serving the public through excellence college quarterly either poor or rapid metabolizers of codeine...

2 Message from the registrar

3 Communication sound bites

4 Announcements and events

8 Quality assurance

9 Committee cases and recommendations

10 A word from the College library

11 Disciplinary actions

In this issue:

JUNE 2012 | ISSUE 76

COLLEGE OF PHYSICIANS AND SURGEONS OF BRITISH COLUMBIA

QuarterlyCollege

Serving the public through excellence

and professionalism in medical practice

Enclosed with this issue of the College Quarterly:

• AprogramandregistrationformfortheCollege’s2012 Education Day

•TheCollegelibrary’sCites & Bytes

www.cpsbc.caThe College Quarterly is sent to every current registrant of the College. Decisions of the College on matters of standards, policies and guidelines are contained in this publication. The College therefore assumes that each registrant is aware of these matters.

2 COLLEGE QUARTERLY JUNE 2012 www.cpsbc.ca

Message from the Registrar

Requirements for Continuing Professional Development (CPD)As you are aware, as a first step in revalidation of licensure, all physicians in British Columbia must participate in meaningful, verifiable and audited continuing professional development. Like most professionals, physicians have an obligation to maintain and improve skills over their professional career. For this College, continuing professional development (CPD) has been a mandatory requirement for renewal of licensure since January 1, 2010 and this is evolving to be a national standard for all physicians across Canada.

Some question the validity or reliability of CPD compliance as a surrogateforcompetency.Thereisnodoubtthat,inandofitself,continuing professional development does not guarantee ongoing competency.Thereverseistrue,however.TheCollegedoesidentifyphysicians who have been the subject of a complaint who have simply failed to stay current as medical knowledge has evolved.

Modern regulation of the medical profession dictates transparency and accountability. For CPD to be accountable, physicians are asked to manage their CPD though enrollment in and compliance with the requirements of either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. We defer to these expert certification bodies as providing a framework for verifiable CPD activities.

Todate,theCollegehasexperiencedahighlevelofcompliancewiththis mandatory requirement. Registrants may make a request to the registrar to be exempt from this requirement and so far, the most commonly approved request for an exemption to CPD requirements has been for physicians who provide surgical assists only. In exchange for this exemption, physicians are required to sign an undertaking stating that they will limit their professional activities to surgical assisting only, and they do not have the authority to prescribe or write pre- or post-operative orders.

More recently, the College has received exemption requests from physicians whose professional activities include a very narrow scope of practice, such as the provision of medical legal reports or teaching medicalstudentsonly.Theyhavearguedthatitisredundantforthemto participate in life-long learning given that their limited scope of professional activities does not include direct patient care.

But of course this is folly. Even medical administrators, including myself, have an obligation to keep up with the medical regulatory literature; attend workshops related to licensure, regulation and quality assurance; and participate in meaningful professional development opportunities.

Following careful consideration at the Board, and with the benefit of Dr.Cochrane’sinsightfulreportthatsoaptlyidentifiedtheneedforimproved quality assurance processes in the health-care system more generally, the College directed that exemptions to CPD requirements belimitedtophysicianswhodosurgicalassistingonly.Thebottomline is this—if you need a licence to provide your professional service, you need to be engaged in CPD.

Heidi M. Oetter, MDRegistrar

www.cpsbc.ca COLLEGE QUARTERLY JUNE 2012 3

Currency of clinical practice Important changes in requirements for physicians to demonstrate their currency of clinical practice came about with the transition from the Medical Practitioners Act (MPA) to the Health Professions Act (HPA) in June 2009. Section 2-8 of the Bylaws under the Health Professions Act, RSBC 1996, c.183 requires that registrants who are absent from clinical practice for a consecutive period of three years, or who have practised less than eight weeks a year (320 hours) in the preceding three years, must notify the registrar in writing before returning to practice. Similarly, a registrant who wishes to change the focus of his/her clinical practice to an area in which the registrant has not practised for a consecutive period of three years or more, or who has practised less than eight weeks a year in that area in the preceding three years, must notify the registrar in writing prior to changing the focus of his or her clinical practice.

ExAMPLE 1: A physician who has been granted registration for general/family practice but who would like to change the focus of his/her clinical practice to “surgical assists” or “cosmetic medicine” only, and has who not practised in this area for a consecutive period of three years or more, or less than eight weeks a year, must notify the registrar in writing.

