ALBERTA, CANADA
REVALIDATION TAKES SHAPE
Revalidation is a quality assurance process in which physicians are required to provide evidence of commitment to continued competence in their practice.
Last year, the College of Physicians and Surgeons of Alberta (College) Council appointed a working group to make recommendations for a revalidation process in Alberta. The working group examined information from other revalidation systems, physician feedback, current measures of physician performance in the province, and how quality improvement in medical practice could be supported.
The College will use the CanMEDS competency framework of the Royal College of Physicians and Surgeons of Canada as a foundation for Alberta's revalidation program. In this framework, an effective physician is not only a knowledgeable expert with technical skill, but also one who:
Manages a practice, health information and other resources necessary for efficient and effective care,
Advocates for patients and a better healthcare system,
Collaborates with other professionals working in the best interests of patients,
Communicates in ways that seek to understand and to be understood,
Contributes to medical knowledge and the teaching of medical knowledge to others, and,
Acts ethically and lawfully in the best interests of patients.
The following working group recommendations were accepted by Council in September 2007:
The Physician Achievement Review (PAR) Program – PAR will be enhanced to provide physicians with more help in using their feedback.
CME – Physicians' commitment to lifelong learning will be measured and demonstrated through their successful participation in either the MAINPRO program of the College of Family Physicians of Canada or the MOC program of the Royal College of Physicians and Surgeons of Canada (RCPSC).
The MAINPRO and MOC programs are available to any registered physician for an annual fee; certification or national membership is not necessary for participation. More information about these programs will be published in upcoming issues of The Messenger.
By the end of 2009, all Alberta physicians must demonstrate satisfactory participation in either the MAINPRO or MOC programs in order to maintain their license.
Quality improvement in practice – The availability of electronic health records and other databases are making it easier for physicians to measure their performance indicators. Quality improvement activity that is based on measured practice performance is already a special category within the MAINPRO and MOC programs. Eventually, such activity will become a mandatory component in Alberta's revalidation program.
The College continues to work with the Alberta Medical Association and university departments of Continuing Medical Education and Continuous Professional Learning to improve resources available to assess practice performance and to improve physicians' effectiveness for their patients.
Reprinted from the February 2008 online version of The Messenger, published by the College of Physicians and Surgeons of Alberta.
MANITOBA, CANADA
PROCESS FOR WITHHOLDING OR WITHDRAWING LIFE-SUSTAINING TREATMENT RELEASED
A formal statement issued on Jan. 30, 2008, by the College of Physicians and Surgeons of Manitoba (College) will result in greater transparency, clarity and consistency in cases where the withholding or withdrawing of life sustaining treatment is being considered. The statement outlines the ethical obligations of doctors and establishes a process that they must follow prior to withholding or withdrawing life sustaining treatment. The statement is binding on all Manitoba physicians and ensures that consistent criteria and processes are followed province-wide.
“Decisions about end-of-life care are usually made by physicians together with either their patients or in the case of incapacitated patients their families, through thoughtful and open communication,” noted College Registrar Bill Pope, M.D. “These serious and important decisions are best made by patients and their physicians in an open and supportive environment, without arbitrary or unnecessary requirements. Our hope is that this statement will limit the need for outside intervention to the rare cases of irresolvable conflict.”
The statement became effective on Feb. 1, 2008, Dr. Pope noted. It represents an important step forward in end-of-life care by clarifying for physicians, other members of the health care team, patients and their loved ones what the required process is, he explained. It mandates patient involvement when withholding or withdrawing life-sustaining therapy is being considered. The statement also provides meaningful guidance and transparency through a measurable standard when decisions about withholding or withdrawing potentially life-sustaining treatment are being made.
“This statement is the result of extensive consultation and input from close to 100 stakeholder individuals and groups from across the province and country,” Dr. Pope said. “Those involved will now know what to expect and understand their rights and responsibilities during a difficult time.”
