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Listen to expert CMPA physician advisors discuss a variety of topics affecting Canadian physicians and their practice. Covering a range of topics - from reducing risk and enhancing safe medical care, to physician wellness and how the CMPA supports its members in a changing healthcare environment - this podcast will cover what you need to know, when you need it most.
Hosts: Dr. Steven Bellemare and Dr. Yolanda Madarnas
Professionalism and ethics
The healthcare system
September 2022 | 17 minutes
Disclosure of patient safety incidents to patients or caregivers is a legal, ethical and professional obligation for physicians. Appropriate disclosure conversations facilitate dialogue during the incident management process and reinforces patient-physician trust. In this month’s episode, Steven and Yolanda discuss the best ways to handle disclosure of patient safety incidents and the importance of efficient communication in addressing patients’ needs throughout the process.
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Announcer: You’re listening to CMPA: Practically Speaking.
Dr. Steven Bellemare: Hi everyone, Steven Bellemare here.
Dr. Yolanda Madarnas: Yolanda Madarnas. Hi.
Dr. Steven Bellemare: Welcome to our podcast.
Yolanda, have you ever heard a colleague say something like, “What were they thinking?”
Dr. Yolanda Madarnas: Yeah.
Dr. Steven Bellemare: When they’re talking about the care of a colleague.
Dr. Yolanda Madarnas: Or, “I can’t believe they did that.”
Dr. Steven Bellemare: “They should not have done that.”
Dr. Yolanda Madarnas: Well that was clearly missed.
Dr. Steven Bellemare: Yeah, I’ve heard those things before...
Dr. Yolanda Madarnas: Yeah, so have I.
Dr. Steven Bellemare: And unfortunately, this typically ends up in someone having to pick up the pieces of a poorly done, incomplete or frankly, inexistent disclosure.
Dr. Yolanda Madarnas: Or someone having to contend with an upset, confused patient, completely unprepared and blindsided.
Dr. Steven Bellemare: In fact, you know what? Many of the complaints or legal actions can start with misunderstandings based on comments from people who only know part of the story.
Dr. Yolanda Madarnas: That’s true. Unexpectedly discovering, or learning about a situation, or there was an unexpected outcome, one that happened under someone else’s care can leave us struggling to find the right words.
Dr. Steven Bellemare: It could be that a patient safety incident wasn’t disclosed to the patient.
Dr. Yolanda Madarnas: Or a patient safety incident that the patient is already aware of, but that you’re only now discovering.
Dr. Steven Bellemare: Or maybe even a situation that you think might be a patient safety incident but you really don’t know.
Dr. Yolanda Madarnas: Much of what is already available as material on this topic, presupposes you were involved in the patient safety incident, and provides guidelines about disclosing it.
In this podcast, we thought we’d explore those situations where you perhaps discover a serious medication error, a previously described imaging finding that was not followed up on.
Dr. Steven Bellemare: And we thought we’d discuss what we can do to appropriately support a patient when a patient safety incident occurred but under someone else’s care.
Dr. Yolanda Madarnas: So this isn’t intended to revisit who and how to disclose. We can’t possibly cover all those permutations, and there’s a fair bit of CMPA literature already on this that I’d refer our listeners to.
So first the basics.
Dr. Steven Bellemare: Doctors have an ethical and a legal duty to disclose harm.
Dr. Yolanda Madarnas: CMPA encourages our members to disclose all patient safety incidents to patients and their families, but that may extend to you as a new MRP discovering new information.
Dr. Steven Bellemare: So again, as you said, we have lots of material existing on disclosure of patient safety incidents and generally, our advice is that the most responsible physician at the time of the event should ideally, be the one disclosing the issue.
Dr. Yolanda Madarnas: But you may be left holding the bag and having to do it for whatever reason.
Dr. Steven Bellemare: And it may not be a patient safety incident at all. It may be a perception of a patient safety incident.
Dr. Yolanda Madarnas: And that is a crucial point that is so important for the patient who suffered or thinks they’ve suffered harm. What we say, matters a whole lot.
Dr. Steven Bellemare: Oh absolutely. Harm is a very complex issue. It can occur in a number of different contexts. It could be the evolution of disease, or of a condition that the patient has. It could be a patient safety incident and, in fact, if it is a patient safety incident, Yolanda, there are subtypes of harm as well, right? It could be due to a recognized complication or risk of a procedure or a treatment.
Dr. Yolanda Madarnas: A system failure.
Dr. Steven Bellemare: Or sometimes, provider performance. It could be the physician, the nurse, or any other health care provider that’s been involved in the patient safety incident.
Dr. Yolanda Madarnas: Often, I suspect, it’s a combination.
Dr. Steven Bellemare: In fact, it is. Yeah and when we know something happened, or when we think something may have happened, it’s natural human reaction to want to understand what happened.
Dr. Yolanda Madarnas: Sometimes, wrongly or rightly, we find someone to blame. Deciphering the root causes of a patient safety incident is a very complex task that requires a lot of investigation and study and it’s all the more complicated when an event is thought to have taken place under the care of another health care provider.
Dr. Steven Bellemare: Yeah. You know, if we make a comment, however well-intended, when we don’t understand, or know all the facts, we risk making unprofessional comments and you know this is an important issue. We’ve studied that in certain patient populations, or physician populations I should say at the CMPA, and we know that when there’s a provider issue, and I mean that as opposed to a team issue, or a systems issue, when there’s an issue with the care of a provider. Unprofessional or inappropriate physician manner or behaviour is often alleged in our medico-legal cases. In fact, up to a quarter of our cases, allege an improper manner on the part of the physician.
Dr. Yolanda Madarnas: That’s a big number.
Dr. Steven Bellemare: Yeah.
Dr. Yolanda Madarnas: So, this brings up to our take-home messages for today’s podcast. Disclosure is an ethical, legal and professional obligation on physicians.
Dr. Steven Bellemare: The second one would be that if we discover something that happened under someone else’s care, we should be mindful of how we say that.
Dr. Yolanda Madarnas: And to that point, the third point, is choose your words carefully. To support a patient is important, poorly chosen words can actually perpetuate or cause harm in and of themselves.
Dr. Steven Bellemare: So let’s start with the professional obligation to disclose. When we’re faced with the discovery of what could be a patient safety incident that happened under the care of someone else, we face a dilemma, right? Do we disclose, or do we not disclose? On the one hand, we may be aware of and want to meet our professional duty to disclose.
Dr. Yolanda Madarnas: But we may not want to wander into a premature discussion that might wind up drifting into blame and finger pointing.
Dr. Steven Bellemare: Yeah and we may want to be an advocate for the patient and tell them that something went wrong that shouldn’t have.
Dr. Yolanda Madarnas: And then on the other hand, we might feel that it’s up to the other health care provider to take ownership of the issue and take on the disclosure.
Dr. Steven Bellemare: For sure. Now we may want to be cautious and truthful.
Dr. Yolanda Madarnas: But not appear evasive or covering things up.
Dr. Steven Bellemare: And we may think we know what happened and want to explain it.
Dr. Yolanda Madarnas: But at the same time, we don’t want to throw a colleague under the proverbial bus.
Dr. Steven Bellemare: We have to remember, Yolanda, that it’s not our place to assign accountability for an event. That’s for the courts, the hospital, the regulatory authority, whatever body will be looking at a complaint. That’s for them to do.
Dr. Yolanda Madarnas: And we have to remember that most of the time when we weren’t involved, we’re not going to be able to distinguish between an actual patient safety incident versus a perceived patient safety incident. It’s a very different conversation for each of those scenarios, but the underlying issue is the same. We don’t have all the facts.
Dr. Steven Bellemare: So yes, we do have to attend to disclosure, and we do have to make sure someone tells the patient but there are ways to do that.
Dr. Yolanda Madarnas: And this takes us to take-home message number two: Choose your words carefully. This makes me think of an example that highlights this quite well.
Dr. Steven Bellemare: Okay.
Dr. Yolanda Madarnas: So this is the case of a 32-year-old woman, who was seen by her gynecologist for signs and symptoms of premature ovarian failure. She’s very distraught and tells the gynecologist that the year before or after the delivery of her first child, she developed late onset preeclampsia, wound up in the ICU, and had to have a D&C for retained placental fragments. She wasn’t placed on antibiotics but did develop sepsis and septic pelvic thrombophlebitis afterwards.
Dr. Steven Bellemare: So she was quite sick.
Dr. Yolanda Madarnas: Very sick. So her gynecologist, who wasn’t involved in the care at the time, says well, it’s because of what they did to you at the hospital and she of course, takes on...
Dr. Steven Bellemare: Thought that that was it.
Dr. Yolanda Madarnas: A complaint against the obstetrician who looked after her.
Dr. Steven Bellemare: See Yolanda, that’s a perfect example. Thanks for bringing it. It illustrates the point very well that once a patient hears our comment and particularly if it aligns with what they want to hear or what they perceived may have happened, it becomes their truth even though your comments may be completely off the mark.
Dr. Yolanda Madarnas: As was the case here and we see and know that that can lead to unwarranted medico-legal proceedings: complaints, lawsuits.
Dr. Steven Bellemare: Yeah and see, that’s the take-home message number three right there, isn’t it? Ill-advised comments are a very important form of harm. Harm that can be avoided by carefully choosing our words.
Dr. Yolanda Madarnas: And really, patients aren’t well-served by incomplete information and speculation on our parts.
Dr. Steven Bellemare: No. You know what? While it’s okay to advocate for the patient by asking a question, or suggesting more information is required for you to understand another colleague’s actions, give your colleagues the professional courtesy of addressing the patient and to advocate for their knowing the truth, but by doing ‘s concerns, themselves. It’s easy, Yolanda, to want to align with the patient and to advocate for their knowing the truth, but by doing so in an ill-advised manner, you may just land yourself, in fact, a prominent role in potential legal proceedings.
Dr. Yolanda Madarnas: Yeah. Don’t get us wrong, legal proceedings are a right of patients and they have their place.
Dr. Steven Bellemare: Absolutely. And disclosure conversations should be well considered so as to aim to preserve trust in us as health care providers and trust in the profession overall.
Dr. Yolanda Madarnas: So when we find out about events that took place before coming into a patient care scenario, no matter how outrageous, egregious or unbelievable they might be, we really do need to strive to maintain trust. We need to find a way for the patient to trust that we’ve listened to them, we’re hearing them, and that we will help them deal with this harm, real or perceived adverse event without undermining their trust in the other health care providers.
Dr. Steven Bellemare: You know speaking of trust, Yolanda, here’s another example.
Dr. Yolanda Madarnas: [signals agreement]
Dr. Steven Bellemare: This was a baby born at 39 weeks by planned caesarean section. He was born flat and the pediatrician says well of course he’s flat, he looks only 37 weeks based on his visual inspected at the time when he was resuscitating the baby. So now, you have a baby who needs to go to the NICU unexpectedly and a mother who believes that the obstetrician delivered her too soon. You know and that case ended up eroding the mom’s trust in the obstetrician when, in fact, the pediatrician was incorrect and didn’t appreciate all the dating exercise that had actually been taken on prior to the delivery. That baby was, in fact, 39 weeks.
Dr. Yolanda Madarnas: So this is an excellent example, and I think it might be a good time to share with our listeners the article from The New England Journal of Medicine by Gallagher et al. and the reference will be available on our podcast site. So, it stresses the importance of before initiating a conversation about a possible error to make sure you have the facts, and to give your colleagues the chance to correct mistaken assumptions and join in the disclosure discussions with patients.
Dr. Steven Bellemare: Especially, of course, if they were the ones involved in the care that you have questions about in the first place.
Dr. Yolanda Madarnas: [signals agreement].
Dr. Steven Bellemare: It’s especially important for docs with no direct patient care, Yolanda. I’m thinking here radiologists, pathologists, right? Here’s another example. Family doctor believes a pathologist, or radiologist made a mistake because of an amended report. So, they get an amended report that leads them to believe that the radiologist had misread the imaging, for instance.
Dr. Yolanda Madarnas: That would seem like a perfect setup for the family physician to potentially throw the radiologist or the pathologist under that proverbial bus.
Dr. Steven Bellemare: Yeah. So that situation can potentially be avoided if we pace ourselves, realizing that there’s potentially more to it than can be seen. If we take the time to talk to our colleagues and offer them an opportunity to be present with us when we have the disclosure discussion with the patient, if in fact, there was a patient safety incident at all.
Dr. Yolanda Madarnas: It’s important to remember that non-clinicians, so those who don’t have direct patient care involvement, do have the same duty to disclose as clinicians and being there and sharing in those dialogues with these colleagues, helps us ensure as the story comes out.
Dr. Steven Bellemare: Being there, you know, I understand that people who don’t have direct patient contact may feel a tremendous amount of apprehension at the thought of having a disclosure discussion with patients, but you know, being there helps you ensure that your story comes out.
Dr. Yolanda Madarnas: I’ve had instances on the phone with members, where there was a patient safety incident and the clinician who had the patient in the office with him or her had the non-clinician, in this case, the laboratory specialist, on the telephone during the disclosure discussion. So, he was able to share in more of the fact-finding without physically being present but was still present at that discussion. So, there are multiple models.
Dr. Steven Bellemare: Right and I can imagine how helpful and supportive that must have felt for the patient to say this team cared enough to join in by teleconference to be part of that explanation.
Dr. Yolanda Madarnas: That discussion.
Dr. Steven Bellemare: Yeah. Yolanda, let’s look at a different example here. I’m thinking of a patient who was seen in emergency with a pulmonary embolism. The emergency physician sees a few ECGs from a previous visit that that patient had had at the hospital and sees what he clearly identifies as atrial fibrillation and he discovers that the patient had not been anticoagulated. It’d be easy to rush to the conclusion that well, this AFib was clearly missed and had this patient been anticoagulated, the PE would not have happened, right?
Dr. Yolanda Madarnas: Exactly. It’s so important that we resist the tendency to lay blame because, in fact, we may discover there was a very good reason not to anticoagulate this patient. In this case, this was a patient at high risk for bleeding and for whom anticoagulation was actually relatively contraindicated. So, after a thorough discussion, the clinician and the patient decided not to proceed with anticoagulation.
Dr. Steven Bellemare: Yeah and you see the emergency physician had no way of knowing that with the patient in front of them at that moment. So, you know, we’re all going to end up faced with situations like that, where we do not quite understand the reasoning of the person who provided care ahead of us. So, in a similar situation, the advice we would give is look, raise the issue professionally with the patient, but frame the conversation not as an “I can’t believe they did that,” but rather as “I’ll help you get the information you need.” There’s a piece of information here that I’m missing that you should go and discuss with your previous physician.
Dr. Yolanda Madarnas: So really stressing the principle of explore but don’t ignore. So, it’s okay to acknowledge that you don’t understand the situation but that it may very well be because of lack of critical information.
Dr. Steven Bellemare: In fact, the best thing to do is to encourage the patient to seek more information from the previous provider.
Dr. Yolanda Madarnas: And we can even do it on their behalf, depending on the situation. Like that example I cited of the pathologist present on the phone when we discussed.
Dr. Steven Bellemare: Yeah. I think the most important thing that I can think about here, is to reemphasize that we have to remind ourselves that we were not there. We probably, in fact, most likely, don’t have all the facts to allow us to understand the situation and the version that the patient may present to us, is somewhat going to be filtered through their own understanding and a lack of recollection of detail.
Dr. Yolanda Madarnas: And hopefully, we can trust that the decisions made at that time may have made sense in the context they were in.
Dr. Steven Bellemare: Right. So you know what? While chartings should be thorough, it isn’t always complete as it could be. Surprise, surprise, right? And crucial pieces of information may be missing.
Dr. Yolanda Madarnas: And we’ve come to that point in the podcast again, Steven, for our pearls.
Dr. Steven Bellemare: Wow.
Dr. Yolanda Madarnas: So this sounds like a good time for a documentation pearl.
Dr. Steven Bellemare: Okay. Well, how about this one? Remain objective. Keep your comments and chart notes reflective of facts and observations known to you but without editorializing. Does that make sense?
Dr. Yolanda Madarnas: It does.
Dr. Steven Bellemare: Yeah. How about the communication pearl? You want to go there, Yolanda?
Dr. Yolanda Madarnas: Well, resist the urge to shoot from the hip. Outside of being an expert doing a complete case review, it’s probably not a good idea to comment on another physician’s care. Stick to the facts and commit to gathering more.
Dr. Steven Bellemare: Yeah and, in fact, you know, I think that’s really the best way to support the patient.
Dr. Yolanda Madarnas: And that’s all for today. Well that was our point of view for this episode. I’m Yolanda Madarnas.
Dr. Steven Bellemare: And I’m Steven Bellemare. Remember, when you change the way you look at things...
Dr. Yolanda Madarnas: The things you look at change.
Dr. Steven Bellemare: Oh, I forgot, Yolanda. If people want to send us ideas for podcasts, please do so. You can do that at the address: [email protected].
Dr. Yolanda Madarnas: Yes, we welcome any suggestions for future podcasts. Thanks again, and talk to you next time.
Dr. Steven Bellemare: Have a good day, guys.
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian health care providers.
August 2022 | 20 minutes
Decision support tools are designed to ease shared decision-making and patient involvement on health care decisions. When patients actively participate in decision-making and understand what is required of them, they are more likely to follow through. To establish an efficient shared decision making process, physicians must consider patients values, preferences and circumstances. In this month’s episode of CMPA Practically Speaking, Steven and Yolanda discuss the importance of patient’s decision aids to overcome communication challenges and build a strong patient-physician relationship.
Dr. Yolanda Madarnas: Hi Steven.
Dr. Steven Bellemare: Hi Yolanda, how are you?
Yolanda: I’m well, thanks. I wonder. Sometimes it doesn’t hurt to restate the obvious.
Steven: Well I agree. You know, and actually, it would lend itself very well for this particular podcast.
Yolanda: Yeah. So we know that communication with patients can be challenging.
Steven: Yeah, obvious, right? That’s absolutely true. Probably the hardest thing we’ll ever do. Even the best of us can actually find it difficult to build a strong relationship in a very short period of time.
Yolanda: Yeah, especially in the setting of where we have changing patient demographics, physician demographics, a mix of diverse culture, language barriers.
Steven: More engaged and more informed patients or maybe even misinformed.
Steven: And scarcity of physician time.
Yolanda: Yeah. So this—I think this helps explain why communication-related issues are a number one factor that we see in many of our medico-legal files.
Steven: And in fact, Yolanda, if you read the literature, it’s all over the place.
Steven: Patient-physician communication issues are a big problem. Some of the challenges that, you know, that we note in our files have to do with establishing rapport with patients, communicating clearly, honestly and directly, and checking for patient understanding of their diagnosis and their treatment options, for instance.
Yolanda: Yeah. But let’s not despair because there really are ways that we can improve on our personal communication skills and our communication styles…
Steven: Oh, for sure.
Yolanda: And techniques and tools. And coming to today’s topic, is the use of decision aids, so deliberately approaching communication with our patients with a shared decision-making approach that might include the use of a decision support tool, is one concrete way that we can address these important problems.
Steven: And this is exactly what we’re trying to do with these podcasts, right, is provide some concrete examples of some little changes we could try in our practice, to try to make it overall better.
Steven: So by decision support tool, we’re actually talking about patient decision aids and you’ve used the term before, something that you use with patients to help move the discussion forward, to promote patient understanding. And that’s not to be confused with clinical decision support tools that may be part of an electronic medical record system and that are designed to actually help with identifying relevant differential diagnoses.
Yolanda: So these patient decision aids are used for the more complex decisions that we sometimes have to face with our patients, where we need more detailed information and more careful consideration of a variety of complex options.
Steven: Yeah. Complex decisions often involve multiple options that people value differently. Sometimes the scientific evidence about options is limited and how we value each one can play a major role in how we decide to proceed.
Yolanda: Absolutely. So, you know, the best choice depends on the importance a patient places on the benefits, the harms, and the scientific uncertainty. So the goal of using a patient decision aid is to improve the quality of that decision-making process and ultimately, the quality of the decisions.
Steven: And you know, Yolanda, the quality of the decision hinges on the extent to which the patient feels they chose care that’s congruent with their values.
Yolanda: And those values will help our patients better understand and better be able to make trade-offs between benefits and risks of one option, one treatment, one test, over another.
Steven: And that’s entirely their choice, isn’t it?
Steven: So, using patient decision aids can be helpful for the physician, too, right? It can help structure discussions and make them fulsome, allowing for the patient inputs to be provided and as such, to create some dialogue.
Yolanda: Absolutely. So with regards to the decision aid concept and tools, we want to offer three take-home messages today.
Steven: As we normally do, right? The first one would be shared decision-making approaches to treatment and screening discussions increase patient engagement and satisfaction.
Yolanda: And I wonder. By extension, could it possibly decrease medico-legal risk?
Steven: Well maybe, right? Improving communication between a patient and their physician certainly couldn’t hurt, but using them will require some investment of time on your part.
Yolanda: Right. And bear in mind as well that the use of these tools may not necessarily lead to an instant decision. We need to manage our expectations of such a tool and our patient’s expectations as well.
So take-home point number two would be using decision aids is one technique we can use to facilitate shared decision-making.
Steven: Right. And take-home number three would be that shared decision-making is the link between person-centred care and informed consent. Isn’t that profound?
Yolanda: Sometimes the simplest is the most challenging to accomplish.
Yolanda: So, let’s take a case, an example, say, a 55-year-old male, we’ll call him Joe, who comes to see you and says I heard about this blood test for prostate cancer, this PSA, and he wants it done because he’s afraid of prostate cancer. Joe is asymptomatic and he has no family history. So what would you tell him?
Steven: Well, I guess we could just say sure, let’s do it and leave it at that. That would be an option.
Yolanda: Well, doing what a patient wants as the path of least resistance might not exactly be the best way to go about reaching sound decisions, and it could even be viewed as a somewhat paternalistic approach to medicine.
Yolanda: And the whole point of this podcast is to talk about how you could engage patients in a shared decision-making process, using a decision aid.
Steven: And you know if you were younger and you responded no, that’s necessary. Well, that would be no better.
Yolanda: Just as paternalistic.
Yolanda: In both cases, it’s the lack of dialogue about the why of the medicine, be it a PSA, a mammogram, an MRI, a surgery, a vitamin, w, x, y, z assay that makes the care not person-centred.
Steven: Right. You know, Yolanda, there was a study back in 2019 in the CMAJ and it showed that older patients in rural settings that lived in the province of Quebec, specifically, and are in part of a visible minority group, actually perceived significantly decreased levels of shared decision-making.
