Autumn 2006
CAPP update: Fall 2006
A third cohort of 30 International Medical Graduate (IMG) physicians was assessed in June 2006 by the College’s Clinician Assessment for Practice Program (CAPP). The Credentials Committee of the College of Physicians and Surgeons of Nova Scotia met in August 2006 and deemed that nine candidates (five women and four men) were eligible for a defined license to practice family medicine in Nova Scotia. These physicians will begin Part B in late Fall 2006.
In June 2006, the CAPP formally requested mentors to rate and comment upon topics that, in their opinion, should be included in a structured orientation program for new CAPP physicians, ideally before they begin their mentored practice. Based on the information gathered, the CAPP has developed a 5-day orientation program for the new CAPP physicians who will begin their practices later this year.
The program, primarily funded by Health Canada as a pilot project, is intended to address a number of important aspects of practice in Nova Scotia. The program was held in mid October and will be immediately followed by site visits by the new CAPP physicians to communities in the province identified by the Department of Health and the District Health Authorities in need of new family practitioners.
NSPAR update: Fall 2006
In early October, the Nova Scotia Physician Achievement Review (NSPAR) Program expanded to include most medical and surgical specialties.
NSPAR is a survey-based program that collects detailed, anonymous feedback from physicians' patients, medical colleagues and professional co-workers. Completed questionnaires are sent to an independent research firm that assembles the results, prepares a summary and sends a report to each physician.
Approximately 120 family physicians and 120 medical specialists and surgeons will be randomly selected to participate in NSPAR each year, with each eligible physician participating in an NSPAR assessment at some point within the next seven years, with seven-year re-assessments thereafter.
NSPAR fulfils the College's obligation under the Nova Scotia Medical Act to conduct peer assessment. In accordance with the Act, participation is mandatory, subject to a limited set of exemption criteria. NSPAR reports for individual physicians are protected from use or disclosure in any disciplinary process or legal proceeding.
NSPAR Resources available for all physicians
NSPAR maintains a comprehensive list of CME resources assembled by Dalhousie CME that can be used by all physicians, regardless of whether or not they have participated in the program. The list is available online at www.nspar.ca/physician-resources.htm or by contacting the NSPAR Program at the number below.
Further information on the NSPAR Program, including a physician Q&A, instructional video, sample questionnaires and a sample report are available at www.nspar.ca, or by calling the NSPAR Program at (902) 482-2921.
New College policies and guidelines: October 2006
The following new policy and guideline were approved by the Council at its October 13 meeting. A comprehensive new record-keeping guideline will also be distributed to members in the coming weeks.
Policy regarding Ultrasound for Non-Medical Reasons
This policy was produced with the assistance of the College of Physicians and Surgeons of Ontario.
Guidelines for the Use of Methadone in Office-Based Management of Chronic Non-Cancer Pain 
(PDF format only)
This guideline contains detailed information on assessment, side-effects and treatment planning, and is accompanied by “A Review of the Use of Methadone for Treatment of Chronic Non-cancer Pain” by Dr. Mary Lynch.
Standards of follow-up care in private and publicly funded systems
Concerns have been raised with the College about instances in which physicians providing non-insured services have not been available to provide postoperative care and follow-up to their patients. In addition, concerns have been raised about physicians working in the public system who have made disparaging comments when providing follow-up care to patients who have undergone non-insured procedures.
The College reminds its members that the same standards of professionalism, care and follow-up of patients is expected of physicians working in the private (eg. non-MSI insured) sector as is expected of those working in the public health care system.
Avoid part fills for controlled drugs
Editor's note: The following information is contained in a memorandum to pharmacists and prescribers signed by Dr. Cameron Little, Registrar and CEO of the College of Physicians and Surgeons of Nova Scotia; Dr. Bill MacInnis, Registrar of the Dental Board of Nova Scotia; and Susan Wedlake, Registrar of the Nova Scotia College of Pharmacists.