The College has tackled a difficult subject in its statement and recognizes that it may be perceived by those who advocate for more patient-driven decisions as too “doctor-centered” and by others as imposing unnecessary limits on physician autonomy. Dr. Pope stated that the College worked to achieve an appropriate balance, noting that the statement:
provides greater recognition and protection of the patient's role in the decision making process than currently exists;
emphasizes communication and seeking consensus by physicians;
requires physicians to exercise their best clinical judgment in accordance with the current standard of care through careful and thorough assessment;
prevents physicians from imposing their own value judgments on quality of life issues;
emphasizes the need for a supportive environment and the role of palliative care;
encourages physicians to seek input from others who have valuable information and/or expertise, including members of the patient's family, other members of the health care team, ethicists, social workers and chaplains.
Dr. Pope commended the Manitoba Law Reform Commission for its assistance, input and endorsement of the statement. He added that while the statement provides needed guidance, it will not eliminate the possibility of an unresolved conflict ending up in the courts. For more information contact: Dr. Bill Pope, Registrar, at (204) 774-4344 or (877) 774-4344. The statement is available on the College website: www.cpsm.mb.ca.
PHYSICIANS ORDERING LAB TESTS FOR THEMSELVES AND IMMEDIATE FAMILY MEMBERS
Recently, the Central Standards Committee of the College has been informed that some physicians have been ordering laboratory tests for themselves and for immediate family members. Article 11 of the Code of Conduct states “Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available.”
The broad interpretation of the word “treatment” is deemed to include the ordering of laboratory tests and diagnostic imaging. Members are reminded that the ordering of these procedures for self or immediate family members is a breach of the Code of Conduct and could be deemed to be professional misconduct.
ASSESSMENT OF INTERNATIONAL MEDICAL GRADUATES
The new three-month family practice assessment (FPA) is about to start its fourth group of international medical graduates. This important new assessment replaces the CAPE assessment with an onsite clinical assessment. This permits international medical graduates to demonstrate their knowledge, competence and communication skills in a real life environment. Successful candidates are mentored for the first year in practice to allow a smooth transition into the community. The College registrars are very much involved in the development of these processes and their assessment and modification that will continue actively during 2008.
CLINICAL LEARNING AND SIMULATION FACILITY (CLSF)
Completion of the 10,000-square-foot Clinical Learning and Simulation Facility in the Brodie Centre occurred in January 2008, with a grand opening anticipated soon. The facility consists of 14 clinical rooms, a conference room and a dedicated task training area. Interprofessional educational programs will focus on the continuum from undergraduate, postgraduate, continuing professional education and faculty development for individuals and teams. Simulation will be achieved using standardized patients, as well as utilization of the highest level of human simulation technology. The facility will provide an opportunity for development of expertise in collaboration with the Winnipeg Regional Health Authority. Achievement of an endowment for a Professorship in human simulation will allow the recruitment of an outstanding educator in the field.
Reprinted from the College of Physicians and Surgeons of Manitoba website.
NOVA SCOTIA, CANADA
COLLEGE TO REVIEW EXPECTATIONS OF PHYSICIANS PERFORMING INVASIVE/NON-INVASIVE COSMETIC SURGERY PROCEDURES
In keeping with its public protection mandate, the College of Physicians and Surgeons of Nova Scotia will soon consider possible policy and/or regulatory changes regarding the provision of invasive and non-invasive cosmetic surgery procedures by its members. This review, like others across the country, has been prompted by several well-publicized events, including a case in Ontario in which a patient died shortly after receiving liposuction treatment from a family physician.
As part of its review, the College will survey other Canadian medical regulatory authorities regarding their existing or planned policies, regulations and initiatives in this area. Other Canadian medical regulatory authorities are considering or have taken steps such as requiring physicians to report any changes to their scope of practice; requiring physicians to demonstrate proficiency in any new or changed competencies to the satisfaction of the regulatory authority; accrediting cosmetic surgery facilities; and undertaking public education campaigns that encourage prospective cosmetic surgery patients to question practitioners about their relevant training, qualifications and experience.