ExAMPLE 2: A general/family physician whose practice has been confined to “surgical assists” or “cosmetic medicine” only and wants to return to general/family practice but has not practised in this area for a consecutive period of three years or more, or less than eight weeks a year, must notify the registrar in writing and may not return to general/family practice without permission from the registrar.

ExAMPLE 3: A female physician wishes to return to her specialty practice after having a three-year absence for maternity and child rearing.Thisphysicianmustnotifytheregistrarinwritingandmaybe required to complete additional training or a preceptorship before returning to clinical practice.

Registrants are urged to become familiar with section 2-8 of the Bylaws when planning a long-term clinical practice absence or a narrowing of their scope of practice. All of the College Bylaws can be found on the website at www.cpsbc.ca>About the College>Health Professions Act.

Communication Sound Bites

Food allergy / food intolerance testingTheCollegereceivedaprecautionaryletterfromagroupofimmunologists regarding the office testing for food allergies or intolerances that is being promoted to physicians by a number of companiesintheUnitedStatesandCanada.Theessenceoftheconcern raised is that these tests measure IgG antibodies to food proteins.TheproductionofIgGantibodiestofoodproteinsisconsideredanormalphysiologicalprocess.Theseantibodiesarenotconsidered pathological and there is no scientific evidence linking them toanydisease.Thesetestshavealsobeeninappropriatelypromotedfor the management of numerous other conditions, including autism, attention deficit hyperactivity disorder, eczema and asthma, to name a few.

Physicians should be aware that these tests are not approved by Health Canada or the US Food and Drug Administration. Moreover, as experience with naturopathic and alternative practitioners utilizing these tests has shown, the cost to patients can range from hundreds to thousands of dollars. Furthermore, the result of these tests may lead to inappropriate restrictive diets as well as patients being delayed or not receiving appropriate investigation and treatment for their condition. More importantly, these tests cannot determine if an individual is at risk for anaphylaxis from a food.

Precautions for codeine use in childrenThehealthauthoritiesrecentlyreleasedajointstatementwarningphysicians of the risks of codeine analgesia, especially in the pediatric population.Thestatementwarnsthatasignificantnumberofpeopleare either poor or rapid metabolizers of codeine to morphine due to genetic differences in metabolism. While slow metabolizers may find a lack of analgesic benefit, rapid metabolizers may encounter serious narcotization events including reported pediatric death.

For more information about the statement, please contact:

TerriBetts,BScPharm,[email protected]


Announcements and Events

Intraocular lens supply managed through health authoritiesAs was previously reported in the March 2012 issue of the College Quarterly, the Ministry of Health has implemented a standardized process for purchasing and managing the supply of intraocular lenses for elective cataract procedures throughout the province basedonbulkbuyingpowerofBC’ssixhealthauthorities.Theministryhasalsoannouncedthat,effectiveJune4,2012,itwillofferfoldable monofocal intraocular lenses free of charge to all patients. Patients who choose specialty lenses will only have to pay the cost difference between the price of the lenses they choose and the foldablemonofocallens.Thehealthauthoritieshaveensuredthattheappropriate safeguards are in place to purchase and stock adequate quantities of lenses on-site at hospitals, and that specialty lenses and new technologies are available to patients who elect to purchase non-insured services.

2012 bugs and drugs antimicrobial reference guide – available this fallCollege registrants are eligible to receive a complimentary copy of the updated Bugs & Drugs Antimicrobial Reference Guide as either an iPhone application or as a printed booklet. Copies of the guide can be ordered online at http://app.fluidsurveys.com/s/bugsanddrugs/. Funding for this initiative is provided by the BC Ministry of Health, Pharmaceutical Services Division.

College announces recipients of the 2012 Award of Excellence in Medical PracticeThe Board of the College of Physicians and Surgeons of British Columbia is pleased to announce the recipients of the 2012 Award of Excellence in Medical Practice. The recipients were presented with their awards at the annual President’s Dinner in Vancouver on May 30, 2012.

