ALBERTA, CANADA
From The Messenger, a publication of the College of Physicians and Surgeons of Alberta
WRITING TO THIRD PARTIES
With increasing frequency, the College is receiving complaints about physicians’ reporting to third parties, such as lawyers, on behalf of their patients. Problems arise when physicians are not careful to attribute or identify the source of the information, or when physicians make opinions based on second-hand information. Physicians also must be careful to ensure that the person receiving the information has a right to that information.
Consider these scenarios:
A psychiatrist wrote on behalf of his patient who was in the process of divorcing her husband and seeking custody of the children. In the letter to her lawyer, the doctor characterized her husband, whom he had never met, as self-centered, narcissistic and pathologically controlling. He referred to events and actions as though he had witnessed them when he had not, and drew conclusions about the husband and his family from these second-hand descriptions.
A physician wrote a letter at the request of his male patient, who was getting divorced, to his lawyer. Both this man and his wife had been patients of the doctor. The doctor wrote that the woman had a past history of drug abuse, and he questioned her ability to care for the children. The woman had not given the doctor consent to disclose her personal medical information to anyone.
A physician wrote a note on behalf of her patient and his children that the children were suffering physical and psychological effects of a motor vehicle collision without examining or speaking with the children. The information about the children had come from the father, but that was not made clear in the letter. As a result of the letter, the children’s mother was prevented from taking her children on a holiday. (The parents were in the process of divorce.) A subsequent examination by another physician found the children to be suffering no effects of the accident.
A physician wrote on behalf of his patient that he had at all times found him to be a good and caring parent and had no concerns about this individual’s ability to care for his children on his own. The physician did not report that he had only seen his patient and the children in the office setting and could not comment on the home situation.
There are some common themes from these examples:
Many of these complaints occurred on a background of conflict – divorce or custody disputes.
The physician failed to attribute the source of the information in the letter.
The physician advocated strongly for the patient, perhaps too strongly. There is a need to maintain professional boundaries and not to become emotionally involved in the patient’s personal situation.
The physician failed to consider the risks he/she faced by writing such reports. All of these examples (which have been partially fictionalized) came to us as complaints. At least one of these physicians has been sued in the civil arena for the letter written.
What lessons can physicians learn from these examples?
Be very careful when asked to write a letter on the background of a situation of conflict.
Ensure you attribute the sources of your information. (Consider writing, “My patient told me that…” for example).
Be careful to clarify what you personally observed and what is second-hand information.
Be as objective as possible, and limit your opinion to areas where you have expertise. For example, some physicians may not feel comfortable commenting on parenting skills and might therefore state that “the children appeared clean and well cared-for” or “my patient interacted well with the children while in the examination room.”
Be very wary about characterizing an individual whom you have never met.
After drafting your report, re-read it from the perspective of a lawyer who might challenge you. Can you attest to the truth of the information you have written? What have you directly observed? Is your reporting objective?
Do not write about any of your patients without their consent. (There may be a rare circumstance, such as reporting an allegation of child abuse to Child and Family Services, where such reporting is legally sanctioned).
Be careful about your professional boundaries. It is fair to advocate for your patient but you must be as objective as possible. Be prepared to defend your statements and your opinions, and, if you cannot, then delete or reword them.
MANITOBA, CANADA
From From the College, a publication of the College of Physicians and Surgeons of Manitoba
MEDICAL INFORMATION NUMBER FOR CANADA
Starting this year, all physicians in Canada (as well as residents and students in most provinces) have a new national unique lifetime identification number assigned to them.
Called the Medical Information Number for Canada (MINC), this identifier was developed through the collaborative efforts of the Medical Council of Canada and the Federation of Medical Licensing Authorities of Canada, of which the College of Physicians and Surgeons of Manitoba is a member.
The increasingly complex, inter-related and computerized medical system in Canada has made the accurate and reliable identification of physicians, as well as medical students and residents, a significant problem.
Many medical/health organizations have attempted to resolve this by issuing their own identifiers for their physicians; the result has been a proliferation of identifiers, none of which is linkable with other organizations. The MINC numbering system has been developed to provide a nationally-recognized standard identifier.
MINC numbers will:
be a simple serial number with no encoded information, e.g., CAMD-9999-999
be issued by a central hub computer at the request of 1 of the 2 sponsoring agencies
be considered confidential personal information
not replace College registration number, LMCC number, provincial billing number (if any), nor any other identification number that physicians currently have
not convey any status, rights, or privileges
not change the way in which any information concerning physicians is released
For the MINC number to be generated, the College provides the physician’s name (plus prior names, if applicable), their date of birth, and their university and date of medical degree to the MINC database run by the Federation and the Medical Council.
All registrants on the college’s various registers will receive documentation of their new MINC numbers when they are issued. Other colleges in Canada are currently working on implemention of MINC numbers for their registrants. There is no cost to physicians, and no registration or application is required.
