ALBERTA, CANADA
IMG MEDICAL PRACTICE OBSERVERS
Some physicians have been reluctant to accept International Medical Graduate (IMG) physicians as observers in their practice unless the observers have their own Canadian Medical Protective Association (CMPA) coverage. As these individuals are not eligible for a license (and one is not required for the supervised activity they would participate in as observers) they are not eligible for CMPA membership.
The CMPA has stated that under the conditions outlined in the Medical Practice Observation/Experience Guideline, physician members of the CMPA may be eligible for CMPA assistance for circumstances that may arise while the observer was present. Physicians are encouraged to offer IMGs an observation opportunity and to consult the Medical Practice Observation/Experience Guideline for detailed information on what the supervising physician's responsibilities are. Consult the CMPA for further advice about liability concerns.
STANDARDS OF PRACTICE: CLEAR, CONCISE RULES FOR ALBERTA PHYSICIANS
When the College moves from under the Medical Profession Act to the Health Professions Act (HPA), the College is required to develop Standards of Practice for physicians.
Standards of Practice represent the minimum standard of professional behavior and good practice all Alberta physicians are expected to meet. They are essentially the “rules” doctors must follow, and will replace the College's existing policies and guidelines. The expectations outlined in the Standards of Practice are generally not new – they reflect existing expectations outlined in the College's policies and guidelines.
The main advantage of the Standards is that they are written in clear, concise language, and describe what type of behavior is acceptable. Although the HPA is not expected to be implemented until 2009, the College's executive team has already drafted many of the new Standards. As physician input will play an important role in the final version of the Standards, a stakeholder consultation process has been scheduled for the fall of 2008.
More details on the consultation process will be available in the August issue of The Messenger and on the CPSA website at www.cpsa.ab.ca.
Reprinted from the June 2008 version of The Messenger, published by the College of Physicians and Surgeons of Alberta.
NOVA SCOTIA, CANADA
COLLEGE ENDORSES FMRAC POSITION ON PHYSICIAN REVALIDATION
At its March 28, 2008, meeting, the College's Council endorsed the following Position Statement on Physician Revalidation that was developed by the National Revalidation Working Group of the Federation of Medical Regulatory Authorities of Canada (FMRAC). Colleges in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Prince Edward Island and Newfoundland have already endorsed this statement.
All licensed physicians in Canada must participate in a recognized revalidation process in which they demonstrate their commitment to continued competent performance in a framework that is fair, relevant, inclusive, transferable and formative.
Fair: The process of revalidation is transparent to the physician, uses fair and standardized tools, and is considerate of cost and administrative burden to the physician.
Relevant: The process of revalidation is designed to confirm a physician's competence within the scope of his or her practice.
Inclusive: Revalidation applies to all licensed physicians.
Transferable: Participation in the process of revalidation will be mutually recognized by each Canadian jurisdiction and will not inhibit mobility in Canada.
Formative: The process of revalidation is a constructive educational quality assurance process, independent and distinct from the disciplinary processes of the regulatory authorities.
The full FMRAC document is available at www.fmrac.ca/policy/revalidation_eng.html
Within the next year or so, Council will assess options for an approach to revalidation in Nova Scotia that embodies these principles. It is likely that periodic assessment by the Nova Scotia Physician Achievement Review (NSPAR) combined with appropriate participation in the maintenance of certification programs of either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada will be seriously considered as requirements for revalidation in Nova Scotia. Such an approach has the advantage of creating little or no added obligation for most physicians licensed here. Further information about revalidation will be provided to members as it becomes available.
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.
Maintaining security and confidentiality of patient information
On Jan. 10, 2008, the College received a package of laboratory results from Mrs. Brown, who had found them unattended at a community hockey arena the previous weekend. Mrs. Brown filed a complaint against Dr. White, to whom she believed the documents belonged, noting that Dr. White was often seen working on medical charts while at his son's hockey practice and did not appear to be concerned about patient confidentiality. The results contained hematology and chemistry findings and personal information for five individuals. The complaint was forwarded to an Investigation Committee for review.
In responding to the complaint, Dr. White, a 46-year-old cardiologist, stated he often used his Saturday mornings at the arena to finish paperwork he had not completed during the week and admitted to reviewing patient information in a public place on at least five occasions. He stated that he was unaware that he had left the laboratory results at the arena, but that nothing like this had ever happened before. He apologized to the Committee for the incident.
The Investigation Committee was concerned that patient confidentiality had been breached when Dr. White had taken patient charts to a public location. The Committee was further concerned that until Dr. White received the complaint, he was unaware that patient information was missing from the files he had taken to the arena. On April 16, 2008, the Investigation Committee issued a Caution* to Dr. White that he had a professional responsibility to maintain and protect patient confidentiality and that he must ensure that patient data is reviewed in a secure and confidential manner.