Yolanda: Well that’s interesting. I wonder what reasons would explain that.
Steven: I suspect it’s either not being done or it’s being poorly done. What we do know from the literature, is that it seems the barriers include gaps in physician knowledge, either about what clinical situations or patients are appropriate for this approach, or thinking that it’ll take too much time.
Yolanda: So our take-home point—one of our take-home points today was the shared decision-making approaches increase patient engagement and patient satisfaction.
Yolanda: However, it doesn’t quite seem to be the norm yet in many areas of clinical practice, like in some worlds, like my own oncology, for example, such tools and decision aids are used quite extensively, but it’s not necessarily the case across all domains of medicine.
Steven: And some might actually think they are engaging in shared decision-making. But you know, we all have blind spots and sometimes taking the opportunity to receive feedback from a colleague or actually from our patients about how well we engage in shared decision-making, it can actually be a good starting point to improve our care.
Yolanda: Well that would really make a fantastic topic for those self-assessments, high value credits, right?
Steven: Right, for CPD. Everyone’s always looking for ways of getting feedback about their practice.
Steven: So this would be a great topic for sure. You know, working towards being a better communicator can be worth its weight in gold in terms of job satisfaction, too, right? Shared decision-making is just such a way to be a better communicator. It’s a conversation between a physician and a patient, where the physician shared medical information that’s relevant to a health decision. And the patient shares information regarding their values and preferences and together, they arrive at a collaborative decision.
Yolanda: So let’s come back to Joe’s case. If I asked Joe and about his values, he might not really know what I mean. But so it’s how I say it. So it might be better to say I’m curious to understand why you’re asking about this test now, Joe.
Steven: Absolutely. You know, I think you’re right. If you said to people what are your values? They’d look at you like a deer in the headlights probably. So the phrasing and the tone are very important here, right? You don’t want to come across as critical either and you know there are some scripts available as well when you don’t quite know what to say and it doesn’t come naturally. I’m thinking specifically for discussions around opioids, for instance. There are some very nice scripted conversations that you could rehearse or follow that could be of help.
Yolanda: So really, it’s about finding out what our patients want, what they think, what’s going on in their lives right now, what concerns they have so that we’re better equipped to help them.
Steven: Now, Yolanda, shared decision-making takes time, as I said before...
Steven: And that can be a concern for some.
Yolanda: It can, absolutely, but, we can’t stress enough that investing that time is absolutely worth it in the long term. The dividends and the return on that investment are huge in terms of general satisfaction with care on the part of patients and families, and the relationship where it is strengthened. And our article in Perspective, speaks to some of the literature on this topic.
Steven: Right. And I think we’ve mentioned it in another podcast too, where we have to think about how much time we want to invest now with the clinical interaction versus how much time do we want to invest in responding to a college complaint...
Steven: Because the patient wasn’t satisfied…
Steven: With the interaction.
Steven: You know, some patients, though, may not be used to sharing decision-making and we may actually have to socialize them to that concept so to speak.
Steven: The previous or their other doctors may in fact, not have engaged in shared decision-making and so they can be very confused.
Yolanda: Yeah. So Joe would say well, you’re the doctor. You tell me.
Steven: And actually, Yolanda, that’s exactly the kind of situation where using the decision tools might be helpful to a patient like Joe.
Yolanda: Yeah, to help us elicit their values and foster a better understanding, both on our part and theirs, of what the needs are in this situation.
Steven: Right. And if patients push back a bit, that’s actually okay in a clinical conversation. It’s an opportunity to learn.
Yolanda: Absolutely. So, there are various models in the literature that promote the shared decision-making concept. But fundamentally, it’s about two things: communicating risk and clarifying patient values.
Steven: Essentially, shared decision-making can be framed as being based on choice, option and decisions.
Yolanda: Yes. We first introduce a choice and then we describe a series of options.
Steven: And that’s where integrating the use of a patient decision support tool can actually be very helpful.
Yolanda: So that you can finally help your patients explore their preferences and approach to making decisions.
Steven: So with Joe, in step one, you would introduce the choices of PSA screening or not screening, or other options if they’re relevant.
Yolanda: And then in step two, you could describe the options and the data around each option. So for example, what proportion of men in his age group has a negative test? Or what proportion of men in his age group have a cancer detected earlier than had they not had the screening test done?
Steven: And that type of data is exactly what’s in the patient decision aid, right? And then having reviewed that that may explain the fact that the test may not be the panacea that Joe was expecting it to be.
So then in step three, you would discuss Joe’s preferences and values as they relate to his informed decision. For example, which risk would matter most to him? Does he prefer to test and risk a false positive and all the potential treatments and investigations that would ensue? Or does he prefer to do nothing with the understanding that most likely the test would not change anything anyway for him.
Yolanda: And that is uncertainty.
Yolanda: There are benefits and risks on both sides of that process. But instead of me telling Joe, nah, you don’t need the test. Or sure, let’s do it and leave it at that, you’ve given Joe the opportunity to understand and to decide for himself what fits his needs bests.
Steven: So before we go, though, it’s important to say that not all decision aids are created equal.
Yolanda: That’s true. So there are standards used to evaluate decision aids and there’s an entity called the International Patient Decision Aids Standards (IPDAS) Collaboration, quite the mouthful. And in general, there are a number of things to look at to determine if we have a good decision aid. They include, in a first instance, we like to see that the decision aid has included both positive and negative consequences of a clinical decision with the outcome probabilities, as you described.
Yolanda: Secondly, the decision aid describes options so that patients can imagine the outcomes in each of those settings using their personal values when approaching the decision.
And finally, the decision aid links to the evidence that was used to create them and describe the synthetic process or the process that was used to come up with this tool.
Steven: And that’s actually critically important because…
Steven: That’s important for you, right? To critically assess the quality of the patient decision aid and the literature upon which it’s based. Just like we learned to do with medical literature….
Yolanda: Correct. We don’t want to propose something that was fished out of a hat in a fly-by-night operation. We want something that’s founded on evidence.
Steven: Right. And so often, the professional societies might be the ones who actually are putting out these decision aids, which actually is probably also a good hint about their quality.
Yolanda: Absolutely. And it’s important to remember not only, you know, certain speciality societies or entities like the one I referred to, at times our own institutions or facilities might have their own decision aids in certain settings. So if relevant, it might be important to be aware of what’s being used in your community or in your practice setting.
Steven: Right and again, that goes back to being aware of the standard of care and applying it to your practice, one of the concepts that we bring up frequently in podcast.
Yolanda: You’re right. And we interweave this all the time into our discussions.
Steven: Yeah. You can’t talk to a reasonably—a respectable CMPA physician without talking about standard of care or documentation, right?
Yolanda: So hopefully it’s not too confusing for you, but Steven, I’m still curious, do you think decision aids might actually help decrease our medical legal risk as physicians?
Steven: Well, it’s not the use of the aid per se, it’s the benefit that it brings in terms of your relationship with the patient, I think. The concept of readiness to make a decision, I think is the key to a strong doctor-patient relationship and embarking on a treatment endeavour.
Yolanda: And coming back to that point you mentioned of consent. We very frequently see in our medico-legal files that there are problems with consent and that hinge on either poor patient selection that our experts identify as a problem with the consent process where the patient wasn’t ready to accept the risks or didn’t understand them well. This is a setup for dissatisfaction with the care and very often for medico-legal risk.
Steven: But you know it may be a fallacy to believe that at the end of one discussion, our patients will be able to choose. The patients may very well need to take this home with them, mull it over and think about it more before they can actually decide.
Yolanda: Yeah. It’s a process. It’s not plug-in the data, poof spits out an answer. It is a process that requires time and our acknowledgement of that process, in fact, epitomizes patient-centred care and moves away from paternalism and bases itself on dialogue. In fact, I’ll take that one step further, where consent and person-centred care intersect, is where shared decision-making lives.
Steven: Well that’s profound, Yolanda. I like it. It’s about promoting the patient participating in informed consent, having a say in what happens to them.
Yolanda: And it’s important to remember that we interpret these tools through the lens of our own medical knowledge, balanced with our understanding of our patients values and expectations and above all, that no tool is perfect and as with most things in medicine, it’s important that we not be too rigid as well.
Yolanda: So Steven, I think it’s time for a communication tip.
So how about you, Yolanda, do you have a documentation tip for our listeners?
Yolanda: At the risk of repeating ourselves, document. We cannot stress enough the importance of good documentation. And that’s not a message we haven’t said before at the CMPA, but really, seriously. If you used a decision aid to help your patient’s discussions, document it. And don’t just document that you used it, but keep a copy of the tool on the patient’s file. Send the patient home with a copy of the decision aid so they can process it, digest it and share it with their family, because sometimes the family’s values are important in their decision-making process, so documentation is more than just writing it in the record that you used it, but keep a copy, send it home with them, let them process it.
Steven: And that’s really important because keeping a copy of the version of the tool can actually help you later on to understand why you may have suggested to go one way or another. Remember, these tools change over time. As the data improves, as the science evolves, the stats that those decision aids and then…
Yolanda: Quoted are framed in that time set. It is also helpful not wanting to tempt fate, but in the event we had to defend, well we set the standard of care based on that. We’re not going to compare care delivered in 2001 to care delivered in 2021. And if you used a decision aid that quoted data from X year that will frame what the standard of care was at that time.
Steven: Well said and thank you for coming to my rescue there because I was just at a loss for words.
Well Yolanda, it really is the end of the podcast. I think we’ve gone overtime now. So thank you everyone for listening to Practically Speaking.
Yolanda: Yes, thanks for joining us today. Remember we welcome your comments, your questions and any ideas you might have.
Steven: We do. We do and you can email us at [email protected]. So that’ll be it for today, everyone, thank you very much. And remember, Yolanda, when we change the way we look at things…
Yolanda: The things we look at change.
Steven: Goodbye, everyone.
July 2022 | 17 minutes
When considering medical clearance for participation after injuries, there are numerous components to take into consideration to ensure physicians act within the standard of care, and that they keep patients’ best interest in mind. In this month’s episode, Steven and Yolanda discuss the precautions and responsibilities of both parties in assuring a safe return environment. The duo highlights the importance of shared decision-making to establish an efficient framework.
Announcer: You're listening to CMPA: Practically Speaking.
Dr. Steven Bellemare: Hello, everyone. Hi, Yolanda.
Dr. Yolanda Madarnas: Hey, Steven.
Steven: How are you?
Yolanda: I'm well thanks. How are you?
Steven: I'm well, I'm well. Listen, Yolanda, have you ever had to fill out any paperwork for patients?
Yolanda: Oh, way too many times.
Steven: Of course you have.
Yolanda: It's - it's, yeah.
Steven: Who hasn't, right?
Yolanda: Yes, yes, yes.
Steven: What's one of the themes that you think comes up frequently that causes some concern amongst physicians?
Yolanda: Well, many times these forms are in the setting of someone either absent from work or absent from one of their activities, be it a professional activity or a hobby. Then, it involves giving the green light or the go ahead for a return to those activities.
Yolanda: Be it sports activities, or back to work.
Steven: That's what we thought we'd talk about today is in fact return to play.
Yolanda: I think that's…
Steven: Return to work, return to activities. While most of you don't have patients who are professional athletes I'm sure, chances are that you will see some patients in your practice who will need clearance to return to sport, or return to work, or some other type of activity.
Yolanda: Today's podcast really complements the article on the fitness to participate, but really it's essentially clearing a patient to return to an activity.
Steven: Why do we worry about this?
Yolanda: Well, there's a concern among physicians about liability if your patient is re-injured or relapses from the condition they were off for, and there's a concern among physicians as well about, "Well, what if our patient doesn't follow the advice and the constraints placed for this return to work?"
Steven: Right. There's also fears about managing uncertainty, so are you making the right decision, especially if it's not a decision that aligns with what your patient really wants. The secondary agenda that patients or parents of younger patients may have and the ensuing relational problems if you end up making a recommendation that they don't quite like.
Yolanda: Returning patients to active participation, be it in sport, or hobby, is really rewarding, but it's important to balance this against the competing interests, so really the desire to return to activity versus the safety of that return.
Steven: This is a really emotional issue, isn't it?
Steven: Lots of people may apply lots of pressure, and I think the theme from the podcast will be stick to your basic principles as a way to hopefully make the right decisions and stay out of trouble.
Yolanda: Emotions can run high with our patients who are athletes, their parents, their coaches, their team members.
Steven: And insurance companies, employers, the parents themselves, right, all able to exert some significant pressures on us as physicians.
Yolanda: Recognize that you're not alone in this, so drawing upon collective expertise of other healthcare professionals involved in that patient's care can really be a helpful approach to manage these situations.
Steven: What would be our key messages for today, Yolanda?
Yolanda: Well, I think first and foremost stick to the basic principle of keeping your patient's best interests and safety in mind as the driver for those decisions about returning to activities, despite competing interests.
Steven: Right. Number two, ask for help if you're not sure what the latest guidelines - or if you're uncomfortable with the nature of the illness or the injury that you're dealing with and the implications for returning to activity.
Yolanda: Our third takeaway, it's really important to remember to include discussions about short-term and long-term risks of a potential return to activity in your discussions with your patients.
Steven: Let's take take-home message number one then, keeping the best interest of our patients in mind. What does that mean?
Yolanda: Well, it goes without saying that these decisions have to be taken with great care, and first, an issue we see in many cases though is the thoroughness of the assessment. It's helpful to remind ourselves to be mindful of our scope of practice, and our experience with that particular condition.
Steven: Really, it's about knowing what you're talking about and having an approach, whether you're dealing with something high stakes like an exercise-induced syncopal patient with a positive family history of sudden cardiac death, or something perhaps a little bit more mundane like a twisted ankle, sprained ankle. The basic principles are the same in coming to a decision, right? Act within the standard of care. Take a history, do a physical exam, consider the risks and benefits, and discuss those with the patients.
Yolanda: Absolutely. Remember as well that physicians are held to a standard of means, not a standard of results.
Steven: Well, that's an interesting concept. I think that's the first time we talk about that in our podcast.
Yolanda: I think so.
Steven: What do we mean there?
Yolanda: It means that the courts and the regulatory authorities don't expect perfection from us. They don't expect us to guarantee a good outcome. Rather, they expect us to come to our decisions and our recommendations in a diligent manner, as a result of a sound decision-making process that meets the standard of care.
Steven: In the end, we're not infallible, and it's hardly ever, if at all, possible to offer any guarantee. Finding that threshold of safety is the key, right? It involves some element of judgment on your part and on the patients, and that speaks to peoples’ risk tolerance as well.
Yolanda: That also is shared decision-making.
Steven: Right. I have to say, don't be fooled by the "seemingly mundane low-stakes situation." Right? Your approach - and that means being systematic, is the key to ensuring you do your due diligence and adhere to a recognized standard of care.
Yolanda: Whether it's a big injury, a serious injury, or more mundane run of the mill injury, keeping your patient's best interest at heart is the key, and that really takes us to take home point number one.
Steven: You may face tremendous pressure to make the "right" decision for you patient, but that may not be the right medical decision.
Steven: We need to balance those two things.
Yolanda: Absolutely. Let's consider, so what the patient feels is the right choice. What the coach feels is the right choice. What the employer feels is the right choice. What an insurance company might feel is the right choice.
Steven: Don't always align with what you think is medically the right choice.
Yolanda: Yeah. Right, and this is where sticking to accepted criteria, an approach, and a standard of care is really important.
Steven: It's the opportunity to draw upon the collective expertise to see clearly through these competing interests.
Yolanda: It's not unusual for patients to insist to return to play, for example, or the corollary to stay away from work, even though you see things otherwise, and your recommendations are counter to those.
Steven: Right, but that doesn't mean you must do what your patient wants necessarily.
Yolanda: Yeah. Sure. They have to consent to the way forward, and ultimately it's their choice, but it's particularly important when your advice is contrary to what they want to do.
Steven: You need to stand on something solid, and that's knowing and adhering to the standard of care in terms of how you went about doing your assessment and how you came about for your recommendation.
Yolanda: For instance, taking an approach using algorithmic decision-making models from the literature can really help guide you in your decision-making process but can also serve as an educational tool for your patient, explain why you're basing your decisions on this evidence.
Steven: That's right. It's a powerful thing to actually be able to take the algorithm and follow it in person with the patient together to say, "See, you answered yes. That means we have to go there as opposed to there, and therefore the decision." That takes some of that subjectivity away.
Steven: The literature, you know, talks about decision modifiers, such as proximity to play offs, or the presences of a university scout, for instance, as a significant pressure that physicians can face in returning a player to the game, for instance.
Yolanda: When those are at play, you really need to be careful to document your rationale and decision-making process for whatever recommendation you make.
Steven: Even the patient's best interest can be a grey area.
Yolanda: Yes, it can. Let's use a sports example. Your patient may think going back to play is in their best interest, but you see it differently. For you, for your patient making it to the big leagues, for example, may be their priority, whereas for you, your concern is about not developing osteoarthritis in their 20s or turning an acute injury into a chronic problem.
Steven: That's right, and so we've talked about it in our other podcasts, exploring the patient's feelings, interests, function, and expectation - what we call the FIFE model, becomes very important.
Yolanda: Doing so in the end, using such an approach can really help you build a strong alliance with your patient, and in the end, you can agree to disagree.
Steven: That's right. Okay, second take home message; don't be afraid to ask for help.
Yolanda: Absolutely. There are numerous healthcare professionals often involved in the care of our patients. For example, a physiatrist might know the ins and outs of a given injury much more than you.
Steven: While the patient may be coming to you to fill out a form, it may be that an orthopod or a physiotherapist that are involved in the patient's care may actually be better placed than you to opine on the return to play.
Yolanda: These are really valuable resources that you shouldn't hesitate to leverage.
Steven: You know, but that said, we have to be careful not to punt them all to these other resources, because you have to consider your long-term collaborative relationships. When we do hear on the phones sometimes that there are…
Steven: …there are tensions, exactly. Some people who are kind of "known to always send these types of things to colleagues," and you definitely want to be mindful of the collaboration.
Yolanda: I mean, you are fundamentally the most responsible physician. You are the patient's treating physician, so you're a central point, and no one likes to be dumped on.
Yolanda: It's still helpful to consult with these colleagues, a phone call, an email, a letter saying, "This is what I'm facing. What are your thoughts on this?" It's a joint decision. You didn't pull this out of a hat. You've taken this together, again, in your patient's best interest.
Steven: We just need to make sure we're judicious when we do that.
Yolanda: Remember, these interprofessional relationships can really be valuable, and don't hesitate to tap into them when something feels off, or when you're out of your comfort zone in the management of a condition. For example, there are physiotherapists who specialize in concussion rehab and management of post-concussion syndrome and can be an invaluable resource to help you help your patient in these return to work or play decisions.
Steven: Yeah, and when we consult our colleagues and seek their advice, we have to be mindful and remember that not all advice is formal, in fact.
Yolanda: Absolutely. You know, a phone call or an email to the neurologist or to the physiotherapist can be invaluable in helping you assess and manage the situation.
Steven: It's important to take note of that, because it forms part of demonstrating your diligence in coming to that recommendation.
Yolanda: Absolutely, and the same goes the other way. If you receive a call from a colleague who seeks your advice, again it's perfectly fine to give advice over the telephone, remaining mindful of your duty of care to the patient.
Steven: That's right, and I was going to say it's important though to take notes of those informal consults and indicate what points you considered in making your recommendations, because you can be sure the other person - the one who called you for advice, will have noted in the chart that they called you.
Yolanda: This takes us to our third take home point. Remember to have fulsome discussions about the potential risks of return to work or return to play with your patient and to document these carefully in your record.
Steven: Shared decision-making is important, and for instance, it's important to remember to include, for instance, any potential long-term risks that may be incurred with a return to play too early.
Yolanda: In the end, we have to recognize that it's up to the patient to weigh those risks and benefits of a return to play…
Yolanda: …and take into account their personal preferences and values.
Steven: You're making a recommendation, but it may or may not be followed.
Yolanda: For sure, and this isn't a new concept in medicine, right? It's not uncommon for patients not to follow our recommendations in any number of aspects. Steven, let me ask you, we often hear people talk about clearing a patient, but can we really ever clear someone?
Steven: Yeah, you're right. It's a matter of an informed decision on the part of the patient, I think, based on your recommendation, and this is why the article mentions that you may not want to sign a blanket clearance certificate to say, for instance, that a person is fit to fly or fit to leave the country for three months. Rather that you write a statement about the stability of the condition and the risks as you see them at that time.
Yolanda: It's important to ensure the patient understands that it's their decision to make, based on your professional recommendations, and that they have taken into account the risks involved, however small they might be.
Steven: Right, and you know one of the things that comes up sometimes is people will feel compelled to stick to form, right? It's a “yes” or a “no” check box, and you're not quite sure. Our recommendation, in general, is well then don't write - don't check yes or no, write a statement to explain what it is that you're thinking. It's much clearer, and it much more represents the fact that you're thinking about it, that you're making a judgment call.
Yolanda: Yeah, qualify those statements, and really it's not the yes or the no or the black and the white. It's the approach and the framework that are important, and they really apply across the board.
Steven: Your due diligence is key here, whether it's a broken small toe or a third concussion, right? The stakes may be different, but the decisional process…
Yolanda: The approach, the framework is really what's at the heart of this.
Steven: They're the same. Establishing a sound practice pattern that you repeat over and over again is truly the way to promote safe, reliable care.
Yolanda: Let's take for example an athlete trying out for a team. They might want to portray the illusion of health and are not too keen on wearing the brace, and they may want to go back to play before they're actually ready. Well, it is their choice, but if something were to happen, you'd want to be able to demonstrate that your recommendations included a discussion of the risks of not wearing the brace or going back to play too soon.
Steven: Is that your documentation tip?
Yolanda: That is indeed my documentation tip. I guess that was. Steven, it's your turn. How about a communication tip for us.
Steven: Well, I would say that everyone has a voice, as we've mentioned. The patient for sure has a voice, but sometimes even the coach, the employer, the teacher, the insurance company, and while you can listen to everyone, your duty is to your patient. Be mindful of the tone you use when you make your recommendation, especially when it doesn't align with what your patient wants. Those are very emotional decisions, and those are key moments in the doctor-patient relationship that can make it or break it.
Yolanda: That's such as good tip, Steven, because in the majority of our College complaints, there's at least an element of dissatisfaction with communication or a frank communication breakdown, and these scenarios that we've described do put stress on the doctor-patient relationship.
Steven: Well, that's it. I think that's all the time we have, so I do hope this podcast was helpful.
Yolanda: My goodness. Time flies when we get going, doesn’t it?
