Spring/Summer 2007
Physician feedback on complaints and investigations used to improve process
As part of its ongoing quality improvement process, the College recently commissioned an anonymous survey of 164 physicians who received complaints that were resolved in 2006. The response rate was 52 percent. Overall, respondents were satisfied with the fairness and management of the process, but concerns were expressed regarding the length of the process, the stress it produced for the respondents and the thoroughness of written decisions. Work is underway to address these concerns.
Summary of key quantitative findings
Agreement with the following statement: Overall, I was satisfied with the services I received from the College.
67%: Agree / Strongly Agree
15%: Neutral
18%: Disagree / Strongly Disagree
The following statements received index scores of 70 or above, indicating generally strong levels of agreement or support:
- I am confident that all information regarding the complaints was kept confidential (Index Score: 78)
- I was treated fairly (Index Score: 73)
- I would benefit from access to a confidential support person during the investigation process (Index Score: 70)
The following statements received index scores below 70, indicating weak agreement or need for improvement:
- I was provided with reasons for the decision (Index Score: 55)
- I would benefit from an educational session on how to avoid a complaint (Index Score: 49)
Summary of key narrative findings
Themes that emerged in narrative feedback are listed below in approximate order of frequency:
- The complaints and investigations process can be stressful for the physician involved. Some sort of personal support should be available to augment the services provided by the physician's legal counsel.
- Committee decisions should be more clearly explained or justified.
- The Investigations Committee was fair when examining the complaint.
- The complaints and investigations process takes too long.
- The College exists to regulate the medical profession and the complaints process is a necessary part of that mandate.
- The College was helpful and provided the necessary information.
- Frivolous complaints should be diverted from the formal investigations process.
- The investigations process should account for patients who irresponsibly submit complaints about multiple physicians.
Acting on the findings
Efforts are underway to use the research findings to improve the complaints and investigations process where possible. These include:
- The College is working closely with Doctors Nova Scotia to designate one or more individuals to serve as “physician navigators.” These physicians would provide emotional, moral and informational support to physicians undergoing complaint investigations.
- The investigations committees have begun to produce decision letters that more fully describe the decisions and the underlying reasoning.
- Enhancements are being examined that would allow committees to more efficiently process frivolous complaints within the terms of the Nova Scotia Medical Act.
- As part of the College's ongoing quality initiative, administrative enhancements and benchmarking are being used to enhance the efficiency of the complaints and investigations process.
The College extends its thanks to all physicians who submitted the survey. Further information about the complaints and investigations process is available at www.cpsns.ns.ca/publications/complaints-discipline-process-physicians.htm or www.cpsns.ns.ca/publications/investigations-faq.html or by contacting the College.
From the Investigations Committees
The following summaries describe cases examined by the College's Investigations Committees. This information is provided for educational purposes. Names and certain details have been changed to preserve confidentiality.
Inappropriate personal comments
Mr. C, 63-year-old male, was referred by his family doctor to Dr. D for poorly controlled blood pressure. Mr. C was seen by Dr. D, who recommended an echocardiogram and added another medication to his regimen. Two weeks later, Mr. C filed a complaint, alleging that during the consult Dr. D had asked him “Why is everyone in your town unemployed?” and told Mr. C, “If you got a job you might lose some weight and your blood pressure would be okay.” Mr. C felt the comments were unnecessary and rude. He expected the specialist to be more professional. Mr. C did not fill the prescription Dr. D had given him and returned to his family doctor asking to see another specialist.
Dr. D was interviewed by the Investigation Committee and admitted he had made the statements without thinking and was only trying to emphasize to the patient the need to lose weight.
The Investigation Committee agreed that the comments were unnecessary and unprofessional. Dr. D received a written Counsel from the Committee to refrain from unwarranted comments and to conduct himself in a professional manner at all times.
Disclosure of pertinent positive and negative diagnostic findings before securing consent
Ms. K is a 13-year-old female who had been referred to a Dr. M for recurring right-sided pelvic pain. Her family doctor had ordered a pelvic ultrasound prior to the consult. Dr. M saw Ms. K in consult 2 weeks later, at which point he ordered a pelvic CT scan. The pelvic scan showed a 2 cm mass in the pelvis. In follow-up with Ms. K and her mother, Dr. M recommended a laparoscopic examination.