Undertaking regular screening for chronic disease in long-term patients
On Dec. 22, 2007, the College received a complaint from Mrs. Green regarding her former physician, Dr. Grey. Mrs. Green had applied for life insurance in September 2007 and had signed a consent to allow the insurance company to receive a copy of her medical file from Dr. Grey. Dr. Grey forwarded a copy of the record for the period of 1997 to 2007 to the insurance company. On Oct. 22, 2007, the insurance company informed Mrs. Green that because of her pre-existing diabetes and chronic renal failure, she was being denied an insurance policy. In her complaint, Mrs. Green stated that she had been unaware that she had diabetes before being informed by the insurance company.
After hearing from the insurance company, Mrs. Green contacted Dr. Grey's office and obtained a copy of her medical record. Mrs. Green's daughter, a registered nurse, reviewed the record. Laboratory results done in 1997 showed a random blood Glucose level of 22 mmol/l and a Creatinine level of 160 μmol/l. Other laboratory results from 2004 showed a Glucose level of 21 mmol/l and a Creatinine level of 310 μmol/l. In her complaint, Mrs. Green asked why Dr. Grey had not told her that she had diabetes or had treated her for the problem. She stated that she had transferred her care to another family physician who had begun to treat her diabetes and had referred her to a nephrologist.
Dr. Grey, a 60-year-old physician, stated in his response to the complaint that he had been Mrs. Green's family physician for 30 years. He stated that Mrs. Green was diagnosed in 1996 with Multiple Sclerosis and that at times she was unable to walk. Because of Mrs. Green's problems with walking, Dr. Grey started to see her at home. Dr. Grey stated he had seen Mrs. Green at home every month for the last ten years. He described Mrs. Green as a pleasant woman and that the nature of the visits usually involved discussing her pain and muscle weakness. He had drawn random blood samples from Mrs. Green on the two occasions noted in the chart when she had complained of a possible fever. Dr. Grey outlined in his response that he had no explanation for the lack of follow-up or routine screening of Mrs. Green, other than he might have become complacent by the nature of their regular visits and the absence of any major or new complaints.
In its review of the complaint, the Investigation Committee examined Dr. Grey's medical record of Mrs. Green. The record contained documentation demonstrating the regular monthly visits, but did not contain any laboratory results apart from those noted in the complaint. There were also no other investigations or consultations noted. The Committee requested an audit of Dr. Grey's practice. A chart audit conducted of 75 of Dr. Grey's office records found documentation that indicated the appropriate screening for chronic and relevant diseases in all of the charts reviewed.
The Committee agreed that Dr. Grey, due to the regular and informal nature of his house calls, had not provided the same degree of surveillance and investigation of Mrs. Green's problem that would have happened if scheduled and problem-oriented appointments had occurred. The Committee was concerned that this led to a lack of follow-up and investigation of abnormal lab results. The Committee was of the opinion that the deficiencies in Mrs. Green's care appeared to have been an isolated event. The Committee also noted that Dr. Grey had recognized how this variance in his practice had occurred and had acknowledged its potential consequences.
The Committee issued a Caution* to Dr. Grey to provide and maintain a high level of screening and surveillance for chronic diseases for all his patients.
* A Caution is intended to express the dissatisfaction of the Investigation Committee and to forewarn the physician that if the conduct recurs, more serious disciplinary action may be considered. A Caution 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.
Reprinted from the Spring/Summer version of ALERT, published by the College of Physicians and Surgeons of Nova Scotia.
ONTARIO, CANADA
COUNCIL APPROVES AMENDMENT THAT LIMITS USE OF SPECIALIST TITLE
Council demands clear, accurate communications about credentials
At its April meeting, Council approved amendments that will require physicians to be clear and accurate about their credentials and training in their advertising and other communications with patients.
Council's approval of the regulation amendments means that doctors can only imply specialty and subspecialty titles if they are eligible to use the titles of the Royal College of Physicians and Surgeons of Canada (RCPSC) or the College of Family Physicians of Canada (CFPC). A general practitioner who doesn't have a surgical designation by the RCPSC, for example, will not be able to advertise that he is a surgeon or imply that he does surgery in his practice description.
The intent of the regulations is not to restrict practice; they restrict how doctors refer to themselves. Needed medical services will not disappear by virtue of these amendments. Under registration policies, the CPSO will recognize individuals as specialists in accordance with comprehensive criteria, but within this recognition, will only use the designations as set out by the RCPSC. In other words, these amendments will not see the CPSO creating any new specialty or subspecialty designations – the College will only recognize those designations of the RCPSC and CFPC.
The College will submit the approved regulation amendments to the Ministry of Health and Long- Term care for its consideration.
