International Briefs

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.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.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.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.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.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.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.pdfThe 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.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.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.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 said of the College of Physicians and Surgeons of Ontario have not had information to allow to be the of cosmetic surgery there has been little information available about the regulatory framework in which cosmetic the training of the physicians or about the with the he its in Council its with the Council were not concerned with the of public were also by the that the of cosmetic surgery had to this of practice. Physicians from a of practice were now providing a new of services to patients in a of they to be these some of which can to and to the Council College has had a change of scope published in which the that physicians report to the College the scope of their clinical practice to an of in which they not have appropriate training or The College's experience to that physicians the College about their the Council to a patient safety that would regulatory the practice of cosmetic surgery. The began by complete information on the practice of physicians who cosmetic the the College those physicians that it believed were in the cosmetic At the same time, a was being to the of procedures taking into the nature of the the training of the physician it and the facility in which it was being the College sent out a – for which was mandatory – physicians where they the services provided in their facility or and the formal training and continuing professional development that has been On the of the information the College will be the of those physicians of practice – training and facility – appear to immediate assessments are to will be to safety are in the and if at there may be room for Council in the about patient safety and cosmetic surgery and even more for the safety were some which will regulatory College has the to support patients in making informed decisions that may help the patient safety and to that physicians providing cosmetic procedures in Ontario are and in that patient said Dr. will the College the practice of cosmetic surgery in he the College's said it was that the College take a on this need to be that the only physicians cosmetic surgery are those who are to said Dr. public of cosmetic surgery is that it is and cosmetic are and a of knowledge and surgical skill, including the to both and other forms of The Council is of one on this – training, and continuing medical education are as important in cosmetic surgery as in other of he said. The new at the is being that will make it mandatory for physicians to report to the College the scope of their clinical practice to an of in which they not have appropriate training or The physician must undergo a College assessment of knowledge, judgment and skills to practice in the new of focus or will only be able to use the of if they are either by this or the national This too will a regulatory increasing of physicians are providing cosmetic invasive surgical outside of the environment. The training and qualifications of those procedures are are that could be to A of regulatory in other are to assess all physicians who have been deemed to immediate based on their training, the nature and of the procedures they and where they practice. are information about the procedures training to the where they practice and the within their have a of to cosmetic procedures and the training required to such have an easy to understand public information to the public about cosmetic including their It is critical that the public is made of the that all with have and for the public to they have the best possible information to in making decisions about their health are at the that physicians to on an annual believe that may information from The possible mandatory that could be not from the cosmetic procedures they of public in which information availability about physicians to the College could be College has a that out the responsibilities in is a need to the of the and the process by which the College about The is currently and will be to Council in the first of from the 2007 online version of published by the College of Physicians and Surgeons of like for information from your to be for in the your and to at or to

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