ONTARIO, CANADA
From Members’ Dialogue, a publication of the College of Physicians and Surgeons of Ontario
THE DRUG-SEEKING PATIENT
Drug-seeking continues to be a common and serious problem, and the inability to identify and manage drug seekers can lead physicians to become disenchanted with their practices.
“Any physician can be a target for drug-seekers. I’ve had them come to my office,” said Dr. Meldon Kahan, a family physician and Director of Addiction Services at St. Joseph’s Health Centre in Toronto.
But there are simple strategies that doctors can adopt that can help them minimize the disruption to their practices, he said.
“My experience is that it’s best not to write a script in the first place if you have a patient who makes you uneasy,” said Dr. Kahan. “Patients will react much more angrily if they have been receiving scripts from you and then are cut off,” he said.
If a physician feels that a patient is pushing them to prescribe a particular drug, said Dr. Kahan, the easiest thing to do is tell the patient that he or she is bound by the office’s practice policy and can’t prescribe to new patients, for example. A patient won’t argue over a set policy, but will argue if he or she feels that the doctor has some discretion, said Dr. Kahan.
To help physicians identify the drug-seekers in their practice, the following include some of their clinical features:
They ask for a drug of choice by name (although they would prefer that the physician name it first): “It starts with an F; it is a dark blue capsule …”
They refuse all other therapeutic options, claiming that they cause adverse effects or don’t work.
They make it difficult to confirm their story regarding drug use. For example, they may come to the office of a new physician late on Friday afternoon, knowing their regular physician will be difficult to reach.
Their presenting medical condition lacks objective signs (e.g., migraine headache), making definitive diagnosis impossible. Favorite ailments of drug-seekers include acute low back pain, migraine headache, toothache, and renal colic.
If the physician shows reluctance to prescribe the desired medication, drug seekers will pressure the physician through pleading, bargaining, anger, or dogged persistence. They will attempt to create a sense of urgency – they are in desperate pain and need the medication right away. When refused, they become very angry.
How can drug-seeking be minimized?
When suspicious, ask, “Have you sought or obtained a prescription like this from any other doctor in the last month?” Make it clear that the answer will be written in the medical record. It is an offense for a patient not to disclose this information and it may be enough to demonstrate to the drug-seeker that you understand the rules. Often such action will convince the person to move on. The failure of the patient to honestly provide this information to a physician is commonly referred to as “double-doctoring.”
Use general policy statements, such as, “I never prescribe Fiorina,” or “this clinic does not allow physicians to prescribe narcotics to new patients.” Definite and categorical statements leave little room for argument, thus avoiding prolonged negotiations with the drug-seeker.
Know the strengths and limitations of your consultants. Physicians who continue prescribing opiates, hoping that the specialist’s appointment two months hence will resolve matters, are often disappointed. The consultant should be informed of any concerns about drug-seeking, and asked specifically about the role of opioids in the patient’s treatment.
Only give opiates if you honestly believe that the patient is “on the level.” Giving the patient a prescription to get them out of the office is a mistake. The patient will return again in a short time requesting more medication, and if he or she is refused, the confrontation will likely be angrier and more time-consuming than if they were initially refused.
Don’t make decisions based on stereotypes. While drug-seekers are often young, it is a mistake to rely on age, appearance, or social class in deciding whether someone is a drug seeker.
Be skeptical of the patient’s story as to why he or she ran out of medications. If the medication is so important to the patient that he can’t live 1 more day without it, then why did he allow the medication to run out just before the weekend?
Make your system for dispensing prescriptions “tamper proof”:
Record the amount to be dispensed in both words and numbers on the prescription.
Put several lines through unused space on the prescription.
Use a narcotic flow sheet that records dates and amounts.
Do not allow phone repeats.
Keep your prescription pad in a secure location.
If possible, use numbered or non-reproducible prescription pads.
Ask the patient whether they have a problem with the drug they are requesting, e.g., “This drug is potentially addicting, and some patients who take this drug regularly develop problems with it. Do you think you have a problem like this?” Occasionally, patients will acknowledge their drug problem if asked in a nonjudgmental manner.
Do not attempt an outpatient opiate taper even if the patient acknowledges his/her addiction. Opiate-tapering should only be attempted when the physician has a long-standing relationship with the patient and is fairly certain that the risk of double-doctoring is minimal. Remember that although opiate withdrawal is uncomfortable, it is not dangerous, and the physician is not obligated to provide an opiate prescription to an addicted patient.
Opioid drugs other than methadone are not to be used in the treatment of opiate dependence. In other words, it is not acceptable for a physician to maintain an opiate-dependent patient on narcotics until he/she gets into treatment.
These precautions may seem troublesome, but it is wise to remember that only 1 or 2 instances of injudicious prescribing will quickly result in a significant number of drug-seekers making an appointment for a visit, said Dr. John Carlisle, Deputy Registrar of the College. “The inconvenience and difficulty caused to the doctor by such drug-seeking activity will be far more troublesome than a few simple day-to-day precautions,” he said.