The ultrasound, which had been conducted in another hospital, did not show a mass. Dr. M received the ultrasound report after the consult and prior to the procedure.
One week later, Ms. K underwent the laparoscopic procedure with no problems. No masses or abnormalities were noted. Dr. M reported his finding to Ms. K and her mother, by saying “I guess the ultrasound was right after all.” Ms. K's mother asked Dr. M what he meant. At this point, Dr. M explained about the negative ultrasound finding.
One month later, Ms. K's mother filed a complaint which stated that in failing to disclose the negative ultrasound finding, Dr. M had not allowed for informed consent for the laparoscopic procedure.
Dr. M met with the Investigation Committee and acknowledged that he had not disclosed the ultrasound findings during the follow-up consult or on the day of the procedure when the mother signed the consent for the procedure. It was Dr. M's opinion that the investigation was warranted, even with a negative ultrasound, as the pelvic CT showed a mass. He acknowledged that he did not discuss the ultrasound with Ms. K or her mother. He reviewed his standard approach to discussing risk and benefits of a laparoscopic procedure prior to obtaining consent.
The Investigation Committee was of the opinion that Dr. M had used reasonable judgment by recommending and conducting the laparoscopic examination, but felt the negative finding of the ultrasound should have been disclosed to the patient and her mother. Dr. M received a written Counsel to disclose all pertinent positive and negative findings of investigations when recommending treatment or further investigations.
Correct disposal of sharps and other contaminated waste
Ms. Y, 38-year-old female, had an appointment with Dr. X for the removal of a small cyst. The procedure was done in Dr. X's office without any problems. However, upon leaving the office, Ms. Y felt something sharp in her foot. She looked down to notice a syringe on the office floor. Dr. X explained that it was the syringe used for her freezing and not to worry. He picked it up and put it in a sharps container next to the exam table.
One week later, Ms. Y returned to Dr. X's office for suture removal. While she was waiting to see Dr. X, she noticed a syringe lying next to the sharps container. Dr. X came into the room and removed the sutures. Upon leaving, Ms. Y pointed out the syringe to Dr. X, who responded that she “must have missed it again.”
Ms. Y filed a complaint to the College, stating Dr. X did not seem to appreciate the safety issue of needles on the floor and hoped the College could get Dr. X to change the way in which she disposed of sharps.
In her response to the complaint, Dr. X admitted that she had “missed a few times” but since she received the complaint she had moved the sharps container to an office shelf, next to the exam table.
The Investigation Committee appreciated the changes made by Dr. X, but had concerns the changes had only been made after a complaint had been made, not after the patient had received a needle-stick injury.
Dr. X received a written Caution from the Committee, to ensure that used sharps and other biohazardous wastes were used in manner that would decrease the risk of an injury to patients and others.
CAR standard: Radiologists should directly communicate certain reports
When a diagnostic imaging study is interpreted by a radiologist and an unexpected abnormal finding is present of urgent clinical significance, the reporting radiologist must take extraordinary measures to see that this finding is communicated to the attending or ordering physician in timely manner. This expectation applies equally to studies referred from Emergency Department settings as to those from community practice. Examples would be a pneumonia, the presence of which is not indicated in the history; an unexpected fracture; or findings suggestive of malignancy in a patient not known to have cancer.
These measures would preferably involve an expedited personal two-way communication (i.e. in person or phone call) whereby the receiving physician is able to acknowledge receipt of the report. Faxing a printed report without acknowledgement of its receipt is less than desirable. Clearly the delays involved in transcription and delivery of paper results to the attending physicians in this situation are unacceptable.
This advice is consistent with the “CAR Standard for Communication in Diagnostic Radiology” (www.car.ca/en/about/standards/library/communication.pdf), Section IV (approved June 1997 and reviewed September 2001).
