college case studies · • case studies . college of physicians and surgeons of british columbia...

A health-care system purpose built for all patients—elusive pipe dream or emerging reality?

College Case Studies 2014 Education Day and Annual General Meeting

College of Physicians and Surgeons of British Columbia

Overview • Introductions

Panelists:

– Mr. William Clark

– Dr. Marjorie A. Docherty

– Ms. Susan Mehinagic

Presenter:

– Dr. Galt Wilson, Deputy Registrar

• Audience response – using your i-Clicker

• Case studies


Using your i-Clicker 1. Turn your i-Clicker on using the on/off button at the bottom of the panel; a

solid blue light indicates power is on.

2. Select your preferred answer using the corresponding buttons: A, B, C, D or E.

3. If your answer was received, the vote status light will be green; if your answer was not received, the vote status light will be red.

4. You can only register one answer per question.

5. Let’s do a trial run.

6. Please don’t forget to return your i-Clicker at the end of the session!


Trial Run The i-Clicker can also be used as:

A. An entry fob to the College offices.

B. A next generation multimedia smartphone.

C. A hand-held device to access my electronic medical records.

D. All of the above.

E. Absolutely nothing – I’ll leave it on the table following the session.


Format 1. Present scenario

2. Questions – first glance, ponder

3. Considerations – resources

4. Questions – i-Clickers

5. Results, panelist discussion and questions—move to microphones


WARNING

Uncertainty is an inevitable part of practising medicine.


We made them up… You don’t know these cases—they aren’t real.


Advocacy When someone you care about asks for help 1


Advocacy When someone you care about asks for help

Dr. Smith is a Vancouver-based anesthesiologist and intensivist, on the staff of a provincial teaching hospital for 30 years. His brother, a semi-retired lawyer from the BC interior, suffers multiple injuries in a car crash and is airlifted to the hospital where Dr. Smith works. Injuries include cerebral contusion, long bone fractures, and rib fractures with hemopneumothorax. Overwhelmed, Dr. Smith’s sister-in-law begs him to serve as the family contact with the critical care team—his colleagues. With trepidation, he agrees. Weeks pass, the injured man stabilizes, and it becomes clear that he has significant residual cognitive impairment. Care is challenging. The team decides that he will be repatriated to his community hospital. His family believes the transfer is premature. Dr. Smith is in the middle of some heated discussions. The unit is over capacity. Transfer is likely to occur on a holiday Monday. On the Friday night, the injured man shows subtle signs of developing delirium. Dr. Smith speaks to a series of nurses. No physician comes.



Dr. Smith maintains a vigil. His brother’s delirium worsens. He contacts the physician on-call for the unit, who dispatches a resident.

There is a difference of opinion that continues through the weekend—nursing and resident staff do not agree with Dr. Smith’s assessment.

Sunday afternoon Dr. Smith’s service chief calls on his cell phone. Dr. Smith’s behaviour has been characterized as “disruptive.” He is reminded of the departmental harassment policy and his obligation to abide by it. The tone is chilly. There is little apparent empathy.

Dr. Smith is a good friend of yours. He seeks your advice.



Dr. Smith is best advised to: A. Recruit someone else to serve as family spokesperson.

B. Advise his sister-in-law to invoke her right to a second opinion.

C. Track down the president of the medical staff, explain the situation, and insist that s/he intercede with the department head on Dr. Smith’s behalf.

D. Insist on speaking to the administrator on call and advise him/her that Dr. Smith and his sister-in-law need to meet urgently and will be bringing a lawyer.

E. Assist his sister-in-law in contacting Global News.

Question to ponder



CMPA

• Safety of care

• Improving patient safety and reducing risks

• The physician voice: when advocacy leads to change

• “Physicians can be effective advocates for [patients] by selecting appropriate strategies…”

CMA Code of Ethics

• Section 26: Respect your patient’s reasonable request for a second opinion from a physician of the patient’s choice.

CanMEDS Framework

• Health advocacy

Considerations



Dr. Smith is best advised to: A. Recruit someone else to serve as family spokesperson.

B. Advise his sister-in-law to invoke her right to a second opinion.

C. Track down the president of the medical staff, explain the situation, and insist that s/he intercede with the department head on Dr. Smith’s behalf.

D. Insist on speaking to the administrator on call and advise him/her that Dr. Smith and his sister-in-law need to meet urgently and will be bringing a lawyer.

E. Assist his sister-in-law in contacting Global News.

i-Clicker question


Service withdrawal When all else seems to have failed 2


Service withdrawal When all else seems to have failed

A group of four surgeons working together for many years at a busy general hospital have seen wait times for their division triple in two years. They believe there is work for six, but see no hope of recruitment without more access to OR time and in-patient beds.

They have raised the issue repeatedly at meetings of the department of surgery to a lukewarm reception. At their insistence, formal proposals for more resources have gone to the MAC and board. Invariably, the response is sympathetic, but unproductive.

