New college data may shed light on issue of sexual abuse by physicians.

During a recent conference on physician health that was cosponsored by the CMA and American Medical Association, physicians learned that there had been an increase in the number of reported cases of abuse of patients by physicians in Ontario. The increase occurred after new legislation made the reporting of suspected sexual abuse mandatory in the province in 1994. Dr. Laurel Dempsey said there was ¿a considerable body of opinion¿ at the College of Physicians and Surgeons of Ontario that there would be a backlog of cases waiting to be reported once the new law took effect. However, it won''t be possible to tell if this backlog actually exists until data have been gathered for at least a few more years.     

Bioethics for clinicians: 8. Confidentiality

Physicians are obliged to keep information about their patients secret. The understanding that the physician will not disclose private information about the patient provides a foundation for trust in the therapeutic relationship. Respect for confidentiality is firmly established in codes of ethics and in law. It is sometimes necessary, however, for physicians to breach confidentiality. Physicians should familiarize themselves with legislation in their own province governing the disclosure of certain kinds of information without the patient''s authorization. Even when no specific legislation applies, the duty to warn sometimes overrides the duty to respect confidentiality. The physician should disclose only that information necessary to prevent harm, and should reveal this information only to those who need to know it in order to avert harm. Whenever possible any breach of confidentiality should be discussed with the patient beforehand.     

Five-year results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

The office practices of 918 physicians selected through stratified random sampling from the College of Physicians and Surgeons of Ontario (CPSO) registry were assessed by peers and the Peer Assessment Committee of the CPSO from 1981 to 1985. The sample comprised 662 general practitioners (GPs) and family physicians (FPs) and 256 specialists in 11 fields. Of the physicians 749 (82%) had neither deficient records nor an unsatisfactory level of patient care. Of the GPs and FPs 97 (15%) had serious deficiencies in one or both areas, as compared with 4 (2%) of the specialists (p2 less than 0.00001). The proportions of certificants of the Royal College of Physicians and Surgeons of Canada and of the College of Family Physicians of Canada (CFPC) with serious deficiencies were low (2% and 3% respectively). Three statistically significant predictors of physician performance were found among the GPs and FPs: age, CFPC membership status and type of practice. Of the 56 physicians who were reassessed 6 to 12 months later 29 (52%) had made the improvements recommended by the committee. Our findings demonstrate the need, feasibility and acceptance of a peer assessment program of office practices in Ontario.     

Huge court fight may be in offing as Ontario college considers penalty for maverick MD

Physicians who practise alternative medicine are paying close attention to the case of an Ontario physician who was found guilty of professional misconduct. The College of Physicians and Surgeons of Ontario says it is simply doing its job.     

Coronary thrombolysis--clinical guidelines and public policy: results of an Ontario practitioner survey.

The Ontario Medical Association (OMA) guidelines for intravenous thrombolysis in acute myocardial infarction were released in March 1988 and contributed to a government decision against special per-case funding to assist hospitals using tissue-type plasminogen activator (tPA). In October 1988, 1512 cardiologists, internists and physician-administrators who were OMA members were mailed a questionnaire seeking their views on the OMA guidelines and related issues. Of the 419 questionnaires (28%) that were returned, 392 contained usable responses. Among the respondents 268 (68%) had used thrombolytic drugs in the preceding 12 months; the mean number of cases was 10.6 (standard deviation 12.9). A strong or a mild preference for tPA over streptokinase was registered by 64% of the respondents; 28% had no preference. However, the self-reported ratio of actual streptokinase:tPA use was about 3:1, and 73% indicated that the government''s funding policy had limited the availability of tPA in their hospital. The respondents were almost equally divided as to whether the policy should be changed. The guidelines were deemed helpful by 85% of the noncardiologists, as opposed to 52% of the cardiologists (p less than 0.005). OMA involvement in developing and circulating such guidelines was supported by 74% of the respondents and opposed by 18%; opposition was more likely to come from those who found the guidelines unhelpful (p less than 0.001). Support for involvement by the College of Physicians and Surgeons of Ontario was much weaker (supported by 32%, opposed by 62%). Overwhelming opposition to government involvement was evident.     