NSPAR program review: Physicians describe their practice improvements, suggest program enhancements
The Nova Scotia Physician Achievement Review Program (NSPAR) has just received preliminary results from a program evaluation survey designed to collect feedback from physicians who have completed the NSPAR review process. Although the results from this first review are qualitative in nature, they provide an indication of how physicians view the process and the feedback they receive in their NSPAR reports.
The following is a summary of some of the narrative feedback received from physicians who completed the review process and responded to the survey. The response rate was 25 percent.
Practice improvements undertaken by physicians based on the results of their NSPAR review:
- Improving communication practices, such as quality of handwriting and consultation letters. (46% of respondents)
- Undertaking practice-management CME. (36% of respondents)
- Undertaking condition-specific CME. (18% of respondents)
- Enhancing access, including better phone and pager connections. (16% of respondents)
- Instituting better record-keeping practices, including use of flow sheets and electronic medical records. (14% of respondents)
- Paying more attention to personal stress management. (11% of respondents)
- Improving patient wait-times with more efficient office procedures. (8% of respondents)
- Changing office practices to enhance patient confidentiality. (5% of respondents)
- Improving office layout. (3% of respondents)
Comments regarding general strengths of NSPAR:
- Useful evaluation tool; preferable to random office audits. (44% of respondents)
- Positive feedback and positive experience. (25% of respondents)
- Demonstrates to the public that meaningful professional review is undertaken. (22% of respondents)
Comments regarding possible improvements to the NSPAR program:
- Finding appropriate CME can be a challenge, particularly for rural physicians. (27% of respondents).
Physicians are encouraged to visit the Physician Resources section of the NSPAR website for a complete list of CME offerings; many of which are available by videoconference, home study, and in smaller communities.
- Length of time for the NSPAR report to be returned to the reviewed physician. (5% of respondents).
The average time from the start of the review to receipt of the final report by the physician is about four months. This period is dependent upon how quickly the physician responds once receiving the NSPAR package and how promptly medical colleagues and co-workers complete their respective surveys.
- More one-on-one peer advice should be available for physicians who have questions or concerns about their NSPAR review. (5% of respondents).
Physicians seeking such support are encouraged to contact Dr. William Lowe, NSPAR Medical Director, at (902) 421-2205 or Dr. Douglas Sinclair, Associate Dean, Continuing Medical Education, Dalhousie University at (902) 494-1236.
For more information about the NSPAR program, please visit www.nspar.ca or contact Mary Power, Program Manager, at (902) 482-2921.
CAPP assesses 20 more candidates
The Clinician Assessment for Practice Program (CAPP) held its fourth assessment on June 4 and 5, 2007. Twenty candidates from across Canada participated. The Credentials Committee of the College will meet in the latter part of August to review the assessment reports and determine eligibility for defined licensure.
Please see the website www.capprogram.ca or contact Gwen MacPherson, CAPP Program Manager at (902) 482-2917 for more information.
PMP moves to full online submission for pharmacies, old Rx pads to be voided by August 31
Online pharmacy claim system
The Nova Scotia Prescription Monitoring Program (NSPMP) initiated a new on-line system in July 2005. Approximately 80% of Nova Scotia pharmacies are now on-line and submitting claims electronically.
The continued existence of ‘off-line' pharmacies has provided some individuals with the ability to obtain monitored drugs for the purposes of diversion or abuse. To fulfill the Program's mandate of promoting the appropriate use of and reducing the abuse of monitored drugs, the NSPMP has passed a resolution requiring that all pharmacists and pharmacies provide prescription information on monitored drugs to the NSPMP Administrator in electronic format by December 1, 2007.
Old triplicate pads voided as of August 31
With the development of the online prescription monitoring system, new prescription pads, which include a unique prescriber identifier, were created and distributed in July 2005.
Some physicians continue to use old prescription pads for the PMP. These physicians will be notified that the old pads will be voided in the PMP system as of August 31, 2007.
New pads may be obtained by contacting the PMP office by phone at (902) 496-7123. New pads will be forwarded the next business day.
Further information is available on the College website at http://www.cpsns.ns.ca/pmp-resolution-online-data-submission.pdf and http://www.cpsns.ns.ca/2007-may-pmp-bulletin.pdf or by calling the NSPMP at (902) 496-7123.