The healthcare community, the public and law enforcement is acutely aware of prescription diversion and abuse in Nova Scotia. One practice that has been brought to the attention of the Board of the Prescription Monitoring Program and to others is that of prescription "part fills" for controlled drugs. In their recent article “The Pharmacotherapy of Chronic Pain: a Review” (March 2006) Drs. Mary Lynch (Dalhousie University) and C. Peter N. Watson (University of Toronto) state:
Guidelines for the Use of Chronic Opioids in Non-Cancer Pain emphasizes the need for a thorough history and physical examination with appropriate diagnostic workup, development of an overall pain management approach based on the individual needs of the patient, and regular follow-up (eg. every three months or more depending on the clinical situation). Continued subscribing should be on the basis of documented pain relief, improved function, or both. [emphasis added]
They go on to say that:
Periodic review should address the ‘5 As': Analgesia, Activities, Adverse effects, Abuse behaviour, Adequate documentation.
Part fills are convenient for prescribers and patients alike; however, the Board has been made aware that part fills for controlled substances, in some instances, have been issued for a year without patient review and follow-up by the prescriber. The suggestion is made that this practice may contribute to drug diversion and abuse.
The mandate of the Prescription Monitoring Program includes “the reduction of the abuse and misuse of monitored drugs.” The Board sees long-term part fills as a practice that could easily contribute to drug diversion and abuse.
Both the Guidelines for the Use of Controlled Substances in the Treatment of Pain approved by the College of Physicians and Surgeons of Nova Scotia, and the Pharmacotherapy of Chronic Pain: A Review (quoted above) suggest more regular follow-up of patients with chronic non-cancer pain who are prescribed controlled substances.
For these reasons, the Board of the Prescription Monitoring Program discourages prescribers from providing lengthy part fills to patients. This, it is felt, will promote better healthcare and discourage prescription drug diversion and abuse.
Timely retrieval and interpretation of radiological findings
The College has recently become aware of cases in Nova Scotia in which delays in retrieving and/or interpreting radiological findings may have compromised patient care. Physicians are encouraged to become familiar with the Standard for Communication in Diagnostic Radiology (2001) of the Canadian Association of Radiologists, specifically sections III and IV, which are reproduced below:
III . Written Communication
A. The timeliness of reporting any radiologic examination varies with the nature and urgency of the clinical problem. The written radiological report should be made available in a clinically appropriate, timely manner.
B. The final report should be proofread carefully to avoid typographical errors, deleted words, and confusing or conflicting statements, and authenticated by a radiologist, whenever possible. Comment: Electronic and rubber-stamp signature devices, instead of a written signature, are acceptable if access to them is secure. If this is not possible, the name of the radiologist who dictated the report should appear on the report.
C. A copy of the final report should accompany the exchange of relevant radiographic examinations from one health professional to another health professional.
IV. Direct Communication
Radiologists should attempt to co-ordinate their efforts with those of the referring physician in order to best serve the patient's well-being. In some circumstances, such co-ordination may require direct communication of unusual, unexpected or urgent findings to the referring physician in advance of the formal written report. Examples include:
A. The probable detection of conditions carrying the risk of acute morbidity and/or mortality which may require immediate case management decisions.
B. The probable detection of disease sufficiently serious that it may require prompt notification of the patient, clinical evaluation or initiation of treatment.
C. In these circumstances, the radiologist, or his or her representative, should attempt to communicate directly (in person or by telephone) with the referring physician or his or her representative. The timeliness of direct communication should be based upon the immediacy of the clinical situation.
D. Documentation of actual or attempted direct communication is appropriate in accordance with department policy, legal advisability, understanding with the referring physician, and individual judgement.
E. Any discrepancy between an emergency or preliminary report and the final written report should be promptly reconciled by direct communication to the referring physician or his or her representative.
The full document is available on the CAR website, www.car.ca.
2007 License renewals due by January 5
Annual Licensing renewal forms will be mailed to College members in mid-November. Physicians who have not received their renewal packages by December 8 are asked to contact the registration department (see below). Please notify the College of any recent address changes or if you will be out of the province in December 2006.
College members with internet access have the option of renewing and paying for their 2007 license using a simple online renewal form. Information on using the online option will be distributed with the license renewal forms. Online re-registration can be paid with VISA, MasterCard or American Express and involves no additional charge.
If you do not wish to renew your Nova Scotia license for 2007 please be sure to notify the College in writing prior to January 5, 2007.
2007 License Renewal Deadlines (All times AST)
2007 Fee
Re-registration form and fee processed online or received by the College before 4 pm, January 5, 2007. (Payment and form must be received before this date for the fee to apply).
