International Briefs

The Alberta College of Pharmacists has reported a significant increase in verbal forgeries throughout the province. Individuals will call pharmacies with prescription orders, claiming to be a physician. They will often be able to provide the physician’s College of Physicians and Surgeons of Alberta (College) license number, office address, and telephone number. Prevention of forgeries and fraud should be a concern for all physicians prescribing narcotics and other controlled drugs. The following are suggestions to prevent verbal forgeries of prescriptions: Limit the use of verbal prescriptions to exceptional cases.Do not use verbal prescriptions for medications prone to misuse or abuse such as benzodiazepines or acetaminophen with codeine compounds.Fax prescriptions to the patient’s choice of pharmacy.Limit the quantities of prescriptions, where possible, for medications prone to abuse.Be accessible to pharmacists who require verification and authentication of prescriptions. It is not recommended that office staff verify prescriptions for narcotics and controlled substances.Protect your College registration number and only provide it when necessary for legitimate purposes.Verbal prescription forgeries may be the most difficult forgery to detect and prevent. Using these general approaches to prescribing will assist the pharmacist in identifying a potential forgery when it is not the physician’s customary practice to provide verbal prescriptions.The Physician Resource Planning Committee (PRPC), which includes College representatives, is again working to update Alberta’s physician resource plan by Dec. 31, 2005. PRPC’s primary task will be to identify Alberta’s optimal number, mix, skill level and distribution of physicians (working in collaboration with other health providers) to deliver appropriate care that meets the province’s health care needs. The workplan will include consultation with AMA Sections, RHAs and other stakeholders with a significant interest in physician resource issues. In the long-term, PRPC will: provide advice about strategies and mechanisms to meet the requirements of a physician resource plan;develop and recommend strategies to the appropriate stakeholders to integrate physician resource planning with planning for other health human resources provincially and within regional health authorities; andidentify and inform Regional Health Authorities and other stakeholders on opportunities to better coordinate and/or integrate medical services to create an integrated health system.In addition to the College, PRPC members include Alberta Health and Wellness, the Alberta Medical Association, Regional Health Authorities, both Faculties of Medicine, the Professional Association of Residents of Alberta and the Medical Students’ Associations. PRPC also has ex officio representatives from the Post- Graduate Medical Education Advisory Group, Alberta Physician Resource Database Working Group, Rural Physician Action Plan Coordinating Committee, and Alberta International Medical Graduate Program. PRPC provides a forum to coordinate advice and proposed initiatives including those of the member entities. In future communications, the PRPC will provide an update of progress to create a provincial physician resource plan and provide additional information about physician resource issues and upcoming activates for the committee.The College recently received the following complaints:A woman contacted a general practitioner’s office to inquire whether the physician was taking new patients. The receptionist advised the physician was taking new patients but the patient was first required to answer some questions before being granted an appointment. The receptionist inquired as to the woman’s age, and upon learning that she was in her eighties, the receptionist informed the woman that the physician was not taking new patients over 65.The physician responded he felt he was justified in refusing to see elderly patients because they require more time and he did not have the time to devote to additional members of this patient population given the current demands of his practice.A patient attended an appointment to meet a family physician taking new patients. She informed the physician her diagnoses included depression, borderline personality disorder and anxiety disorder. The physician responded that she must seek another physician. When she asked why, the patient was told that his practice was full.The physician responded that prior to seeing the patient, he had recently made the decision to stop seeing new patients, and his staff were not fully aware of this decision. He wrote, had the patient required immediate care, he would have provided it, but because her issues were not emergent, he felt justified in refusing her care.An elderly woman made an appointment for a complete physical with a physician who advertised in the local paper that she was accepting new patients. Upon arrival for the physical, she was informed by the receptionist she would not be given a physical, instead the physician wanted to meet her first. The patient was interviewed by the physician with respect to her medical problems. At the termination of the appointment, the physician advised the patient that she would not accept her into the practice.The physician responded that during the interview, she learned that the patient had a physician but was looking for a new physician closer to her new home in another part of the city. As such, the physician felt justified in refusing to take the patient on. All three complainants believed that they were victims of discrimination. The Canadian Medical Association (CMA) Code of Ethics states: “In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status. This does not abrogate the physician’s right to refuse to accept a patient for legitimate reasons.”The College appreciates that the demands of practice are great. However, the practice of screening patients based on age, medical condition and other grounds of discrimination is not acceptable, despite the fact that some groups of patients in general need more time and attention. Having said that, it is