International Briefs

The Australian Medical Council (Council) has granted accreditation of the training of the Royal Australian and New Zealand College of Psychiatrists, following a review in August–September 2005. The Council has resolved: That the AMC grant accreditation of the education and training program and the continuing professional development programs of the Royal Australian and New Zealand College of Psychiatrists (College) until June 2009.That before the expiry of this period of accreditation (i.e. June 2009), and at a time suitable to the RANZCP, the AMC review the College’s progress in relation to the key issues raised in the Accreditation Report with particular reference to implementation of the new Training and Assessment Regulations. The review will be undertaken with a view to extending the period of accreditation to the maximum period of six years.That in the usual annual reports to the Specialist Education Accreditation Committee, the RANZCP comment on its response to the other recommendations in the Accreditation Report. The first annual report should specifically address:progress in addressing trainee concerns about the examination eligibility requirements, and access to clinical examination places;the College’s overarching principles for engagement with trainees;the progress in relation to the examination for overseas-trained psychiatrists.To assess the College’s training program, the AMC set up an expert team which reviewed the College’s accreditation submission; and submissions from bodies such as health departments, health consumer organizations, other health professions that are part of the mental health care team. In addition, the team interviewed medical schools and other colleges and interviewed College committees, doctors who are completing specialist training in psychiatry, and College Fellows who supervise and assess doctors completing the training programs. In addition, the team visited large and small hospitals in urban and rural sites across Australia and New Zealand.Beginning in 1998, the College has implemented a major review of its training, examinations and continuing education, resulting in the introduction of new training and assessment regulations on Dec. 1, 2003. When the team was assessing the College’s education and training programs, many issues relating to the transition to the new regulations were still be addressed by the College. As well as identifying the strengths of the College’s training and professional development programs, the team’s detailed accreditation report identifies areas where further work is required. The detailed accreditation report was available as a public document beginning February 2006.Beginning January 2006, all applicants for the AMC examination (for non-specialist registration) and the AMC – Specialist College assessment pathway (for registration as a specialist) will require primary source verification of the medical qualifications though the International Credentials Service of the Educational Commission for Foreign Medical Graduates of the United States (ECFMG).Applicants will continue to apply to the AMC for initial assessment. Subject to the vetting of their documents by the AMC, applicants will be able to continue with the AMC examination or the specialist assessment as a “provisional candidate.” The documents will be forwarded to the ECFMG for verification through the original issuing university or institution. When confirmation of verification is received by the AMC the candidature will be confirmed. The AMC will not be able to issue a final AMC Certificate until the verification has been confirmed.As of Jan. 1, 2006, the document verification assessment fee of $225 AUD applies to all applicants. This replaces the previous assessment fees for general (non-specialist), specialist and combined (general and specialist assessment). NOTE: Primary source verification is now a requirement for registration in Queensland and other states are expected to follow.Reprinted from the Australian Medical Council website.Physicians must maintain professional boundaries in their interactions with their patients and not exploit them in any way. The following is a general discussion of the issues pertinent to situations where the professional physician/patient relationship may be compromised by sexualized behaviour.The 2004 Canadian Medical Association Code of Ethics states: Paragraph 1“Consider first the well being of the patient.”Paragraph 2“Practice the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.”Paragraph 13“Do not exploit patients for personal advantage.”The following are examples of behaviour that are considered inappropriate: Altering or removing a patient’s clothing while an examination is taking place without express patient consent.Not allowing the patient the privacy to undress or dress and not providing appropriate gowns or drapes.Sexually demeaning or suggestive comments.Requests for “dating”.Sexualized touching, fondling, hugging, kissing, and petting.Sexual intercourse.It is not unusual for a patient to consider the behaviour of a physician to be sexually motivated, even in circumstances where the physician had not consciously considered the behaviour to be sexualized. This most frequently occurs during examinations conducted without adequate explanations or without expressed patient consent.Consideration should be given to the following: A physician should be careful to ensure any remarks or questions asked cannot be construed as demeaning, seductive or sexual in nature.When sensitive subjects, such as sexual matters, have to be discussed, the physician should explain why the questions have to be asked, so that the intention cannot be misconstrued.Hugging and kissing a patient is considered high risk behaviour that can be misinterpreted. Any touching that is not part of the physical examination must be of a type that cannot be misconstrued.Although chaperones are not mandatory, a physician should consider carefully whether a chaperone would contribute to an individual patient’s feeling of comfort and security. Also, a chaperone may protect the physician from unfounded allegations. If a patient asks to have an appropriate support person in the room, that request must be honored. Signage indicating a chaperone is available or a printed policy regarding the provision of chaperones may be helpful.The scope of the examination and the reasons for examination should be explained to the patient.A physician must provide complete privacy for a patient to undress and to dress.A patient must be provided with an adequate gown or drape.The physician should not assist with removing or replacing the patient’s clothing, unless the patient is having difficulty and consents to such assistance.A physician should be aware and be mindful of the particular cultural preferences in the diverse patient population.A physician should avoid crossing non-sexual boundaries such as dual roles and self-disclosure, as these may accumulate and take the physician down the “slippery slope” into the realm of sexual misconduct.Every physician should minimize personal vulnerability by appropriate recognition and attention to personal illness, stressors, emotional neediness and professional isolation.When any questions or concerns