2007 Late Fee
Re-registration form and fee processed online or received by the College from 4 pm, January 5, 2007 until 4 pm, January 31, 2007.
2007 Reinstatement Fee
Re-registration form and fee received after 4 pm, January 31, 2007. (Immediate Suspension – Requires Reinstatement).
For further information, or if you have not received your renewal form in the mail by December 8, 2006, please contact the registration department by phone at (902) 482-2925, toll-free in Nova Scotia at 1 (877) 282-7767, or by e-mail at registration@cpsns.ns.ca.
2007 Incorporation renewals due by December 1
Incorporation renewal forms for 2007 were mailed in late September and are due by December 1, 2006. If you have not received your forms by October 31, please contact the College.
Please note, for your convenience, renewal fees are now payable by Visa, MasterCard and American Express Cards. Please complete the credit card information box on page two of Form “B” if you choose to use this method of payment.
If the College has not received the payment and renewal form on or before Friday, January 5, 2007, the permit to practice medicine under that corporation will be suspended and subject to a reinstatement fee of $100, in addition to the annual renewal fee.
For further information, please contact Ann Chipman by phone at (902)421-2213, toll-free in Nova Scotia at 1 (877) 282-7767, or by email at achipman@cpsns.ns.ca.
Doctor to doctor: What to do when you receive a College complaint
By Dr. Dawn Ross
Editor's Note: Dr. Dawn Ross is a psychiatrist practicing in Halifax. She sits on the College's Investigation Committee “B”
- Don't panic. Call the CMPA (if you are a member) to seek legal advice and support.
- Remember that the College is legislatively obligated to investigate every written complaint it receives, regardless of its triviality.
- Secure the chart and all documents related to the case. You will need to send copies of everything related to the case to the College.
- Maintain a record of your activities and correspondence related to the investigation.
- Recognize the value of your legal counsel in helping you place the seriousness of the complaint in perspective.
- Find a confidential confidante for support. Don't try to go through the process alone.
- Prepare your response promptly, and remember …
- Know the details of the case
- Keep it simple but complete
- Don't be defensive, political or abusive
- Accept responsibility for what is yours
- Recognize the value of apologizing when appropriate
- Don't blame the patient
- Be honest and forthright
8. Be prepared for the process to take up to a year, depending on its complexity.
What to do if you are asked to appear before an Investigation Committee
- Don't panic. This is your best chance to tell your side of the story and show yourself to be a good physician.
- Don't be late. Worse yet, don't be a no-show.
- Dress professionally. Jeans or sweats send the wrong impression.
- Come prepared and know your case.
- Bring all notes, charts, etc. Use visual aids if they help you explain a detail or procedure.
- Be respectful. Don't swear, yell, or threaten the Committee.
- Don't worry if you cry, stutter or forget something. The Committee members recognize that we're all human.
- Don't lie or become evasive.
- Keep your presentation concise.
- Remember that you don't have to come alone. You are entitled to bring your lawyer and a support person if you wish.
- Turn off cell phones and pagers.
And Remember:
- Committees may be required by legislation to offer an interview to anyone whose case has not been dismissed. Committees may wish to hear from you and to offer friendly advice, so don't panic!
- The College now has the option of notifying you that you are to be counseled or cautioned and you may accept that in writing rather than appear.
The possible outcomes of complaint investigations are as follows:
(a) The committee may decide to take no further action where there is no evidence that the care provided was below the acceptable standard, unprofessional, or where there is not sufficient information to proceed further with the investigation.
(b) The committee may counsel (advise) the doctor on how to improve his or her conduct or practice.
(c) The committee may caution (warn) the doctor that if the conduct recurs, more serious disciplinary action may be considered.
(d) The committee may issue a reprimand in some cases where there is evidence of professional misconduct, incompetence, or conduct unbecoming. A reprimand is a finding of professional misconduct that is entered on a doctor's formal discipline record. The investigation committee can only issue a reprimand with the consent of the doctor. If the doctor does not consent, the complaint is referred to a hearing committee.
(e) In cases where the investigation committee determines that there is evidence of professional misconduct, incompetence, or conduct unbecoming, it may refer the complaint to a hearing committee.