Proposed network to enhance delivery of pain treatment in NS
Editor's Note: The College thanks Dr. Peter MacDougall for providing the following information about the proposed Nova Scotia Chronic Pain Collaborative Care Network (NSCPPCCN). For further information about this project, please contact Dr. MacDougall at PCMACDOU@DAL.CA.
Chronic Pain has become increasingly recognized as a significant health problem throughout the world. Recent studies globally and in Canada have estimated that 20 to 30 percent of the population suffers from significant chronic pain conditions. While many chronic pain conditions are treatable, access to care remains a formidable barrier. This is a true of many aspects of medicine and has driven a movement to optimize the available specialist and generalist resources in the health care system.
One method of resource optimization that has proven particularly successful is the mentor-mentee network model. In short, a group of primary care physicians is matched with a specialist who provides advice, support and CME. The primary care physicians have both synchronous and asynchronous access to the specialist via secure e-mail, telephone or face to face meetings. Such a network has been functioning in Ontario providing assistance to primary care physicians with the provision of mental health care. It has proven to be a very successful network with approximately 500 primary care physicians involved throughout Ontario. Furthermore, this network has proven to be extremely cost effective, at a cost of less than $1.00 per patient served per year.
While Nova Scotia boasts a world class multidisciplinary Pain Management Unit in Halifax, the wait time for initial assessment may be as much as three years. Currently, there are provincial plans to increase pain management services throughout the province through the Provincial Implementation Plan for Chronic Pain. In concert with the development of new pain management clinics throughout the province we have proposed a mentor-mentee network similar to that serving the mental health needs in Ontario.
The proposed Nova Scotia Chronic Pain Collaborative Care Network (NSCPCCN) will have three parts; research, CME, and collaborative care. Research will be an ongoing component of the program initially introduced as a Pragmatic Cluster Randomized Controlled Trial (PCRCT), an unblinded trial of introducing the network to one of two health care districts for one year and measuring patient and physician outcomes. The research will continue as part of an ongoing Quality Assurance program integral to the program. CME will be provided formally through two annual conferences and informally by communication with the mentor. CME credit will be provided for both the formal and informal components of the CME. Finally, but by far most important is the actual collaborative care network, matching pain specialists with groups of primary care physicians. The goal of the NSCPCCN is to increase the capacity for primary care chronic pain services and support across the province.
NS physicians with methadone licenses asked to provide input to Offender Health Services
Editor's Note: The College thanks Dr. Risk Kronfli for providing the following information about the Formulary Review Committee for Offender Health Services.
Physicians who hold methadone licenses are encouraged to contact the Formulary Review Committee for Offender Health Services to assist in creating evidence-based protocols, policies and guidelines regarding Methadone and psychoactive substances for a new provincial program. The committee would be interested in receiving information about existing program policies, guidelines and processes, as well as available statistics. Recommendations for the new program would also be welcome.
Input would be appreciated as soon as possible. Please contact Dr. Risk Kronfli by telephone at (902) 460-7300 or Christina Gerstenecker by e-mail at christina.gerstenecker@cdha.nshealth.ca.
Physicians who have questions, wish to be involved in the process, or who would like to be notified of its progress are encouraged contact Dr. Kronfli or Ms. Gerstenecker.
Susan Williams honoured for 30 years of service
Susan Williams, the College's Registration Manager, was recently honoured for 30 years of service. “We get a lot of praise from applicants and licensees about Susan's thoughtfulness and dedication,” said Dr. Cameron Little, Registrar and CEO.” “She exemplifies our focus on top-quality work and attention to detail.”
Referring a child to the Children's Wish Foundation
Children aged 3 to 17 with a high-risk, life threatening condition who are legal residents of Canada are eligible to be granted a wish by the Children's Wish Foundation of Canada. While anyone can refer a child, the child's parents or legal guardians must communicate their interest directly to Foundation. For information about referring a child to the Foundation, contact the Nova Scotia Chapter by phone at 902-492-1984 or by e-mail at Cheryl.Matthews@childrenswish.ca. The Foundation's website is www.childrenswish.ca.
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.
