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Quick answers

Questions from our physician members

Teams

How much judgment can a resident use when faced with conflicting instructions?
Background
I am a PGY4. The attending physician has told me to discharge one of our patients. The nursing director, however, has told me he believes the patient is not yet ready for discharge. He wants me to contact the attending physician. I know the physician will be upset and tell me to use my judgment.

Answer
In situations like this it is not uncommon to feel caught in the middle. As a PGY4, you may have the knowledge to evaluate the basis for the nurse's concerns, and you can assess the patient and evaluate the validity of those concerns. Then you can decide whether the discharge is or is not appropriate, and considering the information given by the nurse, whether the follow-up and discharge instructions need to be modified. However, when uncertain, you should consult with the attending physician.

Always act in the interests of safe care for your patient, and follow the policies of your facility and program. You can then decide whether to carry on with the discharge, cancel it, or consult further with the attending physician. It is important that you document the basis for any decision.

When should a resident ask the supervising physician for help in treating patients?
Background
My supervisor refuses to see my patients because she believes I am fully capable on my own, despite my effort to ask her for help when I feel I lack the skill. I could ask other more experienced colleagues for assistance, but that might jeopardize my relationship with my supervisor.

Answer
In circumstances like this, you can review the situation and consider whether you have the knowledge and skill to manage the patient without the supervisor. If you lack those, then you can explain your limitations to the supervisor. If you have made your concerns known and explained the medical basis for your desire for support, and the supervisor does not respond, you may need to get assistance from a more experienced colleague - a resident, or perhaps another consultant, or address the issue with the program director.

Telephone consultations with supervising physicians are routine in training programs. The supervising physician must determine whether to attend the patient personally based on the information received by telephone and knowledge of the resident's ability.

Your ultimate goal is good, safe care for the patient. Your obligation as a doctor is to take whatever steps you must to achieve that goal, even if it might alienate your supervisor. It is vital that you carefully document what you've done - stating the facts, the information given to each person, the response and advice received, and the rationale for your course of action.

Can I be held liable for harm caused by a trainee's negligence?
Background
One of my residents calls frequently and seems reluctant to follow the treatment I have outlined for a patient. I'm concerned I may be sued if something goes wrong and the patient is harmed.

Answer
Your role as the trainee's supervisor includes assisting the resident to develop a process of making sound, independent decisions, in keeping with greater autonomy provided with increased levels of training. Nevertheless, you both have a primary responsibility to the patient. In situations where the resident is reluctant to follow your approach to treatment, it would be worthwhile asking the resident why they disagree and to discuss your decision and explore treatment alternatives.

You could be held liable for any harm caused by a trainee's negligence if you inappropriately delegate a task or do not properly supervise the trainee. Therefore, it is important to consider if the resident has the required skill, knowledge and experience to perform the task and what level of supervision they require. In the event of litigation, you would be held to a standard of care that could be reasonably expected of a normal prudent physician in similar circumstances, and the resident will be held to a standard appropriate to their level of training.

If the resident takes actions without first discussing them with you, or contrary to the treatment program you have recommended, then it will be important for you to document, in a neutral manner, the steps you have taken to monitor and correct the situation. In some cases you may want to seek advice from the program director.


Communication

What should I do if a patient verbally abuses me or my staff?
Background
A patient shouted at my staff. The staff members are understandably upset but I'm not sure what I can do.

Answer
The basis for a good doctor-patient relationship is mutual respect and understanding. However, neither you nor your staff is obliged to endure abusive behaviour. A clear policy can prevent unwanted behaviour from patients or staff.

It is important to understand the facts. Take steps to defuse the situation and determine the patient's reasons for the bad behaviour. Initially, patients should typically be verbally cautioned about the inappropriate behaviour. If the behaviour persists, consider cautioning the patient in writing and indicating consequences such as dismissal from your practice.

If the abusive behaviour continues you may be obliged to terminate the doctor-patient relationship in accordance with the guidelines of the medical regulatory authority (College) in your province or territory. Precipitous discharge of a patient may lead to a complaint of abandonment.

It is wise to document your discussions and retain any related correspondence.

What are my reporting obligations concerning a patient's condition?
Background
I assessed a patient in the emergency department the other day. It is our practice to send a copy of the emergency record to the family physician. I made a diagnosis of a sexually transmitted disease and gave the patient appropriate treatment. I also filled out the reporting form for public health. When I was doing that, the patient told me that he did not want me to inform his doctor about the condition. I wasn't sure how to respond, but I told him I had to make a report because this is the standard of care.

