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 27 March and 19 June, 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 patient was prescribed medical marijuana for chronic pain. Some, possibly incomplete, information was provided by his family physician to the prescribing doctor. Such did not disclose any significant areas of concern. Nevertheless, after a few months the patient developed significant symptoms of a bi-polar disorder. Whether such was previously present and aggravated by the marijuana, or the specific result of the marijuana, remains a source of dispute. Nevertheless, the original prescription issued by the physician was for a full year of treatment. This precluded any necessity for the patient to return earlier. As a consequence, events unfolded without the possibility to intervene with the patient’s treatment. The physician was Counselled on the appropriateness of shorter prescriptions, for many, if not all, first time marijuana patients.

A patient contacted a new family physician after being assigned such through the Patient Registry. Some general questions regarding the patient’s health, including mental health, were asked by the receptionist. Subsequently, there was no further contact from the physician’s office. The patient noted that she was under treatment for depression by a psychiatrist, but nevertheless, felt that she was being denied access to the family physician’s practice on the basis of her mental condition. The physician responded denying that such was the case. The office understood that the patient was to initiate contact whenever she wished. In reviewing the matter, the Committee felt both versions of events could occur. Nevertheless, physicians should be cautious in such circumstances, as there is potential for a patient to allege discrimination when such was not the case. The physician acknowledged such and instituted changes in her office procedures to avoid any further concerns.

A fourteen-year-old boy was seen by the family physician with a history of frequent bowel movements and weight loss. He then developed evidence of anemia. The family physician’s only response was to institute iron therapy. The weight loss and anemia both continued. Eventually, the patient was seen elsewhere, appropriate referrals made, and the diagnosis of Crohn’s disease reached. In reviewing the matter, the Committee had significant concerns regarding the response of the family physician to the clinical situation of a child with weight loss and anemia. In the Committee’s view, such requires that a diagnosis be pursued. Symptomatic treatment is not sufficient. The Committee felt this was a significant enough error to warrant a Censure regarding the physician’s approach.

A patient, with a previous history of cancer, was attending her family physician for a number of issues. At some point during the visit, the physician became frustrated while attempting to find a specific result in the patient’s chart, which was of considerable volume. The patient interpreted the physician’s frustration as her being dismissive of the patient’s significant medical problems.
In response, the physician acknowledged that her comment could be misinterpreted and apologized for such. The Committee noted that physicians should be cautious in such situations. In this case, the physician was somewhat frustrated by the size of the record, rather than by the breadth of the patient’s problems. The Committee felt that the fact of the complaint was sufficient guidance for the physician regarding future encounters.

A patient was being followed by her family physician and a consultant for a chronic problem. The patient relocated to another community and wished to be referred to a consultant there. Her family physician refused, stating the patient would be better off being seen by the same consultant as previously. In reviewing this matter, the Committee did acknowledge there could be benefits for ongoing care, but in this case, it was up to the patient to make the choice based on informed consent. If, after being presented with the options, the patient still wished to be referred elsewhere, it was her family physician’s obligation to agree to such.

A five-year-old child was being seen by his family physician who made reference to the possibility of surgery being necessary for a cosmetic problem. The mother, who was sensitive to the issue based on considerable discussion within her extended family, advised the physician she did not wish to discuss such. She alleges the physician persisted in a somewhat joking manner. All of this discussion was heard in the presence of the child. The entire process was very upsetting to the mother who made several attempts to discuss the matter subsequently with the physician who declined to do so. In response, the physician felt that is was an appropriate time to deal with the matter given the child’s age. He acknowledges he was aware of some difficulties in the family regarding the issue and that he was aware the mother would be sensitive to any discussion. In reviewing the matter, the Committee did not feel the matter was handled appropriately. First of all, there could be few situations where such discussion should occur in the presence of the child. Secondly, once the physician was aware that the mother did not wish to address the issue, he should have not pressed the matter further. The Committee also noted that the mother did offer an opportunity to discuss it in the days subsequently, which was not accepted. In the end, the Committee felt it appropriate to issue a Counsel regarding physician’s approach.