A meeting of their monthly journal club morphs into an outpouring of frustration. They declare that enough is enough. Patients need their services. Lobbying via proper channels hasn’t worked. They decide to take definitive action to force the issue.


Members of the group may: A. Withdraw their services with 30-days notice, continuing to care for

current patients until no longer required and directing referring physicians and administrators to send new patients elsewhere.

B. Hire independent counsel and take legal action against the health authority.

C. Resign their hospital privileges with 30-days notice. D. Implement a partial withdrawal of services, maintaining care of current

patients and emergency coverage only. Referring physicians are directed to make other arrangements for patients deemed not to be at risk of suffering irreparable harm.

E. Write up a comprehensive job action plan and submit it to the College for approval.

Question to ponder Service withdrawal When all else seems to have failed


College standard Withdrawal of Physician Services • “The ultimate responsibility for any withdrawal rests with each individual

physician to act in the public interest and to ensure that his or her actions are consistent with [expected] ethical and professional standards…”

CPSA standard of practice Job Action • “A physician must not withdraw services with the direct or indirect

purpose of supporting job action for personal economic gain if such actions could put the immediate health of patients at significant risk.”

CMA Code of Ethics • Sections 1, 13, 19, 43, 44

Considerations Service withdrawal When all else seems to have failed


Members of the group may: A. Withdraw their services with 30-days notice, continuing to care for

current patients until no longer required and directing referring physicians and administrators to send new patients elsewhere.

B. Hire independent counsel and take legal action against the health authority.

C. Resign their hospital privileges with 30-days notice. D. Implement a partial withdrawal of services, maintaining care of current

patients and emergency coverage only. Referring physicians are directed to make other arrangements for patients deemed not to be at risk of suffering irreparable harm.

E. Write up a comprehensive job action plan and submit it to the College for approval.

i-Clicker question Service withdrawal When all else seems to have failed


Electronic media And the busy family physician 3


Electronic media—social or otherwise Powerful tools, unintended consequences

A child is evacuated by air to the provincial teaching hospital with extensive burns suffered in a house fire. Initial management included every challenging intervention in the burn manual—from securing the airway to fluid resuscitation. After many difficult hours, the child is stable and the trauma fellow in charge is physically and emotionally exhausted, but justifiably proud of the work of the team.

Before leaving the unit for some well-earned rest, the physician decides to take a photograph of the patient and send it to the service chief and a close senior resident colleague to mark the occasion. The senior resident senses a powerful learning opportunity and forwards the photo to all of the residents on the service, suggesting they stop by and review the record. The photo has now been circulated to 12 personal smart phones.

Later that day the 6 o’clock news identifies the patient.


It would have been better if the fellow had: A. Not sent the photo.

B. Obtained and documented the consent of the parents before sending the photo.

C. Been explicit about limiting the distribution of the photo by, for example, stating “do no forward” in the text message to which it was attached.

D. Printed the photograph and placed it on the chart, then sent a text to the other two physicians, encouraging them to view it at their earliest opportunity.

E. Sent the photo as an encrypted PDF file.

Question to ponder Electronic media—social or otherwise Powerful tools, unintended consequences


College guidelines • Data Stewardship Framework

– Key steps in responding to privacy breaches

• Video Recording (update pending)

– “…give the patient an oral explanation…and document consent”

July 26, 2013 email to all registrants from the College registrar – “…photographs of patients may only be taken for legitimate

purposes…and only with the informed consent of the patient.”

CMPA Using electronic communications, protecting privacy • “…using mobile devices to communicate increases the risk of privacy

breaches…”

Considerations Electronic media—social or otherwise Powerful tools, unintended consequences


It would have been better if the fellow had: A. Not sent the photo.

B. Obtained and documented the consent of the parents before sending the photo.

C. Been explicit about limiting the distribution of the photo by, for example, stating “do no forward” in the text message to which it was attached.

D. Printed the photograph and placed it on the chart, then sent a text to the other two physicians, encouraging them to view it at their earliest opportunity.

E. Sent the photo as an encrypted PDF file.

i-Clicker question Electronic media—social or otherwise Powerful tools, unintended consequences


Telemedicine Powerful tool or virtual walk-in clinic? 4


Telemedicine Powerful tool or virtual walk-in clinic?

For 40 years, Dr. McDonald was the only physician in a rural Alberta hamlet, 30 minutes to the nearest small city. When he relocated to the Okanagan to semi-retire and be nearer to grandchildren, there was no one willing to take over the practice. Regretfully, he was forced to leave his patients to find new physicians in the nearest small city.

Soon after settling into his new home, he received a letter from several of his former patients. They described two-week waits to get an appointment with their new physicians and hours spent in the ER if the problem was urgent. They enclosed an article from the local newspaper about the potential for telemedicine services to bring medical care to small communities. They asked Dr. McDonald to establish a telemedicine practice to supplement what was available in their region. They commented that the local physicians were so busy, they would surely welcome his assistance.


If Dr. McDonald decides to accommodate the request, he is expected to do all of the following except: A. Obtain full registration in BC.