Answer
The group of healthcare providers responsible for providing care to a patient is informally referred to as the circle of care and this would normally include a patient's family physician.

Assuming the patient's implied consent, sharing of information with the family physician is desirable and usual. Patients can, however, place limits and conditions on who can access and share their information, even within the circle of care. They can amend or withdraw consent at any time or any number of times, as permitted by the consent provisions of privacy legislation. You might want to explain to the patient the benefits of sharing the information.

In situations where reporting to public health agencies is legally required, it must be reported even without the patient's consent. This mandatory reporting duty would need to be disclosed to the patient. The discussion with the patient should be documented in the medical record.

What are my obligations for protecting patient information stored on portable electronic devices?
Background
I keep patient data on my tablet computer, and when I sign out for the night or weekend I send this data by email to the covering physician. When I'm on, they do the same. That means we are up-to-date on all the patients, without having to meet personally. I wonder whether this is a reasonable thing to do as I'm concerned about what might happen if someone loses their tablet.

Answer
Patient handovers are best done face to face, allowing information to be discussed and clarified by the receiving physician. The use of email to transmit patient data and identifiers may be problematic. If the email is not encrypted there is a risk of a privacy breach.

If an electronic device (such as tablet, laptop, smartphone, or USB memory device) containing confidential patient information is lost or stolen, determine what type of information was lost, whether it is password protected or encrypted, and, if possible, the number of patients affected and their names.

If the information is not encrypted it may be necessary to notify affected patients. You are advised to contact the CMPA as soon as possible for advice.

In some jurisdictions encryption of personal health information on mobile devices is mandatory. If the lost device is not encrypted this could lead to a complaint to the privacy commissioner or the medical regulatory authority (College) or to litigation.

Do I have to tell police about a patient who is using illegal drugs or diverting prescribed drugs?
Answer
No. Physicians have neither an ethical nor statutory duty to report a patient's use of illegal drugs or diversion of prescribed medications, but do have an obligation to protect patient confidentiality.

If the source of the information is a third party you may wish to discuss the issue with the patient (if you feel safe doing so). This enables you to hear the patient's side of the story and to determine if the trust necessary for an ongoing doctor-patient relationship is still intact. If you believe this to be part of a drug dependency problem, manage it accordingly and continue to provide the patient with sound medical advice. You may wish to consult with others within the circle of care, as long as there is no express direction from the patient to the contrary.

If you know your patient is diverting the drugs you prescribe, you should re-evaluate the indications for those drugs and establish rules (including, for example, using a narcotic contract) for any further prescriptions. If the patient is persistently exploitive, uncooperative and non-adherent, consider terminating the doctor-patient relationship in compliance with medical regulatory authority (College) guidelines.

Must I comply with a police demand that I take a blood alcohol level on a suspected drunk driver?
Answer
While the Criminal Code of Canada allows for the taking of blood samples in certain situations, a patient cannot be compelled to give a blood sample.

You can obtain a blood sample with the patient's consent. That consent must be voluntary and informed, and can be given only by a patient with the capacity to understand the risks and potential consequences of their decision.

A blood sample may be taken to comply with a warrant or court order even when there is no patient consent. Before doing so, you must be of the opinion that the person is unable to consent to giving a blood sample and that the procedure would not endanger the person's life or health.

You may decide to order a blood alcohol level for medical reasons. The results cannot be released to the police without the patient's consent or a court order, as this would be considered a breach of confidentiality.

What should I do if a patient does not take my advice?
Answer
A patient has the right to reject your advice, and may choose to see a different healthcare provider. Sometimes a second doctor's opinion will reinforce yours and satisfy the patient. An isolated occurrence of non-adherence does not usually warrant discharging a patient from your practice.

There may be serious health consequences when patients do not follow your advice regarding their condition. Consequently, you should strive to help the patient to understand the risks, benefits, and reasonable alternatives to your recommended treatment. It may be necessary to discuss the importance of the recommended treatment more than once. It is always important to document these discussions in the patient's record.

If there is a loss of trust in the doctor-patient relationship and this is affecting patient care, it is appropriate to consider discharging the patient. Prior to doing so you should review the medical regulatory authority (College) guidelines in your province or territory.

What are "discharge instructions" in the context of an office practice?
Background
My office practice was recently reviewed. The reviewer said that my discharge instructions were inadequate. Since my practice is strictly office based, what does she mean by "discharge instructions"?