arise, the physician should feel free to contact the The College of Physicians and Surgeons of British Columbia (College) for advice or direction.As indicated in the Medical Practitioners Act (Section 65), and subject to the requirements outlined below, physicians have statutory responsibilities regarding the reporting of sexual misconduct by another member to the College. Subject to the patient’s consent, the physician has an ethical responsibility to report to the College if a patient discloses information that leads the physician to believe that another physician may have acted improperly with the patient. To assist in such instances, the following guidelines are provided: The physician must inform the patient that such alleged behaviour by any physician is unacceptable to the College and the medical profession.The physician must provide the patient with information on how to file a complaint with the College.If the patient does not wish to file a formal complaint immediately, then the physician must offer to file a third party report with the patient’s written consent.If the patient does not give permission to proceed, then the physician has fulfilled the ethical duty. The physician should document the event, indicating that the patient does not wish a complaint or third party report to be made to the College.All allegations of sexual misconduct must be carefully investigated and reviewed by the College.Each situation is considered on its own merit, carefully taking into account such factors as: The nature of the physician/patient relationship.The duration of the physician/patient relationship.The patient’s vulnerability:The presence of a disorder likely to impair judgment or hinder independent decision-makingPsychotherapy in the physician/patient relationshipAge under 19Physician factors:Previous sexual misconductDegree of exploitationImpairmentActual or threatened bodily harm or violenceTermination of a professional relationship in order to pursue a sexual relationship has always been considered to be unethical.Reprinted from The College of Physicians and Surgeons of British Columbia website.The College of Physicians and Surgeons of Ontario (College) has been asked to provide recommendations for change to the legislation that governs the College to the Health Professions Regulatory Advisory Council (HPRAC). In the previous issue of Dialogue, we discussed some of our suggestions for improvement. Here, we continue our prescription for change. The Health Professionals Regulatory Advisory Council (HPRAC) has been charged with the responsibility of providing advice to the Minister of Health and Long-Term Care on a number of issues respecting the regulation of health professionals under the Regulated Health Professions Act (RHPA).When the RHPA was proclaimed in 1993, it envisioned a regulatory system unlike any other in Canada. While there are many good things to say about this act, the College’s 12 years of experience working within the legislation have also revealed some weaknesses. In the November/December issue of Dialogue, we outlined some of our recommendations for improvement. The following is part two of our prescription for change.The full submission is on the College website at http://www.cpso.on.ca under the What’s New button.We have made several specific recommendations about Complaints Committee processes. We recommend the RHPA be amended to increase the time frame in which complaints investigations are to be completed. The College notes sometimes completion within the stipulated period will not be possible. When the statutory time frame cannot be met, colleges should be required to give notice to the parties advising them of the reasons for the delay and the revised time frame for the disposition of the complaint.1While changes to the original legislation have permitted the colleges to deal with complaints that are frivolous and vexatious in a more efficient fashion, we recommend the colleges be permitted the discretion not to investigate complaints that are frivolous and vexatious. The process could be simplified if the Committee were permitted to issue a summary decision based on the initial letter. An appeal to the Health Professions Appeal and Review Board of the decision to decline such investigations should continue to be available.In the rare case where the College has information a member is a threat to patient safety, it cannot suspend the member or place restrictions on his or her practice immediately. Although this does not happen often, we need the ability to act more quickly when it does.2 The College is concerned, however, about ensuring procedural protections for the physician subject to such orders. If this authority is granted to the proposed Screening Committee, the College has submitted that it must be subject to the following procedural safeguards: The Committee must have formed the opinion that the member’s conduct exposes or is likely to expose the public to harm or injury or the member must have refused to cooperate with a practice assessment (or in the case of an investigation into the member’s capacity, a mental or physical examination);The member must be provided with notice of the intended impending suspension together with disclosure of all of the information relied upon by the Committee and its reasons for making the order;The member must be given an opportunity to reply to the notice of intended suspension prior to it being put into effect;The member must be given an opportunity to request a review of the suspension, once made; andOnce the suspension is in place, the matter must be referred to, and disposed of by, either the Fitness to Practice or Discipline Committee on an expedited basis.Many complaints or concerns about physicians received by the College are resolved to the satisfaction of the physician, the complainant and the College without recourse to Complaints or Discipline Committees. Sometimes such resolutions entail undertakings by the physician. Undertakings generally reflect a physician’s commitment to upgrade his or her skills or to refrain from an act or an area of practice. Providing this information to the public for the duration of its term, but removing it once its requirements have been fulfilled, would demonstrate the College’s and the subject physician’s commitment to continued quality improvement.The College recommends the quorum for the Discipline Committee should be amended to allow a retired judge or experienced lawyer to chair discipline panels and to form part of the quorum in the place of one of the public members of Council.It has been the College’s experience the discipline process is becoming more intricate and procedurally demanding. Hearings are prolonged as discipline panels confront issues and arguments that are increasingly complex and highly contested. Panel chairs with adjudicative expertise will enhance Discipline Committee proficiency in conducting hearings and writing decisions, while preserving the principle of self-regulation. This model is being used in other jurisdictions with success.It has been previously recommended the confidentiality provisions in the RHPA be amended to allow a college to acknowledge its dealings with a member when it is in the public interest to do so. Regulatory imperatives such