Steven: It certainly does. Thank you very much for joining me today, Yolanda.
Yolanda: Thanks for listening today. It was a pleasure, Steven.
Steven: Thank you for joining us on our podcast. If you have any suggestions or ideas, please remember that you can send them along at [email protected].
Yolanda: Remember, when you change the way you look at things…
Steven:...the things you look at change.
Yolanda: Good-bye, everyone.
Steven: Have a good day.
Announcer: These learning materials are for general educational purposes only and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian healthcare providers.
June 2022 | 17 minutes
Surgeons put a tremendous amount of focus on mastering the technical skills and maximizing their knowledge base. Data from the CMPA's medico-legal files suggest that a number of adverse events involving surgeons are related to communication issues, rather than to poor surgical technique or insufficient knowledge. This episode identifies techniques to help physicians working in surgery settings reduce their risk of adverse events in the OR.
Dr. Steven Bellemare: Hello everybody, Steven Bellemare here.
Dr. Yolanda Madarnas: Hi, it’s Yolanda Madarnas.
Steven: Yolanda, what are we going to talk about today?
Yolanda: So we know that surgeons put a tremendous amount of focus on mastering the technical skills and maximizing their knowledge base. But it’s also important to view that the data from the literature in our medico-legal files suggest that a number of problems are not so much related to poor surgical technique or insufficient knowledge, but actually communication issues.
Steven: I’m really glad that we picked that topic because, you know, the issue of diagnostic error isn’t at first glance, a big concern for surgeons, right? After all, the diagnosis is usually made before surgery.
Yolanda: But in fact, it is relevant to surgical practice.
Steven: As a listener, you might be inclined to tell yourself, “Well, I’m a nice person. I’m a good surgeon, so this podcast is not relevant to me.” Truth is, most surgeons in our file are not individuals with disruptive behaviour or poor interpersonal skills, right? The relationship issues can be the result of subtle, unappreciated behaviours. So, I’d encourage you to not go away and stick around and listen.
Yolanda: So on that note, let’s talk about what our take-home messages are going to be, Steven.
Steven: Well first one I would say is that it’s important to recognize that individual cognitive capacity is limited. And the use of cognitive reserves of the team can be a useful way to counteract that.
Yolanda: Second point, I would say, is the idea of contributing to a culture that allows the free-flow of important information within teams.
Steven: It’s absolutely crucial, I agree. And the third take-home point, of course, would be around documentation. And what we would like to say here is that documentation is a form of communication. It’s important to record important information, but actually review that documentation either before or after surgery, or both depending on the case.Yolanda: Absolutely. So let’s talk about definitions. I would anticipate there are different definitions of diagnostic error.
Steven: Oh, absolutely. And some are based on diagnosis as the noun, as in the label we give to an illness.
Yolanda: And other definitions are based on diagnosis as the verb.
Steven: Oh, that’s right.
Yolanda: So the reasoning or the process of arriving at a given label. And in fact, the definition [of diagnostic error] from the Institute of Medicine involves both of these. So, to quote, “It’s the failure to establish an accurate and timely explanation of the patient’s health problem, or to communicate that explanation to the patient.”
Steven: Right. There’s no specific definition of diagnostic error in surgery per se, but for our purposes, the concept of diagnosis extends to all of the decisions and the choices made before, during, and after the surgery. You make a choice based on a reasoning process and you could argue that that choice is a diagnosis, right? You’re diagnosing an issue; therefore you’re going to act on it.
Yolanda: Yeah. So an example might be if in the course of an operation, we mistake a structure for another and we convince ourselves that there isn’t a problem, this could in fact, constitute a diagnostic error.
Steven: Right. So, you know, at CMPA, we’ve looked at our files in surgery and we’ve identified that most problems arise in the OR. And many, when they’re reviewed by the experts after the fact are actually felt to be preventable. Sometimes bad things happen, you know, and we realize that, and there’s nothing that you can do about those kinds of things, right?
Yolanda: Yeah. We’re human.
Steven: We’re human and not absolutely everything can be anticipated, but there are those times, though, when things are preventable and that’s really the focus of this podcast.
Yolanda: So let’s take an example, Steven, to illustrate this.
Yolanda: A surgeon performing a cholecystectomy assisted by a third-year resident.
Yolanda: It’s a difficult cholecystectomy with lots of adhesions. And the surgeon sees bilious fluid in the operative field and says, “We’ve probably perforated the gallbladder.” The R3 says, “I don’t see a hole in the gallbladder”, but nothing more.
Yolanda: The surgeon remains focused on the operative field, continues with the procedure and at the end—after aspirating and suctioning the area—doesn’t see any evidence of persistent greenish fluid and is satisfied with his explanation. The R3 leaves it at that; doesn’t revisit the issue of the gallbladder and doesn’t speak up. Postoperatively, the patient does poorly, develops abdominal pain, becomes septic and is taken back to the operative room. And lo and behold, a perforation of the small bowel was discovered.
Steven: So that fits our diagnostic error definition, actually very well.
Yolanda: [signals agreement]
Steven: And our message here is not try harder or do better, right? It’s that these issues creep up on us as physicians when we get tunnelled in and we lose situational awareness, which is that ability to pick up on information, to process it and actually identify its meaning and to project into the future for what it might mean.
Yolanda: We know that hindsight is 20/20. But I’ve certainly spoken with surgeons who’ve told me that in retrospect they wish someone had spoken up with a concern, or they themselves had listened to their inner voice niggling away that something wasn’t quite right.
Steven: Exactly. Think about how often it’s happened in your career, where something happens and in retrospect it makes sense and someone says, “Oh, I had a feeling at that time” and you think to yourself, “Well then why didn’t you just say something?” Right?
Steven: That’s exactly what we’re trying to get to here.
Yolanda: So, this takes us to our first take-home point, Steven.
Steven: Right, and that’s the fact that individuals have limited cognitive capacity and teams have more than the individual. Now, cognitive capacity, of course, is that space in your brain, right? We can only handle a certain amount of information at any one time. Once that threshold is surpassed, something’s got to give, right?
Steven: We can’t handle it all.
Yolanda: And we recognize that there are a number of factors that could impact on our individual or our collective cognition and just to name a few, think of the number of people in a room, the noise levels, our individual stress and the situational stress.
Steven: That’s right, or the fact that we’re hungry, that we’re tired or that we’re running overtime on our OR list, right?
Steven: To only name a few. So when cognitive capacity goes down, so does situational awareness.
Yolanda: Yeah. So, this represents a really good opportunity to leverage the team to mitigate any one individual’s decline in cognitive capacity and recruit complimentary cognition and capacity from the members of the team.
Steven: Right and that’s when we talk about team situational awareness.
Steven: So practically, though, how can we do that?
Yolanda: So we’ve talked about this in another podcast, you know, you can use huddles and debriefs to demonstrate an openness to collaboration that we acknowledge that we can be vulnerable, we’re not perfect and that we are appreciative of someone stepping in to prevent a mistake from happening.
Steven: Right and that’s what the surgical safety checklist is all about in effect, right? Really, it’s a team debrief to help safeguard against diagnostic error. So, in addition, I don’t think we can overemphasize the importance of empowering speaking up. And speaking up is the ability to say what you think in a polite and professional way, of course, but at the time when it happens without fear.
Yolanda: Like our gallbladder case.
Steven: Exactly, right? So in our gallbladder example, the resident had some concerns about the gallbladder not being the source of the bile and he did mention it. He said, “Oh, there’s no hole. I don’t see a hole in the gallbladder” but only once and perhaps not necessarily in an effective way. And so, why didn’t he bring up the issue again. Maybe he perhaps asked to look at the specimen to see if there was a hole. Maybe he was uncomfortable doing that. Perhaps the surgeon had demonstrated in the past that he wasn’t particularly interested in receiving feedback from his assistants. So as a surgeon, what can you do to encourage people to share their perceptions with you, to actually speak up to you so that you’re not in that situation where something happens, a complication down the road and then you’re thinking to yourself, “Well then, why didn’t you just speak up to me?”
Yolanda: What if? Yeah. So, I remember a call with a member quite some time ago, actually, who recounted a story before the time of operative sites being routinely marked and how he was scrubbing into surgery with a medical student and the medical student raised the fact that he noticed a discrepancy between the history and the OR booking, vis-à-vis the side of the lesion. So one was right and one was left. And the surgeon actually listened to this, un-scrubbed, looked it up, wasn’t clear and actually woke up the patient to confirm what side they were operating on.
Steven: Imagine that, right?
Yolanda: Oh my goodness.
Steven: And some people would say, “Well gosh, that’s…”—to some people that’s almost unfathomable. Are we actually going to wake up the patient? But he did the right thing, right?
Steven: And that’s a great example of a diagnostic error averted.
Yolanda: And a great example of speaking up and listening up.
Steven: And listening up.
Yolanda: In a culture where that’s encouraged and accepted.
Steven: Absolutely and what is in fact, a great link to our take-home point number three.
Yolanda: But what happened to take-home point number two? We’d be skipping ahead, but then again, it’s our podcast. So, we can take poetic license.
Steven: Right. Sure, why not? Let’s do away with the script, right? What I was intending to say, is that our take-home three was that documentation is a form of communication and that it’s important to record information, but to actually review it, because that’s the purpose of recording it, either in pre or postop or even both.
Yolanda: [signals agreement] and it’s important to remember that individuals may not have all of the information required to act upon and that different members of the team may actually harbour some of that information.
Steven: Or we may actually fail to appreciate the significance of information, but others might, and then may be in a position to provide a different viewpoint.
Yolanda: Like the R3 in our gallbladder case.
Yolanda: So I think what we’re trying to illustrate here is that diagnostic error, interoperatively, can be compounded by diagnostic error postoperatively and that documentation is a key factor in risk reduction.
Yolanda: Good versus insufficient documentation. So here, we see that diagnostic error can be compounded by inadequate documentation or mitigated by good documentation.
Steven: How the note is written may actually affect how a clinical presentation is interpreted downstream, right? So documenting uncertainty actually can be helpful in helping us, or others, manage the postop patient by allowing us all to get a possibility for a second chance to get it right if we did miss it initially. So for instance, if we’re not 100% sure that an explanation is what it is, i.e., we’re not 100% sure that the bilious fluid is coming from the gallbladder. Writing that down can actually help us revisit that in postop because it might actually escape our mind at that point.
Yolanda: Yeah. Problem is, though, is that we don’t always listen to that little voice and we’re able to convince ourselves that our explanation was actually good enough.
Steven: Well and that’s not just in surgery, right?
Steven: Yeah. We see that all the time. For instance, you know, how many times have we been in M&M rounds, where we’ve heard cases of persistent this or persistent that, that eluded the diagnostician and that in the end, we find was due to something completely different that was completely unexpected.
Yolanda: Yep. Right? Like the pneumonia that isn’t resolving that’s in fact a subdiaphragmatic abscess.
Steven: Yeah. So recognizing that we’re all prone to magical thinking. None of us want to believe that we did something that could have caused harm, right? That can be our saving grace.
Yolanda: So that flows nicely into take-home point number two, Steven. How can we contribute to a culture that allows for free-flow of important information?
Steven: Yes. The creation of psychological safety, it’s so important in creating a high-performing team.
Yolanda: So you might see something as X, but the rest of the team sees that same thing as Y and together we all get a clearer picture.
Steven: But that’s only provided someone actually speaks up about it.
Yolanda: And someone actually listens.
Steven: So in the end, you know Yolanda, it’s about learning. It’s not about who’s right and who’s wrong. It’s not about who’s the boss and who’s not. It’s really about learning. A colleague of mine was telling me recently about how when he was doing a liver resection, he came across a situation like that. He had an excellent final year resident that he knew very well and they were having some troubles getting a margin and when they got to the final attachment, the surgeon used the linear cutting stapler to divide it. And just as he was finishing firing up the stapler, the resident said, “So why are we dividing the cava?” and then he froze and became presyncopal.
Yolanda: Oh, I can imagine.
Steven: And so he had divided the cava not knowingly and the resident had watched him do it. Hadn’t said anything until after it was done, even though it was clear in the resident’s mind that they were about to divide the cava. So the surgeons tells me, you know, he had two options: the usual blame himself for making a mistake and making a solid promise to himself to be more careful the next time and to do better.
Yolanda: Which is not an uncommon reflex, right?
Steven: Absolutely not. But there was also another option that he identified and said that he considered that there was something better that he could do. Like figure out why the resident was so hesitant to say anything and what elements of that might have played a role in his losing situational awareness at that time.
Yolanda: So this brings to light the concept of fixed versus growth mindset.
Steven: That’s right and never missing out on an opportunity to learn.
Yolanda: So someone who has a fixed mindset may tend to focus on their mistake and be discouraged, blame themselves or others and that fundamentally hinders the development of better processes to decrease diagnostic error.
Steven: Right. And the person with the growth mindset will rather take that as an opportunity to learn and improve. They accept the error. That’s not to say that they throw their hands up and say oh well, that’s life. But they accept the error as a feature of being human and then they move on and say so what can I learn from it and they take it to the next level.
Yolanda: Yeah, exactly. So for instance, a debrief with the team to lead by example and foster learning so that we identify ways to prevent a reoccurrence of events like this.
Steven: Right and in my friend’s case, that’s exactly what he did. He sat his team down afterward and said we need to look at this. How did I end up cutting the vena cava and how did it occur? He made it very open and people interjected with ideas and they identified that there had been a lot of unusual chatter and noise going on in the background and that that had distracted him from his task and that that likely had played a big role. So, they were able to make sure that the next time they kept the noise level down, especially at these crucial moments.
Yolanda: So I think it’s important to remind ourselves to leverage our documentation to help prevent an interoperative mishap from becoming a postoperative patient safety incident.
Steven: Yes, but you know what? We can document ‘til the cows come home. Someone actually has to read it.
Yolanda: Absolutely. So Steven, how about a communication tip?
Steven: Well I’d say that we should leverage daily events, like the surgical safety checklists, our huddles or debriefs, to signal to our team that we’re open to collaboration. That we know that as individuals, we’re vulnerable and that we appreciate someone preventing us from making a mistake that they can see coming.
Yolanda: And that brings us to the end of today’s podcast, Steven.
Steven: We hope this was helpful to you.
Yolanda: Thanks for joining us, today. I’m Yolanda Madarnas.
Steven: And I’m Steven Bellemare, reminding you that if you have any questions, you can certainly call us at the Association and if you have comments or suggestions for future topics, send them along.
Yolanda: You can email us.
Steven: Our address is [email protected].
Yolanda: And remember, when you change the way you look at things…
Steven: …the things you look at change.
May 2022 | 16 minutes
Steven and Yolanda discuss key considerations of routine team debriefs: What are they? Who should use them? How should they be implemented? How can they potentially improve patient safety in your clinical setting?
Dr. Yolanda Madarnas: Hi everyone. I’m Yolanda Madarnas.
Dr. Steven Bellemare: And I’m Steven Bellemare. Welcome to our podcast.
Yolanda: Steven, you look like you’re itching to jump into something.
Steven: I am. I have three situations I will put to you here, Yolanda.
Yolanda: Fire away.
Steven: Think about it. A crash C-section, delegating an intra-articular steroid injection to a resident, or a patient in an outpatient clinic that’s double-booked, causes a bit of a scene, security gets called. What do you think these three situations have in common?
Yolanda: Wow, that’s pretty broad. I’m not sure where you want to go with this.
Steven: Yeah, I know, it’s kind of a “guess what I’m thinking” type of thing. They’re all opportunities to do a debrief.
Yolanda: So then today’s podcast, folks, is going to focus on the Perspective article on debriefs in teams [link in episode notes].
Steven: That’s right.
Yolanda: So communication in healthcare is a very important aspect of patient care, and there’s lots of evidence in the literature that shows that good communication amongst healthcare providers is a key determinant of patient safety.
Steven: You know, Yolanda, it’s too easy to say: “communicate better”. I mean that’s trite, right? We have to know how to communicate and debriefing is one of those ways to make sure that information is shared to create situational awareness.
Yolanda: So for those not familiar with the term, situational awareness is a cognitive process where you perceive information, interpret it and project it into the future for what it means to the care that you’re providing. And by maintaining that situational awareness and focusing on what we do, or what we just did, we can learn what works well, what doesn’t work, and what could work better as we strive to learn.
Steven: And Yolanda, that’s a key aspect of teams that provide reliable, safe medical care. They continually learn from their experiences.
Yolanda: So in this podcast, we’re going to discuss how routine debriefs can improve patient safety.
Steven: If we think about the three take-home points that we want to bring in here today, Yolanda, I would suggest that the first one would be that team debriefs are easy to implement and actually would have a low impact on the workload of team members.
Yolanda: That might take some convincing, but we’ll see.
Steven: Well, we’ll try.
Yolanda: So debriefing on a daily basis helps improve team performance, communication, and it lowers barriers to people speaking up.
Steven: That’s another very good point. And finally, I think we can also point out the fact that to be effective, debriefs should follow a structured process. They have to have purpose. They have to be done essentially the same way by everyone, every time so that it’s not really done in a haphazard fashion.
Yolanda: So let’s talk about how to implement debriefings. Well, although I thought it would take some convincing, they’re actually pretty easy to implement in the sense that it doesn’t actually require extra resources and not a huge time commitment. The hard part is planning for it to happen and getting the engagement and the buy-in from the various players.
Steven: Absolutely and so my advice here would be to start with the willing and grow it out from there. Chances are that as you start doing it, people will realize their value and pretty soon, people are going to be saying well, I want to do what they’re doing over there. I want to do it like they do.
Yolanda: There’s also a difficulty in creating what people perceive as a safe space and making it effective. So you don’t want people feeling that they’re wasting their time. You don’t want it to turn into a venting session and complaining, but you want it to be productive.
Steven: Absolutely. You have to be clear on the purpose if you’re going to decide to do team debriefing. And the purpose, really, is to learn from your daily experiences on how to provide safe care. It’s almost like mindfulness for caregivers, if you want: taking the time to reflect on things in real time, while the players are still all there.
Yolanda: So as put forward in the IHI framework for improvement [link in episode notes], really, this is quality improvement in action.
Steven: Absolutely. You know, to make this very valuable, to make it work, it’s important to have a policy in place that clearly places post-event huddles in the realm of quality assurance and also firmly establishes the confidential nature of the discussion, to help provide a sense of security for those that are involved.
Yolanda: These events don’t need to be bad events. They could simply be reviewing what took place that day. It doesn’t need to be an adverse event review.
Steven: Absolutely and in fact, that’s the point. When you routinely debrief, whether things went well or unwell, you’re normalizing the process, right? You’re formalizing it to help decrease the challenge of debriefs being done haphazardly or being done in a moment that’s perceived as threatening because they only get done when things go wrong, for instance.
Yolanda: So it speaks again to the importance of creating a safe space, a shared mindset and having a structure in place to do these and identifying when to use these, because when they’re well done, debriefs can be done on a regular basis without increasing the hassle factor in the workload for staff.
Steven: And I would argue, Yolanda, that they actually make people more efficient, because they can apply their learning to the next patient and learn what works and what doesn’t, in order to continually improve the way they do things.
Yolanda: So let’s move on to the impact of debriefs on team communication, team performance, and the culture of speaking up.
Steven: Well, implementing debriefing in your daily routine’s an important factor to improve your work culture and to promote safety in the care you provide. Everyone needs to understand, though, Yolanda, that the objectives of the debrief is not to criticize the care of any team member, or of the team, or to assign blame when things go wrong. The objective of the debrief, is to review what just happened so that you can learn.
Yolanda: That’s so important because we know that teams that debrief on a regular basis perceive fewer barriers to communication and less hierarchy, essentially fostering that safe work culture and that safe care culture, allowing everyone to speak up about concerns.
Steven: And in the end, you know, that enhances patient safety. In fact, we can’t really talk about debriefing without mentioning briefings.
Yolanda: That’s semantics.
Steven: Well, you know, actually there is a difference there. The briefing occurs before the event, right?
Yolanda: I see.
Steven: And that’s where you make sure that everyone’s on the same page, everyone understands what’s about to be done, people actually know each other, people have a shared vision and shared understanding of the potential complications and are similarly prepared for them. The debriefing comes after the event.
Yolanda: After the event. Yeah.
Steven: And that’s where again, you’re doing pretty much the same thing. Now you’re just going back over what just happened. Did it go as it was planned? If not, why did it not go as planned? What can we learn from this? What do we need to do for the next patient? The very next one that’s coming right after, is there something that we can do right now about that to make sure that we don’t repeat the same problems, same mistakes?
Yolanda: So how would this be different from a huddle, for example, that we hear about a lot in many clinical settings?
Steven: Yeah, that’s a very good question. Huddles are more situational. So those, you would use more at the beginning of a shift, where you’re going to discuss together as a team who’s on call, who’s sick, what’s the bed situation in the unit at that point?
Yolanda: So more context.
Steven: Yeah, context that helps you plan for how you’re going to deliver care over a period of time. Also, discussing what other patients are around and how that might impact your unit’s functioning. So, you know, we call this running the board, right? When we all stand in front of the board and we look at the patient list, that’s part of a huddle. We can broaden the huddle to talk about a few more things other than just who’s on the ward.
Yolanda: So then briefings would be more specific to procedures.
Yolanda: What are we going to do? How are we going to do it? Who’s doing it?
Steven: And what their level of experience is. Have they done that particular procedure before is very important.
Yolanda: What could we expect? What kind of complications?
Steven: That’s right. Do you share the same mindset about why this is going on? Is this urgent or elective? And the issue of shared mindset, shared awareness of what’s going on is really what the briefing is helpful for.
Yolanda: So then, briefings, debriefings and huddles are all important to create situational awareness and can be affected by information uncovered during debriefings.
Steven: That’s right and, so you know, when we talk about, oh, we need to communicate better. That’s actually the way we can communicate better, is to use those three techniques, those three tools.
Yolanda: So let’s move on and figure out how debriefs can be structured for success.
Steven: Well that’s the key, isn’t it? You have to plan for them. You can’t just make them happen all of a sudden. No. I think we have to start by talking about them with our teams and feel them out for their interest and the potential pushback that they might have about the idea.
Yolanda: I suppose that’s a time and an opportunity to get a feel for what’s important to the folks around the table.
Steven: Absolutely. You know, there’s literature that you can review to help you address fears such as the impact on people’s time.
Yolanda: That’s a big issue, right? In high volume, time efficient, pressured settings, we really don’t want to be seen as wasting our time doing something that doesn’t have a purpose.
Steven: And you want to make sure that people see the value or see the purpose.
