College Case Studies - cpsbc.ca

Twenty-first century challenges: informing medical practice in an era of increasing complexity and rising expectations

College Case Studies 2017 Education Day and Annual General Meeting

College of Physicians and Surgeons of British Columbia

Overview • Introductions

Panelists:

– Mr. Graeme Keirstead

– Dr. Patrick Rowe

– Ms. Patricia Bowles

Presenter:

– Dr. Galt Wilson, Senior 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.


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. Your opinion – i-Clickers

3. Results

4. Panelist discussion and your input—move to microphones


WARNING Uncertainty is an inevitable part of medical practice and there may be a measure of ambiguity in these scenarios. Some have more than one right answer.

!



We made them up…

You don’t know these cases—they aren’t real.


Complexity and Expectations Topics 1. A new patient on long-term opioids (LTOT) for chronic pain

2. A walk-in patient seeking completion of a CPP disability form

3. An osteoarthritic knee injected with “stem cells”

4. A clinic colleague retiring and closing his practice

5. Obligations regarding medical records when working in a setting you do not own


A new patient on LTOT Safe prescribing is good medicine 1


A new patient on LTOT Safe prescribing is good medicine

A family physician is new to Canada. His practice includes 1,200 patients inherited from a physician just retired after 42 years.

Midway through the third week, the office is contacted by Frank McDonald seeking an urgent refill of hydromorphone (120 MME), alprazolam, and zopiclone. Frank is a 67 year old locomotive engineer with CN. He has been on long-term opioids since he had back surgery 13 years ago.



Frank attends every three months for prescription refills. His chart documents two reports of lost medication (attributed to travel for work) and frequent presentations for early refills.

Other diagnoses include DM 2 and hypertension.

Encounter notes are brief. No physical findings have been recorded in the past five years. There are no urine drug screens. There is no opioid agreement. Transaminases were done three times in 20 years—always elevated.

There is an emergency department note from two years ago—a broken nose and facial lacerations suffered in a fight outside a local bar.

Frank is accommodated with a same-day appointment.



The best way to respond to Frank’s request is: A. Advising that his use of opioids and sedatives is not acceptable in his safety

sensitive occupational role. They must be tapered and discontinued. And, you have a legal obligation to inform his employer.

B. Advising that standards have changed. Physicians are expected to be more selective in their use of these medications. You do not prescribe opioids in this setting. He is encouraged to find another physician.

C. Advising that standards have changed. LTOT is no longer recommended for chronic back pain and strong pain medications must not be combined with other sedatives. Renew his medications, but future prescribing will be based on findings of a comprehensive reassessment—three to five visits at two weekly intervals. Regardless, either the opioid or sedatives will be tapered/stopped.

D. As per C, but tapering begins immediately. E. Advising that he likely suffers from an SUD—probably to several drugs.

Prescribing will be contingent on attending for an addictions assessment.

i-Clicker question



The best way to respond to Frank’s request is: A. Advising that his use of opioids and sedatives is not acceptable in his safety

sensitive occupational role. They must be tapered and discontinued. And, you have a legal obligation to inform his employer.

B. Advising that standards have changed. Physicians are expected to be more selective in their use of these medications. You do not prescribe opioids in this setting. He is encouraged to find another physician.

C. Advising that standards have changed. LTOT is no longer recommended for chronic back pain and strong pain medications must not be combined with other sedatives. Renew his medications, but future prescribing will be based on findings of a comprehensive reassessment—three to five visits at two weekly intervals. Regardless, either the opioid or sedatives will be tapered/stopped.

D. As per C, but tapering begins immediately. E. Advising that he likely suffers from an SUD—probably to several drugs.

Prescribing will be contingent on attending for an addictions assessment.

i-Clicker question



CMA Code of Ethics, Article 17: Do not discriminate “In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status.”