Clive P. Duncan, MBBCh, MSc, FRCSC – Vancouver, BCDr. Duncan is a medical graduate of Dublin University (1968). After two years of postgraduate training in orthopedics in the United Kingdom, he moved to Canada as a resident and joined the department of orthopedics at the University of British Columbia in 1977. He served as professor and department head of orthopedics at the University of British Columbia, and department head of orthopedics at Vancouver General and University Hospitals from 1996 to2006.Thefocusofhisclinicalinteresthasbeenthedevelopmentand evaluation of complex surgical techniques for the management of major joints damaged by injury, infection and disease, especially the hip. He has an international reputation as a surgeon, teacher and investigator. Dr. Duncan has published more than 200 scholarly works in peer-reviewed journals and textbooks, and has been credited with a number of innovative surgical solutions. He was one of the principal applicants in the recently successful application for Canadian FoundationforInnovation(CFI)fundstoestablishtheworld’sfirstCentre for Hip Health in Vancouver, an enterprise now destined to become a $26 million VCHRI/UBC enterprise located at the Vancouver General Hospital site.

Gary C. Jackson, MD, FRCSC, FACOG – White Rock, BCDr. Jackson obtained his medical degree from the University of British Columbia in 1979, and completed his residency training in obstetricsandgynecologyin1984.Sincethattime,Dr.Jacksonhasbeen involved in medical leadership serving as chief of staff, medical director and department head of his specialty at Peace Arch Hospital. As a former high-school teacher, he has a natural gift for sharing his knowledge and experience with others, and has served as a mentor to many students, residents and colleagues who have had the privilege of working beside him. His involvement with health-care development and promotion crosses national and international borders. He served as secretary-treasurer and is now head of the Ob/Gyn section of the British Columbia Medical Association (BCMA), and has played a key role in advocating for public cord blood banking, continuing to sit as co-chairoftheBCCordBloodTaskGroup.


Gordon R. McFadden, MD, CCFP – Coquitlam, BCDr. McFadden obtained his medical degree from the University of British Columbia in 1969. After internship at Vancouver General Hospital, he established a full-service general practice in East Burnaby/New Westminster. Dr. McFadden developed an interest and expertise in occupational medicine and was frequently asked to perform individual third-party evaluations related to employee disability issues. His objective assessments were recognized by the College,andin1990hebecameinvolvedintheCollege’spracticeassessment and prescription review work, often adjudicating the most difficult cases involving chronic pain management, narcotic addiction, physician over-prescribing issues, and physician behaviour problems.HewasinstrumentalinarguingtotheCollege’sPrescriptionReview Committee that national guidelines should be developed for opioid prescribing behaviour. His firm position eventually led to the development of the Canadian Guideline for the Safe and Effective use of Opioids for Chronic Non-Cancer Pain. Dr. McFadden was one of three physicians selected by PharmaCare to create a program for the approval of drugs used in the treatment of multiple sclerosis.

Dianne M. Miller, MD, FRCSC – Vancouver, BCDr. Miller obtained her medical degree at the University of British Columbiain1980.ShetheninternedattheTorontoWesternHospitalpriortoworkingasafamilyphysicianinYellowknife,NWT.In1988,Dr. Miller completed her Royal College certification in obstetrics and gynecologyatUBC.ThiswasfollowedbycompletionofaRoyalCollegefellowshipingynecologiconcologyinTorontoin1990.Sheiscurrently the division head of gynecologic oncology in the department of obstetrics and gynecology at the University of British Columbia and gynecologic oncologist at Vancouver General Hospital. She is also the provincial gynecology tumor group chair for British Columbia and a member of Vancouver Coastal Health Research Institute. Dr. Miller is an enthusiastic educator who sets and maintains high standards of research and surgical excellence. She is regarded by her peers as a “visionary” in her field, engaging in numerous cervical cancer trialsandtirelesslypromotingcancerpreventionstrategies.Togetherwithacolleague,Dr.MillerconceivedOvCaRe–BC’sovariancancerresearch consortium of interdisciplinary clinicians and researchers, which is recognized internationally. In addition to her work in Canada, Dr. Miller is involved in international health projects in Nigeria and Uganda, developing cervical cancer training modules for use in low-resource settings.

Lorna Sent, MBChB, CCFP – Vancouver, BCDr.SentgraduatedfromtheUniversityofCapeTownin1971andmoved to Canada to complete her residency training in internal medicinein1973.In1975,shesetupafamilypracticeinVancouver,which she continues to run. Dr. Sent is well known amongst her peersasadevotedphysicianandtirelessadvocateforwomen’shealthissues, particularly for those women who face barriers in accessing health-care services. In 1993, she founded the Asian Pap Smear Clinic (laterrenamedtheAsianWomen’sHealthClinic)toaddressculturaland linguistic barriers limiting access to preventive health services for Chinesewomen.Dr.Senthascontributeddirectlytohercommunity’shealth in many ways. She is also recognized as giving back to her profession through her years of service to the College of Physicians andSurgeonsofBC,bothaspresidentfrom2003to2005,andasachair and member of numerous committees.

