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.
President - Dr. Douglas Brien, Saint John
Registrar - Dr. Ed Schollenberg
At its meeting on 29 October, 2004, Council considered the following matters:
There were two separate complaints which arose after patients were transferred from a community hospital to a regional centre. In both cases, the receiving physician made comments to the patients which appeared critical of the care received from the referring physicians. This situation can present difficulties. Patients are entitled to complete information and honest opinions. However, such should not be done in a way which might unnecessarily impugn the reputation of other physicians.
In the second such case to arise in several years, a patient with hearing difficulties complained about the care received from a physician. Both cases involved frustration that the physician appeared either inattentive or impatient due to the difficulties in communication. In both cases, the patient and the physician were unfamiliar to each other. The Committee notes that these can be difficult circumstances and it is expected that physicians will make every effort to facilitate communication with the patient.
There were a number of complaints alleging that physicians in a hospital wrote orders, or otherwise interfered with patients admitted under other physicians. While this is normally precluded by hospital policy, the matter was not clearly enforced. In reviewing the matter, the Committee felt that it is only in exceptional circumstances that physicians should do so. In addition to the obvious legal implications this could create significant confusion for other staff, patients, and their families.
A physician performed a procedure on a patient which resulted in a pathological specimen. The patient was advised that he would be contacted if there were any significant results. The histology did, in fact, reveal a significant pathology. However, the report was misplaced by the physician and the results were not communicated to the patient for more than two months. The delay in initiating treatment may have been significant for the patient's clinical course. In the past, physicians have been reminded that they are completely responsible, legally and ethically, for following up results and communicating them in a timely fashion. In other words, physicians should develop systems for tracking such. While no such system is perfect, in this case there appeared to be no system at all.
A patient who had longstanding chronic pain transferred to another physician. While the physician continued some of the treatment previously offered, the patient alleged that this was insufficient for his needs. He more specifically alleged that the physician had not properly reviewed the past history. In this case, the Committee felt the physician may have made certain decisions without a complete appreciation of the patient's past difficulties, but it was still the patient's current status which was important. While physicians should be respectful of past treatment choices, they are only obligated to provide treatment which they feel is in the patient's best interest.
A patient was admitted by a family physician and a consult requested. The situation was not an emergency, but the family physician hoped that the patient would be seen within a day or two, which was a weekend. The patient complained that, although the consultant was not only present in the hospital, and on the patient's ward, actually attending another patient in the same room, the physician still failed to assess the patient, resulting in the patient discharging himself. In response, the consultant stated that the workload of the weekend precluded him seeing the patient. The Committee felt that, while this may have been a valid reason, the consultant had an obligation to communicate such to the patient and family physician and attempt to see if alternate arrangements were possible.
There was a complaint from the family of an elderly patient that he had not been properly assessed by a physician. The family had requested certain investigations which the physician had not performed. The family asserted it had the right to request such. In response the physician stated that the matter was discussed with the patient himself, who the physician felt was competent to make his own decisions. In reviewing the matter, the Committee felt that the care provided was quite appropriate. While physicians are to be respectful of the needs and concerns of families, they must accept direction from a patient until there is clear evidence that such cannot be competently provided.
A patient did not initially have satisfactory results after an elective procedure. On the first visit postoperatively, she advised the surgeon of such. She felt the surgeon did not appropriately respond to the difficulties and arranged no further follow-up appointments. The matter continued to progress and the patient eventually needed a further corrective procedure. In reviewing the matter, the Committee was satisfied that the patient was given adequate warning regarding the potential for failure of the treatment, as well as other complications. Nevertheless, when difficulties were evident on follow-up, it would have been better if the surgeon had continued to see the patient, rather than leaving her to seek further treatment on her own.
A child became ill shortly after moving from another province. The attending physician made several comments to the parents regarding the child's Medicare coverage. The parents felt the physician appeared to be preoccupied with this issue and, to some extent, resisted providing appropriate care. While it was unclear if this was the case, the fact is that this should not have been an issue at all for the physician. The patient's original province does participate in reciprocal billing with New Brunswick Medicare. As a consequence, the process, from the physician's point of view, should be "seamless". There appeared to be little reason to even raise the issue.
The Committee determined to close several outstanding complaints alleging insensitive behaviour by a physician. There was reason to believe this was due to certain personal difficulties which, it was hoped, had resolved. The Committee could reopen the matters if new concerns arose.
The Committee also had a lengthy second meeting with a physician concerning possibly excessive narcotic prescribing. After that discussion, the Committee provided certain specific advice to the physician and determined to continue to monitor the matter.
There was a request that Council revisit this matter following the publishing of new guidelines in British Columbia. A similar circumstance had arisen several years ago when the College in Saskatchewan offered advice to its members. At that time the Council determined to follow the guidelines of the Canadian Paediatric Society, which concluded as follows:
The overall evidence of the benefits and harms of circumcision is so evenly balanced it does not support recommending circumcision as a routine procedure for newborns. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. The decision may ultimately be based on personal, religious, or cultural factors.
These guidelines are under review, but Council felt it appropriate to continue to recommend following them. Council did note that there were several valuable comments raised in the policy from British Columbia, which is available on their website at www.cpsbc.ca. Among the most important, in Council's view, was the suggestion to require clear informed consent from both parents.
CODE OF ETHICS
The Canadian Medical Association has recently adopted a new Code of Ethics. As has been the case in the past, Council has adopted the new version as binding on New Brunswick physicians. This will take effect on publication in the Medical Directory in the spring. The new Code does not impose any significant new obligations, but does clarify certain issues.
- Reviewed a recent decision of the Supreme Court of Canada which appeared to impose greater liability on professional regulatory authorities who fail to deal aggressively with complaint matters.
- In follow-up to comments in the last Bulletin, determined to advise the College of Physicians and Surgeons of Ontario that it may now be acceptable for physicians seeking licensure there to be assessed in New Brunswick provided appropriate safeguards are met. Physicians can contact the College office for details.
- Reviewed the matter of an overdose death referred by the Chief Coroner. The principal issues the case raised were the failure of the physician to strictly impose the terms of a treatment contract with the patient, as well as possibly excessive concomitant prescribing of Benzodiazepines. It is noted that these specific issues were to be dealt with in a Prescribing Skills Program developed by the New Brunswick Medical Society.
- Reviewed recent statistics on international medical graduates from the Canadian Institute for Health Information. In the last five years, the number of international graduates licensed in New Brunswick had increased by 9%. Nationally, the increase had been ½%. In five provinces, the number of international graduates has decreased. The percentage of international graduates licensed in New Brunswick remains lower than many other provinces based on a variety of historical factors. However, New Brunswick is the only province to show an increase in this percentage (from 21% to 22%) over the last five years. Nationally the percentage of foreign-trained physicians fell from 22% to 21%.
By now all physicians should have received notices regarding fees for 2005. If not, the College office should be contacted immediately. Physicians will note that there has been no change in the College fees for next year. As always, if paying by cheque, such must be received by January 1st to avoid suspension.
FROM THE ARCHIVES
Seventy-five years ago
In 1929, Council reaffirmed its requirement that students complete two years of Arts before being given permission to enter medical school. They also reviewed extensive correspondence with the Bishop of Chatham concerning two priests who were alleged to be practising medicine without a license.
Fifty years ago
In 1954, it appeared that Council did not do anything interesting.
Twenty-five years ago
In 1979, Council criticized a physician who had placed his name in the yellow pages of all of the phone directories in the province, expressed concern regarding the kind of surgical procedures being performed in small hospitals, and agreed to begin the process of "divorce" from the Medical Society.