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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.

At its meetings on April 6, 2018, 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. 

There were two unrelated complaints involving head injuries. In one case, an adolescent was injured during a sports activity. She had minimal symptoms except for significant scalp swelling. No immediate investigation was done. She was later determined to have a depressed skull fracture. On reviewing the matter, it was noted that there were conflicting opinions regarding the appropriate assessment in such situations. Some physicians would feel that significant swelling could suggest the presence of a fracture, which may or may not need to be treated. Other guidelines would instruct the physician, in this situation, to not order any imaging immediately. In this light, the Committee could find no fault with the care provided.

In another matter, a patient was sent home after suffering a head injury. She had no symptoms. In subsequent weeks she developed a significant headache. She complained that she had not been given appropriate advice following the injury regarding activities to avoid. In response, the physician noted that avoidance of certain activity was discussed, but such was done in a busy hallway. In reviewing the matter, the Committee noted that normally specific instructions of this nature would not be necessary in this situation. Furthermore, the avoidance of some activities are more about avoiding certain symptoms rather than preventing injury.

 A sixteen-year old patient was admitted involuntarily for a number of symptoms, mainly related to substance abuse. His behavior improved quickly in hospital and it was determined he could be discharged to a treatment facility. His parents noted that arrangements were made without their knowledge and without assessing the risks that the patient would simply abscond. The patient was given a discharge prescription for a three-month supply of a benzodiazepine. These were subsequently abused by himself and his colleagues. On reviewing the matter, the Committee could find no fault with the physician’s decision to discharge the patient who no longer presented a risk to himself. At the age of sixteen he is considered an adult for purposes of making his own medical decisions. Nevertheless, the Committee felt that a Caution was appropriate for recklessly prescribing a large quantity of a potentially dangerous medication to a patient in these circumstances.

A patient was referred to a consultant and began a sequence of treatments at intervals of approximately one to two months. After the second course of treatment, the patient was advised that another referral from her family physician was necessary for further treatment to be provided. She felt this was unnecessary.

The physician asserted that this approach was common practice and he considered it perfectly justified given the circumstances. He offered that he would continue to see the patient without a referral if she had failed to respond to the treatments or developed complications. Since she in fact responded to the treatment, he felt a request for a referral was appropriate. In reviewing this matter, the Committee had to note that such use of the referral process is a departure from that expected from the College or Medicare guidelines. By definition, a referral or consultation must be initiated by the primary physician and cannot be requested by the consultant. Furthermore, there was no evident reason that a further "opinion" from the consultant was necessary before continuing the treatment as recommended. The Committee felt a Caution was appropriate to remind the physician of his obligations in such matters.

A patient from Quebec was injured while traveling through New Brunswick. She was referred to a consultant who, without seeing the patient, advised that he would not assess or treat the patient unless she agreed to pay the full amount of his fee in advance. The patient objected and, subsequently, had a long, very uncomfortable, trip back to her home. In response, the physician outlined the difficulties with treating Quebec patients and billing for same. He did acknowledge, however, that his approach would be altered as a result of this complaint. In that light, the Committee determined to take no further action on the matter. Physicians are reminded that the College Regulations are very clear that payment for any necessary treatment cannot be demanded in advance. Such does not have to be an emergency situation. Instead, the issues around payment difficulties should be discussed with the patient and on agreement reached on how best to handle the matter.

A thirty-two year old patient presented to a physician with unilateral breast pain. An examination was inconclusive although there was a suggestion of a possible mass at that location. The physician did not feel the patient was at risk for breast cancer so it was determined do some initial blood work and advise the patient to return to be reassessed at some point in the future. The patient attended again a few months later for a prescription renewal and again mentioned the breast pain. At this point the physician did not examine her. She was subsequently found to have breast cancer. It was alleged that the initial assessment was insufficient. In reviewing the matter, the Committee noted a difference of opinion on the possible approaches to this situation. In some views, the presence of any mass would warrant imaging appropriate for the patient’s age. Others would feel that a careful follow-up within a short period of time was indicated. In this case, neither imaging nor a clear plan for follow-up was in place. The physician was Cautioned to recognize the risks of breast cancer even in younger patients and, in the future, develop a clear plan to deal with any potential cases.