Nowinitseighthyear,theCollege’sAwardofExcellenceinMedicalPractice Program is an annual peer recognition program that honours individual physicians who have made an exceptional contribution to the practice of medicine in teaching, research, clinical practice, administration or health advocacy. Other criteria include character, integrity, and ethics beyond reproach, demonstrated leadership, and collegiality in all interactions with patients and colleagues.

Error in 2011-12 printed directory

Registrants are advised of an error, which appeared in the printed 2011-12MedicalDirectory.Theerrorhascreatedsomeproblemsforphysiciansattemptingtofaxreferrals.Thefaxnumberlistedinthedirectory is, in fact, the cell phone number of a local businessman.

Physicians listed in the 2011-12 Medical Directory are being asked to update their own copy of the Medical Directory, and any other records that may have been created for the following physician:

Dr. David J. RhineEmergency DepartmentKelowna General HospitalFacsimile: 250-862-4361

Medical office employees should also be made aware of this change.

TheCollegeremindsphysiciansthattheprintedMedicalDirectoryis being phased out and will no longer be available as a referral tool in the coming year. Physicians and their medical office employees are strongly encouraged to familiarize themselves with the online directory, which is constantly updated, and available through the College website at www.cpsbc.ca.


Information about College-sponsored educational initiatives are published on the website at www.cpsbc.ca>Physicians’ Area >Physician Education.

Medical record keeping workshop – Vancouver

Thiscourseisprimarilydirectedatgeneral/familypractitionersandother physicians providing primary care. It is an interactive program using real case examples and simulated patient encounters to demonstrate the practice of effective clinical record keeping. Six to eight weeks after the course, attendees are asked to submit files to the instructor for review to ensure that the newly learned techniques are being incorporated into daily practice.

Date: September 12, 2012

Time: 8:30a.m.to4p.m.

Location: 300–669 Howe Street, Vancouver, BC

Registration Fee: $481.60($430+$51.60HST)for registrants $593.60($530+$63.60HST)for non-registrants

A registration form is available on the College website. For more information,pleasecall604-733-7758extension2234.

This program meets the accreditation criteria of the College of Family Physicians of Canada for up to 6 Mainpro-M1 credits. Those completing the post-course feedback exercise qualify for 8 Mainpro-C credits.

Other locations Registrants should contact the College if they have a group interested in holding the course in their community (class size 8-12 participants).

Courses and workshops – mark your calendars

Seeking applicants for peer assessor contractTheCollegeisinvitingapplicationsfromfamilyphysicianswithbroadclinical experience for three part-time peer assessor contracts (up to 20 hours per week).

Under the direction of the senior deputy registrar, the peer assessor carries out the mandate of the quality assurance and practice assessment department to assess the practice of community-based general physicians in compliance with College policies and procedures, and in accordance with the Bylaws under the Health Professions Act, RSBC 1996, c.183.

TheassessorswillconductpeerassessmentsintheLowerMainland,interior and northern areas of British Columbia, work in a collaborative team environment, and function as experts in the review and assessment of a medical facility, medical charting and clinical practice. Exceptional interpersonal skills are required, including current understanding of best practices, up-to-date knowledge on clinical care guidelines and familiarity working in a multi-physician clinic setting. Physicians selected for this position will require a successful peer assessment.Theabilitytotravelisessentialforthisposition.

ThecandidatemustworkcollegiallyandinteracteffectivelywithCollege staff. Interested candidates may submit their cover letter and resume by email before end of day on Monday, July 9, 2012 to Human Resources at [email protected].

Announcements and Events continued


Methadone 101 – Vancouver

Thisworkshopisanintroductoryworkshopinguidelinesfortheuseof methadone for the treatment of opioid dependency. Participation in the Methadone 101 workshop is required for physicians who wish toobtainanexemptiontoprescribemethadoneundersection56of the Controlled Drugs and Substances Act. All physicians seeking exemptionmustapplytotheCollege’sMethadoneMaintenanceProgram.

Date: October 26, 2012

Time: 8a.m.to5p.m.

Location: St.Paul’sHospital–NewLectureTheatre Providence Wing, Level 1 1081 Burrard Street, Vancouver, BC

Registration Fee: $308($275coursefee+$33HST) for registrants and non-registrants

Formoreinformation,pleasecall604-733-7758extension2628.