Answer
Patients should be instructed about how to recognize and react appropriately to symptoms and signs that would alert them to seek additional medical attention after leaving your office. This advice is known as "informed discharge."

"Discharge instructions" may include a prescription, recommendation for follow-up or investigations, advice about possible reasons to return, potential adverse effects, and the importance of following through with treatments and recommendations.

If the patient calls with a question later, good notes in the patient's medical record will help your office staff to refresh the patient's memory. Good notes also enable a subsequent physician to have the information necessary to provide appropriate follow-up. It may be helpful to review a document outlining discharge instructions before the patient leaves the office. Meanwhile, the document should not replace a discussion with the patient or the patient's representative.

What are my reporting obligations if I learn that a child patient is engaged in sexual activity?
Background
My 14-year-old patient is having sexual relations with her 21-year-old boyfriend. Do I have to report this to the police?

Answer
According to the Criminal Code of Canada, when a 14-year-old engages in consensual sexual relations with a 21-year-old, this would be considered a criminal offence.

Physicians are not obliged to report criminal sexual offences to the police. If the patient is a mature minor (i.e. able to consent for treatment), her consent is required for release of information to the police or her parents.

Every province and territory has legislation that imposes a duty on physicians to report to a child protection agency if there are reasonable grounds to believe that a child (under 16 to19 years of age, depending on the jurisdiction) is in need of protection due to sexual abuse or exploitation. Physicians should consider whether there are reasons to believe that the child is in need of protection, based on the sexual relationship and other factors such as social and family issues.

Some other points to consider from Section 150.1 of the Criminal Code:

  • The age of consent for non-exploitive sexual activity is 16 years.
  • A 14- or 15-year-old may consent to sexual activity with a person no more than 5 years older.
  • A 12- or 13-year-old may consent to sexual activity with a person no more than 2 years older.
  • Children younger than 12 years of age cannot consent to sexual activity with anyone.
  • The age of consent for exploitive sexual activity (e.g. prostitution) is 18 years.

If in doubt, you are encouraged to contact the CMPA for advice.

How do I tell patients about the risks of medications without scaring them into non-adherence?
Answer
Physicians are obliged to provide their patients with information that a reasonable individual in similar circumstances would want to know in order to make a decision about a proposed treatment. Based on this information and any subsequent discussions, the patient can then provide informed consent.

The information concerning a proposed treatment or management plan should generally include:

  • the diagnosis or differential diagnosis
  • the nature of the proposed treatment
  • the benefits and potential side-effects
  • reasonable alternatives to the treatment, including no treatment
  • material risks that a reasonable person in the patient's position would likely attach significance to
  • rare risks of a serious nature (such as death or paralysis)
  • special risks to which the particular patient might be prone, such as when there is a pre-existing condition

The discussion with the patient should be done using plain language, avoiding the use of jargon. Physicians have a duty to take reasonable steps to reasonably satisfy themselves that the patient understands the information provided, and to answer the patient's questions.

The consent discussion and signed consent form (if applicable) should be documented in the medical record. If an adverse outcome occurs and an allegation is made that you did not tell the patient about a particular risk or side effect, a well-documented consent discussion is important to help defend such a claim.


Managing risk

Who is supposed to follow up on tests ordered in the ER?
Answer
Physicians are responsible to follow up on tests they have ordered. The ordering physician should be satisfied there is a procedure in place at the hospital that ensures the test result will be seen and acted on.

Before leaving your shift you might want to inform your replacement of pending tests and the reasons for them. If the results (such as outpatient imaging) are not expected for some time, consider making arrangements for a physician to see and act on the results and instruct the patient on how to follow up.

What should I do if a patient cannot be reached for follow up?
Answer
Physicians have a professional obligation to follow up on all investigations they order and must exercise due diligence when contacting patients with the results. It is advisable to update the patient's contact information frequently to ensure it is accurate and up-to-date. Confidentiality issues should be addressed.

The number of attempts to contact the patient depends on clinical circumstances. For example, marked hyperkalemia need emergent follow up and treatment, whereas mild hyponatremia may be of a less urgent nature. If the patient cannot be reached by phone, alternatives should be considered for finding them, such as mail, wireless communication, or contacting a relative, friend, or the patient's employer. If the matter is potentially life threatening, social services or the police may be able to assist.

To preserve confidentiality, the message needs to be clear on the need and mechanism for follow-up, but exclude specific medical details.