Change of scope, re-entry to practice policies revised
Council has updated two policies that clarify requirements when physicians want to change their scope of practice or wish to re-enter clinical practice after a prolonged absence.
The objective of the changing scope policy is to ensure that physicians have the skills, training and experience necessary to practice in the area in which the physician chooses to practice.
The policy sets out the College's requirements for physicians to demonstrate their competence in the new area of practice. The requirements will be individualized for each physician but, in general, the core activities involved are training; supervision; and assessment. The re-entry to practice policy applies to physicians who have been out of practice for a period of at least three years or who have practiced less than a total of six months in the preceding five-year period and who intend to enter the same type of practice in which they were previously involved. The policy applies to physicians even if they have continuously maintained their certificate of registration during their absence from practice.
In accordance with the bylaw, when asked by the College, whether in the annual renewal form or elsewhere, physicians must report to the College when they wish to change their scope of practice or when they wish to re-enter practice after an absence.
Pharmacists' extension of prescriptions Council has endorsed a draft agreement that will allow pharmacists to extend prescriptions under specific circumstances. The Ontario College of Pharmacists (OCP) has a regulation-making power under the Drug and Pharmacies Regulation Act authorizing the OCP to make regulations about how a prescription can be refilled without a further prescription. Such a regulation would make it legal for pharmacists working in community pharmacies to extend prescriptions.
The Pharmacist Authorization of Prescription Extensions Agreement will ensure consistency in a practice that has been previously done on an informal, unofficial basis. Under such an agreement, all pharmacists will be looking at the same conditions which must be met in order to extend prescriptions.
Council agreed that there is a definite patient need for prescription extensions and this draft agreement appears to address this need. The agreement provides appropriate patient safety mechanisms – for example, no narcotics; patient must have a stable history; only for certain medical conditions; and the physician must be notified within one week if a pharmacist has extended the prescription.
The OCP has stated that it is not seeking prescribing authority for pharmacists but considers extending prescriptions to be an essential part of the medication management role of pharmacists
Reprinted from the Volume 4, number 2 online version of MD Dialogue, published by the College of Physicians and Surgeons of Ontario.
LONDON, ENGLAND
COUNCIL APPROVES AMENDMENT THAT LIMITS USE OF SPECIALIST TITLE
New research supports the potential for using patient and colleague questionnaires in the revalidation process
New research commissioned by the GMC and published June 3, 2008, confirmed patient and colleague questionnaires may offer a reliable method for assessing the professional performance of UK doctors.
The pilot study, led by Prof. John Campbell, Foundation Professor of General Practice and Primary Care at Peninsula Medical School, involved 541 doctors who were assessed by their colleagues and patients using standardized questionnaires developed by the GMC.
The patient questionnaire focused on gathering the views of patients on a doctor's communication skills, ability to explain conditions and treatments and to involve the patient in the decision-making process. The colleague questionnaire asked that colleagues give their views on a number of key issues such as a doctor's clinical knowledge, teaching skills and prescribing.
A white paper on the regulation of health professionals published in 2007 confirmed patient and colleague questionnaires would become a key element in the revalidation of doctors in the future. This new research confirms that patient and colleague questionnaires, developed by the GMC, have potential as a means of collecting information regarding doctors' performance.
This is an important study as it is essential that any such tools used for assessing the professional performance of doctors, as part of the revalidation process, are adequately researched and validated.
The GMC has now commissioned the research team, led by Prof. Campbell, to undertake more in-depth testing of the questionnaires across whole organizations and in different clinical settings. The outcome of this further research piece will help underpin work on evaluating the professional practice of doctors as part of the revalidation process.
“The revalidation of UK doctors is an important development in the regulation of the medical profession,” said Prof. Campbell. “Only by adopting processes thoroughly grounded in research evidence can patients, society and the medical profession have confidence in the evaluation of a doctor's professional performance. This study provides that initial confidence. And, in line with aspirations recently expressed in the government's white paper, Trust, Assurance and Safety, these tools appear to offer doctors the possibility that they can provide real evidence in relation to their clinical practice. Our current work will provide further evidence on the utility of feedback obtained from patients and colleagues in identifying those doctors whose performance might require further scrutiny.”
Reprinted from the General Medical Council UK website.
NEW ZEALAND
THE NEW ZEALAND MEDICAL WORKFORCE IN 2006 — WORKFORCE SURVEY RESULTS
On March 18, 2008, the Medical Council of New Zealand released The New Zealand Medical Workforce in 2006. During the 2006 survey, 11,662 survey forms were sent out to doctors with New Zealand addresses and an annual practicing certificate. Of those 10,035 doctors responded giving a response rate of 86 percent.