This program meets the accreditation criteria of the College of Family Physicians of Canada for up to 7.0 Mainpro-M1 credits.

Methadone 201 – Vancouver

Thisisanadvancedworkshopforphysicianswhoalreadyhaveanexemption to prescribe methadone for the treatment of opioid dependency. (Physicians wishing to obtain an exemption to prescribe methadone for opioid dependency must first complete the Methadone 101 Workshop.)

Date: October 27, 2012

Time: 8a.m.to5p.m.

Location: St.Paul’sHospital–NewLectureTheatre Providence Wing, Level 1 1081 Burrard Street, Vancouver, BC

Registration Fee: $308($275coursefee+$33HST) for registrants and non-registrants

Formoreinformation,pleasecall604-733-7758extension2628.

Application is being made for continuing medical education credits through UBC’s Division of Continuing Professional Development.

What’s in the cards? Ethical and professional implications of new genetic technologies and other emerging trends in clinical practice – Vancouver

Mark your calendars for the much-anticipated College Education Day.

From preimplantation genetic diagnosis (PGD) to the prospect of genome-based personalized medicine, medical practitioners are increasingly becoming the interface between their patients and an arrayoftechnology-driven,revolutionaryinterventions.Thegoalofthisyear’seducationdayistohelpphysiciansanticipateandidentifyrelevant concerns and implications for the future of medical care in this rapidly evolving landscape.

Theprogramincludesplenarysessions,casestudiesandinteractiveworkshops for an all-encompassing educational experience.

Date: September 21, 2012

Time: 8:30a.m.to4:30p.m.

Location: Vancouver Convention Centre

Registration Fee: $84($75plus$9HST)

Plenary Sessions

MORNING PLENARy Stacking the deck: Preimplantation Genetic Diagnosis (PGD)

Jeff Nisker, MD, PhD, FRCSC, FCAHS

Coordinator of Health Ethics and Humanities and Professor of Obstetrics-Gynaecology and Oncology, Schulich School of Medicine &

Dentistry, University of Western Ontario

AFTERNOONPLENARY Playing the hand you’ve been dealt: implications of the new genomics

Michael M. Burgess, PhD

Professor and Chair in Biomedical Ethics, W. Maurice Young Centre for Applied Ethics and the Department of Medical Genetics, Faculty of Medicine, University of British Columbia

A program and registration form are enclosed for your convenience. More information, including speaker biographies and session descriptions, is available on the College website.


Quality Assurance

Non-Hospital Medical and Surgical Facilities Program

The College’s Non-Hospital Medical and Surgical Facilities Program (NHMSFP) has the legislated mandate to establish, monitor and ensure standards of practice in private medical and surgical facilities in BC. There are currently 66 accredited facilities providing a range of minor to more complex surgical procedures, which are approved by the NHMSFP Committee.

Cosmetic surgery in an office-based setting

TheNHMSFPCommitteeremindsallregistrantsthatwhilesomephysicians are able to perform non-surgical or minor surgical cosmetic procedures in their offices—such as Botox® injections, superficial laser treatments, or the removal of minor lesions—only qualified specialists(plasticsurgeons,ENTsurgeonsanddermatologists)withthe requisite surgical training are authorized to perform invasive cosmetic procedures. All specialists must demonstrate competency and evidence of their training to the College to receive the required privileges to perform invasive surgical procedures in an accredited non-hospital medical/surgical facility.

Registrants are further reminded that all forms of body sculpting, radiofrequency-assisted techniques, and all liposuction procedures that require skin incisions and utilize a cannula inserted under the skin, or any procedure described as minimally invasive are considered tocarrythesamerisksasconventionalliposuctionprocedures.Theseprocedures can only be performed by a qualified specialist who has been granted privileges by the College to perform such procedures. Liposuction can only be performed in a non-hospital medical/surgical facility accredited by the College.

Theseliposuctionproceduresincludebutarenotlimitedto:TumescentLiposuctionTechnique,SuperWetTechnique,SmartLipo™,VASERLipo®,CoolLipo™,ProLipoPLUS™,WaterJetAssistedLiposuction,BodyTite™,andCellulaze™.

