VICTORIA, AUSTRALIA
PATIENT AND PRESCRIBER IMPACTS
Significant health benefits can be derived from the safe and effective prescribing and use of benzodiazepines, opioids and other potentially addictive medications. However, there is also the potential for these medications to result in significant negative health and social consequences as detailed by the Parliamentary Committee. Responsible, safe and legal prescribing of medications is in the interests of the community, the medical profession generally and individual prescribers.
When the board has investigated inappropriate or dangerous prescribing, it has usually been the result of ignorance, naïveté or the inability to refuse a patient's request for medication. Regardless of the reasons for the prescribing, the consequences have often been harmful and have included:
the death of the patient
delayed treatment of the patient's medical condition substance abuse resulting in dependence or the maintenance of dependence
social consequences for the patient, their family and others
diversion of medication and illegal sale.
Consequences for the prescribing practitioner have included:
gaining a reputation as a 'soft touch‘ in the community, and particularly by drug seeking patients who begin to dominate the practice;
prosecution for not complying with the Drugs, Poisons and Controlled Substances Act 1981 and the Drugs, Poisons and Controlled Substances Regulations 2006;
investigation by the Medical Practitioners Board of Victoria, including at disciplinary hearings which can generate adverse publicity;
restriction on prescribing rights.
Medical treatment – prescriber responsibilities
Medical practitioners must only administer, prescribe, sell or supply Schedule 4 and 8 poisons:
1. for the medical treatment of a person under their care;
2. after taking all reasonable steps to ascertain the identity of the person to whom they will administer, prescribe, sell or supply S4 or S8 poisons; and
3. after taking all reasonable steps to ensure a therapeutic need exists for that drug or poison.
It is not acceptable to prescribe:
4. anabolic steroids for bodybuilding purposes or to enhance sporting performance;
5. stimulants merely to enhance or prolong wakefulness in long distance drivers;
6. additional opioids for patients receiving opioid substitution treatment from another practitioner;
7. for people who are not under the doctor's care, such as a resident in another country, or people who have not personally consulted the doctor, including internet-based prescriptions (see Board Statement: Countersigning Prescriptions for Patients Overseas).
When prescribing drugs of dependence, medical practitioners should:
make their own assessment about whether to prescribe a drug of dependence on the basis of their clinical judgment. A drug of dependence should not be prescribed just because it has been prescribed previously.
regularly review whether ongoing treatment with drugs of dependence is necessary.
Before prescribing a drug of dependence:
consider whether there are other options for treatment, such as nonpharmacological treatments or non addictive pharmacological treatments
ask what other prescribed and over the counter medications the patient is taking.
In particular, ask about any products containing codeine
inform the patient of the potentially addictive nature of the drug
inform the patient of the potential side effects, consequences of drug interactions and risk of overdose
consider whether the patient is at risk and whether strategies such as limiting amounts prescribed or arranging for small quantities to be obtained from a nominated pharmacy are indicated
inform the patient that this is intended to be a short-term measure
refer the patient to a relevant specialist or specialist unit for advice and management early if this is indicated.
For example, patients with chronic pain may benefit from review by a pain management specialist. It is acknowledged that waiting times for such an appointment can be lengthy but the patient will be seen sooner if an early referral is made – document in the medical record what is prescribed, the indications for prescribing and any discussions with the patient about side effects, warnings etc.
Legal requirements for prescriptions
When prescribing medication, medical practitioners must comply with the Drugs, Poisons and Controlled Substances Act 1981 and the Drugs, Poisons and Controlled Substances Regulations 2006. This is regardless of whether or not the medication is prescribed as a pharmaceutical benefit.
Failing to comply with the legislation and regulations puts practitioners at risk of prosecution as well as investigation by the board.
Prescriptions for Schedule 4 and 8 poisons must:
contain full details of the prescriber, including name, address and telephone number
contain the patient's name and address
identify the medication unambiguously
show the quantity and number of repeats in words and figures for Schedule 8 poisons
be signed by the prescriber, preferably in a manner that prevents a patient from adding an additional item above the prescriber's signature
contain precise directions for administration, except if directions are too complex and are provided separately in writing or if administration is to be carried out by a doctor or nurse.
Reprinted from the March 2009 issue of the Bulletin, published by the Medical Practitioners Board of Victoria.
ALBERTA, CANADA
INSPECTIONS OF MEDICAL PRACTICES AND OTHER CHANGES TO THE HEALTH PROFESSIONS ACT (HPA)
The Health Professions Amendment Act (Bill 46) was introduced on Nov. 6, 2008, passed third reading on Nov. 21, 2008, and will come into force on proclamation (no date set at this point). Some of the changes to the Health Professions Act (HPA) will affect Alberta physicians.
Inspections of Medical Practices
The College of Physicians and Surgeons of Alberta (College) monitoring and quality improvement programs generally take an approach that engages the physician in a conversation about his or her practice and then facilitates changes to practice, when needed. For instance, many physicians have received letters from the College about their Triplicate Prescription prescribing and have engaged in a dialogue that ended with affirmation of their current practice or with their agreement to make improvements. Our recent program focusing on the cleaning and sterilizing of reusable medical equipment in members' offices is another example.
This consensual and collaborative approach to quality improvement has worked and will continue to be the preferred way the College conducts programs to monitor practices and promote improvements.
Some time ago, we asked government to ensure that authority to operate practice improvement programs that require access to information on members' practices would continue under the Health Professions Act (HPA). Originally the HPA limited a college's access to information about a member's practice to circumstances of complaint investigations and to continuing competence programs (e.g. the College's PAR Program).