If an adverse outcome occurs, an allegation may sometimes be made that the physician did not do enough to ensure follow up. Good documentation in the medical record can demonstrate that you made reasonable efforts to contact the patient.


Adverse events

Should I offer my opinion to patients about the care provided by other physicians?
Background
Patients sometimes ask me to comment about the care provided by other physicians, but I'm uncertain how I should respond.

Answer
Many unjustified complaints or legal actions start with misunderstandings based on comments from people who know only part of the story.

Patients are not served well by incomplete information and speculation. Don't rush to judgment and accusations. Prior to commenting on the care provided by others, consider if you know enough of the facts to offer a viewpoint on whether the care was reasonable at the time. Even with those facts in hand, remember to keep an open mind and realize that there is often more than one way to manage a medical condition.

A respectful conversation with the treating physician may clarify the situation. In most instances, the original treating physician should be the one to discuss the quality of their care directly with the patient and disclose any adverse events. Sometimes, you may need to turn to your healthcare organization for assistance.

Do I have to tell patients when something has gone wrong?
Answer
Physicians have an ethical, professional, and legal obligation to disclose any adverse event. Even in the absence of harm, such as a "near miss," there may sometimes be an obligation to tell the patient.

If the patient were to learn of the incident from someone other than you, it could cause further distress and irreparably harm your doctor-patient relationship.

Disclosure discussions should be documented in the medical record, and the information disclosed should be shared with the entire care team. In some cases, there may be a duty to report an adverse event or near miss.

When there are several physicians involved, who should disclose an adverse event?
Background
An X-ray report on one of my patients shows an unexpected finding. I call the patient in and tell him about it, and re-examine him. I find nothing abnormal and contact the radiologist. The radiologist tells me there is no abnormality, but a junior resident had read the X-ray and the radiologist had not reviewed it before the report was sent out. My patient suffers some anxiety as a result of my phone call. I consider this an adverse event. Who should be disclosing it to the patient: me, the radiologist, or the radiology resident?

Answer
In situations such as this, the family physician will often initiate the disclosure discussion on the basis of an established relationship with the patient. If there are unanswered questions, the radiologist may need to be involved in subsequent meetings. Trainees are encouraged to attend disclosure discussions, but typically would not lead them.

A disclosure discussion should occur as soon as possible after the adverse event is recognized. The physician who is responsible for contacting the patient should be determined promptly.


Professionalism

May I provide treatment or prescribe to family members?
Background
My daughter is ill with what appears to be strep throat. I want to prescribe antibiotics for her.

Answer
In a situation like this, the emotional bond of the parent-child relationship might interfere with sound medical judgment — perhaps unconsciously. For this reason, physicians should generally not provide medical care for immediate family members.

The CMA Code of Ethics states, "Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available; there should be no fee for such treatment." Treating family members, even episodically, is problematic because:

  • it is difficult to be objective
  • care often becomes fragmented (for example, between you and the patient's family doctor)
  • maintaining confidentiality of information can be difficult
  • record keeping is usually inadequate
  • the precedent may create expectations of providing care for other family members
Familiarize yourself with your medical regulatory authority's (College's) policy on treating family members before making your decision. You can avoid uncomfortable situations by clearly communicating that you have a policy of not providing medical care for family members, but that you may refer them to another physician.
What issues should I consider when treating another physician?
Background
One of the physicians in my community has asked me to take her on as a patient, but I'm uncertain whether I should accept.

Answer
It is not uncommon for doctors treating doctors to make false assumptions, such as:
  • physician-patients know about risks and benefits, so the consent discussion can be abbreviated or eliminated
  • physician-patients can manage their own care
  • physician-patients will recognize complications and appropriately refer themselves
  • physician-patients share your knowledge level about diseases
  • fewer, or more, referrals and investigations are required than for other patients
  • you can leave out some information in the medical record to protect professional confidence
  • medical records are not always necessary

It is recommended to treat physician-patients as any other patient. Depending on the closeness of your acquaintance or friendship with the physician, it may be necessary to be even more vigilant about boundary issues than usual.

You may have an ethical or legal duty to report a physician's health status (e.g. mental or physical incapacity or infectious diseases), or behaviour (e.g. sexual impropriety with a patient). Familiarize yourself with your medical regulatory authority's (College's) policy on mandatory reporting obligations of physician colleagues.