Responsibilities of the medical directorMedical directors working in non-hospital medical/surgical facilities are reminded of their responsibilities and reporting requirements as set outinsections5-5to5-8oftheBylawsundertheHealth Professions Act,RSBC1996,c.183.TheBylawsstatethatmedicaldirectorsare responsible for ensuring the standards and delivery of medical care provided and procedures performed in the facility. All matters

pertaining to such medical care include but are not limited to the following: heating ventilation and air conditioning systems, medical gas piping systems, all appropriate city inspections, and applicable BC building codes and CAN/CSA compliance.

Orientation to emergency cart medication, equipment and suppliesIn all non-hospital medical/surgical facilities, emergency procedures, medication, equipment and supplies must be available to address emergencies. All facility personnel, including physicians who hold privileges, must be orientated and trained in the use of emergency equipment and supplies. Facilities must be able to demonstrate orientation policies which support and provide initial and ongoing education, training and professional responsibilities in regard to emergency protocols. Prior to working in a non-hospital medical/surgical facility, all regulated health-care professionals must be familiar withthelocationofthefacility’semergencymedication,equipmentand supplies and complete hands-on practice and training with emergency equipment such as: defibrillator and monitor, AED, oxygen tank, suction machine, and be familiar with where supplies are stocked on the emergency cart.

Flash sterilizationFlash sterilization, also described as immediate use steam sterilization, must only be used in a situation where there is an urgent or unplanned need and when routine sterilization cannot be done. Flash sterilization should not be used as a substitute for insufficient instrument inventory. Instrument inventories should be sufficient to meet anticipated surgical volume and permit the time to complete all critical elements of reprocessing.

Complete information regarding medical device reprocessing can be found on the website at www.cpsbc.ca >About the College>Accreditation Programs.


Committee Cases and RecommendationsInquiries and complaints Providing evidence in a civil action involving custody and access

TheInquiryCommitteerecentlyreviewedacasewhichfocusedontheappropriate role of a treating physician in providing medical reports ortestimonyinacivilactioninvolvingcustodyandaccess.Thecasehighlighted the types of situations that may give rise to potential or perceived conflicts of interest.

If treating physicians are asked to provide evidence in judicial or quasi-judicial proceedings regarding the care and management of patients, they are expected to maintain objectivity, impartiality and professionalism. In providing evidence in such proceedings, physicians are reminded that

• theyhavearesponsibilitytoprovideobjectiveandimpartialopinions in areas that fall within the scope of their expertise,

• theyshouldrefrainfromassumingtheroleofanadvocate,and

• theyshouldclearlyandcomprehensivelysetoutthefactsorassumptions upon which their opinion is based and ensure that material facts, which could detract or alter their opinion, are not omitted.

Considerations when called about the imminent death of an unfamiliar patient

TheInquiryCommitteerecentlyconcludedacomplexreviewofcomplaints arising out of the death of an elderly nursing home resident withcriticismofanon-callphysicianforfailingtoattendthepatient’sdistressed family in person. Unfortunately, this is a recurring theme.

On-call physicians who are informed about the imminent death of a patient should be attentive to the needs of the family. Grief is an isolating experience, and physicians should never underestimate the healing power of their presence and expression of concern for families during this emotional time—even if the patient was being treated by another physician and the family is unfamiliar.

Feeling let down by the medical team when a loved one has died might be regarded as an inevitable part of grieving for some people; however, deliberate attention to a brief checklist may ease the emotional burden on families, and save physicians the difficulty of responding to a complaint.

Thingstoconsider

• Makeapointofconductingatleastpartofyourdiscussionwiththe nurse at the bedside, where family members can hear, offer their own perspectives and ask questions.

• Askthefamilyifthereisanyoneelsetheywouldlikeyoutocall.(If there is no one at the bedside, insist on making some calls yourself.)

• Examinethepatientattentively,withfamilymemberspresent.

• Taketheopportunitytomakesureadvancedirectionforlevelsofintervention and symptom control are appropriately documented.

• Beclearthatyouwanttobecalledforanyconcern.

• Finally,makeapointofpullingupachairandsittingquietlyinthatcircleofconcernforjustafewmoments.Thisisespeciallyimportant if the loved one has already died.

What physicians do, say, and communicate non-verbally in these types of situations makes a profound and lasting impression. A decision not to attend in person is a missed opportunity to prevent needless suffering on the part of those left behind—suffering which is poignantly communicated to the Inquiry Committee every time it meets.