A patient complained a physician was improperly modifying his drug treatment. The physician responded that the patient had been on high doses of narcotics and he was making an effort to decrease the patient’s dependence on such. A number of initiatives were tried without success and the patient was eventually returned to the dosing he had been on previously. The Committee could find no specific fault with the care provided in regard to this matter.

 An elderly patient fell at home and was taken to the hospital with back pain. The examination was otherwise negative. The family complained that no x-ray was done at that time. The patient was subsequently found to have compression factures of his spine. In response, the physician asserted that, even if x-rays had been done at the first visit, they would have not modified the management. The Committee agreed and noted that best the physician can do in such circumstances is try and to make the family involved in the matter understand the reasons for the approach taken.

A patient with a longstanding work injury had gone through many investigations and consultants without a satisfying result. With a new family physician he began insisting on further referrals. When the physician resisted such, a significant argument developed. The patient was immediately discharged from the physician’s practice. In reviewing the matter, the Committee did agree that it appeared likely the relationship between this patient and this physician was at an end. Nevertheless, physicians are still expected to make every effort to provide a warning to the patient before terminating care. Such was not done in this case and the Committee felt a Counsel was warranted.

Opioids

There are a number of developments of which physicians should be aware.

1. Access through the Provincial Health Portal to past prescribing information is now available to every physician. Council has approved, in principle, the expectation that physicians will review past history through the portal before issuing any prescription for an opioid. The only exception to this requirement will be the renewal of prescriptions previously issued by the same physician. In those circumstances a periodic review, likely every three months, will be expected. If past prescribing history is not available, either through the portal or from another source such as a pharmacist, physicians should not prescribe opioids. It should be clear this is an eventual expectation which will become a clear obligation at some point in the future. (See further information on next page) 
2. The federal government is in the process of eliminating the need for special permission to prescribe methadone. Consequently, any physician may legally provide opioid substitution therapy with either methadone or buprenorphine-naloxone (Suboxone). No special permission is required. Nevertheless, as with all medications, physicians are expected to acquire the relevant knowledge, training, and experience before initiating such treatment.  
3. Guidelines have recently been published in the CMAJ (April, 2018) on the management of Opioid Use Disorder. The guidelines emphasize the importance of substitute, or agonist, therapy as the preferred approach. They caution strongly against the use of simple withdrawal alone for this issue. Such apparently often moves the patient to seek alternative sources of narcotics, often illicit. This creates the now recognized and significant risks of overdose and death, an epidemic of which has recently been confirmed to have spread to New Brunswick.

It is appreciated that many factors have contributed to the current national and international crisis. Nevertheless, physicians must accept some responsibility for the situation developing over the years and, consequently, take such leadership role as they can in helping to resolve it.

Prescription Monitoring Program (PMP) enhancements coming soon.

The PMP is in the process of completing work on additional information and tools for pharmacists and prescribers to use in managing patients prescribed monitored drugs. New information, such as real-time PMP alert messages and the ability to track a patient’s prescriber and/or pharmacy restrictions is being made possible within the Electronic Health Record. These messages will also flow directly to the community pharmacy system when a prescription is dispensed. They are intended to help in your day to day work by helping to identify patients who have breached their pharmacy and/or prescriber restrictions.

You will notice some changes to the Prescription Monitoring Program (PMP) view in the Electronic Health Record (EHR). New section headings have been added to the PMP screen in preparation for the PMP enhancements but have not been activated at this time. The PMP has made available the updated PMP screen to a limited number of authorized users. This is allowing for further assessment of the application before making it available to all authorized users. The Monitored Drug Summary is still viewable further down on this screen and more information will follow as these enhancements become available more broadly.

Visit www.eHealthNB.ca to sign-up for your free access to EHR today!

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