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Yearly testing makes no sense. A baseline test followed by testing if a needle-stick type injury occurs make more sense both from the patients’ point of view and from the physicians.
Annual testing is a waste of resources in an era of evidence based medicine. Once a baseline has been established, annual testing is wasteful
Annual testing should not be mandatory.
Is thiat the standard of practise for regulatory colleges in the western world ?
Regarding high risk procedures, I think the inclusion of:
“Interactions with patients in situations during which the risk of the patient biting the physician is significant; for example, interactions with violent patients or patients experiencing an epileptic seizure”
is just too non-specific and applies to a very large number of physicians with a low risk.
I feel the blood borne pathogens policy is an unfair and unethical policy which puts surgeons at a high and unnecessary risk of potentially losing their ability to practice. There are many jurisdictions and large medical centres in north america that allow physicians with blood borne pathogens to continue to practice with no increased risk to patients.
An annual test is incredibly difficult to obtain and if the CPSO is insistent on it they should personally facilitate the testing.
What’s the value in routine yearly testing? It’s a waste of time and resources.
The blood borne pathogen (BBP) policy is a perfect example of CPSO overreach. It is a worthless policy and should be abandoned for the following reasons:
- it is not based on evidence. This is stated explicitly in the policy. There is no evidence that physicians utilizing standard universal precautions pose a risk of transferring BBP’s to their patients (apart from HBV which I will address below).
- it invades the privacy of physicians, by forcing those of us who perform exposure prone procedures (EPP’s) to put our sensitive health information into the hands of non-physician bureaucrats at the College. The CPSO would and should be vocally opposed to such an institutional violation of patient confidentiality, but is willing to sacrifice their members’ rights to confidentiality in this way.
- it will not result in any change in practice for an affected physician. The College will not have the right to limit a physician’s practice solely because that member becomes infected with a BBP; any attempt to do so will swiftly and successfully be challenged in court by the OMA and CMPA. The CPSO has previously amended the BBP policy and stated they would not require infected physicians to double-glove for procedures, citing lack of evidence of any benefit, and the fact that double gloving can detrimentally affect dexterity.
This begs the question, how would the College intervene in the case of an infected physician? Would they simply ensure that the physician is following universal precautions? This is already the standard of care for EPP’s. The BBP policy is not required to enforce this existing standard.
- doctors who perform EPP’s do not have the right to refuse treatment to patients simply because of the patient’s serological status (with respect to HIV, Hep B&C). Nor do we have the right to force every patient we operate on to undergo testing for these pathogens. Why? Because we assume that every patient could be carrying transmissible BBP’s, and we use universal precautions which have been shown to be adequate to protect ourselves from this risk. Although the science shows that existing universal precautions are adequate to prevent patient to doctor disease transmission, the College apparently doubts that they will prevent doctor to patient spread.
- the College references the American SHEA guidelines in this policy. The SHEA guidelines make 2 ‘practice-changing’ recommendations for an infected physician. One is that they double-glove for procedures, which as I note above has already been abandoned by the College. The other is that infected physicians with high viral loads not perform major cavitary surgery, known as Category III procedures, citing an increased risk of transmission to patients. In the case of HIV and HCV this is not supported by any evidence (SHEA p 212). It would be unlikely that such a restriction of practice would survive a court challenge given the lack of evidence.
In the case of HBV, every practitioner in Ontario is required to be immunized before they leave medical school, and to be checked to ensure HBV immunity. This makes HBV testing redundant in immunized individuals. Indeed, the US guidelines state that HBV testing need only be done on unimmunized physicians (SHEA p215). Why then, is the CPSO reaching beyond the recommendation of the paper they cite?
In summary, yearly annual testing of physicians is costly, wasteful, invasive of our privacy, and not supported by evidence. Furthermore a positive result would not result in a significant practice changing recommendation (at least not one that would stand up in court). As we say in clinical practice, if an investigation would not result in a change of management, it should not be performed.
A much more rational policy would be to ensure that every practitioner is immunized against HBV, and that physicians who perform EPP’s are using established universal precautions.
I agree wholeheartedly with the above comments. I would just like to add that other respected international organizations do not force physicians to disclose their status. As an example, the International Committee of the Red Cross recommends that physicians get tested for blood borne pathogens, but do not ask for results. This is because they do not wish to discriminate against physicians who may be seropositive.
As one of the first surgeons caught up in the trap set by the CPSO to detect BBPs in physicians in Ontario, I have some unique insights into this issue.