Warnings regarding the use of transdermal fentanyl

A recent complaint to the Inquiry Committee identified three seemingly common misconceptions about transdermal fentanyl. In this instance, an experienced, otherwise highly competent physician ordered that a fentanyl patch be cut in half and administered to an elderly patient with limited or unknown opioid tolerance.

Transdermaldrugdeliverysystemsshouldnotbecutorusedifdamaged, unless specifically designed for that purpose. Disrupting the integrity of the system defeats the controlled release design features.Theliteraturerecordstwopotentialadverseresults.Mostcommonly, the medication simply drains away; however, there are also case reports of inadvertent bolus overdosing leading to life-threatening hypoventilation. (http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM164429.pdf).

Additionally, fentanyl patches must be used with caution in the elderly, especially if other CNS depressants are taken concurrently. Theproductmonographcontainsmanywarningsabouttheriskofrespiratory depression including a statement that transdermal fentanyl is contraindicated in opioid-naïve patients at any dose.

Physicians considering the use of transdermal fentanyl are advised to familiarize themselves with the details contained in product information, and should consult with colleagues who have more experience if any doubt exists.


A Word from the College Library

Fast and thorough, at your servicePhysicians use point-of-care tools to inform decisions quickly and reliably.Tofillthisneed,theCollegelibrarysubscribestotheonlineresource, Best Practice,publishedbytheBMJEvidenceCentre.Thisunique database employs the best characteristics of quick access sources: easy to find subjects, bulleted lists, drill down searching, and outline formatting. But Best Practice is not just another attractively organizedonlineoutline.Theinformationisalsoevidence-based,constantly updated, and peer reviewed to give clinicians a virtual “second opinion.” Searching begins by entering a condition, which can be a distinct disease or a symptom, or by clicking on “drug information.” For example, a search on abdominal pain in pregnancy gives an overview, options for urgent assessment, step-by-step diagnostic procedures, differential diagnosis and treatment. A bibliography of linked references, list of images, and printable patient leaflets are also included. If the preferred approach is by disease, Best Practice includes broad categories, like seizures, or distinct diseases like amyotrophic lateral sclerosis. Over 10,000 diagnoses and 3,000 diagnostic tests are covered, supported by full-text diagnostic and treatment guidelines.

Embedded in the “conditions” section or separately searchable is a drug database derived from Martindale: The Complete Drug Reference. Martindale is arguably the favourite pharmacopia of health librarians—not only is it complete, current, and authoritative, it is also international. Each generic drug monograph comes with the usual preparations, uses, interactions, and precautions, but alsoincludesalistofinternationaltradenames.Thelibrarysectionof the College website provides registrants with access to eCPS through eTherapeutics, but Martindale gives a broader approach to pharmaceutical information, while still including Canadian trade names.

For those College registrants who prefer to use their portable electronic devices for information, Best Practice may be accessed on any web-enabled hand-held device, including iPads, iPod touch, and iPhones. Although an app has been developed, it is not yet available to Canadian institutional subscribers at this time.

Winner of the Dr. George Szasz awardTheCollegeispleasedtoannounceMs.PaulaOsachoffasthisyear’swinneroftheDr.GeorgeSzaszaward.For40years,Dr.Szaszwasa member of the Library Committee and gave generously of his time and professionalism to enhance medical library services for BC physicians.The$500awardisgrantedannuallytoamemberofthe College library staff to assist with professional development in medical library services.


Disciplinary Actions

Dr. Brian Arthur WHITE, Nanaimo, BC

Dr. Brian Arthur White, a general practitioner, has admitted to engaging in unprofessional conduct in February 2009 by prescribing a controlled medication to an individual when he knew that such medication was intended for a relative of that individual. Dr. White wrotetheprescriptionwithoutanydirectknowledgeoftherelative’smedical condition or any potential prescribing concerns. Dr. White failedtoconsultwithorinformtherelative’sfamilyphysicianofthe prescription and failed to keep a proper medical record of the medication he prescribed.

Following the issuance of a disciplinary citation, Dr. White consented to the following disposition by the College:

Dr. White will be transferred from the Full – General/Family class of registration to the Conditional – Disciplined class of registration, effective2400hours,January31,2012,subjecttothefollowinglimitsand conditions:

(a) Dr. White will be suspended from practice for three months commencing2400hours,March1,2012andending2400 hours, June 1, 2012.

(b) Dr. White will relinquish his prescribing privileges for narcotic and/or controlled drugs.

