ALBERTA, CANADA
USE OF MEDICAL DATABASES IN RESEARCH STUDIES
The College’s Research Ethics Review Committee has been increasingly concerned about the use of medical databases to search for suitable research subjects.
Under the Health Information Act (HIA), a research ethics committee must review any proposed database search to determine whether the researcher must obtain the consent of identified individuals (those whose names and personal health information appear in the database). This applies equally to manual and electronic databases, and includes physician office medical records.
The research ethics committee usually requires consent unless obtaining the consent is unreasonable, impractical or not feasible (HIA, Section 50(1)(iv)).
Researchers requesting that the research ethics committee waive consent should include with their application a reasoned argument as to why such waiver should be considered.
Physician researchers must also obtain the review and approval of a research ethics board recognized under the HIA before data matching is performed. Physicians who are or likely to be engaged in research should review their database processes and consider the option of obtaining patient consent to use the data for research purposes. Patients must also be made aware that their consent can be withdrawn at any time.
Sections 48 through 56 of the Health Information Act govern disclosure for research purposes. A copy of the Act is available at http://www.qp.gov.ab.ca/documents/acts/H05.cfm.
CPSA PRIVACY PROJECT
On Jan. 1, 2004, the Personal Information Protection Act (PIPA) came into force in Alberta. The intent of this legislation is to establish a strong and common set of rules for handling all personal information in the province (although health information will continue to be regulated by the Health Information Act).
PIPA has an interesting feature in that it allows professional regulatory organizations (like the CPSA) to be exempt from most of PIPA. This special exemption is only possible if that organization develops its own personal information code (PIC) that is approved by government.
Exemption was established because regulatory authorities, in order to fulfill their mandates, have special needs for how they treat personal information. For example, the CPSA must at times gather information without consent, keep it for longer periods than would normally be considered sufficient, use it for purposes not contemplated at the time it was collected, and be able to refuse to release it. However, the rules by which the CPSA operates must be clear and consistent with its mandate to regulate the practice of medicine.
The CPSA’s project to comply with privacy legislation will have three phases:
The development and approval of a Personal Information Code (PIC). This is the set of policy-level rules for how the CPSA will collect, use, disclose and destroy information. Our target is to present the PIC for Council approval at its September 2004 meeting, and then forward it to government for approval.
The development of operational rules, processes and tools by which the CPSA will implement its PIC. Much of this work has already been done by staff over the last two years, but will need some additional work and documentation.
Implementation, which will take place as we go. A number of improvements have already been made such as instituting privacy oaths for new staff, adding privacy statements to forms and emails, and changing the wording on some forms to clarify how the information will be treated.
The entire project will be done and operational by the time the Health Professions Act comes into force for the CPSA, in spring 2005.
Reprinted from issues 109 and 110 of the Messenger, published by the College of Physicians and Surgeons of Alberta.
ONTARIO, CANADA
POLICIES CLARIFY RESPONSIBILITIES IN MEDICAL EDUCATION PROGRAMS
A sick patient is admitted to a teaching hospital. While awaiting surgery, the patient is approached by a clinical trainee. The trainee explains that he has come to do an arterial puncture for blood gas analysis. The patient balks, refuses to let the trainee do the arterial puncture and then demands to see “a real doctor.”
The college has developed two policies that clarify the roles and responsibilities of physicians in teaching settings so that awkward situations, such as the one described above, might be avoided or minimized. The policies are Professional Responsibilities in Postgraduate Medical Education and Professional Responsibilities in Undergraduate Medical Education.
“The team concept of health care today is not readily understood by much of the public. Most people expect that the most responsible physician — the one named on their health care bracelet — will be the only physician caring for them,” said Dr. Dale Mercer, chair of the college Education Committee and a surgeon affiliated with Queen’s University.
“But physicians — perhaps because of their hectic lives and the fact they are so familiar with life in the academic environment — are often unaware that the public may not be fully cognizant of the teaching milieu and have considerably different expectations,” he said.
Communication, therefore, is central to both policies, he said. It is critical that the most responsible physician or supervisor engage the patient early in a discussion about who will be members of the medical team and their roles and responsibilities. “The patient should not be surprised by the number of clinical trainees and medical students actually seeing them. They should be made aware beforehand of what is involved in a teaching setting.”