I answered my CPSO re-application form honestly in 2009 (yes, I did EPP, and no I hadn’t been recently tested), therefore I was tested and found to be positive for asymptomatic HCV – with normal LFTs, and normal liver ultrasound. After consulting with my own physicians, I elected to observe the “disease” with close followup and obtain treatment if there were signs of progression – which there were not. I suspect I became infected about thirty years ago, when I was doing a large volume of trauma, and Hepatitis C hadn’t even been discovered yet.
The CPSO took over 18 months to decide how to deal with my case. Throughout the whole process, I had the impression that they were treating me as a misbehaving MD who should have immediately sought treatment to eradicate the HCV from my body. However, I had Genotype 4 which has a lower chance of cure, and requires a minimum 48 week course of interferon, therefore I did not voluntarily start treatment. However, in May 2011, the CPSO, after be aware of my status since October 2009, issued a notice restricting my practice including all open procedures in the chest and abdomen, and making it impossible for me to take call. (The only surgeon on the panel, an academic surgeon, suggested I could take call with a backup surgeon, who could come in if the patient needed an open operation …perhaps in an academic center but not where I work)
So, I reluctantly started Interferon. Not only did I have Genotype 4, but I was a “slow responder”, and ended up being on Interferon for 72 weeks. It was about 6 months after starting treatment that my HCV titre undetectable, and therefore the CPSO allowed me to resume full practice.
There are several misconceptions on the part of physicians that have written in their feedback on the BBP policy. One is the comment in #7 that the policy will “not result in any change in practice for an affected physician”. In my case, organizations expressed condolences for my situation but were not interested in pursuing any legal action, and the CPSO given its public statement on physicians with BPP did not feel they could successfully argue against restricting my practice.
The second misconception is that the CPSO will review your case fairly. I repeatedly asked for an in person meeting with the Fitness to Practice Committee to discuss my case (because according to all the available literature, my chance of passing HCV to a patient was about 1 in 10,000 but the “expert” panel who reported to the fitness to practice committee used the 1% to 2% risk – which is the risk if I injured myself, and then passed my blood into the patient – and the committee did not realize the difference).
There has never been a case of transmission of HCV from a surgeon to a patient in Canada – NEVER. There has never been a case of transmission of HCV worldwide from a surgeon to a patient in any of the procedures I was banned from doing by the CPSO.
I realize now that the CPSO is not interested in patient care, but in maintaining the perception that they are interested in patient care. Most of my correspondence with the CPSO was with lawyers and lay people. It appears to me that the CPSO is run by lawyers, with occasional input from physicians.
The EPP policy is unnecessary at this stage except for public relations. For HBV, a single blood test on entering practice to show immunity is appropriate. For HCV, transmission from physician to patient has never occurred in Canada, and the likehood of it occurring is growing more and more remote with awareness of universal precautions, etc. For HIV, the likelihood of spread before the physician is symptomatic is also extremely low.
I am now required to get an HCV viral load every six months, and my infectious disease specialist has to report back to the CPSO every six months. My ID specialist has told the CPSO that I am cured of HCV, and no more likely to infect again than any surgeon, and should only require routine surveillance, however the CPSO won’t alter its position – again the inference is that I must be a sloppy surgeon because I got HCV once, and have to be closely monitored for the rest of my surgical life.
Finally regarding the definition and reporting of EPP, if one just uses the broader definition of palpating sharp objects inside an enclosed cavity, many surgeons will claim they do not that, and therefore will tick off NO in their CPSO reappointment forms (I personally know of a cardiac surgeon, and a thoracic surgeon who answer NO to that question). However, when one goes to the SHEA appendix, and then to the original article by Reitsma in 1995, it appears the actual list of procedures is derived from case reports up to the point in the literature in which BBPs were spread in EPPs, and they classified each procedure that had documented spread as in EPP. Thus, we have a subtotal thyroidectomy as an EPP and a non EPP, and a total thyroidectomy as a non EEP. All open laparotomies, and all open thoracotomies are EPPs, and even most laparoscopic and video-assisted thoracic procedures, by the strictest definition, should be classified as EPPs because one might have to convert – the CPSO made it quite clear to me that even if there is a small chance of conversion to an open procedure, it has to be treated as an EPP
I suspect over half of the physicians performing EPPs (including assistants) are answering NO to the question. If the CPSO really wants good data, it should audit the results from a group of surgeons i.e. OAGS, and see how many are answering the question YES – the vast majority should.