For advice, information and support during your complaints process, contact the Investigations staff as needed:
Manager of Investigations:
Veronica Livingstone
Phone: 421-2201
Coordinator Committee “A”:
Suzanne Husbands
421-2207
Coordinator Committee “B”:
Corina Osborne
421-2214
College of Physicians and Surgeons of Nova Scotia Main Number:
(902) 422-5823
Toll-free in Nova Scotia : 1-877-282-7767
Continued Care Prescriptions Agreement helps patients, physicians and pharmacists
Editor's Note: Concerns have recently been raised with the College about the existence of the “Continued Care Prescriptions Agreement between the Nova Scotia College of Pharmacists and the College of Physicians and Surgeons of Nova Scotia” which has been in place since September 10, 2004. College members may not have received adequate information about the agreement at the time of its implementation. The College offers the following overview of the agreement and its implications.
Pharmacists in Nova Scotia have for many years been informally renewing prescriptions for patients when their physician was unavailable due to vacation, or when the physician had relocated or died. In many instances, physicians were never informed of these prescription renewals. Like physicians, pharmacists have become more cognizant of legal liability and had begun to refuse to renew prescriptions in these situations, to the chagrin of patients and some physicians.
The Continued Care Prescription Agreement tries to correct what has been done previously informally and provide more restriction to pharmacists renewing patient prescriptions. The agreement tells pharmacists that the College of Physicians and Surgeons of Nova Scotia will not view the renewal of a prescription under very particular conditions as the practice of medicine and therefore contrary to the Medical Act. If pharmacists renew prescriptions without following the terms of the agreement they may be deemed to be practicing medicine without a license and subject to sanction. The following are some particular terms of the agreement:
- the continued care prescription must be reported as soon as reasonably possible to the original prescribing physician or to the primary care physician if different from the prescribing physician
- the pharmacist must “continue” an existing prescription only once. [emphasis added] Further requests for extensions must be handled by the patient's physician or an on-call physician
- the pharmacist must document on their patient record in such a manner to ensure that the prescription will not be “extended” a second time
- the amount of medication must not exceed the previous amount filled or one month, whichever is the lesser
- the medication to be continued must be for a chronic or long-term condition
- the pharmacist must be reasonably satisfied that the physician if available would in all likelihood provide the authorization
- the patient must have an established stable history with no recent changes to dosages or drug therapy
- the original prescription must be with that particular pharmacy and the patient must be obtaining their prescription from that pharmacy
Importantly, the agreement assumes that continued care prescriptions cannot and do not take the place of ongoing medical care and that pharmacists assume full responsibility for extending the refill.
It is of course possible that some pharmacists may not live up to the terms of the agreement but both the Nova Scotia College of Pharmacists and the College of Physicians and Surgeons of Nova Scotia would take this very seriously.
The College encourages physicians who encounter problems with patient care as a result of the agreement to contact the Registrar of the Nova Scotia College of Pharmacists at (902) 422-8528 or the Registrar of the College of Physicians and Surgeons of Nova Scotia at (902) 422-5823.
Below is a link to the full text of the agreement:
www.cpsns.ns.ca/publications/continued-care-Rx-agreement.pdf
Chronic pain symposium October 27 and 28
CDHA Pain Management is presenting a CME-accredited symposium, “Pharmacotherapy of Chronic Pain” on Oct. 27 and 28, 2006 at Pier 21 in Halifax. The symposium will explore different pharmacotherapy options to address chronic pain. Related topics will also be discussed to provide a well-rounded environment to allow clinicians to make the best decision for pharmacotherapy treatment.
After completing the program, participants should be able to understand the current pharmacological approach to management of chronic pain; combine different treatment modalities when managing chronic pain; and manage chronic pain with an increased level of comfort and understanding. To register or for more information, contact Denise Titus by phone at (902) 473-1288, by fax at (902) 473-3398, or by e-mail at denise.titus@cdha.nshealth.ca.
Adverse reaction reporting by health professionals and consumers
Editor’s Note: The following information was kindly supplied by the Marketed Health Products Directorate of Health Canada
Why report?
All marketed health products have benefits and risks. Although health products are carefully tested for safety and efficacy before they are licensed, some adverse reactions may not become evident until the general population uses a health product under “real life” circumstances. By submitting a suspected adverse reaction report, you are contributing to the ongoing collection of safety and effectiveness information that occurs once health products are marketed.