Anesthetist receives jail sentence after patient left in vegetative state.

A former Saskatchewan anesthetist is the first Canadian doctor to be jailed as a result of criminal negligence causing bodily harm. He received a 6-month jail sentence after a 17-year-old patient was left in a vegetative state after an operation. The anesthetist had left the operating room during the procedure and the patient became disconnected from his respirator. Dr. Dennis Kendel, registrar of the College of Physicians and Surgeons of Saskatchewan, says that the sentence "sends a very clear signal to physicians."     

US report on violence in the medical workplace may hold lessons for Canadian MDs.

Concern about the growing incidence of violence against health care professionals has prompted the Young Physicians Section of the American Medical Association to research and develop a publication designed to raise physicians'' awareness. Violence in the Medical Workplace. Prevention Strategies provides some commonsense precautions that could minimize the possibility a physician will fall victim to violence at the hands of a patient.     

The Medical Library Service of the College of Physicians and Surgeons of British Columbia

A unique provincial medical library service has been established in British Columbia. Under the direction of professional librarians, the central library in Vancouver is building an extensive, largely clinical collection while 30 smaller branch libraries in hospitals throughout the province are establishing basic, up-to-date collections. Financial support comes from an annual fee of $25.00 per doctor paid to the College of Physicians and Surgeons of British Columbia. Photoduplication, mail and telephone services meet many reference needs. Reading is vital to continuing medical education. The library works closely with the University of British Columbia''s Department of Continuing Medical Education to bring current medical knowledge to every doctor in British Columbia.     

Importance of and satisfaction with work and professional interpersonal issues: a survey of physicians practicing general internal medicine in Ontario.

OBJECTIVES: To explore the importance of and satisfaction with clinical responsibilities, teaching, research and interpersonal issues among general internists; to understand the barriers to satisfaction in these domains and the usefulness of potential solutions to these problems. DESIGN: Cross-sectional survey conducted from November 1992 to June 1994. SETTING: Ontario. PARTICIPANTS: General internists who were fellows of the Royal College of Physicians and Surgeons of Canada and members of the Ontario Medical Association. Of 1192 physicians, 1007 (84.5%) returned a completed questionnaire; only the 199 who devoted at least 50% of their time to the practice of general internal medicine were included in this analysis. RESULTS: The respondents were satisfied with their primary role as clinicians dealing with complex, undifferentiated problems caring for the total patient and providing consultation. Guidelines for the referral of patients to general internists, computerization of test results, recruitment of general internal medicine fellows and more confidence in the future of general internal medicine were some of the solutions considered likely to increase professional satisfaction. The respondents involved in teaching suggested additional solutions, such as an opportunity to improve their teaching and evidence-based medicine skills and a greater recognition for their teaching efforts. Few of the general internists conducted research, barriers included lack of personal and project funding, and pressure to generate clinical earnings. In the domain of professional interpersonal issues, women were significantly more likely than men to rate having a mentor, peer support groups, ongoing career counselling, promotion and tenure guidelines for parental leave, availability of on-site day care, addressing gender discrimination and adoption of gender-neutral language as likely to improve the work environment. CONCLUSIONS: The primary role of general internists is that of patient-centred clinician. Our findings suggest that general internists want to take responsibility for revitalizing this discipline. The potential solutions generated in this survey may help to promote action that will improve professional satisfaction in the area of clinical responsibilities, teaching, research and interpersonal issues.     