The survey results include only the 9,547 doctors in “active employment”, working four or more hours per week. Prof. John Campbell, the Council's chairperson said key facts from the survey were:
Using registration data to estimate the annual growth in the number of active doctors shows an increase in the active workforce of 7.7 percent from 2005 to 2006.
The proportion of women doctors increased to 37 percent of the total workforce; 57 percent of house officers; 43 percent of GPs; and 32 percent of specialists including GPs. Women made up only 24 percent of hospital specialists.
The proportion of international medical graduates (IMGs) rose by just under three percent to 40 percent of the workforce. They made up 31 percent of house officers, 41 percent of GPs and 40 percent of specialists including GPs. These increases may result from the change to the sampling frame of the questionnaire (see “Method” section). So rather than representing an increase, the 2006 figures most likely give a more accurate picture of the role of IMGs in the medical workforce.
Accident and medical practice, family planning and reproductive health, neurosurgery, palliative medicine, psychiatry, radiation oncology and rehabilitation medicine had more than 50 percent IMGs.
The increase in the proportion of IMGs was most notable in accident and medical practice (from 50 percent to 64 percent), emergency medicine (35 percent to 47 percent), musculoskeletal medicine (29 percent to 40 percent) and vascular surgery (25 percent to 43 percent). There were also notable decreases in the proportion of IMGs in medical administration (55 percent down to 38 percent) and rehabilitation medicine (71 percent to 60 percent).
The proportion of Maori doctors was 2.5 percent (240 doctors) in 2006, 2.6 percent in 2005, while Pacific Island doctors were1.6 percent (155 doctors) in 2006 and 1.5 percent in 2005. Both of these groups continue to be markedly underrepresented compared to their proportion in the population. The 2006 census indicates that 14.6 percent of New Zealand residents identify as Maori and 6.9 percent identify as Pacific Island people.
On the workforce survey, general practitioner numbers increased by 6.2 percent and are now beginning to approach the year 2000 level of 3,166.
Medical officer numbers continue to increase steadily and are up 18.8 percent since 2002. Only 17 percent of medical officers reported being in vocational training, and 84 percent listed public hospital as their main workplace.
41 percent of medical officer hours were spent in emergency medicine or psychiatry, with the next largest work type being internal medicine (12.5 percent).
59 percent of medical officers were international medical graduates and 44 percent were women.
All vocational trainees in breast medicine, family planning and reproductive health and sexual health medicine were women. Women also outnumbered men in training in obstetrics and gynecology (63 percent), pediatrics (72 percent), palliative medicine (63 percent), pathology (61 percent), public health medicine (78 percent), radiation oncology (73 percent) and otolaryngology, head and neck surgery (56 percent).
Vocational scopes where women outnumbered men were breast medicine and sexual health medicine. All doctors working in breast medicine were women. In sexual health medicine, 83 percent of doctors were women.
Retention of New Zealand doctors
A review of graduate retention statistics since the introduction of the Medical Practitioners Act in 1995 continues to show that by the third year after graduation about 25 percent of doctors are not practicing in New Zealand. On average 81.9 percent of graduates are retained by the second year after graduation, dropping to 74.2 percent by the third year.
After this, the retention average increases slightly in years four and five, and then slowly decreases again through years six to 11. There is little variance in the percentage of registered graduates retained in any given postgraduate year across the class years analyzed.
There are no firm statistics about what medical graduates do if they do not register to do their intern year in New Zealand. Figures do include fee-paying students, and the initial drop in retention may possibly be caused by these graduates returning to their sponsoring countries. Others do their internship overseas, and some have the year off.
The Council does not collect information about doctors no longer practicing in New Zealand. They may be practicing overseas, or not practicing at all. Some doctors leave New Zealand to gain postgraduate qualifications and then return some years later.
Retention of international medical graduates
Less than 50 percent of IMGs are retained in the year immediately after initial registration. This trend has been consistent across the period analyzed with little variance in the proportion retained.
After this initial drop, the percentage of IMGs continues to reduce gradually, dropping to just fewer than 33 percent in the third year after initial registration. Doctors from Asian countries have the highest retention rate, followed by South African doctors and then European doctors.
More than 50 percent of doctors from Asian countries are retained even six years after registration. The retention rate of South African doctors drops below 50 percent only after five years. Doctors from the United States and Canada have the lowest retention rate, with less than 30 percent at one-year after registration and less than 10 percent as early as four years after registration.
Doctors from the United Kingdom also have lower than average retention rates. Fewer than 30 percent of these doctors are retained two years after registration, and the rate drops below 20 percent after six years.
These figures suggest that doctors from North America and the United Kingdom are more likely to come to New Zealand to work for a limited period than doctors from Asia, South Africa and Europe.
Reprinted from the Medical Council of New Zealand website.
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