College standard Access to Medical Care

https://www.cpsbc.ca/files/pdf/PSG-Access-to-Medical-Care.pdf

“… complex medical problems…, insurance claims”

Considerations

https://www.cpsbc.ca/files/pdf/PSG-Access-to-Medical-Care.pdf


College standard Safe Prescribing of Drugs with Potential for Misuse/Diversion https://www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf

Michael G. DeGroote National Pain Centre 2017 Canadian Guideline for Opioids for Non-Cancer Pain CME • Foundation for Medical Excellence Chronic Pain Management Conference

March 2 to 3, 2018 • College Prescribers Course

October 13, 2017 • PSP Chronic Pain Module

Considerations


https://www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf


A transient increase in pain intensity with modest dose reduction is often due to opioid withdrawal. Many patients with CNCP who have relied on opioids for a long time are hard to convince.

A few years ago, an expert suggested an approach:

– prescribe a slow taper

– dispensed at two-week intervals

– see the patient after six cycles

Would this be considered safe and appropriate in 2017?

A. Yes

B. No



Longitudinal care in a walk-in setting A primary care home by adoption 2


Mary Jones is a 58-year-old with ischemic cardiomyopathy. She is short of breath with minimal exertion. She has worked as a clerk in a pharmacy for 30 years. Her employer has accommodated her declining functional capacity—treated her “like family,” Mary often comments.

The time has come for Mary to stop working. Her employer suggests she apply for CPP disability benefits.

Longitudinal care in a walk-in setting A primary care home by adoption


When Mary’s family physician retired five years ago, she was unable to recruit a replacement. After a fruitless search for a new GP, Mary began attending the Urban Life Urgent Care Clinic for prescription refills and re-referrals to her cardiologist.

The clinic is on the ground floor of her apartment building.

Clinic staff and physicians had regularly encouraged Mary to find a family physician, but she was content to attend there. The facility was well-appointed and the physicians young and current—she liked them.



When Mary presented with her CPP disability form on a Thursday morning Dr. Mona Lum was on duty. Dr. Lum qualified 10 years ago. She has two young children. She was unable to balance the demands of her own practice with family life and found a professional home at the Urban Life Urgent Care Clinic. At present she is working two half-days a week and alternate Saturdays. The MOA approaches Dr. Lum. She is unfamiliar with the CPP form. Dr. Lum hasn’t seen one since joining the clinic a year ago. She has seen Mary once before. Dr. Lum has no clinic patients she regards as her own.




In response to Mary’s request to complete the CPP form, Dr. Lum should: A. Empathically decline. Urban Life is an urgent care centre. Mary needs a family

physician. The local Division of Family Practice may be able to help. B. Review the EMR. If it is clear Mary has been receiving primary care at Urban

Life, Dr. Lum must complete the form and may use information in letters from the cardiologist and/or do her own assessment, at her discretion.

C. Empathically decline to complete the form herself and direct Mary to return when the clinic medical director is on site. She manages administrative issues like this one.

D. Explain her reservations to Mary. The form is normally completed by a family physician. Explore Mary’s reasons for bringing it to Urban Life.

E. Review the EMR, determine which physician has seen Mary most often and offer to have staff leave the form for her to complete.

i-Clicker question



In response to Mary’s request to complete the CPP form, Dr. Lum should: A. Empathically decline. Urban Life is an urgent care centre. Mary needs a family

physician. The local Division of Family Practice may be able to help. B. Review the EMR. If it is clear Mary has been receiving primary care at Urban

Life, Dr. Lum must complete the form and may use information in letters from the cardiologist and/or do her own assessment, at her discretion.

C. Empathically decline to complete the form herself and direct Mary to return when the clinic medical director is on site. She manages administrative issues like this one.

D. Explain her reservations to Mary. The form is normally completed by a family physician. Explore Mary’s reasons for bringing it to Urban Life.

E. Review the EMR, determine which physician has seen Mary most often and offer to have staff leave the form for her to complete.

i-Clicker question


College standard Walk-in, Urgent Care and Multi-physician Clinics

https://www.cpsbc.ca/files/pdf/PSG-Walk-In-Urgent-Care-Multi-Physician-Clinics.pdf

“Patients who do not identify a family physician but who attend the same walk-in, urgent care or multi-physician clinic repeatedly must be assumed to be receiving their primary health care from that clinic.”

Considerations





3 Stem cell therapy for osteoarthritis What would you do?


Stem cell therapy for osteoarthritis What would you do?

Doug Lawrence is an 84-year old retired engineer. His osteoarthritic left knee interferes with sleep. He won’t walk more than 200 m if he can help it.

