ALBERTA, CANADA
DRAFT STANDARD FOR TERMINATION OF PREGNANCY
Council continues to work through and refine the draft Standards of Practice for Alberta's medical profession. Having reviewed and edited all but two of the standards at its March meeting, Council expects to have completed its work and to have ratified the standards when it meets in June.
The draft standard on termination of pregnancy has generated a great deal of feedback. Most respondents take exception with the draft, believing that the College will require physicians to refer patients for termination of pregnancy, or at the very least to be compliant in arranging a patient's abortion, contrary to the physician's personal beliefs. This is not true. Some also argue that the physician's individual moral conscience should be the inviolable principle to which all other obligations are secondary.
Recognizing the emotion around therapeutic abortion, here is some context around this issue:
Termination of pregnancy is a legally available medical procedure.
Under Canadian law, the unborn fetus does not have status of a person. The Code of Ethics states physicians should:
○ Consider first the well-being of the patient;
○ Inform patients when a physician's personal values would influence the recommendation or practice of any medical procedure the patient needs or wants; and
○ Provide patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of their ability.
The College's current policy (in place for the past decade) states:
While recognizing the varied personal convictions of physicians it must still be the responsibility of physicians to ensure that pregnant women who come to them for medical care are provided with or are offered access to information or assistance to enable them to make informed decisions on all available options for their pregnancies including termination.
The important are these:
A Standard of Practice on this subject will not change the obligations of physicians that have been accepted by this College since 1991. The words are a little different, but the intent is not, as the principles underlying the standard have not changed during the past 20 years.
Physicians have the same obligations to provide informed consent (the information that a reasonable person would want to have) to patients who are pregnant as they have to patients with any medical condition. This information might include the natural history of the condition, the options available, and the risks and benefits associated with the various options. The situation is no different for a patient who presents with a new pregnancy, nor when a patient is seeking an abortion. The exception is when the physician's personal values would influence the recommendation or practice of any medical procedure. In that situation, we (and the Code of Ethics) offer the physician an option.
The issue here is not the physician's individual moral beliefs or conscience. As a physician, and a medical professional, physicians must first consider the well-being of their patients (Code of Ethics #1). They also must, as professionals, resolve conflicts of interest in the best interest of patients (Code of Ethics #11).
Understandably, this standard places some physicians in a difficult moral quandary. The option available to those with such moral distress continues to be to refer the patient to another physician or resource that will provide the patient with all available medical options so that the patient can make an informed choice. By doing so, our members will be acting professionally and will affirm their obligation to put their patients' interests above their own.
OFFICE PROCEDURES REQUIRING COLLEGE APPROVAL
Office procedures requiring College approval now will be listed in the CPSA Standards of Practice. Physicians seeking College approval to perform a procedure on that list must now submit evidence of satisfactory educational qualifications, and compliance with any other practice requirements adopted by Council. Physicians' privileges granted by a public health authority in a facility administered by that health authority are not subject to this regulation.
Previously, only those procedures limited to accredited non-hospital surgical or diagnostic facilities were subject to College approval. Currently, acupuncture and hair transplantation are the only office procedures requiring approval from the College. Acupuncture has required College approval since 1991. Approval is granted to physicians who provide evidence of successful completion of a recognized training program including:
The Acupuncture Foundation of Canada program
The Acupuncture Certificate Program at the University of Alberta
The McMaster Medical Acupuncture Program
Hair transplantation recently was added to this list after consultation with providers and Council advisory committees. Approval for hair transplantation will be granted to physicians who demonstrate sufficient education and experience in the procedures and the operation of a hair transplant practice. Those practices must also demonstrate compliance with infection prevention and control requirements, including the cleaning, disinfection and sterilization of medical equipment.
With this recent addition, all physicians who currently perform hair transplants must immediately begin the approval process.
Reprinted from Issue 150 of The Messenger, published by The College of Physicians and Surgeons of Alberta.
BRITISH COLUMBIA, CANADA
AGREEMENT ON INTERNAL TRADE
The Agreement on Internal Trade (AIT) was signed in 1994 by federal, provincial and territorial governments with the intent to reduce or remove inter-provincial barriers to the movement of workers, goods, services, and capital. Chapter 7 of the agreement, which was amended and signed on Dec. 5, 2008, outlines the commitment to achieve full labor mobility in regulated trades and professions in Canada. The provisions in the amended chapter were implemented on April 1, 2009.
Currently, through our national credentialing examinations, physicians have the benefit of mobility across Canada if they hold a Licentiate of the Medical Council of Canada (LMCC), and have certification with either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. Physicians with these credentials have met the standard for full licensure in every Canadian jurisdiction, and therefore face no barriers to portability of licensure other than the requirement to apply for licensure. The amended Chapter 7 now grants mutual recognition to physicians who hold licenses in categories other than full, including provisional, temporary, conditional or restricted.
By statute, the College has the authority to regulate the practice of medicine, including establishing standards for licensure. However, under the AIT, the provincial and territorial governments have agreed to reconcile differences in standards for licensure, and to mutually recognize qualifications of workers certified in at least one Canadian jurisdiction. Whether this will result in a national standard for licensure that ensures that only competent and qualified physicians are duly licensed, or a “race to the bottom” that codifies the lowest standards, remains to be seen.
