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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 2015-2016

Council Update

At its meetings on 2 October and 27 November, 2015, 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, prescribing methadone to a patient, became aware that another physician had seen the patient and issued a yearlong prescription for narcotics.  After contact with the first physician, the second physician did not cancel the prescription, but determined to continue to provide the prescription on a monthly basis.  On inquiry, it was clear that the physician had been misled by the patient regarding her past medical history.  In the Committee’s view, the prescribing of narcotics by this physician was reckless and dangerous.  To continue the medication even when certain facts became clear was completely inappropriate and warranted a Censure. 

A pharmacist in another province complained about the behaviour of a physician licensed in New Brunswick who attended the pharmacy along with a friend.  The physician wished the pharmacist to fill a prescription for sedatives and hypnotics for the friend.  The physician from New Brunswick provided no satisfactory identification and the pharmacist resisted accepting the prescription.  It was alleged the physician became abusive.  In reviewing this matter, the Committee felt the approach of the physician was quite improper in prescribing for an individual who was not her patient and then reacting inappropriately when the pharmacist questioned such.  The Committee felt the behaviour warranted a Caution. 

A patient complained that, on attending a physician’s office, children were present in the staff area and were assisting in directing patients, along with their charts.  The patient was concerned regarding the privacy implications.  The physician asserted that the children were relatives who were visiting and did not have any direct contact with any patient information.  In reviewing the matter, the Committee felt that, generally speaking, it would be unwise to have children present in that context.  If they were there at all, any involvement should be with expressed consent of patients. 

A patient died of what proved to be hypercalcemia secondary to a parathyroid adenoma.  The family complained that the family physician and treating urologist should have made the diagnosis earlier.  In reviewing the matter, the Committee noted that the patient had a wide range of symptoms, not easily related to this issue.  In reviewing the overall picture, the Committee could not fault the physicians involved for the care provided.

A premature baby, very recently discharged from hospital, developed an upper respiratory illness, as well as some feeding difficulties.  After a few days, the parents took the child to three different physicians who all reassured them that this was likely an insignificant illness.  The baby was subsequently seen by a pediatrician and transferred to a tertiary centre for a significant respiratory infection.  The Committee felt it appropriate to Counsel all three physicians regarding the danger in assuming an illness is benign in a patient at this age, especially if they were

premature.  While the actual assessments performed by the physicians were acceptable, they failed to realize that, at this age, even significant illnesses may present with minimal signs and symptoms.

A patient complained that the initial examination by the physician missed a significant injury to his eye.  It was subsequently determined that the patient had a foreign body penetration of the eye, which later becoming infected, requiring extensive surgery.  The physician appeared to have done an appropriate assessment, the history did not suggest a high velocity metal impact, and the matter had been discussed with an ophthalmologist.  On that basis, the Committee could find no fault with the care provided.

A patient was admitted for an injury which could have required potential surgery.  Such ultimately proved unnecessary.  Nevertheless, during her course in hospital, she suffered several episodes of respiratory failure likely secondary to a combination of medication and longstanding lung disease.  She eventually was transferred to intensive care.  The family alleged that the care provided by the attending surgeon had been inadequate.  On reviewing the matter, the Committee did note that the surgeon had consulted medical specialists, but had not made an effort to transfer the patient to a medical colleague or even to a medical ward.  It had become clear that surgical treatment was not necessary, but the patient continued to deteriorate.  The surgeon must accept responsibility for the developing clinical course, regardless of his own expertise.  The patient should have been transferred earlier rather than later.  The Committee felt a Counsel was an appropriate comment.

A patient was referred to a surgeon for cancer surgery.  During the course of the investigation, it was determined that she had a second, unrelated, tumor.  Due to underlying medical illness, she had two separate procedures separated by recovery time, assessment by a medical consultant, and other investigations.  By the time of second surgery, on the original lesion, a year had passed.  Results had shown that her prognosis had significantly deteriorated during that time.  The surgeon responded that the patient’s course was unusually complicated.  The investigations before surgery had actually not been consistent with the eventual surgical findings.  On reviewing the matter with an expert, the Committee agreed that the case was indeed complicated and that the surgeon had made appropriate clinical decisions throughout the course.  Nevertheless, the Committee was left to wonder as to whether some of the delays which had crept into the sequence could have been avoided by anticipating the length of time needed to arrange consultations and investigations.

A patient relocated from another province and, on the first visit with the physician, insisted that he be prescribed medical marijuana, as he had been previously.  He complained the physician refused to do such.  In response, the physician asserted that, without any background information, it would be improper for him to simply continue such.  The Committee agreed with him and found no fault with the care provided.

A patient, with a previous work injury, attended a walk-in clinic due to an acute exacerbation. He was told that the physician would not see him because the original problem had been work based.  In response, the physician asserted that she was not provided with that information, but only told that the patient wanted a form completed.  In reviewing the matter, the Committee noted communication gaps between the patient, the receptionist, and the physician.  On that basis, the Committee could not fault the physician for the care provided.

A physician discharged, without warning, a couple due to the lengthy numerous medical complaints one of them provided during the course of a visit.  The physician acknowledged that she had become frustrated with the patient who never seemed satisfied with the service she, or anyone else, provided.  She, consequently, suggested the patients go elsewhere.  On reviewing the matter, the Committee noted that, for neither patient, had the physician provided appropriate warning to terminate the care.  This violated the College guideline on the matter.  Furthermore, there appeared to have been no issues at all regarding one spouse, and consequently, no reason at all to consider discharging him from the practice.  The Committee felt that the approach taken warranted a Caution.