JOINT POSITION STATEMENT ON PATIENT SAFETY
The College of Physicians and Surgeons of Nova Scotia (College) released a joint statement on patient safety together with the College of Licensed Practical Nurses of Nova Scotia, the College of Occupational Therapists of Nova Scotia, the College of Registered Nurses of Nova Scotia, the Nova Scotia College of Pharmacists and the Nova Scotia College of Physiotherapists. The complete statement can be found on the College website at the following link: www.cpsns.ns.ca/2008-joint-patient-safety.pdf
FROM THE INVESTIGATIONS COMMITTEES
The following summaries describe cases examined by the College's Investigations Committees. This information is provided for educational purposes. All names and certain details have been changed to preserve confidentiality.
Importance of clear and defined professional boundaries
Dr. White is a 39-year-old female physician in practice for eight years. Dr. White started seeing the Brown family in May 2006. On several occasions, Dr. White saw Mr. Brown and Mrs. Brown separately or together with their 10-year-old son. In March 2007, Dr. White saw Mr. Brown for problems related to his mood and marital problems. Between March and September 2007, Dr. White saw Mr. Brown five times for marital problems.
Dr. White and the Brown family lived in the same neighborhood. Both families had a son on the same soccer team. Often Dr. White and Mrs. Brown would take turns taking the children to soccer practice and participated together in team fundraisers. The two families had traveled together to an out-of-town soccer tournament in August 2007.
On Sept. 6, 2007, Mr. Brown moved out of the family residence into his own apartment. On Sept. 27, 2007, Mrs. Brown filed a complaint with the College alleging that Dr. White was having an affair with her husband at the same time that she was seeing the family as a physician and involved in their son's soccer team.
Dr. White denied having an intimate relationship with Mr. Brown. Dr. White admitted to seeing Mr. Brown during the summer of 2007 for marital counseling. She did not feel that there was a conflict between seeing Mr. Brown as a patient for counseling and her relationship with the family outside the office. Dr. White stated she thought very highly of the family and really wanted to help Mr. Brown with his problems.
The Investigation Committee reviewing the complaint found no evidence to support the allegation that Dr. White and Mr. Brown had an intimate relationship. The Committee was concerned by the lack of professional boundaries that Dr. White had with the Brown family. The Committee was of the opinion that Dr. White had both a real and perceived conflict by providing counseling to Mr. Brown, while at the same time she had a personal relationship with the Brown family. The Committee believed it would have been prudent for Dr. White to have referred Mr. Brown to another professional for marital counseling.
The Committee therefore issued a Counsel* to Dr. White to maintain clear and defined professional boundaries at all times in a doctor-patient relationship.
* A Counsel is advice as to how to improve the physician's conduct or practice. A Counsel is kept in the physician's file but is not disclosed to the public, on Certificates of Standing or to other licensing authorities without the physician's consent.
Complaint alleges benefits denied due to physician's comments
Mr. Green is a 48-year-old man who has worked in the fishing industry since age 16. He has been a patient of Dr. Black for 15 years. Dr. Black is a 55-year-old physician in practice for 26 years. Dr. Black saw Mr. Green for back injuries on several occasions in 2005 and 2006. Throughout this time, the injuries had resolved and Mr. Green was able to continue his employment. On June 3, 2007, Mr. Green saw Dr. Black after he fell at home on a wet garage floor. Dr. Black diagnosed Mr. Green with low back pain and recommend anti-inflammatory medication and physiotherapy. Mr. Green attended physiotherapy on June 7, 2007 and began treatment on June 16, 2007.
Mr. Green attended physiotherapy for three sessions between June 21 and July 15, 2007. During this time he was unable to work due to back pain. On July 18, he saw Dr. Black and stated that his back was not getting better. Dr. Black examined Mr. Green and recommend that he continue with physiotherapy for a further month. Mr. Green attended physiotherapy on one more occasion, then failed to attend two more appointments and was discharged by the physiotherapy office. Physiotherapy assessment notes for all of Mr. Green's appointments were sent to Dr. Black.
