Winter 2003
District 5 Ballots Due by Friday, April 11
Two seats representing District 5, which consists of the county of Halifax (including Metro Halifax-Dartmouth) are being contested in the College's 2003 Council election.
The six candidates in District 5 are:
Dr. Ethel Cooper-Rosen
Practice: Family Practice and Obstetrics
Dr. Maureen C. Nolan
Practice: Radiation Oncology
Dr. Barbara Mary Parish
Practice: Obstetrics and Gynaecology
Dr. Colin Powell
Practice: Geriatric Medicine
Dr. Ronald Thomas Tanton
Practice: Gastroenterology
Dr. Arthur W. Zilbert
Practice: Obstetrics and Gynaecology
A more complete biography of each candidate is contained in the ballot package that was mailed to members in District 5 on Wednesday, March 19. Completed ballots must be received by the College no later that 8:30 am on Friday, April 11.
District 5 members who have not received their ballot packages by Friday, March 28 are asked to call Carolyn MacDonald at (902) 421-2209.
Scrutineers will count ballots at the College offices starting at 9:00 am on Friday, April 11. Candidates are welcome to attend.
College to Host Emerging Infections CME
On Saturday, May 31, the College will host a CME-accredited symposium entitled “Risk of New Infections: Perception and Reality” that will take place in the Port Royal Room of the World Trade and Convention Centre in Halifax between 8:30 am and 12:50 pm. The College's Annual Meeting will follow from 1:00 pm to 1: 30 pm.
The keynote speaker will be Mr. David Ropeik of the Harvard University Center for Risk Analysis, who will discuss public perception of risk. Also speaking will be Dr. Maureen Baikie of the Nova Scotia Department of Health, who will discuss public health management of new infections; Dr. David Haase of Dalhousie University, who will discuss West Nile Virus infection; and Dr. Joanne Langley of Dalhousie University, who will discuss Enterohemorrhagic E. coli infection.
The symposium is free and open to all. Although registration is not required, physicians who wish to receive CME credit for their attendance must remit a $20 CME credit processing fee. Details about symposium topics, speakers, and how to receive CME credit will be forwarded to College members in April. For further information in the meantime, please call Dawne Miller at (902) 421-2208.
Results of CPSNS Online Member Survey Released
Thanks go out to the 467 College members who completed survey questionnaires that were distributed by e-mail in late January. In response to the survey findings, the College will undertake to make its guidelines and physician listing available for download to Palm Pilot and Windows PDA devices through its website. Also in response to the findings, the College will not accept paid advertising in the Alert newsletter.
The survey allowed members to submit comments on the College and its services. Comments focused on members' wishes to have College information available for handheld devices, concerns about the annual licensing fee, interest in receiving College guidelines, dissatisfaction with the College's voicemail system, and eagerness to be able to re-register online.
In keeping with the College's desire to provide the best possible service to its members, an annual online survey will be conducted in future.
Below is a summary of the 2003 online member survey findings.
If the College offered a free service that enabled you to download the Annual Listing (Nova Scotia physician listing) to a handheld device, such as a Palm Pilot or Windows PDA, would you:
Never use this service: 27%
Consider using this service: 50%
Be very eager to use this service: 23%
If the College offered a free service that enabled you to download documents such as “Guidelines for Conscious Sedation” or “Guidelines for the Use of Controlled Substances in the Treatment of Pain” to a handheld device such as a Palm Pilot or Windows PDA, would you:
Never use this service: 19%
Consider using this service: 44%
Be very eager to use this service: 37%
How often do you read the PAPER version of the College's “Alert” newsletter?
Never: 10%
Occasionally: 39%
At least each time it comes out (three times per year): 51%
How often do you read the ONLINE version of the College's “Alert” newsletter?
Never: 40%
Occasionally: 39%
At least each time it comes out (three times per year): 21%
Not including the “Alert” newsletter, how often do you consult the College website or printed College publications?
Never: 21%
Once or twice per year: 42%
Three to ten times per year: 29%
Ten or more times per year: 8%
The College's “Alert” newsletter contains anonymous summaries of selected complaint investigations and outcomes. How would you describe your opinion of these summaries?