Reported adverse reaction information may contribute to:
• the identification of previously unrecognized rare, or serious adverse reactions;
• changes in product safety information, or other regulatory actions such as withdrawal of a product from the Canadian market;
• international data regarding benefits, risks, or effectiveness of health products;
• health product safety knowledge that benefits all Canadians.
What to report?
Health Canada, through the Canadian Adverse Drug Reaction Monitoring Program, is responsible for collecting and assessing adverse reaction reports for the following health products marketed in Canada: Pharmaceuticals, biologics (including fractionated blood products as well as therapeutic and diagnostic vaccines), natural health products and radiopharmaceuticals.
You do not have to be certain that a health product caused the reaction in order to report it. Adverse reaction reports are, for the most part, only suspected associations.
We want to know about all suspected adverse reactions, but especially if they are:
• unexpected adverse reactions, regardless of their severity (not consistent with product information or labelling);
• serious adverse reactions, whether expected or not;
• adverse reactions related to recently marketed health products (on the market for less than 5 years).
How to report?
Complete the adverse reaction reporting form which can also be obtained by e-mailing cadrmp@hc-sc.gc.ca.
By contacting your Regional Adverse Reaction Centre:
Toll-free phone: 1-866-234-2345
Advisory Committee on Bloodborne Pathogens: An update
The Advisory Committee was established in 1999 to meet the Health Canada (now the Public Health Agency of Canada, or PHAC) recommendation that expert panels be established in each province to evaluate health care workers (HCWs) infected with HIV, hepatitis B, or hepatitis C in regards to their risk for transmitting a bloodborne pathogen in the work setting. Current members of the Committee are: Dr. Lynn Johnston (expert in infectious diseases and infection control), Dr. Nuala Kenny (expert in medical ethics), Dr. Donald Langille (expert in community and public health), and Mr. Guy MacLean, lay member and former provincial ombudsman. Since established, the Committee has met with and advised six physicians. Its mandate includes practicing physicians and physicians-in-training (medical students and postgraduate trainees).
PHAC guidelines state that HCWs who perform exposure-prone procedures and who learn that they are infected with a bloodborne pathogen, are ethically obligated to report this to their regulatory body. In Nova Scotia, physicians may contact the Advisory Committee by self-referral or through their personal physician. Any one of the Committee members (noted below) may be contacted.
PHAC guidelines also recommend that after a significant exposure from any HCW has occurred, the patient must be notified that he/she was exposed to the blood of a member of the HCW team. The HCW has an obligation to be tested following a significant exposure to the patient. This position is supported by the Canadian Medical Association. Communication with District Health Authorities throughout the province has determined that they are aware that they may be asked to manage patient exposures to a bloodborne pathogen.
Physicians referred to the Committee should be assured that the evaluation is confidential, as is all the information it receives, except as required by law or in cases where it learns that a physician is putting patients at risk by not complying with recommendations.
Committee members can be reached at the following numbers:
Dr. Lynn Johnston: 473-5553
Dr. Nuala Kerry: 494-3801
Dr. Donald Langille: 494-1312
Mr. Guy MacLean: 429-9412
Please refer to the Winter 2004 Alert newsletter for further information about the Advisory Committee.
Registered Nurses must have a license when administering immunizations and/or performing registered nursing competencies
The College has become aware that physicians may occasionally employ individuals who are not licensed with the College of Registered Nurses of Nova Scotia (CRNNS) to administer immunizations at certain times of the year. Physicians are advised that immunizations or other competencies considered to be within the realm of the practice of registered nursing as defined in the RN Act (2001) may only be performed by registered nurses holding current active-practising licences. Otherwise, such individuals are effectively practicing registered nursing without a licence, do not have liability coverage with the Canadian Nurses Protective Society (CNPS), and are not "protected" by their employer's liability coverage. In addition, these individuals may be subject to disciplinary action by the College of Registered Nurses of Nova Scotia.
Reporting potentially unfit drivers to the Registry of Motor Vehicles
Physicians can report a patient that they have deemed unfit to drive by writing a letter on their official letterhead or by completing the Driver's Medical Examination Report form. This form is available through the Department of Service Nova Scotia and Municipal Relations. Physicians can also report a patient who is questionable in terms of fitness to drive.