A patient was seeing a consultant in follow-up. The examination was somewhat uncomfortable. When the patient then requested a copy of certain records, the physician became frustrated and appeared to strike the patient with the file folder. In response, the physician acknowledged some frustration in searching for a specific report and further acknowledged that he had not acted appropriately. While the Committee could find no issues regarding the physician’s clinical management, it had to agree that the behavior was inappropriate and issued a Caution against further such incidents.

An adolescent was seen at the Emergency Room for abdominal pain. After an assessment, the physician raised the question of anxiety playing a role. This continued on into a discussion on spirituality. The patient and her mother objected and complained that the physician was inappropriate in his discussion. In response, the physician asserted that he believed he was trying to be helpful and was simply offering some comments in that direction. In reviewing the matter, the Committee noted that, in another context, it may have been reasonable to pursue these issues to determine what factors might be affecting the patient’s well-being. However, when the patient, and in this case her mother, resisted that discussion, the physician should have discontinued such immediately. The Committee felt a Counsel was appropriate.

A pharmacist called a physician to discuss a medication choice. The physician responded angrily and hung up. He later acknowledged that he had not acted professionally and apologized. The Committee noted the importance of communication between professionals in the patient’s best interest and felt that a Counsel was appropriate.

A patient attended a walk-in clinic for purposes of accessing a “second opinion” on a persistent problem. However, she offered no information on what had been tried already and refused to assist the physician in accessing such. A dispute arose and the physician terminated the visit. The Committee noted this was a difficult situation and felt the physician handled the matter as best as could be under those circumstances.

A patient asked for a referral to a psychiatrist.  Because of her own employment in the mental health system, she requested a referral to a specific psychiatrist in his private office.  Her physician agreed, but on the referral being sent out by the office staff, it was forwarded to the fax number listed which was actually the public mental health clinic.  The patient alleged this violated her privacy.  In reviewing the matter, the Committee felt the physician had acted appropriately and the entire situation had developed as a result of a number of unfortunate circumstances.

ELECTIONS
Recent elections to Council saw Dr. Robert Fisher of Hampton and Dr. Julie Whalen of Moncton re-elected by acclamation.  Newly elected members include Dr. Sylvain Matteau of Bathurst and Dr. Ronald Hublall of Edmundston.  Recently appointed as a public member was Ruth Lyons of Tide Head. 

METHADONE
Council has approved a guideline on opioid substitution therapy. It essentially incorporates standards from elsewhere. It also requires a training process for physicians who wish to initiate methadone prescribing or renew their right to do so. A copy of the guideline is available on the College website.

FROM THE ARCHIVES

Ninety years ago
In 1925 Council debated at great length on a request for reciprocity with the General Medical Council in Great Britain.  Eventually they determined to only recognize physicians who had undertaken appropriate British examinations.  Council also authorized the Registrar to purchase a typewriter desk to a maximum value of $25.  There were 237 physicians licensed in the province. 

Sixty years ago
In 1955, Council decided that there was still no need to require the registration of interns, considered the possibility of increasing the internship for "alien" doctors to two years, and considered changing auditors because it was felt that the audit fee of $100 was excessive.

Thirty years ago
In 1985, Council began looking for a full time registrar, decided to start a newsletter, and expressed reluctance at the government proposed amendment to the Medical Act regarding abortions performed outside of a hospital.  Council was also troubled by a sudden and unexplained increase in complaints.  There were 877 physicians licensed.  The annual licensing fee was $200.   

HEALTH MAINTENANCE
As an alternative to traditional annual physicals, le Collège des médecins du Québec has approved a number of recommended areas for physicians to review as part of ongoing healthcare for the patient. A copy is enclosed with this newsletter and is also available on the College website.