Not useful or interesting to me: 3%
Somewhat useful or interesting to me: 48%
Very useful or interesting to me: 42%
I don't read the summaries: 7%
If the College's “Alert” newsletter were to carry advertising from selected businesses NOT involved in medical, pharmaceutical or legal matters, such as restaurants, car dealerships, or real estate firms, would you:
Probably approve of this: 37%
Probably not approve of this: 38%
Probably not have an opinion: 25%
Canadian Online CME Available
MDcme.ca is web portal providing accredited online CME with content support from seven Canadian medical schools. Courses are easy to navigate and can be completed at the participant's convenience.
The online courses at MDcme.ca are MAINPRO-M1 or C accredited (three to five credits per course) and run for three to four weeks. Each course is case-based, and discussion activities are asynchronous in nature, allowing participants to review or post comments at any time via a virtual discussion board. A specialist or GP is available through the duration of the course for consultation, and a help desk is available seven days a week.
Current course offerings include:
• Emergency Medicine: Case Studies (MAINPRO-M1)
• Introduction to Assessment and Management of Dementia (MAINPRO-C)
• Introduction to Telehealth (MAINPRO-M1)
• The Osteoporosis Continuum (MAINPRO-C)
• Management of Whiplash and Back Injuries (MAINPRO-MI)
(Check the website below for current information on these courses)
Courses available in September 2003:
• Management of Arrhythmias
• Parkinson's Disease
• Follow-up Cancer Care
• Cervical Disc Disease
• Lipid Management
Physicians can find information, schedules, and registration information at http://www.MDcme.ca .
For additional information, e-mail rmdcme@mun.ca .
From the investigation Committees : Breach of Confidentiality
I have often regretted my speech, never my silence.
-Publelius Syrus (100 BC)
For physicians, gathering and recording of personal information about patients is a fundamental component of providing medical care. Requests for physicians to disclose personal information may come from many sources, including patients, patients' relatives, employers, insurers, and lawyers. Unfortunately, disclosure of patient information can sometimes result in complaints alleging a breach of confidentiality. The following article summarizes five complaints of breach of confidentiality investigated by the College and offers some advice on avoiding such complaints. Some facts have been changed to ensure confidentiality.
Case 1
Dr. Y had been Ms. A's psychiatrist for approximately one year after which they mutually agreed that she was not benefiting from psychotherapy, so she was discharged from her care. The following year, Ms. A called Dr. Y and in a brief telephone conversation asked her if she would be willing to do an assessment on her behalf for a third party and Dr. Y agreed. One week later a member of the staff of the third party organization called Dr. Y to schedule the assessment and during their telephone conversation Dr. Y talked about Ms. A's psychiatric diagnosis and her former patient's psychiatric history. Later that month when Dr. Y met with Ms. A to complete the requested assessment Ms. A was upset and questioned Dr. Y about what she told the third party during their telephone conversation. During this visit the patient decided not to have Dr. Y complete the assessment. Ms. A then complained to the College that she had not agreed that Dr. Y could release medical information over the phone to staff of the third party. Upon investigation it was determined that Dr. Y did not have a duty to disclose information in the circumstances nor had she clearly obtained the patient's consent to release information to the third party. She was counseled in relation to the complaint.
Case 2
Mrs. W, the widow of a 58 year-old man who died from complications of a respiratory illness, complained that her family doctor breached confidentiality when she released medical information about her deceased husband to an insurance company. Mrs. W stated that the information disclosed from her husband's medical record ultimately led to a denial of her insurance claim. In her response to the complaint, the family physician stated that she had been contacted in writing by the insurance company and asked to provide details of her attendance on the patient during the proceeding three years. She provided the Investigation Committee with a copy of a consent form signed by Mrs. W authorizing the physician to furnish copies and/or give details of all available information about the deceased to the insurer, including details of the deceased's prior medical history. The complaint was dismissed.
Case 3
A 34 year-old man complained that his ex-wife was granted sole custody of their two children, primarily because of a report written by their family physician on behalf of his ex-wife. The complainant stated that the doctor obtained much of the information detailed in her report from his contact with her as his attending physician. Included in the report were details of his past abuse of drugs and alcohol.
The investigation revealed that: The physician was asked by the ex-wife's lawyer to prepare a written opinion on a range of issues related to the ex-wife's application before the court for custody; she acted on this request and not in response to a court order or subpoena; she had the consent of the ex-wife to release information but she did not seek or obtain consent from the ex-husband, who was also her patient, to release his medical information; and she did not identify information sources in her written opinion. The physician was cautioned in relation to the breach of confidentiality.