Is there an obligation to report a resident who drove while intoxicated?
Background
I was at a party the other night. A resident on another service was obviously intoxicated. At the end of the evening, he decided to drive himself home despite the pleading of his friends to let them drive him. This left me wondering what I should do.

Answer
There is no legal obligation to make a report to the police or the residency program director. However, if you were concerned that the resident posed a safety risk to himself or other people on the road, you could have called a taxi or physically intervene. Since you didn't know if this episode was an isolated incident, you were not in a position to assess if the resident's drinking habits are affecting his ability to perform his medical duties. As you cannot say that there is a patient safety issue, a report to the resident's program director may not be appropriate.

Depending on your professional relationship with the resident, you may decide to have an informal discussion with him about the event and explore his drinking habits and the potential risk for harm. You could offer support and suggest available resources to assist him in making a change.

Do I have to report a doctor who is intoxicated?
Answer
A single episode of impairment in a non-clinical situation that does not impose an immediate threat to patient safety probably does not warrant you making a report. Initially, you could express your concern directly to the physician. However, if you believe that patients are at risk, you should take immediate steps to protect them by notifying the physician's supervisor (e.g. department head).

In serious situations where patients may be at risk, you may want to consider whether you have an ethical or legal obligation to report your colleague to a medical regulatory authority (College) or the healthcare institution. You may want to review the College policy on your reporting obligations in your province/territory and contact the CMPA for advice.

Making a report about another physician may have serious professional consequences for both physicians. It can also be stressful. It is important that you document your rationale for making a report and the steps taken. This document should be retained in a secure manner.

Sometimes a physician's consumption habits, for example of alcohol, can be a manifestation of a more serious mental health condition. This may require a personal discussion and an intervention by the doctor's treating physician, or referral to a physician health program.

How should I respond to requests for medical advice during social events?
Background
I am frequently asked for medical advice at parties and other social events, but I'm uncertain as to how I should respond.

Answer
In these social situations, you are unlikely to be given enough medical information to be able to provide professional advice to the individual. A physician who provides advice may owe a duty to provide that advice so that it meets the relevant standard of care.

You could politely explain to the individual that you are unable to provide medical advice in such a circumstance, and outline the importance of seeking care from the treating family physician or specialist who would have access to the their medical history. It may be helpful to explain the ethical and legal reasons why this is the best course of action. In situations where the individual's symptoms appear severe, early referral to an emergency department or clinic may be appropriate. In an urgent situation, you would be acting as a good Samaritan and undertake what is reasonable given the circumstances.

How should I communicate that I do not prescribe opioids in my clinic?
Background
My patient is insistent that I prescribe narcotics for him. Can I post a sign indicating I do not prescribe opioids in my clinic?

Answer
Medical regulatory authorities (Colleges) have policies and clinical practice guidelines for opioid prescribing, and clearly state that patients who suffer from chronic pain may not be refused into one's practice on that basis. Physicians who are uncomfortable caring for patients with chronic pain should seek out appropriate resources to assist in providing care. Physicians who feel unqualified to treat a particular patient may consider referring the person to another physician.

Posting a sign in your office stating you do not prescribe opioids might be interpreted as denying some patients necessary pain relief. You should consider the appropriateness of prescribing opioids for non-malignant pain on a case by case basis while ensuring compliance with your College's guidelines. You are under no obligation to provide investigations or treatment you feel are inappropriate for a patient's condition.

If you do prescribe opioids, it is prudent to communicate with other providers within the circle of care and to be vigilant for suspicious usage patterns, drug seeking behaviours, and missing prescription pads in your office. Any of these could be indications of prescription fraud.

Diligent documentation of the indications for treatment and the consent discussion is important to defend against potential medical-legal difficulties related to opioid prescribing.

May I intervene in the treatment of family members, and if so, should their physician be notified?
Background
My mother suffers from high blood pressure. Her home blood pressure monitoring shows no improvement on the medications prescribed by her doctor. I think her medications should be changed to something more potent, but I'm not sure if I should notify her doctor first.

Answer
In a situation such as this, it would be advisable that you provide your mother's doctor with your observations and discuss treatment recommendations.

Most medical regulatory authorities (Colleges) have policies that advise physicians against treating or prescribing for family members, except for minor conditions or in emergent circumstances. The CMA Code of Ethics states, "Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available."

Physicians contemplating providing treatment to a family member or friend should consider whether the personal relationship might affect their ability to provide appropriate care. If so, it would be prudent to refer the person to another physician. If you choose to provide treatment, both the care and the reasons for providing it should be documented.