Government's response is an amendment to the HPA in Bill 46 giving a college the authority to inspect a member's practice to determine compliance with standards of practice and conduct without the need for a complaint investigation. Although this is not exactly what we asked for, we can accept it. Regardless of the power granted by the HPA amendment, our intent is to limit mandated inspections to the investigation of a complaint about a member's practice. Non-consensual inspections are better reserved for circumstances when they are absolutely necessary; such as when we are unable to engage a physician in a collaborative process.
Abandoned Patient Records
Bill 46 also created a new responsibility for each health profession's college – a responsibility for abandoned patient records. While not a new concept to our members, all colleges under the HPA will be required to ensure that their members have enduring arrangements in place for the care of patient records after they leave a practice. When a physician dies or otherwise leaves practice, patients' records are occasionally abandoned with no available and qualified custodian in place.
These amendments place the responsibility for safekeeping of those records on the College, which becomes the trustee unless, or until, an appropriate custodian can be found. They also provide the Courts with the ability to seize files and to impose financial liability on a member or an estate for the costs incurred by the College. Details will become clearer as the regulations are developed.
Continuing Competence Programs
Another amendment transfers the College's Physician Achievement Review (PAR) Program from the HPA to our own regulations, making its placement consistent with other professions. This change will have no impact on the way the College operates PAR.
Medical Facility Assessment Committee
Finally, amendments also transfer the authority for accrediting a medical facility from Council to the Medical Facility Assessment Committee – leaving Council with the more appropriate role as an appeal body for Committee decisions. None of these amendments will have an impact on the operations of the College until we come under that legislation, now likely late in 2009.
STANDARDS OF PRACTICE
Sometime in 2009 the Alberta government is expected to announce that the College of Physicians and Surgeons of Alberta will move from under the Medical Profession Act to the Health Professions Act (HPA).
In compliance with HPA requirements, the College recently prepared draft Standards of Practice for Alberta's medical profession. Most of the standards are not new. They were developed by drawing on current College policies and guidelines. These draft documents contain the minimum standards for professional behavior and practice. These standards will be a benchmark for adjudicating complaints regarding physician conduct.
During the consultation process from Sept. 1, 2008 to Nov. 3, 2008, the College received hundreds of written submissions from:
physicians
medical groups
other regulatory bodies
regional health authorities
the public
interest groups
We also held discussion groups in both Edmonton and Calgary. Stakeholder feedback was consolidated and reviewed by College administrative staff in preparation for presentation at Council's December 2008 meeting. Council received all of the responses as well as the consolidated document for review.
The College wants to thank all of those individuals and groups that contributed to the consultation. The input was of great value in reviewing and revising the draft Standards of Practice.
Given the amount of feedback received and the number of standards that required review, Council was unable to finish all of the standards at its December meeting. Council will continue its review at the March 2009 meeting.
Additional updates on the standards of practice development process will be posted on the CPSA website at www.cpsa.ab.ca/collegeprograms/standards_of_practice.asp.
Reprinted from the February 2009 issue of The Messenger, published by The College of Physicians and Surgeons of Alberta.
ONTARIO, CANADA
ENSURE DISCLOSURE OF HEALTH INFORMATION HAS PATIENT'S EXPRESS CONSENT
A married couple with a history of infertility was referred to an obstetrician gynecologist with an interest in infertility. The woman attended a number of preliminary sessions. Her husband then accompanied her in a follow-up visit to receive results of tests done on him.
During the course of this appointment, the doctor revealed information about the woman's sexual and fertility history that her husband had been unaware of. This led to some subsequent tension between the husband and wife. She was distressed enough to lodge a complaint at the College of Physicians and Surgeons of Ontario (College) that the doctor had disclosed confidential information about her without her consent.
In her letter of complaint, the woman took the position that just because her husband was present, did not mean that she consented to full disclosure of information to him about her past history. She stated that the doctor's comments were inaccurate and irrelevant. In his response, the doctor wrote that he regretted some of the factual information that he gave out, nevertheless, he did not believe that the communication itself was inappropriate.
He noted that it is impossible to keep health information about a partner confidential from the other partner when investigating fertility issues. He noted that at no time had the woman indicated to him that any health or personal information was to be kept confidential from her husband.
The Committee considered the matter. It referenced the College's policy on Confidentiality of Personal Health Information. The policy states, “Situations may arise where physicians are asked by a family member or friend about the condition of a patient. Patients are permitted to restrict the disclosure of such information. For this reason, physicians will be required to obtain express consent from the patient before they are able to disclose the patient's personal health information.”
The doctor noted in his response that he would not have disclosed the information had the woman “pre-warned” him and expressly directed him not to disclose it. The Committee believes that the onus was on the doctor to seek consent and not on the patient to direct him not to disclose. Thus, the Committee stated that a “more prudent and appropriate approach in this case would have been to discuss the relevance of her medical history with her alone, and to obtain her express consent to raise (the issue at hand) with her husband before actually doing so.”
The Committee accepted the doctor's position that in managing infertility, the history in question might have been relevant and that fulsome and frank discussion with all the parties is best practice (with consent), but believed that the information is still privileged and confidential. The Committee thus considered it appropriate to counsel the doctor on the importance of ensuring that, in future, he will be careful not to disclose sensitive information without his patient's express consent.
A counsel is issued in circumstances where the Committee has identified an area of the member's practice that might be improved upon. It is an educative disposition, designed to guide the physician in his or her future practice.
Reprinted from the February 2009 issue of MD Dialogue, published by the College of Physicians and Surgeons of Ontario.
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