Unfortunately he also has DM 2, ischemic heart disease, and heart failure. His BMI is 37. His cardiologist advises a total knee replacement would be high risk, but could improve his quality of life.

Doug’s brother had a total knee replacement five years ago and regrets it.

Doug is not pressing for surgery.



Doug recently saw a story on the news about professional athletes receiving stem cell injections to help them overcome injuries. The reporter mentioned similar interventions for arthritis.

He Googled “stem cells for arthritis” and the name of his town and found the website of a physician offering the service. There were videos and references to scientific studies. Doug checked the College website and confirmed that the physician was in good standing.

The treatment was noted to be unproven and not covered by the MSP. No referral was necessary.

Doug made an appointment.


The clinic was impressive. Modern. Clean. Obviously well-equipped. The staff seemed knowledgeable. He asked many questions and was satisfied by the responses. Doug had never encountered a physician as enthusiastic as Dr. Smith, an athlete himself.

Dr. Smith was very clear. He could not guarantee improvement, but most of his patients were better and none had suffered any complications. He patiently reviewed a list of potential complications.

At $1,200, it wasn’t going to be cheap, but a low-risk chance at improvement was worth a try.

As it turned out, Doug derived no benefit from a single treatment. He decides to consult you before returning to Dr. Smith.



When Doug asks about stem cell injections, your best answer is:

A. Physicians in BC are permitted to provide unproven therapies as long as they pose no more risk than conventional care and the patient is fully informed.

B. Stem cell therapies have enormous potential. By all accounts, hockey legend Gordie Howe benefited. And his son is a physician. Why not give it another try?

C. Regrettably, you are obliged to report Dr. Smith to the College. Harvesting, extracting, and administering stem cells may only be performed in a facility accredited by the Non-Hospital Medical and Surgical Facilities Program.

D. Regrettably, stem cell therapy for osteoarthritis has not been approved by Health Canada. You are obliged to report to them.

E. Regrettably, the Medicare Protection Act prohibits private payment for insured services. Injections for osteoarthritis are considered medically required care as defined in the Act.

i-Clicker question



When Doug asks about stem cell injections, your best answer is:

A. Physicians in BC are permitted to provide unproven therapies as long as they pose no more risk than conventional care and the patient is fully informed.

B. Stem cell therapies have enormous potential. By all accounts, hockey legend Gordie Howe benefited. And his son is a physician. Why not give it another try?

C. Regrettably, you are obliged to report Dr. Smith to the College. Harvesting, extracting, and administering stem cells may only be performed in a facility accredited by the Non-Hospital Medical and Surgical Facilities Program.

D. Regrettably, stem cell therapy for osteoarthritis has not been approved by Health Canada. You are obliged to report to them.

E. Regrettably, the Medicare Protection Act prohibits private payment for insured services. Injections for osteoarthritis are considered medically required care as defined in the Act.

i-Clicker question





Health Professions Act, RSBC 1996, c.183 Alternative medicine 25.4 The college must not act against a registrant or an applicant for

registration solely on the basis that the person practises a therapy that departs from prevailing medical practice unless it can be demonstrated that the therapy poses a greater risk to patient health or safety than does prevailing medical practice.

College standard Complementary and Alternative Therapies

https://www.cpsbc.ca/files/pdf/PSG-Complementary-and-Alternative-Therapies.pdf













A colleague retires What are my obligations? 4


Four physicians have shared expenses and a waiting room for many years. If asked, they’d probably tell you their arrangement was founded on a handshake in 1983, but it’s likely none of them recalls even that.

They have shared call and covered for one another during vacations, but their practices are separate entities. Three are incorporated. One is not.

One of the group surprises his colleagues with plans to fully retire in three months. He claims to have tried to find a replacement. Letters are on their way to patients. Notices are going up.

A colleague retires What are my obligations?


Which of the following is TRUE:

A. The professional standard on Walk-in, Urgent Care, and Multi-physician Clinics imposes an obligation on the remaining physicians to assume care of all of the patients.

B. The retiring physician must identify and make reasonable efforts to place patients under active treatment and make arrangements for incoming reports to be managed.

C. Article 19 of the CMA Code of Ethics obliges the retiring physician to continue to care for his patients until someone else agrees to take over.