Case 4
A 52 year-old woman complained that her long-time family physician breached confidentiality when he sent copies of her family's medical records to her lawyer in response to her request that he send information about her health in relation to an auto insurance claim. In his response the physician admitted that through an oversight on his part he had sent a copy of the entire family's medical records to the lawyer who in turn provided them to the insurance company. He explained that at one time it was his practice to maintain a common chart for all members of a family and that he had not reviewed the old record before it was copied to the lawyer. The committee cautioned the physician to review charts prior to their release to ensure that consent had been obtained so that there would be no breach of confidentiality.
Case 5
A 62 year-old man complained that Dr. H, a family physician, breached confidentiality when he disclosed to Dr. C, his then attending family physician, the patient's plans to sue Dr. C for failing to diagnose his illness. Dr. H stated that after opening his new practice he had a single, brief appointment with the complainant during which the patient told him that he was looking for a new doctor because he was suing his current doctor. Dr. H indicated that he told the patient that as he could only accept patients into his practice who did not have an existing family doctor, he would need to check around that he was not “stepping on anyone's toes.” When he called Dr. C to ensure there was no conflict if he accepted the patient on his roster, he assumed she was aware of the legal action by her patient. He casually referred to the lawsuit and at that time it became clear that Dr. C was unaware of her patient's intention to sue her. Dr. C subsequently asked the patient to find a new physician in view of his impending lawsuit. The patient complained to the College that Dr. H had breached confidentiality. The committee concluded that while Dr. H had inadvertently disclosed information to Dr. C about the impending lawsuit he had not breached confidentiality as he had not disclosed any medical information and had not yet established a doctor- patient relationship. The complaint was dismissed.
Comments
Requests for medical information arising from legal proceedings such as divorces, custody hearings, criminal investigations or insurance claims appear to increase the risk of a complaint of breach of confidentiality. When you are asked to prepare reports or provide copies of medical records it is important to obtain the appropriate consents prior to release. If it appears that the person seeking information does not have consent or proper authorization the information should not be disclosed.
Occasionally, requests for records arrive in the form of a subpoena. It is important to remember that a subpoena alone, without the patient's consent, does not authorize a physician to disclose medical information. A subpoena does require the physician to attend court with the information described in the subpoena, in which case the court will direct what information, if any, must be disclosed.
Patient authorization for release of medical information is not required where there is legislative authority for the production of confidential information. For example, physicians are required to report any concerns or suspicions of child abuse or neglect, or if presented with a search warrant regarding medical records or practice, they are required to comply with the warrant. Later this spring, the College will distribute an information booklet to members that will assist them in identifying circumstances where there is legislative authority to disclose patient information without consent.
If you have any doubts about releasing records or what information you can disclose in letters or reports, consult legal counsel or contact the College for assistance.
Department of Health Recommendations for Completion of the Medical Certificate of Death for Expected Deaths in Nursing Homes
The following Recommendations for the Completion the Medical Certificate of Death for Expected Deaths in Nursing Homes have been endorsed by a working committee of the Nova Scotia Department of Health, which consulted with various individuals and organizations during their preparation, including the Medical Society of Nova Scotia and the College of Physicians and Surgeons of Nova Scotia. The College is reproducing this information for the information of its members.
Background
There are currently a number of problems relating to the completion of Medical Certificates of Death for expected deaths of nursing home residents. It is important to nursing home staff and residents' families that the bodies the deceased residents be removed in a respectful and timely manner. However, funeral homes are often reluctant to transport remains without a completed medical certificate of death. The Vital Statistics Act places responsibility on funeral directors for completing death registration forms, which include the medical certificate of death. The registration form must be completed before a burial permit can be obtained. According to the Act, a burial permit is necessary before a deceased person can be removed from a health care institution; transported; cremated; or buried.