In some instances, patients will voice reluctance about having a trainee as a team member. In those situations, Dr. Mercer said it is necessary to have a conversation about the benefits of having a trainee involved in care.
“My own approach is to explain to the patient that I can’t provide the comprehensive care that they need by myself and so I work in a team environment. I will also explain that trainees may be learners, but they only perform the duties that they are capable of, with the aim of improving the health of the patient. And lastly, I make a point of explaining that it is in teaching hospitals, under the close supervision of experienced physicians, that trainees are given the opportunity to learn procedures. The kind of education that trainees need in order to manage the care of future patients can’t be replicated by reading a book or treating a “virtual” patient on a computer screen,” he said.
Dr. Mercer said that he has found, in his 18 years as an academic physician, that patients’ concerns with trainees can easily be resolved if there is an open and frank discussion about consent issues with their physician.
If a patient is adamant about not having a procedure performed by a trainee, the most responsible physician must discuss the implications of this decision with the patient, said Dr. Mercer. Patients have the right to refuse to participate in medical education; however, depending on the treatment setting, the nature of the illness, the proposed treatment, and the need for other caregivers to be involved in order to provide an acceptable standard of health care, this could mean that the patient would need to obtain care at a different institution. In the end, however, the choice must always belong to the patient, he said.
The policies also outline situations in which additional consent is necessary. For example, patients must be asked whether they would consent to a procedure or clinical contact that is for educational purposes only, whether it be a first year medical student doing a history or physical exam, or a trainee performing an electrocardiogram to learn proper lead placements. Because the patient receives no personal benefit from undergoing the procedure, the patient needs to agree to the specific contact, said Dr. Mercer.
The policies also address the college’s expectation of professional behavior and remind physicians that they have a responsibility to be a model of appropriate and compassionate care for the new generation of doctors. “The Education Committee believes strongly that the CPSO has a responsibility to make a statement about ethical and boundary issues in the postgraduate and undergraduate medical education environment,” said Dr. Mercer.
He also points out that these policies are not solely applicable to teaching hospitals, but are meant to be used in any setting where education of a trainee or medical student takes place, such as a family physician’s office or a rural hospital in which trainees have rotations.
The Education Committee also has a word of caution for private practitioners who assume the supervision of trainees/medical students who are visiting from another country. “These supervisors need to realize that they are responsible for the actions of those whom they supervise. We would recommend that these trainees be registered with an academic institution and that the supervisors familiarize themselves with these two policies,” said Dr. Mercer.
The college believes that it also has a responsibility in informing patients about what to expect in an educational setting. The Education Committee, working with the college’s Patient Relations Committee, will be developing an information sheet that will eventually be given to all patients in ambulatory or in-hospital settings in which medical students or clinical trainees participate in patient care.
Reprinted from the College of Physicians and Surgeons of Ontario website.
VICTORIA, CANADA
DOCTORS TREATING MEMBERS OF THEIR FAMILY
In the September 2003 edition of the Bulletin, the Board published a draft statement on doctors treating members of their family. After an extensive consultative process, that draft statement has been revised to reflect the thoughtful feedback received.
Introduction
The Medical Practitioners Board of Victoria believes that it is advisable for family members of medical practitioners to have an independent treating doctor. There are risks associated with medical practitioners treating members of their own family, so this should be avoided. If treatment is to be offered to family members, this should only be done after giving due consideration to the potential problems that can arise. The board has resisted defining “family members.” As a general principle, the closer the relationship, the more relevant is this statement.
