigations took longer to arrange than ideal.  The Committee could not determine exactly how the matter had been discussed between the patient and the physician, and consequently, did not feel it could comment further on the matter.

Upon recommendation of the Committee, Council referred 23 complaints against Dr. Alan Cockeram, of Saint John, to a Board of Inquiry.  Council also accepted the recommendation to take no further action on three other complaints.

 Medical Directories

In the last Bulletin members were requested to comment on the need to continue to print the Medical Directory.  The responses to the inquiry were very mixed with some physicians wishing to continue with the Directory and others happy to rely on the online Directory.  As a consequence, Council has determined to continue to print the directory, but will attempt to respond to each physician’s interest in continuing to receive such.  Normally, physicians who are residents of New Brunswick receive two such copies, while those who reside elsewhere, or are retired, receive one.  The College office will attempt to accommodate those who wish to receive less than the allotted number.  A note by email or fax to request a change would be appreciated.

Lyme Disease

From time to time in the media, the allegation arises that physicians in New Brunswick are failing to appropriately treat Lyme disease.  Such concerns have been raised for at least ten years.  Patients, based on highly questionable serology done elsewhere, have insisted they have a chronic form of the disease, which requires aggressive long-term antibiotic therapy.  They often then request such from their local physician.  The best Council can do is to remind physicians that they are expected to follow prevailing guidelines on Lyme disease, which are available from infectious disease and public health authorities.  The diagnosis is made either with the demonstration of specific symptoms or with accepted serology.  On that basis, Council is unaware of any patient with proven Lyme disease who has failed to find appropriate treatment in New Brunswick.  Regarding the issue of pressure from patients for New Brunswick physician to follow treatment recommendations based on improper serology, physicians are reminded that they should only provide treatment which they are convinced is in the patient’s best interest.  There is never any obligation to do otherwise.

Annual Renewals 

By now, all physicians should have received their combined invoice for their annual fees and those of their professional corporation, where applicable.  Physicians should contact the College immediately if such has not been received.  Physicians should also contact the office by email or fax if there has been a change in their banking information or their contact information.

Narcotics

There has been much media and political commentary more recently regarding excessive prescribing of narcotics by physicians.  The attached graphs, reproduced courtesy of Canadian Family Physician [See Gomes, T. et al Trends in high-dose opiod prescribing in Canada Can Fam Physician 2014; 60:826-32] show a wide variation in narcotic prescribing across Canada.  It has been noted that some provinces have initiated prescription monitoring plans, restrictions on prescribing or, restrictions on coverage.  None of these initiatives appear to have really influenced prescribing rates.  The issue appears to come down to the physician’s behavior.  While the rate in New Brunswick is close to the national average, it is still much higher than other provinces.  There is a growing consensus that such trends must be reversed.  While this will likely be a lengthy process with no clear solutions in sight, Council would like to invite members to provide any thoughts or ideas they may have on the issue.