The Federation of Medical Regulatory Authorities of Canada (FMRAC) and its member Colleges have raised concerns with government regarding the amendments to Chapter 7 of the agreement. The concerns include a lack of meaningful consultation with the medical regulatory authorities, and a lack of defined process to deal expeditiously with any adverse consequences arising from the implementation of the AIT. This College is firm in its belief that it is not in the public interest to wait and see if things go sideways. For example, the AIT does not address the fundamental problem with medical care in Canada: an alarming shortage of physicians. Increasing mobility of a limited supply will undoubtedly exacerbate the maldistribution of physicians that currently exists in Canada. Inevitably, access to medical care will be further limited by a mobility agreement that potentially drains scarce resources away from remote areas that are already underserved.
The College Council and staff will continue to work diligently with FMRAC, its members, and the relevant ministries to ensure that patient access and safety concerns are front and centre. On short notice, an in-person meeting has been scheduled in late March with all of the regulatory authorities across Canada to review and discuss the collective challenges and to seek national solutions. The Ministry of Health Services has been informed of this College's concerns, and we will put forward legitimate objectives in the next few weeks. A number of working groups of the Registration Departments across Canada are attempting to synchronize and align registration processes – with a goal of ensuring that only competent and qualified physicians receive a license, and that national standards for revalidation are upheld.
While we embrace the positives of labor mobility, we must ensure that licensure in any one jurisdiction in Canada cannot be viewed as a “flag of convenience.” To address this challenge, we must have a high level of regulatory cooperation across Canada, including current, comprehensive databases from which to share timely information.
Several physicians have contacted the College with questions about the AIT, specifically about whether or not the agreement allows them to relocate to another jurisdiction without full licensure. Since health care is still regulated at the provincial level, physicians wishing to practice medicine in a province or territory must hold a license in that jurisdiction. Requirements for Certificates of Professional Conduct are still necessary when a physician moves from one jurisdiction to another.
AN UPDATE ON EHEALTH
Patient privacy issues
The College continues to be actively involved in provincial eHealth initiatives and is currently represented on the following committees: BC eHealth Council, Physician Information Technology Office (PITO) Steering Committee, eDrug Steering Committee. The College has recently been invited to the Provincial Lab Information System (PLIS) Steering Committee. Progress on patient privacy issues has been slow. However, the College met with the Minister of Health Services in December and again in February, and is encouraged by his commitment to address the following outstanding issues in 2009.
Role-based access model
Electronic Medical Records (EMRs) facilitate the sharing of patient information with other health providers and agencies, such as the Health Authorities. What type of information should be shared with whom, and in what circumstances, must be carefully considered. Government recently established the Clinical Integration Advisory Committee (CIAC), which will be providing recommendations to the Minister, the Office of the Information and Privacy Commissioner (OIPC), the British Columbia Medical Association (BCMA) and the College by June 2009. The College is a participant on this important new committee.
Disclosure directives
The BC eHealth Act passed this spring enables creation of Health Information Banks (HIBs), e.g. Health Authority Electronic Health Records (EHRs). The Minister of Health Services has the authority to authorize individuals to make disclosure directives respecting their own personal health information. It is critical that patients maintain the right to mask identifiable information should they choose. The notable exception would be “break the glass” provisions in emergency situations. Disclosure directives are also being reviewed by the CIAC referred to above.
Physician information technology office (PITO)
Approximately 1,000 additional physicians will be approved for PITO electronic medical record (EMR) systems in 2009. The College continues to support the PITO initiative, however, the recent “Communities of Practice” initiative including larger, more disparate groups of physicians causes some concern. The College encourages Community of Practice physicians to look carefully at the degree to which identifiable information is being shared and ensure that patient privacy is not compromised. Physicians are encouraged to contact either the College or the Canadian Medical Protective Association (CMPA) before entering into a new type of information sharing arrangement.
Third party services
The College is receiving increasing numbers of inquiries from physicians with EMRs regarding contracting out/delegating administrative services to third parties, e.g. transcribing, patient scheduling, document scanning. The College reminds physicians of security breach risks when engaging third party service providers. Physicians should ensure compliance with the BC Personal Information Protection Act (PIPA) and College policy. Generally, it is not acceptable to delegate these services to out of country providers without informed, individual patient consent. Physicians should contact either the College or the CMPA before entering into this type of third party arrangement.
Privacy toolkit
The College is pleased to report that it is working with the BC Medical Association and the Office of the Information and Privacy Commissioner to update the 2004 Physicians' Privacy Toolkit, which was completed in spring 2009.
Reprinted from Issue 63 of College Quarterly, published by the College of Physicians and Surgeons of British Columbia.
ONTARIO, CANADA
ISSUES AROUND OPIOID PRESCRIBING CAN OVERWHELM PHYSICIANS
“We feel doomed to failure before we even start.”
That was the comment expressed by one family physician in a recent survey the College undertook to get a sampling of physician attitudes around pain management and opioid prescribing.