Yolanda: So I guess you could start out with a small group of converted or engaged or committed people, identifying what key issues should be addressed during a debrief. Did things go as planned? If not, what happened and why?
Steven: Could it have been anticipated, for instance, and what could we learn about that for the future?
Yolanda: So I guess probably the most important thing then, is to act upon the recommendations or the answers to those questions, so that everyone can see learning in action and derive real meaning from that exercise.
Steven: You know what? That’s probably the most important thing. And you know what? That makes me think that’s probably going to be the pearl I’m going to give at the end. Right? This is probably the most important thing we can say about debriefings. Nothing will kill a project like someone who feels they’re wasting their time. So if you actually raise an issue in a debriefing and say this needs to be addressed and it actually doesn’t get addressed and it doesn’t change, you will completely kill the engagement of your team.
Yolanda: You also need to create that psychological safe space, right? For people who want to participate but feel vulnerable or afraid to speak up and are feeling perhaps vulnerable and scrutinized by their colleagues and it becomes a performance anxiety driving exercise.
Steven: We can’t be judgemental and we don’t want to come at it with a blaming frame of mind, we can’t be angry. We have to really focus on the learning. And you know, as I think about this now, the debriefing can have two purposes that are connected but different, right? On the one hand, the debriefing can be about learning from the experience: what can be done better, what went well, what can we keep going with?
The other aspect of the debriefing can be very helpful to help team members share how they feel emotionally about something that happened and so, you know, emergency room teams, for instance, will often debrief after a major trauma or something like that, to make sure that they support one another. That can be another very important role for debrief, but that’s a very different role than the learning role in terms of the provision of clinical care. Both are very valuable, but I felt it was important to point those out.
Yolanda: So I guess this really speaks to having a growth mindset so that when we see mistakes as opportunities to learn and do better from the viewpoint of quality improvement, joy in work, safe patient care, it takes away from blaming ourselves and using words or thoughts like I could have or should have done better.
Steven: You know the growth mindset versus the fixed mindset are very important in promoting physician wellness. The physician who sees themselves as I should have known better, I’m incompetent, I’m a failure, I’m an imposter, has this fixed mindset where they are holding themselves to a standard perhaps that’s unattainable. A person with a growth mindset will say okay, I didn’t do that as well as I thought I could. What can I learn to make this better next time? And if we foster that growth mindset within our team, we’re actually supporting each other and learning and growing together and that benefits patient safety.
Yolanda: I can see how that’ll be a challenge to incorporate in some settings because historically, that’s not been the culture and that’s not been the mindset present in our clinical world.
Steven: But you know what? All it takes is one person to start changing things. And you know, having this culture of “I’ve got your back” is so powerful to create a team that functions effectively in the interest of patient safety. And “I’ve got your back”—don’t get me wrong here, Yolanda—doesn’t mean I’m going to cover for you if you make a mistake.
Yolanda: Or “I’m watching you till you screw up.”
Steven: Absolutely. No, that’s not what it means. “I’ve got your back” is “I’ll be there for you”. We’re a team and I realize that there are times when your performance might not be optimal. I realize there are times when my performance might not be optimal. But together, if we’re looking out for those times, we might be able to intervene if we learn to work well together through our debriefs to help prevent those potential patient safety incidents from happening.
Yolanda: And ultimately provide better patient care.
Steven: That’s what it’s about, right?
Yolanda: So we’re at the end…
Yolanda: …of another podcast, Steven.
Steven: How quickly time flies.
Yolanda: So I guess it’s time for our pearls.
Steven: The pearls, that’s right. Do you want to go first with a communication pearl?
Yolanda: Yes. Let’s start with a communication pearl. So debriefs, when they’re done routinely and with purpose can actually be a safe place for team members to identify concerns and learn to speak the truth to one another in a non-judgemental, non-blaming, and supportive way.
Steven: Wow. I guess the listeners might have to pause here and let that sink in and think about what that means. That’s a powerful statement. So yeah, let’s take a pause and let you do that.
[Podcast pause – instrumental music playing]
Yolanda: So if you did hit pause, welcome back.
So Steven, do you have a documentation pearl for us?
Steven: Documentation, yes. I think that debriefs don’t need to be documented per se. As the article in Perspective points out, if they’re done after a patient safety incident, there should be a note outlining the event in the chart and some thought should be put into initiating a more formal quality improvement review, if need be. But otherwise, if you’re just doing a regular debrief that’s very routine, whether or not things go well or wrong, there’s not a need to document that per se. The key is really to act on the information that was discussed. Sending a note of a needed change in a procedure or equipment to the appropriate person might really be all that’s needed in terms of documentation when the debriefs are more routine.
Yolanda: So that sums up our point of view for today. Thank you, Steven.
Steven: Thank you, Yolanda. This was fun.
Yolanda: On behalf of the CMPA, I would like to thank you for joining us today. If you have any comments, questions or story ideas, we would love to hear from you. Our email address is [email protected]. And remember…
Steven: …when you change the way you look at things...
Yolanda: …the things you look at change.
Steven: Goodbye, everybody.
Yolanda: Should we debrief after this, Steven?
Steven: I think we should. That’s a very good idea.
[Yolanda and Steven start to debrief]
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian healthcare providers.
November 2020 | 11 minutes
Retirement, parental leave, illness, moving to a new practice – what considerations should be made when taking an unplanned leave of absence? This episode looks at the importance of planning for the unforeseen, and ensuring patients’ continuity of care is at the forefront of those arrangements.
Announcer: You're listening to CMPA, Practically Speaking.
Dr. Steven Bellemare: Hello everyone. Steven Bellemare here.
Dr. Yolanda Madarnas: And Yolanda Madarnas. Welcome to today's podcast, which builds on the article about leaving or closing a practice. The principles we touch on today are really going to go well beyond retirement and are applicable to short-term and longer-term absences from a practice, like parental leave or illness, moving to a new practice, or the foreseen departure that's left until the last minute to coordinate.
Steven: In fact, all of these scenarios highlight the need for physicians to maintain continuity of care, and they're applicable to family medicine, as well as specialty medicine, community, or hospital settings, so all of us really. We need to get into the habit of planning for the unforeseen to happen. Let's not bury our heads in the sand here.
Yolanda: This takes us to three take-away messages today. Continuity of patient care is the underlying premise.
Steven: It's a good first one. As a second one, I'd say that having a written agreement when joining a group or clinic can be a lifesaver.
Yolanda: Thirdly, collaborate with colleagues proactively about a plan.
Steven: Let's start with continuity, Yolanda.
Yolanda: Contingency plans for leaving a practice are best made early, at the time you enter into the practice.
Steven: For issues such as who will provide coverage for you when you're off, for instance.
Yolanda: Specifically, who's going to see your patients? Who is going to follow-up on test results when you're not there?
Steven: As well as who will be the custodian of the medical records, and who will continue to have access to these once you leave?
Yolanda: But collaboration and having a contract or agreement are actually two different things.
Steven: Ideally, all of these situations that we just mentioned are spelled out in a written agreement. I'm sure you've spoken to people on the phone about these situations.
Yolanda: Yeah. The reality though is that more often they're not - there is no such agreement, certainly not one in writing. It's an informal gentleman's agreement, not even with a handshake these days, and without an agreement, physicians needing to leave a practice experience way more stress and headaches than needed.
Steven: Right, Yolanda. You know, I don't want us to be too preachy here, right, but good planning is really worth the investment, isn't it?
Yolanda: Absolutely. You can look at it as a way of contributing to your self-care.
Steven: That's right. Planning ahead of time will actually make the issue of leaving practice so much easier for you.
Yolanda: Let me give you an example here of a typical call might be from a physician who is expecting, and had planned her maternity leave effective on a particular date, but due to medical complications during the pregnancy, now has to leave several months earlier than planned. Having an agreement in place to fall back on was invaluable when she was no longer in the mental headspace to deal with handing over her practice.
Steven: Alright now. Hold on here. I know your listeners are thinking, wow, I did not know CMPA could help me with my contracts.
Steven: No, we don't, but your provincial, territorial medical associations might be able to provide you some advice on how to construct such a contract, such an agreement.
Yolanda: Even in the absence of a written agreement, the key is to collaborate with your group leadership and your colleagues, and having a formalized shared plan or mindset regarding the follow-up of test results and ongoing patient care.
Steven: That might be done through securing a locum or a colleague to cover an unexpected leave from your practice, but if that's unsuccessful, and that's not infrequent, right? There are a number of things that we need to consider.
Yolanda: Let's get back to the basics. It's about taking steps to ensure continuity of care for your patients.
Steven: That could be, for example, summarizing the case of more complex patients using your accumulative patient profile.
Yolanda: I know your colleagues will really appreciate this, and your patients are likely to benefit as well.
Steven: You know that keeping accumulative patient profile is actually a requirement in most provinces in the country, so that actually gives you a reason to do it and to keep it up to date, right? What about the doc who practices in a solo practice?
Yolanda: That is a challenge, and although it is a less common scenario, it is still a reality out there for many of our colleagues. At the very least, I'd suggest that we consider developing an alliance with another solo physician, for instance, and agree ahead of time to help each other out in a pickle.
Steven: I think we can't over emphasize that a bit, agree ahead of time, because when you're very stuck at the last moment, and you need someone, that’s of course when you're having - you're going to have the difficulties finding someone to help.
Yolanda: That's the default unfortunately where many patients wind up going to either a walk-in clinic or the emergency department.
Steven: Which isn't ideal, but, you know, can help meet the needs of some patients who really need access. Access to and transfer of your medical records then needs to be considered for sure.
Yolanda: This is definitely a problem in solo practice, and to a lesser extent in a group practice where there's someone there even if you're not who could grant access to the patient or a provider.
Steven: Having a plan for communication about your absence and about how to access healthcare is going to be a big part of this.
Yolanda: Let's get back to the CPP summary. I think that your office might be able to provide a copy of this to your patients during your absence, so that they can take it with them wherever they seek care, remembering the patient is often a vehicle that we can leverage to assist in their own care.
Steven: For that to happen, Yolanda, a very simple step that people may not have thought of is the importance of letting your office staff know that an accumulative patient profile exists on charts for people to access if you were to not be available. That's especially important for patients who are being actively investigated or treated.
Yolanda: To reiterate, it is important to try to engage our patients in their own care, so they understand not only the need for follow-up but the appropriate access points in the healthcare system during our absence.
Steven: This is not something that you'll be able to do if you're suddenly ill. Your staff needs to understand the importance of this aspect so they can do it for you on their own without your direction.
Yolanda: This intends to rely on administrative staff in the office who remain during your absence. That's part of planning for continuity of our administrative staff, and it is important. They really can be the glue that helps keep this all together during an absence.
Steven: You know to this effect, Yolanda, some physicians actually have office overhead insurance that might actually be able to help with this kind of contingency planning. It's part of your financial planning, isn't it?
Yolanda: It is indeed, and it would be money well spent, I think.
Steven: Okay, so that kind of covers the unanticipated temporary absence from a clinic or from an office, but, Yolanda, what if we're not planning to come back, as in, that's it. I'm closing my practice. What do we do then?
Yolanda: One place to start is to consider the records and the custodianship of those records. It's generally not an issue when the clinic or the facility is the custodian of the records, as they shoulder those responsibilities and not the physician. The bigger issue is when the physician is the custodian of the records. Principles that apply here is that the patient can have a copy of the record but not the original. The physician remains the custodian of that original and must do so for the required period of time according to the regulatory authority.
Steven: Right, so those do vary across provinces, and we would recommend that you consult your college guidelines or give us a call at the CMPA so that we can tell you how long to keep these records.
Yolanda: These retention periods vary from five to ten years in most jurisdictions. Our recommendation is that you keep them for the minimum requirement dictated by the college, and for minors, there are also requirements to keep them for a set period of time, often ten years past the age of majority. In fact, it's probably wise to keep records indefinitely, considering that there's no limitation period, for example, in college complaints, and it is extremely challenging to defend a physician who's involved in a college complaint when there is no medical record to speak to the care.
Steven: There are some cases that we do see from time to time where patients can make complaints to the college 15, 20 years after the fact, especially when they're concerned about the nature of the relationship that they had with their physician. When there's no medical records anymore, it makes it a much more complicated issue to explain what went on.
Yolanda: It becomes a he said, she said when there's no record to speak to what took place.
Steven: Is there more to consider do you think, Yolanda, around permanently leaving an office, or for a very long period of time?
Yolanda: Looking after ourselves is important, and it is okay to take a break. There might be requirements to notify your regulatory authority or college in the case of a prolonged absence, but really these are very specific scenarios, and they are too complex to be simplified in a podcast. Our suggestion would be, please call us, because there are many, many issues to consider before taking specific action.
Steven: Right, and by all means, this podcast doesn't cover all the aspects of closing a practice, but it's a place to start.
It's time to wrap up already, Yolanda. How about a communication tip for our listeners?
Yolanda: Let's remember that the patient is potentially a valuable partner in this transition. Giving them a copy of their record, or their CPP will help their new provider deliver more informed care.
Steven, how about a documentation tip to finish up?
Steven: Well, I think that it's really valuable to have a written policy for your office, to ensure your staff remembers to deal with all these issues that we talked about. Things like informing patients, informing colleagues, and the referral base, and informing your local hospitals, and the pharmacies of your absence. Keeping a log of who's been informed and how. These things can be done with signs in your office, by sending emails, leaving voicemail message, or posting on your websites. Even letters sent to specific groups that may be more at risk, but the bottom line is these things have to be considered ahead of time.
Yolanda: Well, that's all for today. We hope you've enjoyed this podcast.
Steven: I hope you forgive me for sounding preachy, but it does come from the heart.
Yolanda: It really does. Just a quick reminder as well that we would love to hear from you, our listeners, if you have any questions, comments, or program ideas, we would love to hear from you.
Steven: Email us at [email protected]
Yolanda: I'm Yolanda Madarnas.
Steven: I'm Steven Bellemare.
Yolanda: Remember, when you change the way you look at things.
Steven: The things you look at, change.
Yolanda: Good bye.
Announcer: These learning materials are for general educational purposes only and are not intended to provide professional medical or legal advice, nor to constitute a standard of care for Canadian healthcare providers.
November 2020 | 22 minutes
Occasionally, physicians may be asked to provide medical care outside of their area of expertise. During the COVID-19 pandemic, for example, more physicians have been asked to fill-in on the ICU and in long-term care facilities. What are your rights as a physician? How can you best handle the situation? How do you ensure your patients’ safety? This episode covers these – and other questions – related to the risks and responsibilities when covering other specialties.
In Québec, health professionals are only permitted to perform acts authorized by their relevant governing legislation and in accordance with specified requirements, if any. Accordingly, physicians can only request that another health professional perform a reserved act if the legislation governing these other health professionals authorize them to perform that act.
Announcer: You’re listening CMPA: Practically Speaking.
Dr. Steven Bellemare: Hello everybody, welcome back. I’m Steven Bellemare.
Dr. Yolanda Madarnas: Hi everyone, Yolanda Madarnas here.
Steven: Nice to see you, Yolanda.
Yolanda: It’s good to see you Steven. Listen, I’ve been getting an awful lot of calls lately from physicians who find themselves being redeployed to work in areas that are not their usual scope of practice.
Steven: Oh that’s an issue for sure, I agree.
Yolanda: So members routinely ask me as part of these conversations, you know, can they do that? Can they force me to do this? Am I allowed to say no?
Steven: Or actually, is it safe for me to do that, right? Occasionally, and hopefully not too often, it may be necessary for you to provide some care outside of your area of expertise, outside of your scope of practice.
Yolanda: And that’s the scope of this podcast.
Steven: No pun intended.
Yolanda: We hope to address some of the medical legal considerations for physicians who are facing the reality of practicing outside of their scope of practice.
Steven: But let’s keep in mind, Yolanda, not all working out of scope situations are created equal and we also have to touch on that.
Yolanda: And we will in the course of the podcast. So, indeed, you know, this issue has really been very topical, front line in the news with the COVID-19 pandemic and physicians being asked to fill-in on the ICU, the intensive units and in long-term care facilities, for example.
Steven: But you know it’s not unique to the pandemic and other health care crises. We’ve heard about this before when hospitals merged, for instance, or when their human resources or other resource constraints are a problem.
Yolanda: Yeah. And although not quite the same, you know the infamous announcement on the overhead speaker onboard a commercial flight: Is there a doctor onboard?
Yolanda: Raises some of the similar considerations.
Steven: Right. All these situations have one thing in common, right?
Yolanda: At the very least, it’s STRESS in capital letters.
Yolanda: It can be incredibly stressful and very destabilizing for a physician to be asked to provide care that you’re either rusty or haven’t provided in a long time, or is clearly not your usual bread and butter. And there are also some shared medical legal considerations in these different scenarios.
Steven: Right. So why don’t we start with defining what exactly we mean by scope of practice, shall we?
Yolanda: Well, simply stated, it’s what you trained for and what you were hired for.
Steven: Sure, the procedures, the activities, the processes that a health care practitioner is permitted to undertake in keeping with the terms of their professional license or their privileges in hospital, for instance.
Yolanda: And even thinking back to the older process of licensing physicians when rotating internships were the norm, so unrestricted general license was granted. These physicians need to mindful of their scope of practice. For example, and we probably all agree, that a seasoned internist or subspecialist might not be considered qualified to practice family medicine in a walk-in clinic as part of their transition to retirement.
Steven: Right. That’s clearly an entirely different scope. Changing scopes of practice can put patients at risk to patient safety incidents and thus, physicians also at medical legal risk.
Yolanda: And this podcast isn’t about that situation, nor does it apply to hallway consults, the instance where you’re giving medical advice outside of your usual scope. But regardless of the circumstances, when a change of scope of practice is planned and elective, it’s prudent to call the CMPA to discuss the implications both in terms of college requirements and your medical legal protection. But let’s get back to what this podcast is about, Steven.
Steven: Why don’t we start with our take-home messages? The first one, despite the challenging conditions of health care emergencies, physicians will be expected to act professionally and in their patients’ best interest.
Yolanda: And in second place, anticipate what additional skills, training or even resources might be required, and make efforts to stay up-to-date as the situation evolves.
Steven: And finally, document the rationale and the context for your decisions, as well as the support that you sought to demonstrate that your actions were reasonable at the time.
Yolanda: So let’s talk about the first point. Physicians are expected to ask professionally and in their patients’ best interest.
Steven: Generally, colleges have advised that a physician should only practice outside their area of expertise during a health emergency or any emergency, if three criteria are met: 1. The care needed is urgent; 2. A more skilled physician’s not available; and 3. Not providing the care would lead to worse consequences than actually providing it.
Yolanda: So essentially what they’re saying, is that a less qualified physician is better than no physician at all.
Steven: Right. So one way to manage this awkwardness, I think, is to be transparent about it with your patients.
Yolanda: Right. So for the physician to candidly discuss the unique aspects of the context of care with their patients is entirely appropriate.
Yolanda: Being mindful, however, that the tone should be one of collaboration and inspiring trust in the relationship and the system while acknowledging the exceptional nature of the circumstances.
Steven: Right, certainly. So you’re not going to be wanting to air your dirty laundry about the hospital politics and having to work outside of your scope with your patients at the bedside. It’s not what we’re talking about.
Yolanda: No, that would be fear mongering.
Steven: That’s right and that’s not professional, not really. Communication issues, Yolanda, are so, so frequent in our cases, right? So that’s why it’s important to acknowledge the reality but not to undermine trust.
Yolanda: Do you have an example, Steven?
Steven: Well, you know, think of the situation on the plane, for instance, right? I know I travel a lot as part of my job and I’ve been on flights when they’ve sought the physician. And as a paediatrician, you can imagine my discomfort and how daunting it is when I have to deal, for instance, with an elderly male with chest pain, right? So, I’d approach that with hi, I’m a paediatrician. I don’t usually do this type of thing, but I’m willing to do my best for you. How do you feel about that?
Yolanda: Right. You’re the only one on the plane. You do your best and you muddle through as best as you can. And that’s really the Good Samaritan principle, and we have an article on that for those who want to read about this more.
Steven: Right. And, you know, while practicing outside of your scope in your hospital because the hospital is asking you to do that as a means to deal with an emergency, it’s not exactly the same as the Good Samaritan situation.
Steven: Nevertheless, there are similarities, right? We want to reassure you that you can be confident that you’ll remain protected by the CMPA, should anything come out of you working outside of your scope of practice in those kinds of circumstances.
Yolanda: Yeah. So we have your back. So, let’s get back to the more formal need to change our scope of practice when it’s imposed on us by the health authority, for instance.
Steven: Right. Well that has come up indeed, and this is where the can I refuse and can they force me issues arise.
Yolanda: And this is a reality that many of our colleagues are facing. Be it as a result of COVID in the setting of the current health crisis, or as a result of acute on chronic resource restrictions. So when physicians ask can I refuse? Well, the answer is no, not really. And to the question can they force us? Mm essentially, yes. Because being a privileged member of the medical staff comes with obligations to comply with hospital by-laws and policies.
Steven: And that can come with risk to disciplinary action if you don’t comply with those by-laws and policies.
Yolanda: Which CMPA would generally assist you with. So don’t worry, but be aware.
Steven: That’s right. So that raises another frequent question, though, Yolanda. And that is, aren’t hospitals or health care authorities accountable to support the doctors that they’re essentially forcing to work out of their scope?
Yolanda: Indeed, to the extent that there is jurisprudence that confirms that hospitals have a separate duty of care towards patients and that the hospital has a responsibility to provide a safe system for patients that includes the coordination of personnel, facilities and equipment in order to ensure reasonable patient care.
Steven: Right. Therein is the key, right, the system and the coordination of the personnel to make the system work. So, hospitals have a vested interest, of course, in ensuring that any proposed policy or procedure for coordinating that medical staff is actually implemented in a way that’s consistent with the applicable standards in the community that they serve, right? So again, one city versus a different city may have different circumstances and standards. And we have to bear in mind of course, the nature of the exceptional circumstances that arise in the context that they’re dealing with.
Yolanda: So, as physicians, digging our heels in and arguing that we don’t want to do this, is not necessarily helpful and could place us at risk. And really, the preferred approach is one of a collegial dialogue and negotiation.
Steven: And here’s a leadership tip on that, right? Have some of these conversations with the hospital, health authority, medical staff, before you actually need to deploy people outside of their scope of practice, before you face that emergency, before you have the critical point that’ll foster much more generous and deep discussions to try to find the best solution.
Yolanda: So really to build the plan before you need it. So planning is the key to that smooth collaboration. Try to discuss the issue as soon as you identify it. Highlight the concerns that you have with regards to patient safety. Offer workarounds or temporizing solutions. But above all, do so in a professional manner.
