A specialist receives a referral from a family physician. She carefully reviews the request and the accompanying documents. The patient’s condition does not seem urgent now, but some of his symptoms suggest he would benefit from being seen as soon as possible. The physician then considers her wait list, which has grown longer in the last few months. This patient’s condition falls within her scope of practice, yet she is apprehensive about accepting the referral. How soon can she see him? Is that soon enough to allow him the best possible outcomes? Is there someone else with the same scope of practice who could see him sooner?
The high demand for access to specialist care can put specialists in a difficult position when asked to accept a new patient. Those who work outside a hospital or institution may find themselves in a situation similar to the physician in the scenario above. They are using professional judgment to determine if they can provide care for a new patient while continuing to provide appropriate and timely care for current patients. Keeping in mind their obligations for accepting new patients and effectively communicating with referring physicians and patients can help these specialists make what can sometimes be a critical decision.
Obligations for accepting new patients
As with all physicians, specialists' acceptance of new patients is guided by ethical responsibilities, as outlined in the Canadian Medical Association Code of Ethics and Professionalism1, and by professional responsibilities, as stated in the policies of the provincial and territorial medical regulatory authorities (Colleges).
College policies on accepting new patients vary across the country, but generally require that specialists accept new patients on a first-come, first-served basis, free from discrimination.
They also generally require that specialists take a number of factors into account, including the following:
- urgency and clinical need
- wait lists
- scope of practice and clinical competence
Urgency and clinical need
Although not generally obligated to agree to treat any individual seeking non-urgent or non-emergent care, specialists who receive requests to accept new patients should consider whether the patient needs emergency care.
The CMA Code of Ethics and Professionalism advises physicians to "provide whatever appropriate assistance you can to any person who needs emergency medical care."1 College policies often advise specialists to address the urgent or emergent situation similarly.2
The College of Physicians and Surgeons of Alberta, for instance, says, “A regulated member must provide care to the best of his or her ability to a patient in an urgent medical situation where no other regulated member is providing care, regardless of whether a physician-patient relationship has been established.”3
Wait lists
With specialists’ care in high demand, many have a wait list. Although the general expectation is to accept patients on a first-come, first-served basis, Colleges advise specialists to triage patients based on the urgency or seriousness of their clinical condition. Patients may need to be moved up the list if their condition worsens.4
Managing a wait list and prioritizing appointments can be a significant part of a specialist's practice as new patients in various stages of illness are accepted and added to the list, and patients currently on the list experience changes in their condition. Some Colleges direct specialists to take relevant factors into account when prioritizing and monitoring wait lists, for instance the patient’s condition, and social factors that can influence health outcomes (e.g. housing, food security, employment, income).4
Effective communication and understanding between the referring physician, the consulting physician, and the patient are valuable in managing a wait list. For instance, it should be clear to everyone who is the most responsible physician at all times, including when patients are waiting to be seen by a specialist. Patients need to know who to contact if their condition changes.
Other approaches to managing a wait list could include hiring additional resources such as an assistant or nurse, and discussing with referring physicians the possibility of discharging patients back to the care of the referring physician.
Specialists should also keep in mind the external environment, for example, government targets for wait lists. If a wait list is not close to the target, it may be necessary to decline referrals.
Even if a wait list is within the target, specialists should use their professional judgment to determine if they’ve reached their personal capacity and it’s necessary to decline new referrals.
Scope of practice and clinical competence
Specialists may feel they must refuse a new patient when they've restricted their practice and/or the patient requires care outside the individual specialist’s clinical competence or scope of practice.
If declining a referral, Colleges generally expect specialists to quickly communicate the refusal to the referring healthcare practitioner and, if appropriate, the patient. This gives referring physicians and patients time to find another healthcare provider. When possible, Colleges recommend that specialists suggest alternative providers who may be able to accept the referral.4
Recognizing that some refusals can be seen as discrimination, some Colleges expect specialists to "clearly and respectfully communicate the reasons to the individual making the request, thereby dispelling possible perceptions of discrimination."5 The refusal and the rationale should also be documented in specialists' files.
While a defined scope of practice is an acceptable reason for refusing a referral, it is not acceptable to use it as a means to discriminate.
Discrimination
When asked to accept a referral, specialists should keep in mind that they are prohibited from discriminating against patients.
Many Colleges incorporate or refer to provincial or territorial human rights legislation when addressing discrimination in their policies on accepting new patients. For example, the College of Physicians and Surgeons of Nova Scotia’s policy refers to the Nova Scotia Human Rights Act. That legislation prohibits discrimination regarding provisions of or access to services or facilities on the basis of “age, race, colour, religion, creed, sex, sexual orientation, gender identity, gender expression, physical disability or mental disability, an irrational fear of contracting an illness or disease, ethnic, national or aboriginal origin, family status, marital status, source of income, political belief, affiliation or activity, or an individual's association with another individual or class of individuals having characteristics aforementioned.”6
Other Colleges’ policies also address forms of discrimination specific to healthcare. For instance, the College of Physicians and Surgeons of Ontario states physicians cannot refuse patients "with complex or chronic health needs; with a history of prescribed opioids and/or psychotropic medications; requiring more time than another patient with fewer medical needs; or with an injury, medical condition, psychiatric condition or disability that may require the physician to prepare and provide additional documentation or reports."4
The bottom line
- Accept new referrals on a first-come, first-served basis, free from discrimination.
- Triage patients based on the urgency of their clinical needs. If you have a wait list, manage it to provide patients with more urgent needs greater access to care. Ensure patients on the wait list are appropriately monitored and they know who to call if there is a change in their condition.
- If it is necessary to decline a referral because the patient requires care outside your clinical competence or scope of practice, assist the referring physician and patient by recommending an alternative care provider, if possible.
Additional reading
Other resources
References
- Canadian Medical Association [Internet]. Ottawa (CA):CMA;2018. CMA Code of Ethics and Professionalism [cited 2019 May 24]. Available from: https://policybase.cma.ca/documents/policypdf/PD19-03.pdf
- The College of Physicians and Surgeons of Saskatchewan [Internet]. Saskatoon (CA): College of Physicians and Surgeons of Saskatchewan;2016 Sept. Guideline, Patient-Physician Relationships [cited 2019 May 24]. Available from: https://www.cps.sk.ca/iMIS/Documents/Legislation/Policies/GUIDELINE%20-%20Patient%20Physician%20Relationships.pdf
- College of Physicians and Surgeons of Alberta [Internet]. Edmonton (CA):CPSA;2010 Jan (reissued 2015 June 11). Establishing the Physician-Patient Relationship. [cited 2019 May 24]. Available from: http://www.cpsa.ca/standardspractice/establishing-physician-patient-relationship/
- College of Physicians and Surgeons of Ontario [Internet]. Toronto (CA):CPSO;2008 Nov (updated 2017 May). Accepting New Patients, Policy Statement #1-17 [cited 2019 May 24]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Accepting-New-Patients
- Canadian Medical Protective Association [Internet]. Ottawa (CA); CMPA; 2018. Accepting new patients: The key to effective practice management [cited 2019 July 3]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2018/accepting-new-patients-the-key-to-effective-practice-management
- Nova Scotia Human Rights Act CHAPTER 214 of the revised statutes, 1989 as amended by 1991, c. 12; 2007, c. 11; 2007, c. 14, s. 6; 2007, c. 41; 2008, c. 59; 2012, c. 51; 2016, c. 4, s. 21