Nursing home staff and/or funeral directors sometimes have difficulty obtaining the signature of a physician on the death certificate in a timely manner. The Vital Statistics Act states that the medical certificate of death should be signed by “the medical practitioner who was last in attendance during the last illness of the deceased or the coroner who conducts an inquest on the body or an inquiry into the circumstances of the death.” Problems arise when the attending physician is not available or reachable. There is also a lack of clarity regarding who can sign under the Act. Consequently, an on-call physician who is covering for the resident's regular physician may be reluctant to sign. There are also questions about the need for a physician to travel to the nursing home or view the body. Involving a medical examiner in an expected death is not necessary or practical on a regular basis.
The importance of death registration
Death registration serves two purposes. First of all, the completed death registration form is a permanent legal record of the death of an individual. It records the personal information about the deceased and the details of the circumstances of death that are legally required to issue a burial permit and to settle the estate, insurance, and pensions. A completed Medical Certificate of Death is required before visitation and funeral arrangements can be finalized and before funeral directors can begin to prepare the remains of the deceased for disposition. Timely completion of the Medical Certificate of Death is especially critical in cases where religious customs dictate that burial take place within a day.
Secondly, death registration forms, specifically the Medical Certificate of Death, are the source of mortality statistics. These statistics form the basis of the oldest and most extensive public health surveillance systems. They provide information on characteristics of the people who die and the vitally important information on the cause of death. These statistical data are the source of information used in Canada, and most other countries, for the preparation of statistics on causes of death. These statistics are indispensable, locally and nationally, in public health surveillance, health education and promotion, in medical research and health planning. Research based on mortality statistics is much more meaningful if all details in the deceased person's medical records regarding the precise diagnoses are incorporated in the Medical Certificate of Death.
Physicians, with their responsibility for completing the Medical Certificate of Death, play a key role in the Canadian death registration system. The quality and value of the statistical data derived from death registration forms has been for many decades – and continues to be – dependant on the certifier's care and judgment in providing complete and accurate information on the Medical Certificate of Death. Timely completion of the medical certificate of death supports the families of the deceased by enabling them to finalize funeral arrangements and begin the process of settling the estate.
Recommendations
The process for obtaining a completed Medical Certificate of Death is recognized to be a collaborative effort among physicians, nursing homes and funeral directors that focuses on the needs of the family and friends of the deceased.
The completion of the death certificate must be timely, i.e. within 24 hours of the death. In some cases the completion may need to be done even sooner than that due to particular circumstances, e.g. where the remains are to be transported outside the place of residence or the province, for certain religious traditions, etc. The last attending physician to complete this certificate will usually be the resident's regular attending physician at the nursing home. Where the regular attending physician is not available, the doctor on-call for this physician will be asked to complete the form. In the exceptional circumstances when neither of these physicians are able to complete the death certificate, the Medical Director of the nursing home may complete the form. Finally, in very exceptional circumstances where none of the above-mentioned physicians are available to complete the certificate, the Medical Examiner's Office will be contacted.
Although physicians completing death certificates may use their professional judgment and choose not to view the body of the resident at the time of death, they should carefully review the medical records or make the necessary inquiries to satisfy themselves the information provided about the circumstances of the death are correct. If possible, they may also wish to attend upon the body to make the determination of death, particularly if they have any questions about the circumstances of the death.
If the last attending physician is not present at the nursing home at, or shortly after, the time of death or chooses not to come or return to the nursing home, this physician may complete the death certificate elsewhere and fax a copy of the signed original form to the funeral home chosen by the resident's relatives to allow the funeral home to remove the body from the nursing home. Note that a faxed copy of the completed death certificate is now acceptable for the body to be released to the funeral home. The physician who signs this form will be expected to communicate with the funeral home as to how the signed original form will be picked up, taken or sent to the funeral home. The funeral home may not begin to prepare the body for viewing or funeral until it possesses the original signed certificate.
A preliminary review of the implementation of the above procedure will take place in six months and a full review will be done within one year.
Definitions:
“Expected Death” in a nursing home occurs in a resident who has a physical condition or combination of conditions that have been determined to have a natural and expected outcome of death as the result of this condition or conditions.
“The last attending physician” of the deceased resident is the physician who has knowledge of the resident's medical condition that led to the resident's death and was in attendance or had knowledge of the last illness so that the Medical Certificate of Death may be appropriately completed.
It is hoped that this new process will make completing Medical Certificates of Death for expected deaths in nursing homes simpler and more streamlined for all parties involved. Blank death certificates are available in all nursing homes across the province. Physicians requiring copies can contact Vital Statistics at (902) 424-4381 or toll-free at 1-877-848-2578.