(c) Prior to returning to practice, Dr. White will participate in continuing medical education in the areas of ethics, boundaries, and professionalism as directed by the College and attend for interview at the College.

Upon return to practice, Dr. White will:

(a) not apply for the reinstatement of his prescribing privileges for narcotic or controlled drugs for a minimum period of one year and provide confirmation of instruction and education satisfactory to the College;

(b) comply with monitoring of his practice; and

(c)paycoststotheCollegeintheamountof$1,750.

Dr. Ronald Harold DABBS, Prince George, BC

Dr. Ronald Harold Dabbs, a general practitioner, has admitted unprofessionalconductwithapatientintheperiod1993to1994.His conduct included self-disclosure to the patient, hugs at patient attendances,anattendanceatthepatient’shomeandfailuretomaintain medical records to the required standard.

Following the issuance of a disciplinary citation, Dr. Dabbs consented to the following disposition by the College:

Dr. Dabbs will be transferred from the Full – General/Family class of registration to the Conditional – Disciplined class of registration, effective2400hoursMarch31,2012,subjecttolimitsandconditionsthat include:

(a) A formal reprimand.

(b) Dr.Dabbswillwithdrawfrompractice,effective2400hours June 7, 2012, until such time as he has

(i) successfully completed assessment and counselling, and

(ii) attended at the College to further assess and determine conditions of registration.

Upon return to practice, Dr. Dabbs will:

(a) offer patients the option of a chaperone with appropriate office signage;

(b) establish a mentorship with a physician approved by the College;

(c) participate in continuing medical education in areas as directed by the College;

(d) comply with monitoring of his practice; and

(e) pay costs to the College in the amount of $10,000.

Dr.Dabbs’futureprofessionalconductmustbebeyondreproachinevery respect.


Members of the Board of the College of Physicians and Surgeons of BCRepresentatives of the Profession

District 1 Dr. D.M.S. Hammell

District 2 Dr. G.A Vaughan

District 3 Dr. D.J. Etches Dr.P.T.Gropper Dr. N.D. James

District 4 Dr. D.A. Price Dr. J.R. Stogryn

District 5 Dr. M.A. Docherty

District 6 Dr. L.C. Jewett

District 7 Dr. A.I. Sear

Registrar Dr. H.M. Oetter

Deputy Registrars Dr. A.J. Burak Dr. S.M.A. Kelleher Dr. A.M. McNestry Ms. E. Peaston (Legal) Dr. W.R. Vroom Dr. J.G. Wilson

Chief Operating Mr. M. EppOfficer

Offices of the College

Suite 300 669 Howe Street Vancouver, BC V6C0B4

Telephone: 604-733-7758Facsimile: 604-733-3503TollFree: 1-800-461-3008Website: www.cpsbc.caEmail: [email protected]

TheCollege Quarterly is produced four times a year by College staff. It contains information relevant to the profession including new policies and guidelines, and disciplinary actions. Medical content contained in the College Quarterlyisreviewedbythepublication’sAdvisoryPanelconsistingofpractisingphysicianswhoarenotemployedbytheCollege.TheCollege Quarterly is sent to every current registrant of the College. Questions or comments about this publication should be directed to the editor at [email protected].

Officers

President Dr. M.A. Docherty

Vice President Dr. L.C. Jewett

Treasurer Mr. W.M. Creed (FCA)

Representatives of the Public

Ms. L. CharvatDr. M. Corfield (DM)Mr. W.M. Creed (FCA) Mr. S.S. GillMs. V. Jenkinson

College Leadership

(LTOR)FRONTROW:Dr. D.M.S. Hammell, Dr. L.C. Jewett (vice president), Dr. M.A. Docherty (president), Mr. W.M. Creed, FCA (treasurer), Ms. L. Charvat

SECOND ROW: Dr. A.I. Sear, Dr. S.M.A. Kelleher, Dr. M. Corfield, DM, Dr. H.M. Oetter (registrar), Dr. J.R. Stogryn, Dr. J.G. Wilson

THIRDROW:Dr.D.J.Etches,Dr.W.R.Vroom,Ms.E.Peaston,Dr.A.J.Burak,Dr.N.D.James,Dr.P.T.Gropper

FOURTHROW:Dr. D.A. Price, Dr. G.A. Vaughan, Ms. V. Jenkinson, Mr. M. Epp ABSENT: Dr. A.M. McNestry, Mr. S.S. Gill

serving the public through excellence college quarterly either poor or rapid metabolizers of codeine...

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