On Sept. 4, 2007, Mr. Green visited Dr. Black and stated that he wanted to apply for the Canada Pension Plan (CPP), as he was still in pain and had no further disability insurance with his employer. At this point, Mr. Green was on medical employment insurance that was about to end. Dr. Black examined Mr. Green and told him that it was his opinion that Mr. Green would get better with more physiotherapy. Mr. Green stated that physiotherapy did not help him and that he wanted to apply for CPP. Dr. Black said it was his experience that people with problems similar to Mr. Green 's were often denied CPP. Mr. Green indicated that he wanted to apply for CPP nevertheless and left the application for Dr. Black to complete. Dr. Black completed the forms and included a copy of the physiotherapy assessments and the dates in which Mr. Green attended his office with his diagnosis. Mr. Green picked up the forms on Sept. 8, 2007.
On Nov. 1, 2007, Mr. Green filed a complaint with the College, alleging that because of Dr. Black's comments on the CPP application, he was denied benefits. Mr. Green alleged that Dr. Black did not believe that he was in pain and that Dr. Black had lied on the application. In his response, Dr. Black stated that he believed Mr. Green was in pain and had hoped that physiotherapy would relieve the pain and help Mr. Green return to work. Dr. Black stated that he did not make any judgmental comments regarding Mr. Green's eligibility for CPP and had only supplied the information requested, including the physiotherapy notes.
The Investigation Committee reviewing the complaint received and reviewed Dr. Black's medical record of Mr. Green and a photocopy of the CPP application that Dr. Black had retained on the record. Based on the documentation reviewed, the Committee was in agreement that Dr. Black had provided the necessary information requested on the CPP application and did not make any comments regarding Mr. Green's eligibility. The Committee found Dr. Black's notes to be thorough and very neatly written. For these reasons, the Committee was of the opinion there were no grounds to take any further action regarding the complaint. The complaint file was closed.
Reprinted from the College of Physicians and Surgeons of Nova Scotia website.
ONTARIO, CANADA
THE SAFETY IMPERATIVE: ENHANCED OVERSIGHT FOR COSMETIC SURGERY
With the increasing popularity and easy accessibility of cosmetic surgery, it is little wonder that patients contemplating a change in their appearance may be inadequately informed, or sometimes even cavalier, about the serious nature of elective cosmetic surgical procedures.
One medical journal survey found that many prospective patients believe that such surgery is less risky, has a shorter recovery time and is less technically difficult than any other surgery. In fact, they would appear to believe that cosmetic surgery is not fundamentally medical. Perhaps that explains, says the survey's authors, why many, if not most, patients rarely seek a referral from their family doctor.
There is little doubt that these critical decisions to undergo surgery are being made in an information vacuum, said Jeff Turnbull, M.D., president of the College of Physicians and Surgeons of Ontario (College). “Patients have not had enough information to allow them to be evaluating the risks of cosmetic surgery appropriately. Certainly, there has been little information available about the regulatory framework in which private cosmetic clinics operate, the relative training of the physicians or about the risks associated with the procedures,” he said.
At its meeting in April, Council acknowledged its unease with the situation. Council members, however, were not just concerned with the dearth of unbiased public information. They were also unsettled by the fact that the rapidly expanding field of cosmetic surgery had outpaced our ability to effectively regulate this area of practice. Physicians from a variety of practice backgrounds were now providing a new range of services to patients in a wide variety of settings. Were they qualified to be performing these procedures, some of which can lead to significant complications and harm to the patient? Council wasn't entirely sure.
The College has had a change of scope policy, published in 2002, which established the expectation that physicians should report to the College before changing the scope of their clinical practice to an area of medicine in which they do not have appropriate training or recent experience. The College's experience to date indicates, however, that relatively few physicians contact the College about changing their scopes.
At the April meeting, Council committed to a patient safety plan that would enhance regulatory control over the practice of cosmetic surgery. The plan began by obtaining complete information on the practice of physicians who perform cosmetic procedures.