B. Implement telemedicine technology and protocols that meet standards set by the College of Physicians and Surgeons of BC.

C. Obtain and use duplicate prescription pads issued in BC.

D. Obtain full registration in Alberta.

E. Arrange after-hours coverage for his telemedicine patients.

Question to ponder Telemedicine Powerful tool or virtual walk-in clinic?


College standard Telemedicine • “Physicians who are located in British Columbia must ensure they are

registered with this College…”

• “Ensure that both the physician-site and the patient-site are using appropriate technology that complies with legal requirements…”

• “[Do not] prescribe narcotic or other controlled medications to patients whom they have not personally examined…unless they are in direct communication with another licensed practitioner who has examined the patient.”

CPSA standard of practice Telemedicine • “[You must] hold an active and valid practice permit from this College…”

Considerations Telemedicine Powerful tool or virtual walk-in clinic?


College standard After-Hours Coverage • “The provision of ongoing medical care is not only the responsibility of

the family physician, but also of specialists and other focused-practice physicians…”

• “Physicians cannot exempt themselves from this professional responsibility by identifying the locations at which they work as, for example, urgent care centres or walk-in clinics.”

CMPA Medico-legal Handbook: Duty of Care • “In common law jurisdictions…coverage arrangements must be made

when the physician will not be available to continue to treat the patient.”



CMPA Telemedicine—challenges and obligations • “While the practice of telemedicine is regarded by many as beneficial

for patients—especially those in remote communities…, [jurisdictional] issues may complicate medico-legal matters for physicians, especially those who may not be aware of their obligations in these circumstances.”

• “As with any medical care, patients must receive adequate information about the benefits and risks of the proposed treatment so they may provide their informed consent.”

• “For the purposes of protection, the CMPA deems the location where care is provided to be the patient's location at the time of the telemedicine encounter. If the patient is located in Canada, CMPA members will generally be eligible for assistance…”



If Dr. McDonald decides to accommodate the request, he is expected to do all of the following except: A. Obtain full registration in BC.

B. Implement telemedicine technology and protocols that meet standards set by the College of Physicians and Surgeons of BC.

C. Obtain and use duplicate prescription pads issued in BC.

D. Obtain full registration in Alberta.

E. Arrange after-hours coverage for his telemedicine patients.

i-Clicker question Telemedicine Powerful tool or virtual walk-in clinic?


Disclosure when things go wrong A safety and quality obligation 5


Disclosure when things go wrong A safety and quality obligation

Dr. Harper has just started a two-month locum in a busy, solo family practice. On her third day in the office, she receives a mammography report. It references an abnormality present in the study done a year before and requests information about the result of a biopsy. Dr. Harper finds the earlier report and notes the recommendation for a biopsy. It is a paper copy. There is nothing to document that it had been read. She reviews patient contact notes and her heart sinks as she reads that the patient had called to inquire a year before and been advised that the report had not yet been received. There was no record of any contact since. The report had been filed and no action taken.

The patient, Karen Jones, is 53 years old. Her mother had breast cancer at 57. Karen is familiar with the BC Cancer Agency guideline advising that she have yearly mammograms. She has had three biopsies—all with benign results. Given that history and the general lumpiness of her breasts, she attends her physician for an annual physical examination and is given a requisition for a diagnostic mammogram.


Dr. Harper should: A. Direct staff to call the patient immediately for a clinical examination,

but say nothing about the error. B. Direct staff to call the patient immediately, explain that she ought to

have been contacted the year before, and arrange an urgent visit for a clinical examination and referral.

C. Direct staff to call the patient and arrange for her to come in when her regular physician returns in eight weeks.

D. Direct staff to call the patient to arrange an appointment when she wants to come in, advising that the physician she sees (either Dr. Harper or the usual physician, depending on when she comes) will explain what it’s about.

E. Call the patient herself.

Question to ponder Disclosure when things go wrong A safety and quality obligation


College standard Disclosure of Adverse or Harmful Events • “… physicians have an ethical and professional obligation to disclose

information about adverse or harmful events to their patients.”

• “… the first priority after an adverse event should remain the provision of appropriate clinical care.”

• “Disclosure is usually the responsibility of the most responsible physician; however the involvement of multiple physicians… may require that a decision be made as to who is the most appropriate individual to speak to the patient.”

Considerations Disclosure when things go wrong A safety and quality obligation


Dr. Harper should: A. Direct staff to call the patient immediately for a clinical examination,

but say nothing about the error. B. Direct staff to call the patient immediately, explain that she ought to

have been contacted the year before, and arrange an urgent visit for a clinical examination and referral.

C. Direct staff to call the patient and arrange for her to come in when her regular physician returns in eight weeks.

D. Direct staff to call the patient to arrange an appointment when she wants to come in, advising that the physician she sees (either Dr. Harper or the usual physician, depending on when she comes) will explain what it’s about.

E. Call the patient herself.

i-Clicker question Disclosure when things go wrong A safety and quality obligation

college case studies · • case studies . college of physicians and surgeons of british columbia...

Documents