D. Following retirement, the College must be notified of the location of the patient records.

E. Patient records must be placed in the custody of a licensed medical record storage company.

i-Clicker question



Which of the following is TRUE:

A. The professional standard on Walk-in, Urgent Care, and Multi-physician Clinics imposes an obligation on the remaining physicians to assume care of all of the patients.

B. The retiring physician must identify and make reasonable efforts to place patients under active treatment and make arrangements for incoming reports to be managed.

C. Article 19 of the CMA Code of Ethics obliges the retiring physician to continue to care for his patients until someone else agrees to take over.

D. Following retirement, the College must be notified of the location of the patient records.

E. Patient records must be placed in the custody of a licensed medical record storage company.

i-Clicker question



College guideline Leaving Practice

https://www.cpsbc.ca/files/pdf/PSG-Leaving-Practice.pdf

College standard Medical Records

https://www.cpsbc.ca/files/pdf/PSG-Medical-Records.pdf

Considerations


https://www.cpsbc.ca/files/pdf/PSG-Leaving-Practice.pdf








The records I create belong to me Don’t they? 5


Jennifer Walls, a GP, has been working at the Ideal Medical Clinic for three years. The clinic is owned by a non-physician investor. It accommodates six FTE physicians, including the medical director. Everyone has a panel of patients and contributes to walk-in shifts. Jennifer was one of the first physicians to work at the clinic. It was state-of-the art—well appointed and equipped. The work was paperless from day one. The arrangement is 70/30. Jennifer’s panel is now about 1,200 patients. When a friend from medical school approaches her about joining a new clinic venture as part-owner, she realizes she is ready. The new clinic will be ready for occupancy in three months.

The records I create belong to me Don’t they?


Jennifer provides a letter to the Ideal Medical Clinic owner, giving 90 days notice and requesting access to the EMR for the IT service provider retained to install the computer network at her new location, to facilitate transfer of her records.

The owner responds with a letter stating the he will allow the transfer, on receipt of her payment of $5,000, to cover the investment he claims to have made in the EMR on her behalf.

Jennifer has no written agreement with the Ideal Medical Clinic.



The bitter legal dispute that follows is unresolved when it comes time for Jennifer to begin seeing patients at her new location.

On her final day at the Ideal Medical Clinic, the owner shuts her out of the EMR (and insists that she hand over her keys), advising that the other physicians will manage incoming reports and patients will be given her contact information, if they ask. The medical director assures her that they have the capacity to take care of any patients who choose to remain.



On the first day at the new clinic, Jennifer has no access to her records. A patient with complex care needs asks how that happened. The patient submits a complaint to the College, naming the Ideal Medical Clinic.




How is the College Inquiry Committee going to respond?

A. With criticism of Dr. Walls for failing to ensure enduring access to her records for herself and her patients.

B. With criticism of Dr. Walls for violating privacy legislation, by allowing a non-physician to assume custody of confidential patient records.

C. With criticism of the medical director for not asserting the principle that the physician owns the records she creates.

D. With criticism of the medical director for the absence of data-sharing contracts in the clinic.

E. With no criticism. This is a business dispute. The College has no jurisdiction.

i-Clicker question



How is the College Inquiry Committee going to respond?

A. With criticism of Dr. Walls for failing to ensure enduring access to her records for herself and her patients.

B. With criticism of Dr. Walls for violating privacy legislation, by allowing a non-physician to assume custody of confidential patient records.

C. With criticism of the medical director for not asserting the principle that the physician owns the records she creates.

D. With criticism of the medical director for the absence of data-sharing contracts in the clinic.

E. With no criticism. This is a business dispute. The College has no jurisdiction.

i-Clicker question



“Physicians have an ethical, professional and legal obligation to ensure that before they create a medical record they comprehensively address the issues of ownership, custody, confidentiality and enduring access for themselves and their patients.”

Considerations




“In all situations where a physician creating a medical record is not the owner of the clinic and/or of the EMR licence, issues of custody, confidentiality and enduring access by individual physicians and patients must be documented in a formal contract with the owners and/or EMR service providers.”

Considerations




“The College cannot arbitrate ownership of medical records retrospectively.”


Considerations









Considerations



Documents

College Case Studies - cpsbc.ca