Steven: That’s really the key there, right? And it may be possible, for instance, to negotiate expanding service corridors, for example. And you might be able to lobby for in-service education or refresher courses, so to speak, to bring you up-to-date on that particular aspect of clinical medicine that you’re no longer in touch with. And there, the university continuing professional development offices can be very helpful and we’ve seen that, for instance, in the COVID context, where the CPD departments have put on very timely education about the latest and best around COVID.
Yolanda: Yeah. And let’s keep in mind the importance and the utility of leaving a paper trail of those administrative discussions and negotiations. And here I’m referring to departmental meeting minutes that establish the medical staff’s diligence in being proactive to highlight the patient safety or other risks that they perceive with the proposed policies, but also ensures that the hospital authority is notified and aware.
Steven: So you know, Yolanda, the bottom line is that we may not be able to fix the problem that we want to fix. It may really not be fixable in the way that you might want, right? You might not be able to not work outside of your scope of practice, but you can at least set the stage for justifying your work through the documentation that’s left both in the patient record and your general medical paperwork that you have in your offices, should any medical legal concern arise in the future.
Yolanda: And this point actually takes us to our third take-home message, which is how to document the situations you face. So, let’s take our prerogative to skip ahead and talk about this point now.
Steven: Sure, why not? When you face difficult situations, you can document the rationale for your choices in patient’s charts, if it’s pertinent to the patients care. So for instance, why did you not transfer that patient to the ICU today, whereas normally you would be transferring them to the ICU? Or why did you choose to use what could be seen as a suboptimal antibiotic on that night, if there wasn’t the optimal antibiotic available. So those things are fair game for documentation and the patient record because it’s about their individual care.
Yolanda: So, where else do we document?
Steven: Well there’s other issues that have less to do with direct patient care and choices and that are more about the broader directives that the hospital has provided and that affect care in general. So, you can keep copies of directives and policies or notices as they change in your general office files. For instance, if you’re advised that as of today, all consultations for service X must be sent to hospital Y. Well store those kinds of notices in your files. They can be really helpful to help establish the context that prevailed at the time when experts that look at the file are going to be trying to determine whether or not you met the standard of care, because they’ll be looking at those files on average, two to five years after the care was provided. And goodness knows, in the COVID context, for instance, we saw policies change sometimes on a daily basis in various hospitals and no one in their right mind would ever be able to remember what a policy was…
Yolanda: What was in place when.
Steven: On that specific day. So establishing that context is going to be very important in the future and keeping the documentation is going to be vital.
Yolanda: I’m thinking we’re going to come back to this as one of our documentation tips at the end.
Steven: Ya think?
Yolanda: But Steven, let’s remember that as physicians, we’re often driven to be fixers. And what I often hear on the phone, and what our colleagues worry about, is being the one left holding that proverbial hot potato that leads to the complaint or the lawsuit.
Steven: Right, because we are the face of the system. We are the sharp end of the system. So, yeah, we understand and this is why we’re recording this podcast. We want to reassure that you’re not alone, the challenges you face are there across the country and we’re there for you.
Yolanda: We got your back. So let’s come back to takeaway message number two that we skipped over before. So, we said it was to anticipate what additional skills, training or resources might be required and make efforts to stay up-to-date as that situation evolves.
Steven: Right, so do make enquiries with your college, or the college in the province or territory where you’re going to be called upon to provide medical care, to determine what their licensing requirements are going to be. And we saw again, with COVID, for instance, that the college has demonstrated a lot more flexibility with regards to licensure than they normally would have, in order to expedite the provision of care.
Yolanda: So that said, in an emergency situation, colleges would generally view physicians as having an ethical duty to do their best, to attend to individuals in need of urgent care. And they’ve demonstrated leniency in terms of licensing requirements in order to accomplish this.
Steven: We have to keep in mind, Yolanda that the colleges typically license us to practice in the area in which we are trained and experienced. And so while the college might say it’s okay to practice out of scope for a particular emergency circumstance, once it’s over, physicians have to revert back to their usual scope of practice and stop practicing in that expanded scope, even though they may kind of like it.
Yolanda: Which was an exception, so we go back to the normal.
Yolanda: So, there are other situations where physicians choose to expand or even restrict their scope of practice, having nothing to do with emergency circumstances. And in those instances, it’s important to inform the college and to contact us, CMPA, to discuss continued eligibility requirements and type of work protection in their new practice situation.
Steven: Right. So think, for example, of a family physician who decides to expand their scope of practice to cosmetic medicine, aesthetic medicine, or to one who decides to restrict their scope of practice to in-office vasectomies, for instance. Each of these has different potential implications for patient safety and medical legal risks, and you can be sure the college will want to know about that choice of yours. And we at the CMPA as well, we’re going to want to know because, as you say, of the protection category that you may fall into. So for instance, the college is going to want to know that you’ve got the skills, the training, the experience to actually warrant that change in scope of practice and they’ll want to know that you can be safe in doing so.
Yolanda: So it goes without saying that we all need to be involved with continuing professional development. But it also goes without saying that we generally don’t cover things that we would not normally be expected to do that aren’t on our radar, or ever even anticipate doing, or tapping into another resource. So, it is important to consider consulting with colleagues who might have expertise working in the area, you’re going to deployed to, or colleagues working outside of their scope of practice and clarify what your own limits might be, but also to define what the expectations of you are going to be.
Steven: That’s right. And for instance, when the hospital redeploys you to a different service, it’s very helpful if you can get in writing what the formal arrangements are going to be. Are you going to be working independently, or are you going to be working under the supervision of experts in that field at, for instance, supervising you remotely. So building redundancies is another important piece of the puzzle, right? So that you may be in the front line in the ICU...
Yolanda: But you need a backup.
Steven: Yeah, that’s right. Those experts in ICU who need their rest can be on second or third call, for instance. So, arms-length delegation and supervision, if you’re going to be in a formal supervisory role, if you’re going to be supervising people working in the ICU, for instance, that don’t usually work in the ICU, it’s going to be important for you to be aware of the principles behind delegation and supervision. And we have documentation on that available as well on our website.
Yolanda: That’s a really important point, Steven. So having someone act as a “supervisor”, formal or informal, may be a good way to establish a safety net that helps redeployed physicians feel supported. But we also have to take that responsibility seriously from the point of view of the documentation that we keep.
Steven: That’s right. The parallel can be made, you know, with working with more or less experienced residents, the way you undertake the supervision and the documentation of your advice and how closely you’re looking at things is going to be suited to the situation.
Yolanda: And look, a lot of positive can also come from these situations. I think it’s important to highlight that. You know, support from colleagues, a new found collegiality may lead to identifying better ways of working together that can bring about lasting change.
Steven: Right. One thing’s for sure, though, physicians are expected to make reasonable efforts to access relevant information and to stay informed and to identify their own limitations.
Yolanda: And this means being proactive and trying to anticipate what additional skills, training or resources might be required, and to stay up-to-date as the situation evolves. And this could become part of that administrative discourse we alluded to earlier.
Yolanda: It’s fair to ask for, and even organize and in-service or refresher courses, for example.
Steven: You could also seek out a mentor.
Yolanda: And encourage speaking up.
Steven: Oh, you just stole my communication tip. Speaking up is so important. It’s a cultural mindset, right? It’s what allows you to raise concerns without fear or judgement or repercussion in the interest of patient safety.
Yolanda: And it is also a truly bidirectional thing. So not only should you speak up, but there should be listening up on the other side.
Steven: All right. Well Yolanda, how about a documentation tip since we seem to be at this point in the podcast?
Yolanda: And as you thought documentation. So, let’s suggest a two-pronged approach to documentation. Remembering that paper trail of the administrative discourse with the health authorities, as well as documentation at the point of care, where we document the rationale for and the context for the decisions and the support that you thought to demonstrate that your actions were reasonable at the time.
Steven: Right. And you know what? I’ll throw in getting that documentation—that clarification in writing about how the working out of scope is going to actually work with regards to supervising, being supervised or actually working independently.
Yolanda: And that’s probably part of the administrative discourse as well. So there we are.
Steven: Yeah. I think we’re at the end here. Well thank you very much, Yolanda. This was enjoyable. It went by really fast.
Yolanda: As always, this was really fun and I hope it’s useful to our listeners.
Steven: As always, we invite your comments, your questions or your ideas for future topics. Please do send them to us. The address is [email protected].
Yolanda: Thanks for being with us today. Goodbye.
Steven: Remember, when you change the way you look at things...
Yolanda: The things you look at change.
October 2020 | 17 minutes
When is access to EMRs deemed inappropriate? In this episode, Dr. Bellemare and Dr. Madarnas offer key considerations on how to avoid breaching privacy rules when accessing electronic medical records. They review how privacy legislation, the circle of care, and custodianship of medical records affect how and when physicians can access medical records.
Listen now: Apple Podcasts / SimpleCast / Spotify
Announcer: You are listening to CMPA, Practically Speaking.
Dr. Yolanda Madarnas: Hello everyone, welcome. Hi, Steven.
Yolanda: I'm well, thank you. Steven, I wonder if having a user ID and a password for an EMR gives us the right of access to any information at any time?
Steven: Well I think the way you are asking your question is going to force me to say no. Any information at any time I think is the problem. Let's consider some examples: a celebrity is admitted to a hospital and someone looks them up in the EMR. Is that all right?
Yolanda: What about a friend who asks you to look up their MRI results because they can't get in to see their family doctor?
Steven: What about telling a learner or a colleague, “hey you know what you should follow up this patient in the record to see how they evolve”?
Yolanda: How about accessing a record to remind yourself of the care you provided when you are notified about a complaint or legal action?
Steven: So what is the common thread in all of these scenarios?
Yolanda: Inappropriate access to the EMR.
Steven: You know what, when is access deemed inappropriate? There are some pretty clear examples of inappropriate access, but it can be difficult to slice and dice on that subject in a number of different circumstances.
Yolanda: So today's podcast builds on the Perspective article regarding access to personal health information. So we are going to try and shed a bit of light on this for you and keep you apprised of the latest from the privacy world.
Steven: Let's go to our take-home points then, shall we Yolanda? The first one is that privacy legislation is designed to put a patient's right of privacy first. So in that framework, are other societal objectives, like quality improvement and education, secondary to patient privacy?
Yolanda: The second point is that of the circle of care. This circle of care includes health care providers, providing care to the patient who require information but on a need-to-know basis in order to provide health care to the patient.
Steven: The third point is that physicians, whether they be staff or trainees, really need to understand the custodianship of medical records. And that means that they really should always be seeking permission from their hospital or clinic before accessing patient records after they are no longer involved in patient care.
Yolanda: So let's go back to the first point, about privacy legislation. Let's remind ourselves that privacy is legislated provincially. For example, in Ontario, PHIPA regulates the use and access to personal health information.
Steven: The PHIPA is the Personal Health Information Protection Act.
Yolanda: Yes, so regardless of where we practice, it is important to familiarize ourselves with the legislation applicable in the jurisdiction you are practicing in.
Steven: That's right, because each province or territory has different guidelines to regulate the collection, the use, and the access of physicians or other people to personal health information. They also have criteria for what constitutes a privacy breach and criteria to guide us in reporting privacy breaches. So not everything is a privacy breach and not everything that is a privacy breach is necessarily reportable to the patient. It may just be reportable to an institution for instance.
Yolanda: So all of this information is generally available through your College, your hospital, your institution and you can call us at the CMPA for added information as well.
Steven: I would certainly echo that Yolanda because it's complicated. So, let's use an example to explore this though. You are a well-intended physician who sees someone in the Emergency Department and you want to follow up in their chart for your own education. Look, we have all done that, right and it's a noble thing. It may not technically be allowed and if we happened to do it and the hospital runs an audit, we will have to answer for it.
Yolanda: This illustrates the privacy laws were not drafted with actual medical practice in mind. Their focus is really to protect the privacy of the individual and we need to revisit and rethink our practices within the discipline of medicine as to how they fit into that framework.
Steven: That's right. That's not to be critical of privacy laws; it's just the reality of how things have evolved. So, it's understandable in this age of E-communication and all the privacy breaches that are out there, that we need to pay attention to that.
Yolanda: Such well-intentioned and justifiable access to the EMR may actually constitute inappropriate access to personal health information when you are not in that circle of care.
Steven: Now Yolanda some laws allow access to personal health information for purposes of quality improvement. Whether or not education is quality improvement is going to be a matter of interpretation based on the law at hand and the viewpoint, the policy, of the institution that you work in.
Steven: So asking your hospital or clinic to draft a clear policy to allow access for quality improvement and learning may actually be well worth it. So that you are actually promoting clarity within your institution as to whether or not this practice of accessing patient's medical records to follow up on their condition after you’ve admitted them, is actually allowable or not. But, before you do that, it's actually important to know the provincial laws that might actually affect the drafting of that policy.
Yolanda: So this is a great time to introduce the concept of the circle of care, our second take home message.
Steven: Right. So physicians can generally rely on the patient's implied consent to share personal health information within the circle of care. So that’s what allows me, the pediatrician, to share information with you, the oncologist, about a mutual patient that we have, without actually having to seek their parent's formal permission to do so.
Yolanda: It's implied.
Steven: Yeah. That's right. The health care professionals who need to know the information to provide care are the ones that are included in the circle of care. It's not this “willy nilly” sharing just out of interest of course and the information you can share is actually limited to what's necessary to provide health care to the patient.
Yolanda: Once a physician is no longer in that circle of care, it's important that they consider whether access to the records subsequent to that is A), permissible and whether the custodian has approved or allows the access.
Steven: So at what point though is one "no longer" providing care and I'm waving my fingers in the air doing my quotations marks. Isn't following-up on your patient good medicine?
Yolanda: Absolutely. I don't think anyone would argue with that, that that's not good medicine but strictly speaking we are only allowed to access personal health information for purposes of providing care. So whether following up on someone is continuation of providing of care is perhaps a bit of a grey zone and even being in the context of a circle of care the access does have limits. We are only allowed to access what we need to deliver that care or what we need from their past history to deliver their care today.
Steven: Right. So I am thinking if I'm treating a patient with appendicitis, I would have no reason really to go look in their psychiatry outpatient visit history for instance.
Yolanda: Correct. That is not on a need to know basis unless it's relevant to the care today. So that is common sense. But let's focus on the issue when a physician is no longer providing care, as is the case when a patient gets transferred to another team, another institution. So this physician is no longer considered to be in the circle of care and they do need to stop accessing personal health information.
Steven: Well that is something to think about isn't it? I know many physicians who see someone they are concerned about and may often reflect after the fact, and wonder “Was my care appropriate, was my diagnosis right, should I have done something differently?” and they may seek to learn and improve their practice by looking in the EMR. So that may be a problem, privacy-wise.
Steven: It could be a walk in clinic case where you found out after the fact, for instance that you might have missed something. So, leaving the circle of care is really the turning point then.
Yolanda: Absolutely. We've had cases, we're doing just that, has led physicians to be flagged by an EMR audit as having breached privacy.
Steven: That's right and there may be ways to manage this though.
Steven: It may involve talking to the patient or the substitute decision maker if they are not capable of giving you consent to obtain consent to do just that. To follow up in their record after the fact and learn. If you do that, it's wise to get that consent signed and to really make a note in the record of the fact that you have accessed the medical record with the patient's consent so that you establish that you weren't snooping.
Yolanda: Yeah. So it's not foolproof but at least it creates some transparency for your actions.
Steven: I think that's a great segue then to the third take home point, custodianship of medical records. Why is that important?
Yolanda: Well, honestly as a physician we often regard patient's health information as ours to use in the course of providing clinical care and even for other purposes, like teaching or research, but individual patients do have the right to determine who can access their health information and under what circumstances.
Steven: Right, because the patient owns the information. The physician, the clinic, the hospital may own the system, the EMR system or the paper record that houses the info, but the info belongs to the patient.
Yolanda: So in a hospital or other group practice, it is the institution that is the information custodian, who controls access over these medical records and physicians should seek permission from the institution and be forthcoming about their reasons for requesting access to a patient's medical record.
Steven: That's not to be nit picky, it's really because that's the custodian's duty, their legislated duty to ensure there is no unauthorized access to those EMRs and to personal health information. That's why they actually run chart audits when they do.
Yolanda: So without getting overly complicated, physicians can generally rely on a patient's implied consent to access and share their personal health information for purposes of providing that health care with people in the circle of care. However, when we access the record for purpose other than providing care, the physician should really aim to get explicit consent from the patient or rely on a legislated provision that does allow them to access the record without seeking consent.
Steven: Depending on the provincial or territorial legislation, it may be possible to work with the hospital to create policies or procedures that actually allow access to patient information for educational purposes.
Yolanda: That helps everyone. So the bottom line is two-fold, patient consent is required to access their personal health information for anything other than provision of care and physicians should always seek direction from custodian of the record for purposes here at the hospital or the clinic before accessing patient' records when they are no longer in that circle of care.
Steven: Right. That's why accessing a record to refresh your memory can be problematic once you hear of a complaint, a lawsuit or after a patient safety incident after you have left the circle of care.
Yolanda: So it's not that you are not going to be allowed to refresh your memory or that there isn't a good reason to access. You are entitled to access the record to defend yourself in a complaint or a lawsuit, you just need to do so appropriately.
Steven: That's right. You need to follow the rules. Here is a perfect example, it's not related to a complaint or a lawsuit but I think it illustrates the points. You are on staff at a hospital and your child has a chest x-ray and you look up the results in your EMR. Seems like a benefit of working at the hospital right?
Yolanda: Sure. I mean, you are the parent. You provide consent for your minor child. Of course, so what is the problem?
Steven: Well the issue is that the hospital didn't give you access to their EMR for that purpose and you are not and never were in the circle of care for your child.
Yolanda: So while you have a password and access to the EMR, you still shouldn't access that information, right?
Steven: Exactly. No, you are allowed to get the info of course, you are the parent, and you can consent to that, but you have to do it through the right channels. If you get back to the initial question you were asking at the very beginning of the podcast, having a password to the EMR doesn't give you access to anything, any time.
Yolanda: No carte blanche. In fact, that's what happens when audits are run on hospital medical records. The hospital will often run reports flagging access to a record by people with the same surname, i.e. family member or all access on a VIP or celebrity medical record for example.
Steven: Right. We've seen those, we've seen those cases.
Yolanda: Yes we have.
Steven: So how about we revisit our initial examples, Yolanda.
Yolanda: So remember what about the friend who asks you to do look up their MRI result because they can't get in to see their doctor?
Steven: Nope. Even though you have consent from your friend to do so, you are not in their circle of care and they right way is through medical records or for them to actually do it through their own physician.
Yolanda: So then as a friend, I could tell my friend, why don't you go to medical records, ask for a copy of your report, you are entitled do it, but you need to be the one asking for it, right?
Steven: That's right.
Yolanda: How about when we are working with residents and other learners and we ask them to follow up on a patient they have been involved in and have a look in their record and see how they evolve wanting to see what happened to this patient?
Steven: Nope. That's probably the most shocking “nope” for our listeners I suspect. Again, they have left the circle of care if they are just doing follow up and they are not involved any more. We have to be real. This could have significant impacts on how we learn and how we provide care. Don't we have an obligation to follow up on lab results for instance?
Yolanda: Absolutely. Physicians are responsible for ensuring follow up on all investigations they order. But that follow up implies that you are still in the circle of care to action that result. The issue of following up out of well-intended curiosity for our own learning or QI is really the grey zone and it is best to seek permission to do so from the patient and document your reasons for accessing that EMR if you do do it.
Steven: So following up with a purpose to provide care, i.e. following-up lab results, is different than following-up with a purpose of just learning and keeping apprised.
Yolanda: However noble that may be.
Steven: Subtle, subtle differences, right? Finally then, what about accessing a record if you have been sued or complained about?
Yolanda: Nope. You may still be the circle of care, accessing the file for this purpose is no longer related to delivering care and well we are entitled to access the record for our defence in the case of litigation or complaint, we have to go through the right channels.
Steven: Okay, Yolanda I think we've given our listeners a good primer on privacy issues and the whole business of needing to know information. That was probably what they needed to know about privacy. How about we move on to communication tip then.
Yolanda: So, communicate with your hospital to develop policies and procedures that will allow access to patient information for those circumstances that aren't strictly related to patient care. For example, education and quality improvement undertakings.
Steven: I think that clarity would be wonderful to have, for sure.
Yolanda: For everyone.
Steven: And in everyone's individual context because one hospital might deal with an issue very differently than another.
Yolanda: Exactly. How about a documentation tip, Steven?
Steven: You know my documentation tip would be, linked to the fact that EMRs have built in audit controls to detect each time a record is accessed. They know who accessed the record at what time, for how long, on what page, what was added, what was changed, what was deleted, it's all in the background. So, if anyone is accessing a record for a purpose other than provision of clinical care, documenting the fact that they were doing so with the patient's consent and for the purpose of following up helps build that transparency. I think it's worthwhile to really demonstrate that you are not really snooping.
Yolanda: So documenting a note in the patient record at the time of transfer of care. Patient agreed for me to follow up on their evolution in hospital for example or at the time you accessed the EMR, making a note and saying accessed on this date, today, for this purpose. So doing it proactively rather than at the time when potentially it gets caught and it's still explainable but to do proactively and contemporaneously would be more prudent.
Steven: Well that's all the time we have for today. Thank you for joining us everyone and please don't hesitate to send us your comments, questions and story ideas. Our address is [email protected].
Yolanda: Thanks everyone and thank you Steven, this was great.
Steven: It was great, and remember, when you change the way you look at things...
Yolanda: the things you look at change.
Yolanda: Bye everyone.
Announcer: These learning materials are for general educational purposes only and are not intended to provide professional medical or legal advice, nor to constitute a standard of care for Canadian Health care providers.
September 2020 | 20 minutes
Concerns surrounding wait times in the delivery of health care are not new, however, the COVID-19 pandemic has resulted in further concerns due to the postponement of elective procedures. Dr. Wendy Levinson, Chair of Choosing Wisely Canada, joins the hosts to discuss tips on the safe management of wait times in order to promote safe care and decrease medical-legal risk for physicians.
Announcer: You're listening to CMPA: Practically Speaking.
Dr. Yolanda Madarnas: Hello everyone, welcome, I'm Yolanda Madarnas.
Dr. Steven Bellemare: And I'm Steven Bellemare. It's nice to be here with you again.
Yolanda: It's good to see you again Steven. So what are we talking about today?
Steven: Well, Yolanda, we thought we would talk about resource utilization and wait time management.