“Most new physicians do not want anything to do with dispensing narcotics to chronic pain sufferers,” was the comment from another doctor.
In fact, that survey found that of all the issues doctors face in family medicine, family physicians rank chronic pain management second only to mental health as a clinically challenging area.
Why is this issue fraught with so many difficulties? Consider the landscape. The Centre for Addiction and Mental Health cites prescription opioids as the second most common drug abused by teenagers. In Ontario, individuals in methadone clinics are more likely to be addicted to prescription drugs than they are to street drugs like heroin. Now add the lack of physician education about opioids to the mix – a study by the Canadian Pain Society found that veterinary students receive, on average, three times more designated hours of pain education than students in Canada's medical schools.
It's no surprise then, that underprescribing is every bit as much of a problem as over-prescribing. The Canadian Pain Society has referred to the state of under-treated pain in Canada as a “crisis,” when one considers the number of Canadians who suffer from chronic pain – the kind of intractable pain that keeps them from sleeping at night, holding down a job, and enjoying their lives.
It's an unfortunate situation given that the evidence shows that, with appropriate prescribing and monitoring, opioids may indeed be an appropriate drug therapy for some chronic pain patients.
The College, for its part, has been vocal in correcting any impression that it is “anti-opioid” and has gone on record stating that narcotic therapy for chronic non-malignant pain has never been on trial. In my first communication with the profession as College Registrar, I stated: “Physicians who have run afoul of professional standards in regard to pain care have done so because they refused to adhere to basic medical principles, not because they have prescribed opioids,” says Rocco Gerace, M.D., College Registrar.
Notwithstanding this pronouncement, the reluctance to manage pain persists. We don't want to inhibit physicians from appropriately prescribing opioids to those patients who need drug therapy to alleviate pain. We recognize that the issues around opioid prescribing can be complex and overwhelming for physicians. We don't want physicians to feel as though they have been abandoned to find their own way through this rough terrain.
That is why Council has made a pledge to finding solutions to the concerns that surround opioid prescribing by identifying the issue as a key public policy priority. We hope to make recommendations to the ongoing problems in this area. For example, how can practitioners – whether doctors or pharmacists – be assisted in recognizing drug-seeking behavior? How is the provision of pain management best managed with the input and cooperation of all care providers and patients?
Effective solutions will require partnerships and collaboration with several different stakeholder organizations to develop public policy solutions and advise and influence government. Some of the projects already underway include a research project funded by the Canadian Patient Safety Institute (interdisciplinary education methods for safer opioid prescribing) and a peer education initiative with the Ontario College of Family Physicians.
The project that is most likely to come to fruition in the short-term, however, is a national guideline on opioid use for chronic non-cancer pain. This is a collaborative project of all of the medical regulatory authorities of Canada. The goal is to develop, implement to practice, and evaluate the impact of guidelines on the safe and effective use of opioids for non-cancer pain – guidelines that are based on the best available evidence and expert opinion consensus.
A draft of the guidelines should be ready for broad consultation shortly, with input from physicians solicited through Dialogue and the College's website.
EXCEPTION PROPOSED FOR USE OF SPECIALIST TITLES REGULATION
Council endorsed a proposed exception to the Use of Specialist Titles regulation that attempts to address both the protection of patients and the ability of physicians to accurately describe their practice.
The Use of Specialist Titles regulation is an important part of the College's four-point plan to address problems relating to the provision of cosmetic procedures in Ontario.
The original amendment stated that physicians were only permitted to use terms, titles or designations in their promotional and advertising materials if they were certified and recognized in that specialty.
During the consultation, the College heard from physicians concerned that their area of certification or recognition did not reflect their current area of practice. Examples of this include a general practitioner who provides psychotherapy exclusively or a family medicine specialist who completed extra training in dermatology and now provides dermatological services primarily.
The proposed regulation exception would allow physicians who have focused practices, or who have completed additional training, but are not certified specialists, to describe their practices in their advertising and promotional materials.
Specific criteria for style and format must, however, be met: physicians must include their own specialist or subspecialist information, in keeping with the existing requirements of the regulation; the phrase, “practicing in” must precede any descriptive terms, i.e., “Dr. X, General Practitioner practicing in anesthesia.
There also are restrictions on the use of some terms. ‘Surgeon' and ‘surgery' can only be used by certified or recognized surgeons; ‘plastic' can only be used by certified or recognized plastic surgeons.
MANDATORY CPD AND THE THIRD PATHWAY
Council agreed that physicians who are not members of either national college would be permitted to rely upon a separate monitoring program to track their Continuing Professional Development (CPD).
This option would allow physicians to fulfill their mandatory CPD obligations to the College without reliance upon either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada.
No such alternative monitoring system currently exists and the College would need to approve the system before physicians can rely on it. Final acceptance of such a system will be contingent on it meeting certain criteria, including maintenance of the standards as established by the national colleges, an arm's length auditing system and a mechanism to the College by which failure to meet the established educational benchmarks would be reported to the College.
We will continue to ask physicians about their CPD on the annual survey and work will continue on development of the necessary regulations.