A patient was seen with a cough in an after-hours clinic.  After a very brief assessment, the physician advised that she had chronic lung disease and prescribed a variety of medications to treat such.  Further investigation by her family doctor and others suggested this was not the case.  The Committee felt that a physician, seeing a patient for the first time, with minimal past history, should be more careful about jumping to such a conclusion.  The physician was Counselled to take more appropriate care in future encounters.

A patient had significant medical issues, as well as depression.  She had significant difficulties with insomnia, and was eventually assessed for the possibility of a sleep study.  Such was felt to unlikely to be of benefit absent any history suggesting obstructive sleep apnea.  Somewhat later the patient’s symptoms persisted and an attempt was made to get her another referral from her family physician, as well as a medical consultant.  There was a complaint that such should have been arranged without hesitation.  The Committee noted, based on the patient’s actual symptoms, as well as her previous assessment, there was little likelihood that a formal sleep study would have assisted with her management.

Review Committee
The Review Committee reviewed three complaints against a specific physician.  In the first, the patient attended the Emergency Department in order to specifically see her own physician.  Without assessment, he jumped to the conclusion that she was unnecessarily seeking additional time off work, as well as pursuing narcotic medication.  There was no indication that such had occurred and his reaction was felt to be inappropriate.  The Committee issued a Caution.

An elderly couple attended the physician as new patients.  When he was advised that they were on narcotics, prescribed by a consultant, he became upset and demanded that they immediately proceed to the hospital for a urine screening test.  The Committee felt the response was completely inappropriate.  There was no attempt to get a complete picture of the patients’ facts.  It was also noted that the narcotics had not been prescribed by their previous family physician, but by a consultant.  Finally, urine screening tests in such a circumstance would be useless at determining whether they were, in fact, taking the medication, as opposed to redirecting it.  The Committee felt that the care provided was sufficiently deficient to warrant a Censure. 

Finally, an elderly patient was in a local hospital after a series of treatments at regional centres.  She was there pending  arrangements for her discharge home.  Without warning to the family, the physician discharged the patient.  When he met with the family, he refused to provide any specifics and simply stated that the patient had requested such.  The records provide no evidence that this was true.  His failure to be willing to discuss this matter in any fashion with family members of such a patient warranted a Caution by the Committee.

Privacy
The Council of the College wishes to express increasing concern regarding the approach some hospitals are taking in response to the legitimate access of physicians to medical records.  Physicians may be subject to an investigation, and even a fine, if it is deemed that such access is inappropriate.  Council is also troubled that the standard of such decisions have been altered.  It has always been clear that physicians involved in the “circle of care” of a patient could, at the least, access that patient’s records.  It has now been suggested that the standard is, instead, the “circle of consent”, a much narrower view.  Even outside of direct patient care, there are other legitimate reasons physicians may access a record, including further follow-up, educational purposes, and others.  Now threatened with an investigation for such, members have advised that they feel intimidated when undertaking what has always been considered a perfectly normal part of hospital care.  Council is extremely concerned that these initiatives will improperly impede the legitimate flow of information to physicians and, consequently, could represent a significant risk to patient care.  For that reason, Council feels it appropriate to raise its concerns in the strongest way possible regarding these developments.  Council feels such approaches cannot be in the best interest of the patient.  While Council will continue to reiterate its concerns, it welcomes comments from members on this issue.

Copying Fees
Since the passage of the Personal Health Information Privacy and Access Act (PHIPAA) in 2010, the College has advised physicians regarding the appropriate charges for copying records.  In the case of patients seeking

copies of their own records, provincial regulation makes it clear that the maximum charge can be $0.25/page.  In other circumstances, the consistent advice has been that physicians can charge other rates, including such as may be suggested by the Physicians’ Guide to Direct Billing from the New Brunswick Medical Society.  Such would apply for transfer of records to other physicians, to lawyers, or any other third party.  Such an approach has been in place for five years without significant difficulty.  However, it has recently been suggested, and tentatively endorsed by the office of the Privacy Commissioner, that the lower rate should apply to all copying done at a patient’s request.  In other words, the maximum charged could be $0.25/page regardless of where the record was being forwarded.  The College is attempting to clarify this, but until that time, the rules remain ambiguous.  It is suggested that, until there is further clear guidance on the matter, physicians should not feel precluded from charging at the higher rate where such seems appropriate.  Nevertheless, physicians should be prepared to alter their approach if the issue is challenged.  Further guidance will be provided as soon as it is available. 

Assistance in Dying
As members are aware, the Supreme Court of Canada has accepted that certain patients have the right to seek assistance from physicians in the process of dying.  Since that decision, there has been action on several fronts.  The Council of the College has adopted a preliminary guideline, which is attached to this Bulletin. 

First of all, it should be clear that any policy of the College will be subject to legislation, both provincial and federal.  It is expected such provisions will come into force at some point.  Nevertheless, members are encouraged to comment on Council’s current view, which will remain a work in progress.

Consultations / Referrals
Council has been advised that many consultants are ignoring the College guideline by failing to immediately acknowledge receipt of any requests for consultation or referral.  Physicians should know that this is a very clear requirement of the guideline, which is available on the website, along with a template for a response.  Failure to follow this practice could potentially result in a complaint, but more importantly, could create significant risks for patients as a result of unnecessary delays in assessment and treatment. 

It is also reported that some consultants fail to provide timely reports, often weeks after the patient has been assessed.  Priority should be given to forwarding such reports when timeliness is in the patient’s best interest.  In any case, physicians are reminded that, by definition, a consultation includes forwarding a report to the referring physician.  As a consequence, it would be improper to submit a claim for a consultation unless the report had, in fact, been sent.

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 the invoice  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.