reasonable to decline to take on a patient whose needs cannot be met. For example, while it is not acceptable to screen out all patients over 65, it is acceptable to decline services to an elderly patient who attends with complex medical problems for which she has seen multiple practitioners and is not satisfied with the advice and treatment given to date, when that advice and treatment meets the standard of care. The College would not be critical of a physician who determined, after careful evaluation of the patient’s history, that they had nothing to offer this patient that had not been previously offered by other providers. Physicians also have a right to limit their practices. Examples include: No new patients.Limiting new patients to family members of existing patients or referred patients only.Limitation of types or range of services provided. None of the three physicians listed in the above complaints intended to be discriminatory, yet their actions were clearly perceived by the prospective patients as such.To help avoid complaints of discrimination: Be aware of your ethical obligations.A “meet and greet” appointment should not be used as a tool by physicians to screen potential patients.When screening potential patients on the telephone, office staff should ensure they clearly explain the physician’s limitations. Appointments to meet the doctor should not be given if the patient falls outside the limitations of that physician’s practice.When declining a new patient, the patient should be provided with the reason they were not accepted into the practice.In September 2004, the CPSA established an expert group of physicians to develop consensus standards and guidelines for methadone maintenance treatment in Alberta. Their work has resulted in the development of a draft document titled The Standards and Guidelines for Methadone Maintenance Treatment in Alberta.This resource will guide physicians in how best to prescribe methadone for opioid dependent patients. During the next several months, physicians will be asked to review the draft document and provide recommendations for improvement. Look for details on how you can be involved in future issues of The Messenger.Other stakeholders such as pharmacists and other Colleges across Canada will also be given the opportunity to provide feedback on the draft document. Once the guidelines and standards are finalized, the document will be sent to physicians throughout Alberta to raise awareness of opioid dependency and to encourage physicians to address this issue in general practice. Although other therapies for opioid dependency have been used in locations around the globe, this document will focus on the use of methadone in addressing the issue.Support for this project has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.Reprinted from issues 117 and 118 of The Messenger, published by the College of Physicians and Surgeons of Alberta.A written or stamped message on a consultation report, stating “not to be released to third party,” has no authority or impact if the request for medical records comes from the patient or a patient’s agent, such as the patient’s lawyer. This is in compliance with a ruling of the Supreme Court of Canada (McInerney v. MacDonald, (1992) 93 DLR (4th) 415), which states: “In the absence of regulatory legislation, the patient is entitled, upon request, to inspect and copy all information in the patient’s medical file which the physician considered in administering advice or treatment.”These provisions are added: “unless there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or harm to (an innocent) third party” and “provided the patient pays a legitimate fee for the preparation and reproduction of information.”Pursuant to the Medical Marijuana Access Regulations, SOR/2001-227 (“the Regulations”), marijuana may be prescribed to patients fulfilling the criteria set out in the Regulations. The medical benefits of marijuana have been subject to much debate. To assist members in considering patient requests for medical marijuana and in making an informed decision, the College of Physicians and Surgeons of British Columbia (College) has conducted a review of the current research literature on the risks and benefits of medical marijuana. The results of this review are available to members for review in person at the College’s Library or online through the College website at www.cpsbc.ca. Members may review the table of contents online and email the library to request a copy of any referenced article.Reprinted from Issue 48 and 49 of College Quarterly, published by the College of Physicians and Surgeons of British Columbia.The Physician Advisory Service of the College of Physicians and Surgeons of Ontario (College) receives frequent calls from physicians asking whether it is appropriate for them to sign prescriptions using electronic signatures. While the trend of implementing electronic medical records is advancing rapidly, neither Health Canada nor the Ontario College of Pharmacists currently recognizes electronic signatures as acceptable for signing prescriptions. The College endorses electronic record-keeping and the use of technology to assist in the practice of medicine, however, physicians should not use electronic or digitized signatures for prescriptions at this time. Recently, after inspecting 11 pharmacies that practiced distance dispensing, Health Canada issued a letter to all pharmacists reminding them of their obligations under the Food and Drug Act. The following is an excerpt from Health Canada’s letter dated Nov. 16, 2004:The Ontario College of Pharmacists has instructed its members to verify all prescriptions that contain rubber stamped, electronic, or digitized signatures. This verification must occur either verbally or by a faxed request for authorization to the prescriber. The College’s expectation is physicians will respond to these requests for verification professionally and courteously. Patients cannot be charged a fee for this type of verification, nor is it acceptable to encourage patients to attend pharmacies that inappropriately accept electronic signatures without subsequent verification.The