Yolanda: Well, this isn't a new topic to physicians, but it is timely because there is renewed interest and concern about this topic given the COVID-19 related postponement of elective procedures and such.
Steven: Absolutely. You know wait times, we know have an impact on physicians, the patients, and the system.
Yolanda: So today we hope to give you some tips on safe management of wait times in order to promote safe care and decrease your medical-legal risk.
Steven: But you know what Yolanda, before we get going I have a special surprise for you.
Yolanda: Oh, I like surprises.
Steven: We have a guest on this show.
Yolanda: Do tell?
Steven: Well, let's take a listen, who is on the show with us?
Dr. Wendy Levinson: I am Wendy Levinson, I am a general internist and I am the chair of Choosing Wisely Canada. It's my pleasure to be with the CMPA today for the podcast.
Yolanda: What a great surprise.
Steven: You know, I thought you would like that. We actually spoke to Dr. Levinson via webinar interview just a few days ago. As you'll hear from her, I think that Choosing Wisely Canada's message is actually going to be very helpful in this context of resource management and wait list management.
Yolanda: It does align well with our objective of promoting safe care.
Steven: Doesn't it?
Yolanda: So managing wait times is not a new issue for Canadian physicians, but the magnitude of the problem is.
Steven: For sure. In a post-COVID-19 world, it's expected that there is going to be a gradual movement to return to pre-pandemic level medical services, whatever that is going to be. But now we face a huge backlog of postponed elective care that is going to be really difficult to manage.
Yolanda: Absolutely. Will it fall on physicians to determine which medical services should be reintroduced first and how care should be prioritized in their own practices?
Steven: Well, I guess the answer is yes and no. Not really the physicians by themselves. For sure I think we are going to be told to some extent by public health, hospitals and regional health authorities what to do.
Yolanda: But for the physicians there is likely to be a responsibility, both the consultant and the referring physician in the example of wait times to see a consultation for the physicians, both the referring doctor and the consultant, to address the wait and contribute in some way to making it as safe as possible.
Yolanda: So we have three take-home messages then for today's podcast, Steven. The first one would be to be aware of and follow the direction of the ministries of health, the chief medical officers of health, our regulatory bodies, the colleges and the institutions we are working in.
Steven: Right. The second take-home message of course would be to keep the lines of communication open with your patients to allay their concerns and to monitor the patient's clinical condition.
Yolanda: The third take-away would be to strive to collaborate with other health care providers and administrators to appropriately manage what are our scarce resources and waitlists during this time period.
Steven: You know, Yolanda, in general, physicians are expected to consider what's in the best interest of their patient. The context of the situation however, is going to be a significant consideration in making that decision.
Yolanda: Absolutely. So it may mean making decisions that are proportionate to the system's capacity while minimizing potential harm in trying to keep the priority of your patient's best interest in mind and striking a balance between those two.
Steven: That's right. So why don't we go to take home point number one then? That is to be aware and to follow the direction, the directives of the various bodies. The ministries of health, the chief medical officers, the colleges, and even the institutions that we work in.
Yolanda: To do so, it's important of course to stay aware of what's going on in your area. The various authorities aren't going to tell you who to see first. You will need to figure that out on your own, but to some extent help may be available from your specialty societies, consensus groups, your colleagues.
Steven: Maybe even local medical associations for instance.
Steven: So to a large extent it will be based on common sense.
Steven: However, right.
Yolanda: As we said before, wait times, longer wait times aren't unique to COVID, but the importance of these is just brought to light by the situation that we've been through and it's important to try and have fair and universal criteria for deciding how the triage goes about.
Steven: Absolutely, and to clearly communicate to you patients and to your referral base, what those criteria are.
Yolanda: So with this in mind, Dr. Levinson has an interesting take on the issue of communicating with patients regarding these delays in care. Let's listen to what Wendy has to say.
Wendy: Doctors don't wake up in the morning and think I will go into the office and order a bunch of unnecessary tests or treatments. So how does it happen? Well, there are many reasons we might order a test that we think it not necessary because we think the patient wants it. Often it's just our routine or habits. We learn even in our medical training and throughout our career to do certain things and we don't change those patterns very often. We might be afraid of uncertainty and so we order more tests or treatments and certainly as the CMPA well knows, physicians are often afraid that might be sued if they missed something, so they order more tests to "leave no stone unturned." But you know it's quite interesting what's happened during the time of COVID because now many doctors are having visits with patients virtually. So in that circumstance, if you are concerned and you can't exam someone you might order a chest x-ray that normally you wouldn't order. Or what we hear a lot from doctors is they are ordering antibiotics where they know that they aren't particularly useful, it's a viral infection, but they are just covering all the bases because they can't see the patient. So we might order unnecessary tests or treatments in this virtual situation just to be sure.
It's natural for patients who are waiting to be anxious. They are asking themselves the question, is this delay going to be bad for my health and so they are worried. So I think it's extremely important that physicians have these conversations with patients and tell them what the delay is and how long it's going to be and what they should expect. But I think an extremely helpful question is ask a patient what are you most concerned about in this delayed period and listen to what they say to you because some of their concerns you may be able to allay, you may be able to reassure or you will understand better what they are most worried about and then you can discuss options. So it's really to be able to communicate openly, discuss the options, understand what they are worried about, and reassure patients. Or if there is something urgent then to get it moved up more quickly because it really is needed and the delay would not be in the patient's best interest. The worst thing to do is to not have those conversations because that will leave patients very anxious and feel abandoned.
Yolanda: So then choosing wisely really relies on everyone making wise choices, otherwise the system falls about and doesn't benefit.
Steven: That's right and you know how Wendy was talking about when something is urgent you get it moved up. That's the key, isn't it? If we are utilizing all the resources in a less wise or desirable manner than we might not be able to move things up urgently. So I think it is very interesting how Dr. Levinson makes the link between how we order tests and why we do so as a result of the shift to virtual care. That message about good explanations for patients of course leads well into our second take-home message, doesn't it?
Yolanda: It sure does and remember and that was to keep the lines of communication open with our patients so that we can explore and address their concerns and monitor their clinical condition.
Steven: That's right. This message is actually about what happens before you meet the patient, but after they've been put on your wait list if you are a consultant or what happens after you've sent the patient off for a consultation, but before they get seen, if you are a family doc. It's really not just about communication between the referring doc and the consultant, but also we have to remember the patient. This really is a triad whenever there is a consultant that's waiting.
Yolanda: So then it's multidirectional communication. It's true that patients are likely to become more and more aware of the issue increased wait times after COVID and it's conceivable that they might have begun to feel abandon. So communication about the issue can really help engage proactively with the physician, but it is going to require a certain agility and nimbleness on the part of the physician because fundamentally we want to avoid our patients feeling abandoned.
Steven: Of course and the reality is that you likely owe a duty of care to the patients that are on a waitlist. Even if you are the consultant and you haven't seen them yet, but even more likely if you are the referring physician and you did see them.
Steven: So both physicians have that relationship.
Yolanda: We've seen this in a number of cases over the years, long before COVID happened. So, you are expected to provide sufficient information to the patient so that they can identify signs and symptoms that require a call, or re-evaluation.
Steven: That's right. You want to make sure if you having yet triaged consults that the clinical details that were received say three, six months ago when the consult was made are actually still up to date.
Yolanda: Yes. We need to ensure that the patient has adequate instructions as to what to do if their condition changes. So, it could involve communications with any number of people, the referring physician, the patient, other health care providers, their families.
Steven: What you really want in fact is to avoid being unaware of significant signs and symptoms that are going on and to be blindsided so to speak by a case.
Yolanda: So this is relevant at all times and in all circumstances anyway. Longer waitlists due to COVID and maybe modified approaches rising out of ministry or hospital directives. That's going to mean that we will have to be we are going to have to be wiser and spend more time and attention on this issue.
Steven: But you know in the end if a resource is scarce and we have to differ seeing some patients longer than we like, it's not really going to be easy to do, right?
Yolanda: No, it goes against our nature to some degree. So, of course not, but having to manage these resources means having to balance the individual patient's needs versus the need to manage a resource for the broader society and that is not easy.
Steven: We spoke to Dr. Levinson about this. We discussed her thoughts on discussing resource scarcity with patients and I think her insights were quite good. Let's take a listen.
Wendy: I think it is very important that physicians take care of the patient in the room and not at that moment think about the pressures on the system or society. We don't ration at the bedside. We take care of the patient in front of us and so I think when we are talking with patients we need to discuss their needs and if their symptom or problem is not urgent and can wait for that MRI, then that is appropriate for that patient. We really like to encourage patients to ask four questions. Do I really need this test or treatment? What are the downsides? Are there simpler safer options? What if I do nothing? We think those four questions really help answer patient concerns and have the conversation that is needed between the physician and the patient to make those decisions together. Outside the exam room, I think it's very important for physicians to work with their local leaders that might be at hospitals or primary care clinics, with their government, to think about how we re-introduce services after this time of COVID. We of course have been backlogged in need for operating room space, for delivering chemotherapy, for use of imaging procedures and even also in primary care where we have to think about what are the priorities there. I think in that context physicians need to work together to think about, okay, how do we prioritize which patients really need these services first and which can wait. That's where we think about the limited resources and how we use them most wisely. But in the exam room with the patient it should be about that patient and what they need, whether they can wait for their imaging or whether it's more urgent.
Yolanda: This makes me think about the importance of managing other health care providers expectations as well, right?
Steven: Yeah, it does. It actually links up to take home point number three, I think.
Yolanda: Which is collaborate with other health care providers and administrators to appropriately manage these scarce resources and the wait lists.
Steven: Exactly, what Wendy said. If there is no clear guidance for the work you do, be an active participant in the process and try and actually get consensus amongst your colleagues.
Yolanda: So being an active participate to come up with an approach in your community, to make judicious use of scarce resources is not just good for your patients and promote safe care, but it can actually do wonders for your own wellness.
Steven: Right. Taking control over what you can control is great for actually feeling useful and it's empowering for us to feel like we can actually have an ability to take good care of our patients.
Yolanda: In the end we are experts in our patient population's needs and what better way to use that expertise than to help influence policy development. So reaching out to others in the system that we see as key players, in unlocking a resource so to speak, can actually help to lead innovative solutions.
Steven: But the secret is in how we do it. Advocacy done right can do wonders, but done with too much passion shall we say, it can turn others off and your ideas will fall on deaf ear. We have to be careful not to come across has disruptive but rather as collaborative.
Yolanda: Let's take this a step further in thinking that innovative grass roots solutions could actually lead to a better functioning system by shifting and reallocating services and in fact that's what Wendy told us.
Wendy: Choosing Wisely is a campaign that started six years ago in Canada and the goal was really to engage clinicians, mainly physicians in trying to address the problem of over use of unnecessary tests and treatments and one of the things that Choosing Wisely is based on is a grass roots ground up creation of these recommendations from physicians about what tests, treatments, and procedures are not really needed. COVID actually offers an interesting opportunity for us to reflect on things we do that don't add value. So if you think about it, if we have limited resources in our MRI machines for example and we don't do imaging for low back pain unless red flags are present which is one of the recommendations, then those patients are not using a resource that is really unnecessary. So this frees up operating room space and resources that can be used to do other things, like hip replacements, which we know have a huge impact on quality of life. So there are many things in our system, where if we use the resources more cautiously and eliminated those who don't add value it creates capacity in our system for things that really do matter. So in some ways this new phase we are in, is an opportunity for reflection and potential change.
Yolanda: So value added care helps patients, helps us as clinicians by promoting the likelihood, the resources available when you actually need it and it helps the system by decreasing strain. So money allocated to one resource needlessly can be shifted and added to a resource that is much more in need, for example.
Steven: So thinking back to the COVID-19 crisis and the scarcity of personal protective equipment for instance, what we did was actually choose wisely, how to go about using it and it was because we knew we were going to run out if we didn't do that, if we weren't going to be wise about it.
Yolanda: Well, there wasn't a Choosing Wisely guideline on PPE. The principle was there. COVID led us to rethink our use of personal protective equipment out of necessity mind you but really the analogy I think is valid for wait times nonetheless.
Steven: So in the end, you know, we know managing wait time and resources is not easy.
Yolanda: Of course not, but it is our responsibility to be aware of guidelines and to consider them. Our approach needs to be evidence informed through guidelines, the standard of care, our local context and our own expertise.
Steven: Those are four lenses through which to view the evidence and to make decisions, isn't it?
Yolanda: Yeah and it's really about principles and a framework for decision making. Not stringent hard fast, carved in stone rules.
Steven: With an eye to balancing the needs of both the individual patient and the patient population and the system has a whole.
Yolanda: So we have to wrap things up Steven. Time for a communication tip.
Steven: Sure. I would say it's important to communicate purposefully and that means to clarify the roles for the patient care while the patient is on the wait list. By that of course I mean between the referring physician and the consulting physician.
Yolanda: As well as the patient. That tri-directional—
Yolanda: Communication path.
Steven: Yeah. We can't make the patient responsible for managing their wait times and whatnot, but they do need to be aware.
Yolanda: For documentation tip Steven, let's document what lens we used to make our choice. Which ones of those principles are you basing your reasonableness on?
Steven: That's right. That's a very good point and I think unfortunately we are at the end of our allotted time. I wanted to take the time to thank, Dr. Levinson for taking the moment to share her thoughts with us.
Wendy: It was a great opportunity and I hope the audience enjoys it.
Steven: We certainly appreciate it that's for sure. So with that goodbye everybody. I'm Steven Bellemare.
Steven: And remember when you look at things differently
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a "standard of care" for Canadian health care providers.
May 2020 | 19 minutes
As a result of the COVID-19 pandemic, physicians have had to rapidly pivot their practices to include virtual care provision. This episode covers how to include considerations around clinical judgment, standard of care, informed consent and privacy to provide the best virtual care you can.
Dr. Yolanda Madarnas: Hi everyone. Welcome to the fourth installment of our podcast series in the context of COVID-19.
Dr. Steven Bellemare: I'm Steven Bellemare, Director of Practice Improvement.
Yolanda: I'm Yolanda Madarnas, Physician Team Lead in Physician Consulting Services.
Steven: Today we thought we would talk about virtual care in the midst of a COVID-19 pandemic. You know Yolanda the medical community has been very agile in pivoting to the use of virtual care.
Yolanda: Not everyone is necessarily feeling agile. I know that in speaking with members on the phone, some tell us that they are struggling.
Steven: Yeah, for sure, for sure. But you know we have to give credit where credit is due. The majority of our members are telling us that they are actually using the phone to provide care. This isn't new, but they are using it more and more and you know, that is, technically, virtual care and that's an agile way to pivot to providing care.
Yolanda: That's true. That's true. Using the phone is indeed virtual care. Virtual care isn't just about using platforms with video links and formal telemedicine channels.
Steven: In fact you know, virtual care broadly speaking is simply the provision of medical care using technology with the provider physically separate from a patient.
Yolanda: So, in this podcast, we are going to try to address some of the medical-legal considerations when performing virtual care encounters.
Steven: Many provincial colleges have published standards related to virtual care. It's important to be familiar with these requirements as well as the many resources that are available to you to help you implement virtual care.
Yolanda: Indeed these standards and guidelines highlight the importance of considerations like consent, privacy, limits to care, and documentation.
Steven: So today as we normally do, we will have three take away messages.
Yolanda: Well, first and foremost let's state the obvious. Virtual care can't completely replace face to face encounters. We do need to use our clinical judgment to determine when a patient needs to be rebooked for an in-person assessment.
Steven: Second when it comes to virtual care visits, the standard of care should not be unduly compromised. Medicine is medicine and some conditions are not amenable to virtual care. Patients need to be redirected for appropriate in-person assessments.
Yolanda: Last but not least, not all virtual care platforms provide the same level of protection and security of patient health information. It's important that the patient understands and consents to moving ahead with a virtual care encounter.
Steven: Right. So, Yolanda let's jump to number one. Virtual care cannot completely replace face to face encounters.
Yolanda: Well, that's obvious and goes without saying. Virtual care encounters aren't the same as face to face encounters for many different reasons.
Steven: Of course. Especially when they are done over the phone. Assessments will be missing key pieces from physical examination and from all the nonverbal information we instinctively pick up on without consciously thinking about them.
Yolanda: Yeah. That makes information gathering and information delivery that much more important.
Yolanda: So while the medicine is the same, a virtual encounter may require you put more effort into certain aspects. For instance, the pertinent negatives and pertinent positives and discharge instructions.
Steven: Right. What do you mean by that though?
Yolanda: So, our differential diagnosis and management plan is only as good as the information we receive. Perhaps more so in a virtual care encounter than a face to face encounter. We need to be careful to gather all of the information that we need.
Steven: Right. So garbage in, garbage out.
Yolanda: Kind of and similarly our discharge instructions need to be very clear, almost directive. For example, whether another virtual encounter is appropriate or whether that patient should go to the Emergency Room in the event of the situation not resolving.
Steven: You know we are hearing in fact from our members that virtual care is not unanimously embraced just because, in fact, it can be somewhat awkward.
Yolanda: But the reality is that it has an important role to play and it can be a valuable tool provided we recognize its limits.
Steven: True. Virtual care cannot replace face to face encounters entirely but many conditions can safely be managed through virtual care, would you not say?
Yolanda: That's true and it does take clinical judgment though to decide which ones can or should not be managed with this modality. Which takes us to key message number two: the standard of care.
Steven: Right. So, the colleges and courts expect that physicians won't unnecessarily or unduly compromise the standard of care. They will take into account the context in which the care was provided. We talked about that in podcast number one and in a pandemic situation a court or a college is likely to allow somewhat more latitude for virtual care than in a non-pandemic situation. Context does matter but judgment is critical.
Yolanda: Absolutely. So, while colleges acknowledge that these are unprecedented times it is essential for any physician going to use virtual care to consider just how suited virtual care is to assess any given patient.
Steven: For instance if you need to perform a specific physical exam maneuver for instance.
Steven: You may need to see a person in person.
Yolanda: Sure. Some elements of a clinical exam can be done via a virtual care modality if a camera is present. So a video may help you assess a rash or range of motion of a joint but it's not going to allow you to palpate an abdomen.
Steven: By and large most people tell us the phone is a good enough starting point. There may not be a need to go to a complicated series of web visits and platforms just so you can see a person.
Yolanda: Of course it's important to remember that everyone's practice is unique. So we each have to ask ourselves what problems can we safely assess and treat virtually and which ones can we not.
Steven: And not hesitating if the patient's condition is not amenable to being addressed virtually to rebook them for an in-person assessment either with you, a colleague, or sending them to an emergency assessment center.
Yolanda: Yeah. Let's restate the obvious, that standard of care should not be unduly compromised by virtual care. Medicine remains medicine and we need to offer our patients the best care possible under the circumstances.
Steven: You know speaking to the colleges again, they are aware of this. They have stated, a number of them have stated, that they will assess potential complaints in the context of how the care was provided.
Yolanda: Which is reassuring. But Steven, two situations come to mind where we might stumble.
Yolanda: Take, for example, a patient who insists on being seen in person when they are offered a virtual care encounter. The flip side, a patient who we have asked to come in for a face to face encounter but refuses to come and be seen in person.
Steven: Well, you know what Yolanda, those are good points. We have heard from members about those issues, both of them, and the reality is that, with regards to the patients being concerned that they won't be satisfied with virtual visits, the rapid uptake of virtual care would actually suggest otherwise, that people are actually embracing this and finding it actually rather convenient. The biggest problem is in fact your second situation. It's that people who are seen virtually may in fact refuse to come in for a more in-depth assessment and that can cause a problem for the treating physician.
Yolanda: Absolutely. So, in both situations taking time to explore the issues is a great starting point. So, for example for the patient who insists on coming in, are their unmet expectations. What is the underlying need? Perhaps explaining that there is a risk of contracting COVID if they come in and trying to balance that against their wishes.
Steven: So, that might actually help them understand why a virtual visit may be appropriate despite some apprehensions around that. You know similarly when you do need to see someone for a more in-depth evaluation and they refuse, taking the time to explore their concerns is again a great place to start.
Yolanda: So perhaps there is a misunderstanding or an overestimation of the risk of contracting the virus that in fact needs to be addressed.
Steven: You know what we've seen this with people.
Steven: Not wanting to go to Emergency Rooms. People are saying Emergency Rooms are empty compared to what they were before because there is that fear of the virus and conveying that information, that no, this is still a safe place to come and you really do need to do that is important. We are hearing from patients, from members I should say, that they are seeing, some patients that are more critically ill than they were before.
Yolanda: Because they delayed.
Steven: Yeah, exactly because they delayed attending the Emergency Room. So, you know in those cases where patients are hesitant to go see someone in person, it's important to document the advice that you give and your plans to comply with the standard of care. To do what the standard of care would call for.
Yolanda: In essence, this really is informed refusal. Patients can refuse to be seen, can refuse to follow our recommendations but as a physician, we do need to make sure they do understand those risks. Okay. So let's move to key point number three Steven.
Steven: Are we there already? Informed consent then.
Yolanda: Alright. So, consent for virtual encounters isn't really implied by simply participating in the encounter and it does need to be addressed.
Steven: This is really consent around the potential inherent security issues. The threat to personal health information that comes with virtual care.
Yolanda: It's important that we help our patients understand that privacy and security risks vis-a-vis their health information exist with the use of any platform, be it telephone, telehealth, video conference, email.
Steven: Security is a huge issue. We could spend a few podcasts talking about security but basically the big concern here is that the health care information can be intercepted by a third party.
Yolanda: That's where encryption of the platform is important.
Steven: Simply put, encryption means that the information is scrambled and it's indecipherable for anyone who doesn't have the access key.
Yolanda: Specifically it's important to understand there is a difference between encryption at large and end-to-end encryption.
Steven: Okay, that's going to need a little bit more explanation.
Yolanda: Yeah. It is complicated indeed and I'm going to do my best to try to explain it. So, an encrypted platform doesn't allow anyone but the two users to see the data. The data is scrambled in transit, but it isn't scrambled when it sits on a provider's server. There, it's not encrypted and that could potentially allow the technology provider, that company that sold you the platform, to mine your data while it sits on their servers. Without end-to-end encryption, they could theoretically access the content of that visit and figure out for instance that I'm an oncologist, that I specialize in breast cancer, that I connected with 10 patients in three regions between the hours of 9:00 and 3:00 and they can start building a profile that uses that information about my virtual care consults. Not the actual information but use it for non-healthcare purposes.
Steven: So that's where end-to-end encryption comes in. In end-to-end encryption, the platform company can't even access the content of the virtual care visit. That type of information is completely blocked off to them. It's definitely more secure and those issues whether or not you're platform provides encryption or end-to-end encryption is usually found in the small print, the fine print of your contract.