as procedural fairness and the effectiveness of college programs must be carefully balanced against the desire to ensure maximum access to information for health care consumers.Currently, when allegations of misconduct or incompetence against a physician are referred to the Discipline Committee, the referral is public information, the notice of hearing detailing the specific allegations is publicly available, and the hearing itself is open to the public. Furthermore, the findings and the reasons of the Discipline Committee are in the public domain and easily accessible on our website. Recently, physician reprimands delivered by the Discipline Committee have been made public. At the Complaints Committee level, any individual who makes a complaint (as well as the physician) receives a of the Complaints decision and is also our practice to provide progress reports to parties the the if the Complaints Committee a matter to the Committee, the College cannot provide information about the to the If the to the College through another of for the College cannot information with the source that raised the The of a complaint or an investigation is not believe part of the of the new we have recommended would be to the College to provide progress reports about investigations and the decision and reasons to the source of the This would to the system more We however, that this of our previous submissions we recommended be to when information about dealings with members could be The circumstances under which we recommend it is appropriate to the that we are a member are as The member has made the investigation a matter of public has been an in the member’s in with the issue as is being have been against the member in with the issue as is being made several recommendations about information it to on the public all to Discipline and be on the public We all discipline are a matter of public so change is required. As to to the Committee, if our recommendations about a were such would be While it is the required by the RHPA in with a in a of we are the is to change the however, the referral is we is required. At the should be to progress and reports for referred to the Committee and the Committee must be permitted to its with other College should the matter require referral to the discipline College of Physicians and Surgeons (College) has a statutory to investigate complaints against Complaints are when a complainant has a about the care or conduct of a physician. If the complaint is to the College and is to by or by providing information, the College these concerns in an If the complaint cannot be resolved by that type of the complainant is asked to their concerns in writing the and the provided by the should be the review of the In the on and reviewed in 2004 and not by the of the in 2004 and in As the work does not the for the reports on the most of the 2004 the College received of the of which were with by the were formal complaints in 2004 and which were by the College’s Complaints Advisory Committee the written there were the most allegations being or to or of these were were were were 12 were to be patient and in there was to the this is used when the is to with any of the situation This such allegations as and of the review of complaints is to provide suggestions to physicians in where their care or conduct could be The also to provide the with a of the care The the review of these of complaints is to the physicians and to the The process is and at the time complaints through the Complaints Advisory Committee process do not form part of the physician’s personal and are not on a Certificate of is this process is as an by physicians and them in that it is the patient’s of the that leads to a complaint any care by physicians in changes to their practice or resulting in of complaints in the in the complaints process is and is provided to the complainant if the complainant is the or to a third party with appropriate to act on of the patient or the patient’s The is provided to the does issues to the attention of the appropriate such as the Health when there are issues within the complaints process that need to be addressed by a authority to quality The this as part of an quality also information by of the College to to In the the provided information on the care an with to the of the and information regarding risk factors for and guidelines for for College has satisfaction to and physicians for in the years and are a number of the completion of the were to physicians in in with and to with of the the years was to be on these some changes have been made to assist and physicians in the complaints review raised was whether it was to have the College request the on their process having an independent the The College to for of on the complaints Complaints Advisory Committee members of (general and The public members are and of and of from the issue of College by the College of Physicians and Surgeons of for is a new that the of good of practice and care in Medical Practice with a particular on in health will be for physicians who have a but should be for all Medical Council a in 2004 to and about and how could be up to in a that would be to doctors and in with of patients and practice. two further the new for physicians on the specialist and should have received a of the new with the February issue of for replaces in Health the of for can be with all in the on its website at judgment has for the and all professional and will need to be The have previously the is under a to investigate any complaint of the judge has that there were to has where there has been by a as in this the should not be used to given or for the or The with that it cannot be in the public interest if doctors and other professionals are from and where there has been we have to act to protect the public interest from who of has the principle of so that it would apply for the first time to the of by The is to grant an has not been in would place and other the of their when writing reports for the or This would be even when or their have been by the The would be if the judge to the judgment to a has the particular not for doctors but for all The is carefully the judgment which it to be a in a area of the Medical Council is new for doctors who are as well as who work in new the that are expected of doctors working in a as well as who are that doctors to the for their even when a could the of the areas that has been with the is the of the and that a good The ability to in ability to and work to maximum of is and doctors that when do not have the to provide the for all must on the of information as to and and in with their to protect and and to should also be to into account the set by and the or or also the responsibility a has to concerns if believe that patients may be at risk of harm and the to if are not made The states that have good to believe that patients may be at risk of and have all can to the by concerns within the in which may consider making them provided that patient confidentiality is not review of the was in 2004 with a during which Medical for the the the to this his the for being when it was first a of for or for information from to be considered for in the If and to at or to

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