Results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

This paper describes the experience of the College of Physicians and Surgeons of Ontario in developing and conducting a program for the peer assessment of physicians'' office practices that would allow the standards of medical practice to be reviewed and assessed. Following two pilot projects in 1978 and 1979 that demonstrated the need, the feasibility and the acceptance of a peer assessment program the office practices of 391 randomly selected physicians were reviewed in 1981 and 1982. Included in the sample were 255 general/family practitioners and 136 specialists in seven fields. Serious deficiencies were found in the medical records of or in the care provided by 30 of the general/family practitioners and 3 of the specialists, accounting for 8% of the practices studied. The difference between the two groups of physicians was statistically significant (p less than 0.01). No predictors of significance were demonstrated in the general/family practitioner group. When follow-up assessments were done most of the physicians were found to have made the improvements that had been recommended.     

Canadian medical schools before ACMC.

The earliest medical schools were established to supplement apprenticeship, the only route to practice available in colonial Canada. By 1885, eight medical schools were trying to accommodate the volume of new scientific information flowing from Europe. In 1910, when Flexner evaluated the schools against the Johns Hopkins model, some were woefully deficient, but by 1928 all had achieved Class A rating. The 1921 discovery of insulin in Toronto gave impetus to scientific research and, possibly, influenced the formation and funding of the National Research Council in 1934. Clinical specialization expanded, leading in 1929 to the establishment of the Royal College of Physicians and Surgeons of Canada to accredit training and certify graduates. The Association of Canadian Medical Colleges was formed at a meeting of deans to discuss a federal offer of funding and to accelerate the graduation of physicians for the war effort.     

From Hippocrates to facsimile: Protecting patient confidentiality is more difficult and more important than ever before

Although patient confidentiality has been a fundamental ethical principle since the Hippocratic Oath, it is under increasing threat. The main area of confidentiality is patient records. Physicians must be able to store and dispose of medical records securely. Patients should be asked whether some information should be kept out of the record or withheld if information is released. Patient identity should be kept secret during peer review of medical records. Provincial legislation outlines circumstances in which confidential information must be divulged. Because of the "team approach" to care, hospital records may be seen by many health care and administrative personnel. All hospital workers must respect confidentiality, especially when giving out information about patients by telephone or to the media. Research based on medical-record review also creates challenges for confidentiality. Electronic technology and communications are potential major sources of breaches of confidentiality. Computer records must be carefully protected from casual browsing or from unauthorized access. Fax machines and cordless and cellular telephones can allow unauthorized people to see or overhear confidential information. Confidentiality is also a concern in clinical settings, including physicians'' offices and hospitals. Conversations among hospital personnel in elevators or public cafeterias can result in breaches of confidentiality. Patient confidentiality is a right that must be safeguarded by all health care personnel.     

Legal obligation of physicians to disclose information to patients.

Obtaining a patient''s consent is a routine daily process for physicians, although many are unaware of the scope of this legal obligation. In 1980 the Supreme Court of Canada changed the law relating to informed consent; promotion of patient autonomy shifted the focus from a standard of professional disclosure to one of a "reasonable patient." Physicians have a legal obligation to disclose to patients specific information, the scope of which is determined by a court on the basis of a reasonable patient''s expectation and the circumstances of the case. This gives rise to many controversies in the practice of clinical medicine. It is difficult for physicians to know which treatment risks require disclosure, since this is decided by a court in a retrospective analysis of the evidence. Will the court recognize exceptions to the duty of disclosing information? If several health care professionals are involved in a patient''s care who has the duty to disclose information? Can this duty be delegated? This paper provides physicians with guidelines that are consistent with the promotion of patient autonomy and comply with the doctrine of informed consent. In addition, it suggests ways of improving awareness of the doctrine and procedures to ease its application.     

Prepare for more collaboration with other professionals,Manitoba FPs told.

During the recent scientific assembly of the Manitoba chapter of the College of Family Physicians (CFPC), a session was devoted to the ways health care reform has affected family medicine. Doctors listened to guest speakers from the CFPC, Manitoba Medical Association and provincial Ministry of Health, and there was a stimulating discussion about the critical issues facing FPs.     

Certification of specialists: survey of candidates and review of the literature.