Rationale
The board has developed this statement to assist medical practitioners when they are faced with the dilemma about whether to treat a member of their family. Some of the risks associated with treating family members include:
The standard of care provided to family members might be compromised as the close relationship between doctor and patient can cloud the medical practitioner’s professional objectivity and can impact on their professional judgment
The close relationship can make eliciting a complete personal history or performing a full physical examination uncomfortable for the doctor, patient or both
The close relationship can lead to an informal approach to record keeping and follow up, to the detriment of the patient’s care
Family members can sometimes exert pressure for treatment that is difficult to resist. This is particularly dangerous when the doctor is being asked for diagnosis and treatment outside the area of their expertise or the requested treatment appears to be inappropriate
The treatment of family members can result in intra-familial conflict, particularly when there is an unforeseen adverse outcome
Statement
The family member who is also a doctor can play a valuable role in the health care of family members, particularly in an advisory or advocacy role. The board recommends that:
Medical practitioners encourage family members to have an independent and trusted general practitioner to coordinate their care
Medical practitioners only discuss the health of a family member with a treating doctor with the knowledge and consent of the patient
Medical practitioners avoid being the primary treating doctor of a family member, but may be required to take on this role in an emergency or when other medical care is not accessible
If, after due consideration, a medical practitioner decides it is appropriate to treat a family member, good medical records must be maintained, the consultation should be formalized and follow up should be arranged. If the family member has a regular general practitioner, there should be communication with that general practitioner about the medical treatment given
It is clearly inappropriate for medical practitioners to treat family members in the following circumstances:
– prescribing or administering drugs of dependence (except in an emergency)
– prescribing psychotropic medication
– undertaking psychotherapy or
– performing surgery
OVERSEAS TRAINED DOCTOR UPDATES
Victoria: Cultural Training for Specific Registrants
Since January 2004, the Victorian Department of Human Services (DHS) has funded cross-cultural training for Overseas Trained Doctors (OTDs) who are permanent Australian residents and candidates for the Australian Medical Council examination. The training is designed to support the OTDs professional orientation as they begin their practice in Victorian public hospitals.
The cross-cultural training seeks to raise awareness among OTDs of the cultural context and norms of the Victorian public hospital system and Australia’s diverse cultural community. It uses a problem-centered approach to encourage doctors to test their skills in real work situations and includes:
key cultural differences and their impact on interpersonal and professional relationships
working with women as peers and supervisors
working in consultative workplace environments
doctor-patient relationships in the Australian hospital environment (including protocols for examination of women)
Australian social norms regarding spatial proximity, physical contact, personal and professional boundary issues
underpinning social values in Australian society and professions (individual rights versus collective responsibilities; rights-based system versus an obligation-based system; practical impact of confidentiality, informed consent
possible areas of conflict and effective conflict resolution
Nationally: MedicarePlus and the Australian Medical Council
The Commonwealth Government announced a package of reforms under the MedicarePlus initiatives in November 2003 including initiatives aimed at reducing red tape so an extra 750 overseas trained doctors can enter the Australian medical workforce by 2007.
The initiatives include proposals to streamline the Australian Medical Council (AMC) examination processes, issues relating to screening temporary resident doctors entering Australia and changes to the assessment for registration of overseas trained specialists. The major changes include:
new immigration arrangements
recruitment strategies
reduced red tape during approval processes
developing a generic screening examination for temporary resident doctors (based on a model in use in Canada)
“one-stop shop” assistance for employers and OTDs in arranging placements
improved training opportunities
More information about MedicarePlus can be obtained from www.health.gov.au/medicareplus/index.htm.
Overseas Trained Specialists
The Department of Health and Ageing has set up a working group to consider issues relating to assessment, registration and training opportunities for overseas trained specialists. It identified three priority issues: Area of Need assessment processes; a pathway to full specialist registration; and support and training. A stakeholder working group held in March 2004 endorsed five core principles to underpin a new approach:
consistency and transparency across jurisdictions concerning the declaration of Area of Need positions
the standard and process of assessment for competency and fitness for task for specific Area of Need positions
maintenance of safety and quality, including through access to College CPD programs
retention of applicants in Area of Need positions
provision of appropriate training and support (infrastructure) for overseas trained specialists appointed to Area of Need positions
In principle agreement was reached at the workshop on a new three-category Area of Need specialist assessment model that covers:
Overseas trained specialists with pre-recognized training and qualifications
An agreed list of acceptable qualifications will be developed and employers will assess applicants to determine their “fit” against the selection criteria and provide advice directly to the relevant State or Territory Medical Board.
Overseas trained specialists with a strong track record and verifiable qualifications and experience
Applicants will be assessed as part of the original recruitment and selection process, which will include input from the relevant Specialist College, but will not require formal assessment through the Specialist College pathway.
Overseas trained specialists whose fitness-for-task for the Area of Need position is unclear
Applicants in this category will require formal assessment through the Specialist College pathway.
Reprinted from the March 2004 and June 2004 issues of the Bulletin, published by the Medical Practitioners Board of Victoria.
LET US HEAR FROM YOU
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