College is also aware some private software vendors have indicated to physicians their product has been endorsed or approved by this College. The College does not endorse specific products or services, so please exercise caution when presented with this type of information.For this, and all other practice-related questions, please contact our Physician Advisory Service at (416) 967-2606 or (800) 268-7096, extension 606.At a recent meeting, the Council demonstrated its commitment to the principles of revalidation by moving forward with a consultation of stakeholders on all aspects of the program. The proposed system of revalidation includes educational requirements and practice assessments — components that, in combination, will promote continuous improvement in practice for the benefit of patients. It will be integrated with the national educational systems and is based on the best available evidence about practice assessments and education.“We want a process that ensures extensive feedback from the profession and other key stakeholders in the development of the methods of revalidation,” said Dr. Gerry Rowland, College president.The College foresees revalidation as a system to enhance lifelong learning opportunities for all members of the profession.“It will be an extension of our existing peer assessment program. It is our hope that the final product will give the physician a practical and user-friendly method of evaluating his or her own continuing competence, in an integrated framework of quality improvement,” said Dr. Rowland.The system is based on the premise that all physicians will participate in effective education and are prepared to demonstrate their competence to their and the at throughout their the College has from the the and other it will on a of of the are working a fully and integrated revalidation but the profession needs to have time to the and to help the as as Dr. is that all physicians with the College will participate in a of at the of of the to the of this is to that physicians are and this needs to be for a as as to physician’s practice. It also needs to be so that the can be that a system is in to their in continuing said Dr. Rowland.The proposed system and draft have been over the through a task of representatives from the College of Physicians and Surgeons of the College of Physicians of the Medical Council of and the Ontario Medical is proposed the profession will with the process of revalidation in three commitment to competence, of competence and of The components should be to all in that the used — the peer assessment of and the and of — have been part of the quality process for to is proposed as the first of revalidation — it may be the only of revalidation in which most physicians will be to This level of revalidation is a educational to help all develop a educational proposed components in this include: of a process using to help the of their feedback from and patients to help their education in these and to when of a system of continuing development from the the or the revalidation in a regulatory framework in system of revalidation will meet the following The of revalidation must be based on physician’s and be to evaluation and education will be and will first and work continuous improvement of system of revalidation will be for all physicians and a system will require collaboration and with other medical these will have a system that is to the and for the the quality improvement an opportunity for physicians to their practice the that are in the peer assessment The College will a process for peer assessment as an of quality and all revalidation is to and to help physicians to identify and improvement maintenance of competence is an ethical of the said Dr. of the College’s the of and patients, and in the of the It is a subject that should in patients that they can to on should no be from the controlled provisions of the Health and should a controlled to those who have the appropriate skill and to the College a to the Council the College the practice of as a treatment for for practiced by 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should be some of the the College to an Health Advisory Council the of The the of a consultation group of physicians and staff with in this The document was presented as a of the of these and is not to be considered the of the consultation group should be to the of harm to is not are no standards for to no standards of practice and no for those by other such as the or the College of of The to as a controlled under the include the development of criteria and the to create quality However, to the profession should not be to currently health as this would limit to practitioners with other consultation group and should not be controlled services are from in their their and by those who provide these and are services, and the consultation group that the of able to provide these services would be a to the Ontario consultation group made the following additional recommendations the of should be a new and for should be to those practitioners who do not have the or required for in any existing regulatory the College of and Service and the under the of existing should not be required to have in the new for should be established to ensure standards of care are all who do not criteria for either the existing or the new regulatory may be into in the new where can be established based on practice in or will have an opportunity to provide its as consultation in this The will also participate in a by from and issues of published by the College of Physicians and Surgeons of the Medical Council a in the complaints are It was by Council in that the should to local for where the as if would not call into a to the has been appropriate systems to ensure that referred to local are to the where there is information into a to practice and that written is received that there is no such evidence where the has been systems are in is to taking on which call into the to practice and to However, most of the complaints that are received do not into that if the were they would not be to on The 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