To evaluate the specialty certification process, the Canadian Association of Internes and Residents (CAIR) surveyed 634 candidates who had attempted the written and oral exams of the Royal College of Physicians and Surgeons of Canada. The results suggest that in-training evaluation is a more reliable and valid assessment of competence than the written and oral exams. There is a lack of well defined program objectives that are coordinated with the examinations. CAIR recommends that the present concept of an examination "hurdle" be replaced by different, integrated methods of assessment during training, and that an effective appeal mechanism be developed.     

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province''s evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project''s five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students'' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.     

Storm of protest greets motion to restrict specialty exams

A motion by the Royal College of Physicians and Surgeons of Canada to restrict specialty examinations to Canadian- and US-trained physicians has met a storm of protest from provinces facing acute physician shortages in remote areas. The motion was called a "recipe for disaster" for provinces such as Saskatchewan, Manitoba and Newfoundland that traditionally have recruited specialists from Commonwealth countries to fill positions. The protests prompted the college to postpone action on its motion until June.     

Prevention should be the preferred insurance program for all physicians.

Recent fee increases announced to the Canadian Medical Protective Association (CMPA) and the Ontario government''s plan to stop its CMPA rebate program for the province''s physicians have put the spotlight on medical liability insurance. In this examination of the role played by the CMPA, Ottawa lawyer Karen Capen notes that quality service and attention to physician-patient communication will in most cases ensure a litigation-free professional life.     

Patient-physician sexual involvement: a Canadian survey of obstetrician-gynecologists.

OBJECTIVE: To determine obstetrician-gynecologists'' (ob-gyns'') awareness of and experience with sexual abuse of patients and former patients and their opinions about appropriate consequences. DESIGN: Mailed survey. SETTING: Canada. PARTICIPANTS: All 792 members of the Society of Obstetricians and Gynaecologists of Canada (SOGC); 618 (78%) responded. Approximately half of all ob-gyns in Canada belong to the SOGC. MAIN OUTCOME MEASURES: Knowledge of sexual involvement by an ob-gyn colleague with a patient or former patient (as defined by the respondents and by the College of Physicians and Surgeons of Ontario [CPSO]), self-report of such involvement, attitudes toward physician sexual abuse, desirable length of time a physician should wait before seeing a former patient in a situation that could lead to a sexual encounter, suggested consequences of sexual abuse. RESULTS: Overall, 10% of the respondents indicated that they knew about another ob-gyn who at some time had been sexually involved with a patient. In all, 3% of the male respondents and 1% of the female respondents reported sexual involvement with a patient; the corresponding proportions of those who reported having been accused of sexual abuse by a patient were 4% and 2%. Significantly more of the female ob-gyns than of their male counterparts (37% v. 19%) reported awareness of a colleague''s sexual involvement with a patient that would meet the CPSO''s definition of sexual impropriety, transgression or violation. Most of the respondents felt that the consequence of proven sexual impropriety should be reprimand and fine (chosen by 33%) or rehabilitation without loss of licence (28%). Most of the physicians supported loss of licence for proven sexual transgression (57%) or proven sexual violation (74%), but fewer felt that loss of licence should be permanent for these types of abuse (4% and 24% respectively). The female ob-gyns supported stronger sanctions against sexual transgression and sexual violation than the male ob-gyns. A wide range of opinion was seen regarding the propriety of sexual relationships with former patients. CONCLUSIONS: Ob-gyns have varied opinions about how sexual abuse of patients should be defined and how it should be sanctioned. There is a discrepancy between proposed public policy and the beliefs of physicians to whom the policy is to be applied.     

Managing familial risk in genetic testing

Increasing numbers of people are seeking genetic testing and uncovering information that directly concerns their biological relatives as well as themselves. This familial quality of genetic information raises ethical quandaries for physicians, particularly related to their duty of confidentiality. In this article, the American Medical Association's Council on Ethical and Judicial Affairs examines the informed consent process in the specific context of genetic testing, giving particular consideration to the handling of information that has consequences for biological relatives. Furthermore, it addresses the question of whether physicians' obligation to warn biological relatives ever should override the obligation to protect patient confidentiality.