Yolanda: Something most of us are not trained to understand, know about, or even know to look for, but many provincial medical associations, colleges, and health authorities have actually come out with recommendations on which platforms they deem appropriate for use. Some have even bought licenses for all of their physicians and some have services that can help you sort this out.
Steven: Right. So, Yolanda, if I was to work in a clinic or a hospital and use a virtual care platform for instance that's provided by my provincial government, could I as a physician be held to account for something that I have no control over if there was to be a privacy breach?
Yolanda: Yeah. That's a good question. I mean, generally, physicians are allowed to rely on the systems provided to them by an employer, by an institution, a clinic, a hospital.
Steven: That said, it's also a good idea, to point out privacy concerns that you may have about your systems if you suspect or know about them. Even better for you to do it in writing so you can demonstrate your diligence.
Yolanda: Yeah. That's a great point and in fact, in most of these facilities, there are privacy officers whose job it is to look after that.
Steven: Yeah, you can't just use a patient's consent to use the platform to "wash your hands" of the security issues if there were to be any. In fact, one of the other issues to consider is that patients should avoid using a computer or device that doesn't belong to them, that belongs to someone else. Their employer for instance because some elements of their health care visit information, could be accessed through things like cookies, for instance.
Yolanda: Yeah. So, let's use this as the springboard to talk more about the consent issue. So, are physicians expected to get consent each and every time they conduct a virtual visit?
Steven: Well, it would be the prudent thing to do for sure.
Yolanda: Wow. So, each and every time they see the same patient, or can they just do it the first time?
Steven: Well, you'll see me coming here again, I'm sure. Ideally, you want to do it every time and that's because the issues may be different from visit to visit and the privacy concerns for one type of problem may be more acceptable to a patient then they are for another.
Yolanda: Yeah. So, I guess, generally speaking, it's best to assume that patients haven't even considered the security issues associated with virtual care and so it behooves us to point them out.
Steven: I think that's certainly very diligent, right? Every time.
Yolanda: Every time. People forget, people change, circumstances change.
Yolanda: There is more to consent then the security platform. Another important aspect is the limitations of the care when done virtually.
Steven: That's right. Does the patient actually understand that their issue may not be manageable by virtual care or that there are limitations in what you'll be able to say to them or the advice you will be able to provide?
Yolanda: By that, if a physical exam is deemed to be necessary that they are going to need to rebook for an in-person assessment or present to ER.
Steven: Right. In the end, these consent issues, Yolanda, the good news about those is that they can be delegated to someone else. You, the physician, don't necessarily have to do it yourself every single time.
Yolanda: Yeah, that's right. You can delegate that first step of consent to a practical nurse, a nurse working with you, your medical office assistant, a clerk. As long as you are confident that they have enough knowledge to explain things well and to address any questions that the patient has.
Steven: That confidence comes with you actually having had that discussion with them and training them how to do it, right? Then that way, once they have that consent discussion with the patient, all you would have to do is confirm with the patient when you log on that they are in fact okay with proceeding as you are checking their identifying information.
Yolanda: That's another important point, isn't it?
Yolanda: Checking that you are actually speaking with the right person.
Steven: Imagine that. I mean it's kind of intuitive in person but and its perhaps it's less of an issue when you are dealing with a lot of follow up of people that you know but certainly when are seeing someone for the first time, it's a good idea to check that you are indeed speaking to or seeing the right person.
Yolanda: That can be a simple as asking them to hold up their health card to the camera or asking them for their address, date of birth to correlate with the information that you have on file. I mean, you know when I call the credit card company, these are the questions that they ask me to make sure they are speaking to the cardholder.
Steven: Exactly. Speaking about knowing who you are talking to, consider the privacy of the space that you are in.
Yolanda: That's right. You know many of us are providing virtual care from our homes and it's important that our spouses, children, for instance, can't overhear or see what's going on during our consults.
Steven: Yeah, that might be easier said than done.
Yolanda: I know but we do need to do our due diligence and do our best. The kitchen table is probably not a good place.
Steven: I think that would be safe to say, yeah. You know, I add that it might be wise to ask your patient who at their end, may be listening in or watching as well. That way you will be better able to tailor your questions and conversations.
Yolanda: Remember to document these aspects as well.
Steven: Okay, Yolanda there is so much to cover but I think we need to wrap up on this issue.
Yolanda: I know time flies once we get going.
Steven: Right. Could we provide at least a take-home message for members who are exploring this brand new virtual care environment?
Yolanda: So as with all things, focus on your communication skills. Take time to understand your patient's concerns and their expectations.
Steven: Ask questions but let patients ask theirs as well. It's easy to speak over one another and to interrupt each other without visual cues that we are used to having.
Yolanda: For sure. Virtual care can eliminate some or even all of the nonverbal cues that we usually use to help us confirm understanding or satisfaction with an encounter. So, we need to make extra efforts to use explicit verbal communication to fill in those gaps of the nonverbal nuances that we lose with virtual care.
Steven: Let's not assume anything. You don't want to be filling in those gaps based on your own unconscious biases. You may interpret or believe things to have happened that in fact haven't.
Yolanda: So we know this is a lot. Please don't hesitate to call us to discuss your specific concerns or issues with virtual care.
Steven: Certainly these podcasts are not meant to be all-encompassing deep dives into anything in particular. They are meant to be an overview.
Yolanda: And food for thought. So, a reminder to have a look at the COVID—
Steven: The COVID-19 hub on our website.
Yolanda: On our website.
Steven: Lots of frequently asked questions. Chances are if you are asking yourself the question we've heard it before and it might be on our website. That said, don't hesitate to call us. We are always happy to talk to you in person.
Yolanda: Thanks again for joining us today.
Steven: Have a good day everyone.
Announcer: These learning materials are for general educational purposes only and are not intended to provide professional medical or legal advice, nor to constitute a "standard of care" for Canadian health care providers.
May 2020 | 18 minutes
During the COVID-19 pandemic, physicians may be deployed to unfamiliar clinical units and may need to have difficult discussions around goals of care that they are not used to having, perhaps even with patients they don’t know. This episode covers key messages that may help you effectively support patients and families who need to make plan of care choices as a result of a COVID-19-related critical illness.
Dr. Yolanda Madarnas: Hi Steven. Hello everyone.
Dr. Steven Bellemare: Hi Yolanda. Welcome back to our third edition of our special COVID-19 related podcasts.
Yolanda: Yes. So Steven, in the evolving COVID-19 health care setting, I know that physicians are finding themselves having more and more discussion, possibly with patients they don't know at all about goals of care.
Steven: That's right and you know in addition we may end up by virtue of the fact that we are being deployed in some incidences to units where we don't usually work, find ourselves actually needing to have such discussions that we're actually not used to having at all.
Yolanda: While we know it may be difficult and intimidating.
Steven: These conversations for sure are tough at the best of times.
Yolanda: Not having these conversations early before they become necessary actually robs our individual patients of control and choice and might result in medical care that isn't reflective of what is most important to them.
Steven: That's right. So, in this podcast everyone we want to provide you with an overview of some of the issues we see arising out of our medical-legal cases, especially around end of life care, critical illness care and hopefully we will be able to help you identify how you might be most effective in having those critical illness discussions about goals of care, especially if this is not something you are used to doing.
Yolanda: For sure. So, following the principle of a person-centered approach that aims to include the patient's loved ones and the care team when feasible can help physicians feel that they've assisted their patient in making the most appropriate decisions possible.
Steven: So we have three take-home messages for you today. The first one being that it's important to communicate with families and the care team about goals of care early effectively, routinely, and repeatedly.
Yolanda: Our second point would be that it is important to have an approach to ask patients about goals of care. Having this approach is going to make you more likely to do so and might save you time.
Steven: Finally, we want to impress the importance of normalizing the discussion. Normalizing the discussion is going to actually help reduce the patient misunderstandings, fear, and discomfort and result in overall improved satisfaction with the care that's being received.
Yolanda: So, in essence, these end of life discussions are actually part of the job of every physician but end of life and critical illness communication is still challenging even for the most experienced physicians who have these discussions every day.
Steven: Right. So preparing tools to start or structure or even troubleshoot these difficult conversations can actually make it less scary for everyone and actually help us be more likely to have these conversations especially when time may be short in the COVID settings.
Yolanda: So, planning to have these conversations in a timely patient-centered setting can help the process move along and make it easier for patients and may reduce our medical-legal risk.
Steven: You know Yolanda, patients and families are more likely to be more satisfied with the care they receive when they feel heard and involved in the decisions.
Yolanda: Yes, for sure. So take for example Steven a situation that's not uncommon in many of our college complaints. We had a patient who is admitted to an acute care hospital with a straightforward potentially reversible life-threatening illness.
Yolanda: That rapidly deteriorates.
Yolanda: Our patient has previously told us they do not want to pursue supportive care and heroic measures if survival is unlikely and their family had agreed. So the patient is provided with comfort care measures and passes away comfortably. After, the family files a college complaint alleging the care was poor. The college had no criticism of the care per se, saying that it was consistent with the patient's wishes, but there was some criticism of the physician in having fallen short of having had optimal communication with that patient's family, especially when their condition worsened.
Steven: Right. So essentially you are highlighting a common theme in critical illness or end of life care issues, is that the issues are often not about the medicine they are about the communication, right? This highlights the importance of keeping all the players apprised of the situation and making it clear actually how the care is aligned with the patient's advanced directive and sometimes we may take for granted that it is clear and apparent when it's not.
Yolanda: And it's not. Complaints like this do highlight that for us. So, a reminder that because the changes in clinical status can occur quite rapidly it's so important to plan for frequent updates on how things are going. Particularly now in the COVID context which may well mean having to discuss what will and won't be possible depending on the availability of resources and how this might diverge from a patient or family expectations.
Steven: Right. We know that it is not an easy thing to do. It's not an easy thing to address but one of those most frequent issues we hear from families and patients in our college complaints or even in our lawsuits, is the lack of availability of the MRP, the most responsible physician, to discuss the patient's situation, to hear their concerns and explain to them how it is that things are going.
Yolanda: So while we know that the care is delivered many times in teaching hospitals or even in nonteaching institutions by a team where a number of individuals participate in the care. There is an MRP who may delegate a number of things but these discussions are particularly important to be held by the MRP and providing that opportunity to review the state of affairs how things are going and how the care aligns with the patient's advanced directives is a critically important issue.
Yolanda: Making the time for this can make all the difference.
Steven: You know it's made all the more important in the context of potentially limited access to resources such as medications like Propofol for instance. It's been in the news recently. Equipment like ventilators and palliative care physicians or even facilities. The appropriate rooms for looking after the patients. So, we've all see how fluid the situation around COVID has been evolved and how one region is completely different from another and how very difficult it is to predict where things are going.
Yolanda: Yeah. It may be that you'll never have to address resource issues as part of the goals of care discussions that you have but keeping your eye on that ball will be important to help you feel prepared to do so if and when the time comes and patients and families are likely going to be aware and understand the limitations through the media, news reports and so on but that communication and adaptability on our part are key especially when deviations from a previously agreed to or expected care plan have to take place because of resource shortages.
Steven: Well, look Yolanda we are already quite far into this broadcast and we haven't even got to take home point one. So, perhaps this is a good place to do that and that message was that we should keep in mind the importance of communicating with families and patients and other caregivers about goals of care early and I don't mean early in the morning here, I mean early in the illness or in the situation effectively and repeatedly even.
Yolanda: While we've used the term end of life at several points here in the podcast, it may be somewhat of a misnomer, it doesn't imply that we should wait until a patient is clearly at the end of their life to have these discussions. Critical illnesses in practice or in theory are an optimal time to bring out and highlight these care goals, as any new serious illness or diagnosis and in the setting of COVID, this might ideally mean discussing it with any high-risk patient in the event they contract the illness.
Steven: Right, before they get it, right. Having these discussions when the threat is theoretical and not imminent is likely to be easier on everyone including us, right, as the physicians.
Yolanda:That's been my experience with my cancer patients, having that discussion long before it's really on the radar.
Steven: Right. Don't get us wrong though, we are not suggesting you start calling patients in your practice out of the blue to find out what their wishes out should they get COVID-19. That will be a bit startling.
Yolanda: Not at all. But that said, it may be wise to raise the issue with them during visits for other issues, especially if they have a comorbidity that does put them at higher risk for serious COVID-19 related complications.
Steven: And in that sense you know, even though you may not end up being the one looking after them, should they get COVID and require admission, your efforts to actually raise the issue ahead of the team may at least have primed them to consider the implications of the diagnosis for their care.
Yolanda: Absolutely. We recognize that many frail or older patients may not actually want aggressive life-prolonging measures and they may prioritize quality of life and actually being able to say goodbye to their families.
Steven: Frank communication is so important.
Yolanda: Absolutely. So explaining the impact of their comorbidity on the likelihood of surviving a COVID-19 or other critical illness can actually allow them to make an informed choice as to their level of care and whatever their decision is, many will at least understand the process better and hopefully feel included and heard.
Steven: Right. You know patients listen to the news. They know that COVID-19 has a high likelihood of poor outcomes in patients with comorbidities. So, looking at it not as something awkward to raise but rather as an opportunity to provide guidance on the proverbial elephant in the room so to speak, may actually help you to be more comfortable in raising the issue.
Yolanda: It's already there. You are not really raising anything new. You are allowing permission to talk about it and explain it because people may actually have a misconception of what their risk and their comorbidities are. But it's important to raise it and allow our patients and their families to participate in that shared decision making.
Steven: Right. It's important to point out here Yolanda that the purpose of an early conversation is not to convince anyone to seek a particular kind of care over another, a least invasive care for instance. Quite to the contrary. It's about setting the context for making the decision that is right for them, isn't it?
Steven: We shouldn't avoid the conversation assuming we will have to convince patients to do something or anything. That would be very adversarial approaching it that way.
Yolanda: Absolutely. So starting with goals of care, raising potential resource issues as an additional consideration as well as the impact of any comorbidities they shoulder, doing so early may actually help us and help our patients align their values with the reality of what might and might not be possible during the COVID-19 crisis.
Steven: Yeah. So, that's part one, right. That's addressing with the patient and getting them to think about what they would like to do if they were to contract COVID-19 but before they get ill.
Yolanda: If those stars align then you are also able to continue being the primary physician tasked with looking after them when they are actually ill, then part two comes into play.
Steven: That's about having the discussions about what is and what is not possible at that particular time.
Yolanda: That's quite difficult to plan for as we've seen over the first eight weeks of this pandemic. Information, situations change at an incredibly fast pace and what was available yesterday may no longer be available today and what you thought wouldn't be available has actually not been as scarce as we anticipated.
Steven: That's right. So, getting back to our case example Yolanda, the issue at play there if you'll recall, right, the family didn't have a line of sight into why decisions were being made for their loved ones and how they actually were consistent with previously expressed wishes.
Yolanda: Yeah. So the takeaway or learnable point here is that frank frequent routine and repeated, not one-off meetings and discussions with patients and their loved ones to explain the situation, the options as they are on that day can make the whole difference between the perception of excellent versus negligent care.
Steven: Right. It's all in the relationships you build, right. It's the feeling of control and choice and being heard that will help the patient and their family feel valued.
Yolanda: And hopefully reduce the medical-legal issues for the physician.
Steven: Provided those conversations you have are also documented.
Yolanda: Absolutely. While we recognize this can be a difficult time with time constraints that we are all subject to and the fact that it's unlikely that families are actually going to be present there in person to meet with you.
Steven: Right. In the context of the pandemic, the family most likely won't be there because of the limitations on visiting.
Yolanda: Yeah. So trying to plan ahead for that gets into our take-home message number two. Having an approach to ask about your patient's goal of care values, their fears, their expectations. May make you more likely to do it and might save time in the long run.
Steven: Right. You know, that makes me think of a lot of the resources available. You are talking about fears and expectations.
Steven: That gets back to the FIFE model of exploring people's feelings, people's ideas about their illness, their function as well as their expectations for the care.
Yolanda: While the association doesn't endorse any particular approach per se, there is a Canadian website, www.planwellguide.com that may be worth a look to get some ideas on how to build an approach to these situations that suits your values.
Steven: Yeah. There are a lot of good resources out there Yolanda. Some of them have videos that you can watch to get a little bit of coaching. Some of them even have talking maps, like road maps. They are essentially scripts if you will.
Yolanda: For these difficult conversations.
Steven: Right, and these are all designed to actually help you be more comfortable and better care for patients and families.
Yolanda: This is well within the context of shared care, shared decision making and we can find this just googling it.
Steven: Yeah. Yeah. That's right. There really is quite a wealth of resources out there.
Yolanda: Out there.
Steven: Finally our third take-home point was that using normalizing language can help put patients at ease and facilitate the sharing of opinions.
Yolanda: For example using the third person. So when people with COVID get worse they have to make decisions about their care. They tell me that it's less stressful when those discussions happen earlier.
Steven: Right. Or even things like most people tell me they don't want to burden their families by requiring them to make those decisions without knowing their wishes.
Yolanda: So we recognize that people are likely to want to be reassured that they or their loved ones aren't being singled out. I'm having this discussion with all my patients right now.
Steven: Right. So normalizing family feelings, like many family members feel helpless in these situations. How do you feel? Can be helpful.
Yolanda: Absolutely. So, in the end, these goal of care discussions are not really made all that different by COVID. They are just happening more often out of necessity and they might be influenced by resource issues. So, in fact, COVID might present us with the opportunity to preemptively have these discussions.
Steven: Right. Indeed. What may be different is that you as the physician may not be used to having those discussions with your patients by virtue of your usual scope of practice or by the fact that COVID is forcing you into those kinds of situations that you normally wouldn't be taking part in.
Yolanda: So we hope that these few tips today might help you feel more comfortable having these discussions, knowing a bit more about the issues at play in the typical end of life cases that are likely to impact patient and family satisfaction with care and thus your medical-legal risk.
Steven: Right. You know Yolanda, if there is one key message that we could share it would the power to just sit in silence. Allowing patients and families time to process and think of questions. It's okay not to fill that space. It actually will feel longer than it actually will be.
Yolanda: While that space is long face to face, recognizing that the family is not likely to be in the room during COVID related care, you're likely to be having some of these conversations on the telephone.
Yolanda: Which will probably be extra awkward. So you might want to acknowledge that silence explicitly on the phone, validate it and attempt to ease the family's comfort with it and allow them permission and time to think and process what's just been discussed.
Steven: Right. Well, Yolanda, I think if we don't want to be interrupted by the end of the podcast music we are going to have to start wrapping this up here.
Steven: Thank you so much for joining me today to talk about this important issue.
Yolanda: Thank you, Steven. Thank you everyone for joining us. Just a reminder to visit the COVID-19 hub on the CMP website and as well please call us anytime to discuss specific issues to your day-to-day. Our podcasts are not meant to be all-encompassing but rather touch on highlights that are meant as food for thought.
Steven: Hopefully these highlights are going to be helpful to you.
Yolanda: We hope so.
Steven: Thanks for joining us.
Yolanda: Thanks again. Bye-bye.
Physicians routinely face challenging situations and difficult decisions. This episode covers why it is important to recognize and manage moral distress and explore various coping strategies that physicians can adopt to stay well.
Dr. Yolanda Madarnas: Hello everyone. Welcome to the second podcast in the series of the COVID-19 pandemic. I’m Dr. Yolanda Madarnas.
Dr. Steven Bellemare: And I’m Dr. Steven Bellemare.
Yolanda: So Steven, physicians routinely face challenging situations and difficult decision-making processes.
Steven: No, absolutely. And those can, at times, cause moral distress for us and that can occur even more frequently in times of crisis like COVID-19.
Yolanda: We hear from you every day on the phones. I hear you telling me that you’re worried about having to make difficult decisions that you may not have had to make but for the pandemic. So it’s important to learn how to recognize when we may be experiencing that moral distress.
Steven: We hear from you as well that you’re worried about your safety and that of your loved ones.
Yolanda: And how difficult it is to shift from a patient first ethical framework to a public first one.
Steven: So with this podcast, we thought we’d take the focus a little bit off the medical legal issues and more on physician wellness. We hope to discuss these very normal and common concerns that you have and provide you perhaps, a little bit of a framework to make sure that you help yourself be as well as you can be.
Yolanda: We hope to identify some of the coping strategies that you might tap into to prevent the negative impact on your wellbeing.
Steven: Today, Yolanda, we have a very special guest. We have Dr. Caroline Gérin-Lajoie, who is the Executive Vice-President of Physician Health and Wellness at the Canadian Medical Association.
Yolanda: Dr. Gérin-Lajoie is also a psychiatrist at the Ottawa Hospital. Welcome Caroline.
Dr. Caroline Gérin-Lajoie: Thank you. I’m happy to be here.
Steven: In Canada, you know we pride ourselves on a system that strives to provide everyone with an equal opportunity to access and receive medical treatment.
Yolanda: So this is possible when there is sufficient resources. Our last podcast dealt with that.
Yolanda: That the pandemic might force us to triage patients and make difficult decisions about who receives which level of care and under what circumstances.
Steven: And making these resource allocation decisions can be so stressful for people on the front lines.
Yolanda: Particularly when we sometimes feel that we have to make clinical decisions that are influenced by circumstances that are beyond our control.
Steven: Especially so, right? Caroline, can you tell us a little bit what you know about this difficult issue?
Caroline: Having to triage or to go through that process of setting priorities for resource allocation to manage a surge of patients, it can become even more ethically complex in these times of catastrophe, a little bit like what we’re living now with COVID-19.
Caroline: And these are the kinds of situations that can lead to moral distress. And when you think about that concept of moral distress, it can be when we feel unable to fulfill what we believe to believe, to be an ethically appropriate or a right course of action, and we can think about it as a psychological response or psychological distress, but that’s specifically related to an experience of moral conflict or of moral constraint. So this is especially likely to occur these days during the COVID-19 period, as well as in other situations where there may be extreme resource limitations that can affect patient care, or even the safety of our health care providers.
Steven: In moral distress, if I understand it correctly, someone feels morally compromised by the impossibility to pursue what they believe is the right course of action. Is that right?
Caroline: Yeah, exactly. So this kind of creates a moral conflict or a situation where you believe that an action, or the lack of action, can contradict their ethical obligations or commitments, or they fail to live up to their own expectation of ethical practice.
Yolanda: Caroline, are there common elements to moral distress?
Caroline: Yes, so for example, a feeling of complicity and wrongdoing. So that would be when you believe that you’re doing the wrong thing or that you have very little power to change a situation.