Throughout the summer, the College identified those physicians that it believed were practicing in the cosmetic field. At the same time, a risk matrix was being developed to analyze the relative risk of procedures taking into account the nature of the procedure itself, the training of the physician performing it and the facility in which it was being performed.
In October, the College sent out a questionnaire – for which completion was mandatory – asking physicians where they practiced, the services provided in their facility or facilities and the formal training and continuing professional development that has been completed. On the basis of the information collected, the College will be assessing the practices of those physicians whose areas of practice – procedures, training and facility – appear to require immediate attention. These assessments are expected to begin shortly. Their ambit will be to determine whether safety standards are met in the practices and where, if at all, there may be room for improvement.
When Council met in November, the discussion about patient safety and cosmetic surgery resumed and even more ambitious elements for the safety plan were articulated, some which will necessitate regulatory change.
“The College has the responsibility to support patients in making informed decisions that may help mitigate the patient safety risk and to assure that physicians providing cosmetic procedures in Ontario are qualified, competent and practicing in environments that foster patient safety,” said Dr. Turnbull. “This multi-pronged plan will see the College vigorously regulate the practice of cosmetic surgery in Ontario,” he said.
Preston Zuliani, M.D., the College's vice president, said it was imperative that the College take a hard stand on this issue. “We need to be assured that the only physicians performing cosmetic surgery are those who are qualified to do it,” said Dr. Zuliani. “The public perception of cosmetic surgery is that it is quick and easy. Most cosmetic surgeries, however, are extremely complex and require a high degree of anatomical knowledge and surgical skill, including the ability to manage both life-threatening and other forms of complications. The Council is of one mind on this issue – training, accreditation and continuing medical education are just as important in cosmetic surgery as in other branches of surgery,” he said. The new plan approved at Council's November meeting includes the following:
Scope of Practice Changes
A bylaw is being developed that will make it mandatory for physicians to report to the College before changing the scope of their clinical practice to an area of medicine in which they do not have appropriate training or recent experience. The physician must undergo a College assisted assessment of knowledge, judgment and skills before beginning to practice in the new area of focus or specialization.
Titles
Physicians will only be able to use the title of “surgeon” if they are approved either by this college or the national accreditation bodies. This too will require a regulatory change.
Regulation of Out-of-Hospital Facilities
An increasing number of physicians are providing cosmetic procedures, involving invasive surgical techniques outside of the hospital environment. The training and qualifications of those performing high risk procedures are unknown. We are evaluating different approaches that could be used to oversee out-of-hospital facilities/clinics. A number of regulatory models exist in other jurisdictions.
Targeted Assessments – High Priority Circumstances
We are preparing to assess all physicians who have been deemed to require immediate attention based on their reported training, the nature and frequency of the procedures they perform and where they practice. We are obtaining information about the procedures performed, training to perform the procedures, where they practice (hospital, out-of-hospital), and the supports within their practices (e.g., anesthesiologists, nurses, etc.).
Panel of Expert Advisors
We have convened a panel of experts to identify high risk cosmetic procedures and the training required to perform such procedures.
Public Education
We have developed an easy to understand public information package to educate the public about cosmetic procedures, including their risks. It is critical that the public is made aware of the fact that all surgeries come with risk. We have developed comprehensive questions and answers for the public to ensure they have the best possible information to assist in making decisions about their health care.
Information about Physicians
We are looking at the questions that we require physicians to answer on an annual basis. We believe that we may require additional information from physicians. The possible mandatory questions that could be asked do not directly flow from the cosmetic procedures project. However, they represent areas of public interest in which information availability about physicians to the College could be improved.
Advertising
The College has a regulation that sets out the profession's responsibilities in advertising. There is a need to review the content of the regulation and the process by which the College addresses concerns about advertising. The matter is currently under review and options will be returned to Council in the first half of 2008.
Reprinted from the December 2007 online version of MD Dialogue, published by the College of Physicians and Surgeons of Ontario.
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