When reporting, please include the patient's full name, address, date of birth, gender and driver's master number if available. It is also helpful to include a current diagnosis or any medications, treatment, or prognosis that would help the Registry of Motor Vehicles in determining an appropriate course of action.
Information can be forwarded to the medical section of Service Nova Scotia and Municipal Relations, Maritime Centre, 9 North, 1505 Barrington Street, Halifax, B3J 3K5, by faxing 902-424-0772 or calling 902-424-5732. For further information, please contact the department's Medical Fitness Coordinator, Lori Payne at 902-424-7521 or e-mail paynelk@gov.ns.ca.
College receives major national healthy workplace award
The College is one of two Canadian organizations to receive the 2006 Canada Award for Excellence Healthy Workplace Award Gold Trophy from the National Quality Institute.
“The College works hard to encourage the physical, mental and emotional well-being of its employees,” said Dr. Rex Dunn, College President. “Our experience shows that a healthy workplace pays tangible dividends, and we strongly encourage all organizations to make health and wellness part of their business plans.”
The College's healthy workplace program includes progressive human resource policies; fitness allowances; nutrition, stress management, and ergonomics training; onsite health monitoring and comprehensive healthcare benefits.
In related news, College staff raised $634 in this year's Run for the Cure, a fundraiser for the Canadian Breast Cancer Foundation.
New website helps problem gamblers
Problem gamblers throughout the province now have a new resource to help them address and cope with gambling addiction. WebGAM (www.cdha.nshealth.ca/webgam/index.html), a new online service for people with gambling addictions, offers links and resources for people needing help. WebGAM was created by Capital Health's Addictions Prevention and Treatment Services with $60,000 in funding from the Nova Scotia Gaming Foundation.
Physicians asked to report possible Q-Fever
Nova Scotia physicians are asked to continue to consider Q-fever in their patients who present with pneumonia or a febrile illness who had exposure to parturient cats, cattle, sheep or goats. To date there have been 13 cases of acute Q-fever diagnosed during the study's evaluation of acute Q-fever in the Maritimes. Eleven of these patients have enrolled in the study. The study is now approaching its final year and hopes to find and recruit more patients with acute Q-fever with the aid of Nova Scotia physicians.
Q-fever is very infectious by aerosol and exposure may be minimal. Features of Q-fever pneumonia include: 1 or more cases of pneumonia in a family, 1 or more rounded opacities on chest x-ray, pneumonia within two weeks of exposure to parturient cats, cattle, sheep or goats.
If a patient is suspected to have Q-fever, please send a tube of clotted blood to: QE11 Health Sciences Centre / MacKenzie Bldg, 5788 University Ave., Halifax, N.S.
If the serology shows acute Q-fever, the study organizers will contact the family physician to ask for permission to contact the patient regarding the study. Enrollment involves patients providing 2 urines, 2 blood samples, and a phone questionnaire.
For futher information, please contact:
Dr. Todd Hatchette, QEII Health Science Centre
Phone: 902-473-6885
Pager: 902-473-2220 pager 7865
Directory of French-speaking primary health care providers
This directory was developed for Acadians and francophones in Nova Scotia to improve their access to French-speaking primary health care providers.
The directory offers a list of French-speaking health professionals who are willing to offer primary health care services in French.
The directory is now accessible at www.gov.ns.ca/health/frhcp.
The College's physician listing can also be searched by language spoken.
Change of Name, Address or E-mail?
The College depends solely on submissions from members to keep its address information up to date. For members' protection, the College requires that change requests be submitted in writing. Address changes submitted by e-mail are acceptable if the e-mail is sent from the e-mail address the College has on record for the member.
Third-party change requests are not accepted. Name changes must be accompanied by the appropriate legal documentation. Address or name changes can also be submitted on an Address or Name Change Notification Form, which is available on the website at http://www.cpsns.ns.ca/address-name-change-form.htm or by contacting the College by phone at (902) 422-5823 or toll-free in Nova Scotia 1-877-282-7767, by fax at 902-422-5035, or by e-mail at registration@cpsns.ns.ca.
How to Contact the College
A complete list of College contacts is available HERE.