Steven: You know when we speak to physicians about this very issue they often describe the feeling of not being heard, or not feeling that they have a voice. Is that part of that?
Caroline: Absolutely. And speaking of that lack of voice, that’s when you believe that you have insights and you have knowledge relevant to a situation, but where you feel it’s not heard or it’s not taken seriously.
Steven: So if we experience moral distress at different times or in different scenarios, are those all separate individual experiences or are they somehow cumulative?
Caroline: Actually, Steven, they can be. These repeated situations of moral distress, they leave what we call moral residue and that heightens someone’s level of moral distress in the subsequent experiences that they may have.
Yolanda: So if I understand correctly, moral residue is the distress that remains when the situation that triggered the moral distress initially, has actually ended.
Caroline: That’s correct. So moral residue is what each one of us carries with us from all of those times in our lives when we feel we are morally compromising ourselves or allowed ourselves to be compromised in the face of a distressing situation. And so if the individuals level of moral distress doesn’t resolve but rather, remains high, it may increase even more the next time that they’re encountering a morally distressing situation and that’s really why it’s so important that we deal with it.
Yolanda: Caroline that sounds a lot like the genesis of burnout and compassion fatigue.
Caroline: That’s a good observation. Actually, we know that moral distress can be related to compassion fatigue, to burnout, and even to depression. So these are things that affect the individual physicians or caregivers, but we also know that moral distress can have an impact on the organizational level and we could see that through patient safety incidents, distancing from patients, and even decreased job satisfaction.
Yolanda: Caroline, could you give us an idea of how a physician might recognize when they’re experiencing moral distress. Is it more than just a feeling?
Caroline: Yeah. And I think it’s important to start by clarifying that moral distress really is not a mental health disorder in itself, but it’s important to manage it well so that it doesn’t lead to complications and those could include mental health issues. It’s also important to know that people experience moral distress in different ways. For some people, it may be very easily manageable, but for other people it can be completely impairing. And you may wonder what some of the symptoms are and these could include things like physical symptoms. So these could be fatigue or headaches, difficulty sleeping. They can also include some emotional symptoms. There could be anger, fear, anxiety, but also behavioural symptoms and these could lead to addictive behaviours, maybe drinking or taking drugs are also influencing our behaviours in relationships with our loved ones.
Steven: You know Caroline, as I hear you list these signs and symptoms, I can’t help but think that some of our listeners, if not a number of our listeners, might actually be recognizing themselves in those descriptions.
Yolanda: For sure.
Caroline: They absolutely could and really the key message here is to be aware of the concept of moral distress and to have a better sense of how to recognize it within themselves but hopefully within other colleagues.
Yolanda: So what could physicians do to minimize the impact of moral distress?
Caroline: You know unfortunately, it is not possible to eliminate the situations that cause moral distress or to eliminate many other challenging situations that we may come across in health care. But there are ways where we can try to mitigate its impact, so remembering that moral distress can involve at least three different levels: the individual physician; the unit, team or department; and also the organization or a system. And what that means is it opens the door to potential ways to ease that experience of moral distress at each one of these different levels.
Steven: That’s very interesting. I’m sure that we couldn’t possibly give advice, deep advice on all of the strategies that we could implement in such a short podcast. But Caroline, I wonder if there’s perhaps, one or two things that we could discuss, perhaps for each level?
Yolanda: So could we start at the individual level, a couple of things that a physician or a health care provider could do.
Caroline: So as an individual, and I would say beyond the basics of health and that would include proper sleep, nutrition and exercise, but within the limit of what’s realistic right now. What I would encourage physicians and health care providers to do is share their emotions and their experiences with people they trust. Whether that’s their team at a team meeting, for example, and these could include sharing emotions like distress, it could be guilt. It could be that sense of unfairness. And the idea is to open up communication and to share the stories about what they went through. I would also encourage people to reach out if they need to, the ethicist working in their environment and that can help you to kind of work through some of these really challenging situations when you encounter them and when they may lead to moral distress.
Steven: It’s really about realizing that we are not alone in this, that you’re not the only person—likely not the only person feeling this.
Caroline: And it’s leveraging the people in your direct environment to help you cope optimally in these situations.
Steven: People who can understand you.
Yolanda: Your peers, your colleagues. This may be a little bit more difficult in the days, today. You know a generation ago there was a doctor’s lounge, we could shoot the breeze and chat with our colleagues at the end of a difficult day. That’s no longer as easily or readily available. In fact, absent in some places, so that much more important to dedicate some quality time at some point during the day to exchange these meaningful feelings with our colleagues.
Caroline: And so what that means is the onus is now on us even more so, to do a check-in with ourselves and that if a person recognizes that they are in a high level of distress or having increasing difficulty functioning, they absolutely need to reach out to their family physician, or an employee assistance program if they have one, or even to the provincial physician health program. But at the end of the day, what’s important here is that we learn to treat ourselves with empathy, with self-compassion, and also with self-forgiveness.
Steven: Very good advice there. I mean, we don’t have the time to get into a whole lot of details about managing emotions and cognitive behavioural therapy, but very good point. Caroline, what about team level issues? What are some ways that we can address moral distress there?
Caroline: There’s actually a great opportunity here for leaders to help recognize the impact of moral distress and to try to build in processes to directly address it with their staff. So for example, they may want to hold more regular meetings, and that can be within your department or with other departments and that can help to build this feeling of team cohesion and to help have very clear and timely communication, shared decision-making and this way everyone feels included and part of the experience. Another option could be to hold debrief meetings on a more regular basis, particularly when these morally charged situation occur. So as an example, that could be when there’s a clinical triage decision that needs to be made.
Steven: Or maybe when a patient has died or is about to die and doesn’t have a family member with them. I mean, I know how distressing that it. We hear that a lot and having the opportunity to debrief around that, I think might be helpful.
Caroline: And finally at the team level, it’s important to encourage members to support each other and make sure that no one isolates themselves, and so actively trying to find those people and reach out to offer them support and that can be done by creating a buddy system. And a buddy system is where you just pick someone you trust and you try to do regular check-ins with. And interestingly during COVID, this has been a really popular phenomenon within physician groups.
Steven: You know I brought up the whole idea of debriefs whenever a patient, for instance, is dying and alone and that causes distress. Yolanda, I think we’ll have more podcasts.
Steven: Later on, we’ll have an opportunity to talk about debriefs. But today’s discussion really does highlight the important role that they play.
Yolanda: Recognizing that it may be difficult to find the time for a debrief because they may not be part of the everyday in many groups, the buddy support system takes on that much more importance and might actually be the easiest one to implement, at least at first. Caroline, what are some of the things that can be done at the organizational level?
Caroline: So we tend to forget this, but the organizations can actually play a really big role in these types of situations, particularly in recognizing and validating that experience of moral distress, but more importantly, I think conveying to health care providers that feeling that we’re in this together and that we have your back. It is so crucial.
Steven: Caroline, thank you so much for raising that point. You know, we may have a lot of listeners who are physician leaders, who are in a position to actually put in place processes to implement some of these recommendations. Is there anything more that you can provide, other little tips, pearls for them?
Caroline: Yeah. Other strategies could include things like being very honest and transparent about the situation at hand. For example, if there was a situation with resource constraints, or to provide really clear guidance on changing policies and procedures and we know that can happen at an extremely rapid pace. They can be very clear with triage criteria, for example, and if ever there was to be a triage process activated, it really should be accompanied by some kind of plan to mitigate the physician or health care provider, moral distress. And just to give a little bit of an example there, hospitals and organizations could create triage teams and what that would do is allow for the separation of the clinical and resource allocation decisions. And what that does is it helps to reduce that moral burden created by the decisions for a specific physician so they don’t have to feel so alone in making these really difficult and emotional decisions. And finally, I would recommend that organizations create guides so that their leaders can provide support for their teams even more easily and make efforts to advertise wellness supports, to encourage peer support as we mentioned, and more importantly, it’s to create the opportunity for people to access those supports and to practice a lot of self-care.
Steven: Sounds like we just can’t take for granted that people will instinctively know how to help themselves and each other, that we have a role as institutions in helping promote that wellness.
Yolanda: One advantage of implementing some of these strategies now in our current circumstances is that when the time comes and this health crisis has abated, some of these processes may become part of the new normal, part of the new structure in which we continue to practice medicine and can only continue to help health care providers and their patients.
Steven: In fact, you know what I suspect, Yolanda that when all of this is over, it won’t necessarily mean that all will be back to normal, right Caroline?
Caroline: I agree completely. And that’s why I think we should even be using the term “new normal” because we really cannot go back to how we were living medicine prior to two months ago, for example. But what you raise is the importance of the post-COVID period and what we absolutely need to do is ensure that there are supports and resources available to all staff so that we minimize the moral residue and we really try to enhance wellbeing. And in fact, I would say we have an ethical imperative to prepare for that period because we can probably expect a rise in mental health issues and in needs. So we have a duty to make sure that that’s available. And as human beings, one of the ways that we can cope better through these difficult times is to look back and try to learn from what happened and take those learning’s to then move forward and improve the health care system.
Yolanda: Thank you, Caroline. We have covered a lot of territory in a very short podcast, and the intention wasn’t to go in-depth into too many of these aspects. But before we go, are there two distill takeaway points that we can leave our listeners with?
Caroline: Absolutely. So remember, it’s normal to experience moral distress in the context of a pandemic, such as what we’re going through with COVID-19, and just recognizing moral distress is an important first step to then being able to mitigate its impact. And the second thing would be to always remember the multi-level approach to ease our experience of moral distress.
Steven: Well thank you very much, again, Caroline. This was fantastic advice. For our listeners, if you’re looking for more information, you can certainly visit our CMPA COVID hub on our webpage. And Caroline, are there any resources available at the CMA?
Caroline: Absolutely. And this can be accessed through CMA.ca. And on that webpage you will find a section specifically for COVID-19 with a lot of information and resources.
Steven: Well we hope this was helpful to you, our listeners.
Yolanda: And as I said, while it’s a complex topic, we do hope to have provided you with some practical tools that can help you approach this really challenging issue.
Steven: Good-bye, everybody. Stay well.
Yolanda: Good-bye, everyone. Thank you. Stay well.
Caroline: Thank you.
April 2020 | 15 minutes
A public health emergency may force a shift away from the usual patient-first ethics, to a public-first approach. This episode covers the concept of reasonable care and patient’s best interests to help you make sense of the unusual demands the COVID-19 pandemic may place on you.
Dr. Steven Bellemare: Welcome to a special edition podcast brought to you in the context of the COVID-19 pandemic.
Dr. Yolanda Madarnas: The CMPA recognizes these are unprecedented times for the Canadian medical community, and how stressful the current events may be for you.
Steven: We really want to be there for you.
Yolanda: We listen to your medical-legal questions and concerns, every weekday on the phones.
Steven: And while we’re not able to be out on the road meeting with you face-to-face to offer education, we thought we could bring it to you virtually through a podcast.
Yolanda: Hello everyone. I’m Dr. Yolanda Madarnas, Physician Advisor and Physician Consulting Services.
Steven: And I’m Dr. Steven Bellemare, Director of the Practice Improvement Department.Yolanda, there are so many things to talk about in this context, aren’t there?
Yolanda: For sure. Physicians are being asked to make unprecedented decisions. We’re being asked to practice in unfamiliar settings outside of our comfort zone, we’re being asked to come out of retirement to lend a helping hand. We’re providing virtual care for the first time.
Steven: And perhaps, actually, even to change the way we provide care to accommodate the constrained resources, or to protect public health. You know, as physicians, we wonder about our obligations and our rights in the context of this public health emergency. Specifically, one of the things we hear very much at these times is the issue of managing resource scarcity.
Yolanda: So while many of these answers are available through our website, and the new COVID hub on our website, or you can call us for individualized one-on-one advice, but for this podcast we chose to focus on a particularly challenging issue, the one of managing scarce resources.
Steven: You know the Canadian health system and the resources are already stretched thin, but in the context of the pandemic we’ve been pushed to a place where we’ve never been before.
Yolanda: Absolutely. So, envision this as our collective objective being to make the best use of our precious human resources during these extraordinary times. So in today’s podcast, we’re going to focus on two take-home points that the patient’s best interest should really be our guiding light. And when in doubt, focus on the concept of reasonable care.
Steven: We have to keep in mind, though, Yolanda, that we’re dealing with two very complex issues right now in a very short time.
Yolanda: I know. And by no means this, is intended to be a comprehensive review of the topic. It’s really an introduction and touching on some main issues and food-for-thought.
Steven: Yeah. The objective here is not for you to come out after listening to this and say well, okay. I know all there is to know about this. No, no, on the contrary. If you need more, call us, visit the website.
Yolanda: So, one of the issues on everyone’s mind is so how do I balance my patient’s needs with these scarce resources?
Steven: Well, let’s talk about the issue of best interest then.
Yolanda: But it’s such a stressful issue, Steven. We hear news from around the world what’s happening in other countries where physicians are forced to play God and choose who will get scarce resources like a ventilator. Understandably, Canadian physicians will also feel incredibly stressed about that.
Steven: And that’s for certain. And indeed, you know, what we’re learning from the world’s experience every day, and the issues we face are so very fluid that it’s very difficult to keep up with what’s going on.
Yolanda: The issue of scarce resources is not new or unique to the COVID-19 situation, but the pandemic certainly makes it a screening issue now.
Steven: I do think, Yolanda that we can convey a reassuring message for our listeners and that’s that in the few legal cases that touched on the issue of scarcity of resources, we’ve actually seen the courts have an open mind.
Yolanda: That’s right. The courts have been willing to consider the resources available to physicians when assessing whether the standard of care was met.
Steven: The courts in Ontario, for example, have indicated that a doctor can’t reasonably be expected to provide care which is unavailable or impracticable, due to the scarcity of resources.
Yolanda: So that said, it’s not to say that it would be acceptable for us to throw up our arms in despair and say well, it’s a system problem. There’s nothing I can do about it. Within a resource constraint, a physician is still expected to do the best they can for patient and to act reasonably in each circumstance.
Steven: We need to be very clear here, right? Limited resources are not a defence to an allegation of negligence.
Yolanda: Well it may not be defence, but it is a factor in determining whether the care you provided was reasonable under the circumstances.
Steven: That’s right. And that gets to the essence of the first take-home message, Yolanda. The physician’s duty is to look out for the best interest of their patient.
Yolanda: But in a context, you do the best you can under the circumstances.
Steven: Right. The standard is not perfection. It’s reasonableness. And the underlying legal principles that guide how a potential legal action would be adjudicated, remains unchanged. Those are going to stay the same. It’s the application of these principles that will shift.
Yolanda: And we do need to remember that right now, we are in a global emergency health crisis. It is not business as usual. Context matters.
Steven: You know when emergencies are declared, be they by federal Emergencies Act, or provincial or local public health declarations, they may also include directives to provide guidance and legal authority to physicians who are following those orders in good faith, even that the practice might not be the same in non-emergency situations.
Yolanda: So let’s look at an example, Steven. Take a patient in need of a ventilator who presents to hospital A.
Yolanda: Unfortunately, the ICU is full, there are no beds and there are no ventilators available. So what do I do?
Steven: Well I guess based on what we just said, we could think that it might be deemed acceptable to not offer the required care. Well, but it’s not that simple.
Yolanda: You’re right. We do have to ask ourselves: What would a reasonable physician do under these circumstances? And in this case, it would be reasonable to look elsewhere.
Steven: So, look at transfer care to hospital B.
Yolanda: Right. Call around, advocate for your patient. Look for another service corridor.
Steven: And so if in fact, another hospital, say, hospital B, in a different city has available ventilators, perhaps acting as a reasonably competent physician would mean transferring care?
Yolanda: Exactly, Steven. But, let’s push the situation even further.
Yolanda: Now let’s say that all hospitals in the region are overwhelmed. Field hospitals that have been setup are overwhelmed and that no one has ventilators available. So seeking to transfer this patient is no longer feasible.
Steven: And it may no longer be what a reasonable physician would do. So the concept of reasonable care is contextual then.
Yolanda: You’re right, it is.
Steven: And therefore, I take it that taking note of the circumstances surrounding your decision-making is then very important, because what might justify an action in one context, might not otherwise justify it in another.
Yolanda: Absolutely. Look, in the context of a pandemic where clearly we keep seeing media reports about how scarce resources are, how limited options are. There’s no doubt, our patients and their families are well aware of the issue and might be understanding, but it still doesn’t mean that those hard conversations aren’t necessary.
Yolanda: Noting and documenting the difficult circumstances that play into our decision-making is critical.
Steven: It’s important to remind ourselves again, that the circumstances we’re dealing with here are those of a public health emergency.
Yolanda: Because of those risks involved and because of rationing of resources, we might be asked to do things we might never have considered otherwise. Take for example, being directed by a hospital directive to don personal protective equipment before providing CPR to a patient in a cardiac arrest.
Steven: Right. It seems so counterintuitive to not provide CPR right away. I mean, right now we’re going to have to stop and say no, no, wait a minute. I won’t provide lifesaving treatment like I’ve always done. First, I have to gown and mask and glove. I mean, that seems so counterintuitive.
Yolanda: And yet, in the context of a public health emergency, when we’re directed to do by either a directive or an order in the interest of public health, adapting that standard of care might be justifiable.
Steven: Well, that’s something to wrap our brain around, isn’t it?
Yolanda: It is. But, you know, we’ve seen provincial colleges state that they’re willing to be flexible and reasonable with potential complaints arising in the context of this pandemic.
Yolanda: And, I think the message here that’s being sent is that while it’s important to continue to offer the best care we can at all times, it’s also not time for dogma.
Steven: Now thankfully, we don’t have to make the difficult decisions we anticipate all by ourselves.
Yolanda: That’s right. Using an established ethical framework can be very helpful.
Steven: And will actually help ensure that decisions made are uniform between health care providers and based on sound principles.
Yolanda: In fact, in various jurisdictions there are frameworks under development right now, as we record this, that are based on principles of fairness and other ethical legal practical considerations. It won’t make difficult conversations any easier, that’s for sure. But, using an approved ethical framework can, maybe, bring us a bit of solace when we have to make a decision to treat someone over another.
Steven: That’s right. So, if your hospital doesn’t have one, it may be that another organization, be it a provincial one or a national one, might have one that your hospital can use. It’s also quite likely that your hospital will provide access to an ethics consultation. So, those are helpful tools that can actually help us make the tough decisions that we dread.
Yolanda: They’re helpful to promote consistent application of these sound ethical principles.
Steven: In the end, though, you know what? Despite the guidance that such frameworks can provide, it’s very likely that you’re going to find it hard to discuss what can and cannot be done with patients and their families.
Yolanda: Of course. There’s no amount of framework that’s going to make these discussions any easier.
Yolanda: We all hope not to have to get to the point to tell someone that they can’t access the care they would otherwise be able to if it weren’t for the pandemic. But if it does happen, the way we do so is really important.
Steven: Yeah. In the end, when all is said and done, perhaps people might forget what you said specifically, but they’ll remember how you made them feel.
Yolanda: That’s absolutely right, Steven. I have to say that even though we started out the podcast with two separate take-home messages. They’re actually, very intertwined, aren’t they?
Steven: You’re right. And that’s because typically, the patient’s best interests and the concept of reasonable care are very well-aligned. But you know what? When we’re pushed to the limit, like the pandemic, we may actually start to see these two concepts stray a little bit.
Yolanda: And when you simply cannot offer what is in the patient’s best interests, the notion of what is reasonable has to shift.
Steven: And we’re seeing that now in several provinces with directives to postpone elective care and non-essential services, for instance.
Yolanda: And that relates back to that ethical framework we referred to earlier, to help deal with limited resources aiming to protect the public overall. Let’s be clear, though, those frameworks aim to ensure that services aren’t pulled indiscriminately at any one person’s discretion.
Yolanda: Generally, we look to reallocate resources and make decisions about priorities in a fair and principled manner.
Steven: And so, while the very concept of having to choose who does and does not get access to, say, a ventilator, or the concept of having to delay a cancer surgery, may be hard to accept for physicians who want to provide the best care for their patients. But it may be reasonable to do so in order to comply with the hospital or provincial directive to restrict the use of services in anticipation of a surge in need related to the pandemic.
Yolanda: Yeah. I agree, Steven, but I think that offers little consolation to our listeners and the clinicians out there on the front lines.
Steven: And I agree with you there 100 per cent. We’re living in unprecedented times. Not in our lifetime have we had to face such an acute surge in the need to provide critical care services to patients. And the impact of the pandemic goes way beyond those patients infected with the novel coronavirus, right? It affects care across the board.
Yolanda: And while we understand that we may all, as physicians, be forced to make choices we would never have wanted to make, we do want you to know and remember that the CMPA is here to support you.
Steven: If you keep the best interests of your patients at heart and act reasonably in the circumstances you face on any given day.
Yolanda: That’s really all anyone can ask of you. Do your best under the circumstances.
Steven: Yolanda, I think we’re going to have to bring the podcast to an end here, but before we go, would you have a communication tip to offer our listeners?
Yolanda: I do. I mean, it’s a simple one: take the time. Take the time necessary to build a rapport with your patients, their families. Express empathy, and explain to them the context that you face together and the rationale for your treatment decisions.
Steven: We really can’t forget the human element here.
Yolanda: Absolutely. Steven, do you have a documentation tip for us?
Steven: Well, you know, I would have to say that it’s important to note your efforts to look for other options. If you call another hospital, write it down. If you’re acting under a hospital directive, write it down. If you don’t have the support staff you normally would and that affects your care, write it down. But you know what? Do it professionally, doing it factually. It’s not about judgment. It’s really just about taking note of the circumstances, the difficult circumstances that you’ll be facing at those times.
Yolanda: For sure. And Steven, if I might add: Take notes of those difficult conversations with the patients and their families where you outline the facts and the options available. The same rules about documentation we’ve always emphasized at the CMPA will continue to apply as usual and will serve you well in challenging circumstances like this.
Steven: That’s right. Well that’s all we had for today. Thanks for joining us. We hope this was helpful to you. You’ll find additional up-to-dated resources on the COVID-19 hub on our website. If you have any other questions, though, please contact us.
Yolanda: Please call us.
Steven: Our number is 1-800-267-6522. We’re here to provide you with support, clarity and guidance in these unprecedented times.
Yolanda: Take care, everyone.
Steven: And be well.
This podcast is for general educational purposes only, and is not intended to provide professional medical or legal advice, nor to constitute a standard of care for Canadian health care providers. If you’re a CMPA member and need medical-legal advice or assistance, please contact us at 1-800-267-6522.