FYI: Prescribing of Emergency Contraception Pills by Pharmacists
Regulations that will permit pharmacists to prescribe emergency contraception pills (ECP) have been drafted by the Nova Scotia College of Pharmacists as requested by the previous Minister of Health, Jamie Muir. The regulations are currently awaiting Cabinet approval. To help its members remain abreast of this issue, the College is reprinting the following highlights from a document supplied by the Planned Parenthood Metro Clinic.
Questions and Answers from the Planned Parenthood Metro Clinic
What is the new regulatory change?
The NS Pharmacy Act and regulations have been modified to permit pharmacists to prescribe ECP.
All women in Nova Scotia will now be able to receive ECP directly from their pharmacist without visiting a doctor.
Why was this change put in place?
Despite its safety, effectiveness and unique ability to decrease unintended pregnancies, ECP is underused. This is partly due to the fact that access to ECP is limited for women in Nova Scotia. Given that the treatment must be initiated within 72 hours of the unprotected event and is most effective when it is taken earlier in this time frame (within 12 hours), obtaining a physician's prescription can be challenging for many women. It has been found that many women require ECP in the evenings and on weekends when physicians are difficult to access. Furthermore, there are many women in NS who are unable to locate a permanent family physician. Given these limitations, improved access is needed. Pharmacists are well-positioned to play a role in increasing women's access to ECP. There are over 1,000 pharmacists and 260 pharmacies in Nova Scotia, most of which are open evenings and weekends. To prescribe ECP, limited assessment is needed. Some additional training will be available to those pharmacists needing to upgrade their knowledge and skills.
Is this the first time pharmacists have been permitted to prescribe ECP?
No. In 2001, the BC government made a change to its Pharmacy Act to allow specially trained pharmacists to independently prescribe ECP. In the first two months of this legislative change, 1,200 pharmacists were trained and 90 pharmacies were participating. Over 800 women requested ECP in the first two months and most of the women requested ECP on weekends or during evening hours. There have been no public complaints about this program. ECP is also available from pharmacists in Quebec and in some pharmacies in Toronto as part of a pilot project.
What is ECP? How does it work?
ECP has been in use in North America for over two decades and is an effective method to prevent pregnancy after unprotected intercourse. Sometimes referred to as "morning after pills", ECP consists of two doses of hormone pills, containing either a combination of estrogen and progestin or progestin alone, taken up to 72 hours after unprotected intercourse. The sooner it is taken after the unprotected act, the more effective it will be. Research has shown that ECP can be effective up to five days after unprotected intercourse. In Canada, the only dedicated product specifically approved for emergency contraception is Plan B®, a progestin-only formulation. The most widely used method in Canada is the Yuzpe regimen, a combination of birth control pills administered in two doses 12 hours apart.
ECP works in the same manner as birth control pills to prevent pregnancy. ECP interrupts a woman's reproductive cycle and, depending upon when it is taken, can prevent or delay ovulation, may inhibit transport of the egg or sperm, interfere with fertilization, or alter the endometrium, thereby inhibiting implantation of a fertilized egg. ECP does not cause abortions.
If ECP is a prescription drug, is it safe for women not to see a doctor?
According to the World Health Organization, “there are no known medical contraindications to the use of emergency contraceptive pills.” There is no evidence of adverse risks to an existing pregnancy when ECP is used. The dose of hormones used in ECP is relatively small and it is used for a short period of time, so that the contraindications associated with regular use of oral contraceptives do not apply to ECP. Temporary side effects during treatment with combined estrogen/progestin ECP are fairly common. Approximately 50% of women have nausea, and about 20% vomit. Side effects are less common with progestin-only pills, with nausea occurring in 20% of cases.
Due to its safety, many health organizations, including the Society of Obstetricians and Gynecologists of Canada, have advocated for ECP to have its status changed from a prescription drug to one available ‘over the counter'. Research has shown that women can take ECP safely on their own without a health practioner's involvement.
For a complete copy of this document, or for further information on ECP, contact the Planned Parenthood Metro Clinic at (902) 455-9656.
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 amombourquette@cpsns.ns.ca.
How to contact the College
A complete list of College contacts is available HERE.