But whether surgeons are truthful or not should not be the question. The BBP policy was created for political purposes, to make the CPSO appear to be protecting the public, even though there is no risk to the public (or certainly no risk as far as HBV or HCV). The policy of mandatory testing of physicians for these viruses should be abandoned.
We should not have mandatory testing on an annual basis.
Is this the standard for all regulatory colleges in the western world ?
The one comment I would make is that if a person has proven their immunity through immunization (and they have adequate antibody response), why do they need to be tested for Hep B annually? (Unnecessary lab tests).
I have reviewed the information on the policy associated with blood borne pathogens on the last revision.
In principle, I support the current policy.
Should HIV screening be involved for all physicians in view of the prevalence of increasing spread in Canada? International travel contamination and spread should be considered for HIV and other infectious diseases. Microbiologist opinion would be valuable.
Ontario Medical Association, Section on General SurgeryI am familiar with the CPSO Policy and its rationale. General surgeons are supportive of a policy that protects the public from exposure to these pathogens. Many of the recommendations in the CPSO policy are commendable and provide valuable guidance and advice to physicians.
The two main concerns raised by surgeons is the frequency of the testing for physicians and the consistency and appropriateness of decisions made by the expert panels struck to review a sero-positive physician’s ability to practice.
We believe the frequency of current testing – annually – is excessive. We agree that physicians who have sustained a needle-stick injury should be tested at appropriate intervals to manage the risk associated with such injuries. However, for physicians without such exposure, we would prefer testing at an interval such as 3 years. We would be happy to discuss your experience with the move to annual testing, and whether it has had any appreciable impact on identifications of seropositive physicians.
We have also heard from several sources that the Expert Panels struck to assess the practice options for a seropositive physician may not adhere to current evidence and even SHEA guidelines. We have difficulty assessing the validity of these concerns, as the decisions and rationales are typically confidential. However, we would encourage the CPSO to strive to ensure consistency and fairness throughout these processes. We would encourage a review of your experience to date in dealing with situations of seropositive physician practice restrictions, with a view to assess consistency and application of guidelines.
I am an emergency physician and have complied with the CPSO’s Blood Borne Pathogens Policy. Despite this I disagree with the policy on the basis of the lack of evidence on which the policy is based and the fact that it is applied to emergency medicine where the risk of exposure is minimal. In my over 20 year career, I have not performed an open thoracotomy or open cardiac massage. At the North York General Administrative Conference in the fall, a speaker did not think it was important that the chances of our performing any of these procedures was negligible, therefore our risk of contracting a BBP via these procedures unimaginable.
My time is typically spent assessing chest and abdominal pain, managing the elderly with falls, kids with fevers, managing fractures and situational crises. I provide direct patient care at night, on weekends and holidays and thus 2/3 of my care happens during unsociable hours. Our department, like most in the province, is short staffed and thus I am asked to work more than I’d like to. Ontario does not lead a ill-formed policy that gives emergency physicians one more reason to discourage work in the emergency medicine.
I strongly recommend the College reconsider the BBP policy and would welcome to discuss this with any College staff further.
p.s. below is an editorial in the Canadian Journal of Emergency Medicine which provides a strong argument agaist the BBP policy:
I am the author of the commentary which appeared in the Canadian Journal of Emergency Medicine (http://cjem-online.ca/v15/n3/p127) as cited in an earlier comment posted by an emergency medicine colleague (June 13 at 2:45 pm). I wrote the article after being threatened with disciplinary action for professional misconduct by the College if I failed to be tested for HIV. I argued that it is rare for me to perform a so-called “exposure prone” procedure, and I never did so electively or with advance planning. I only performed these procedures in the context of an emergency resuscitation, a situation in which the theoretical near-zero risk of physician-to-patient transmission of HIV pales in comparison to other risks to both patient and physician.
I also argued that testing was wasteful, with a number needed to test in excess of 1 billion. Indeed, as a physician I rarely order an investigation in the absence of either consent or an indication, and in this case I had neither. My fault lay in first reading the fine print of the procedures listed in the SHEA guidelines and adopted by the College verbatim as being “infection prone,” and then being told that “rarely if ever” was not a valid response to question #H2a on the Annual Renewal Application.
I stand by the commentary as written, and am not aware of any more recent information that dissuades me from its message: mandatory testing of emergency physicians, at any frequency, is unjustified and harmful. It is unscientific, and contributes to the stigma surrounding HIV/AIDS. It also asks all physicians in Ontario who may only occasionally be asked to perform emergency phlebotomy, or who interact with violent or epileptic patients, to either lie to the College by answering “no” to the renewal question, or to submit to mandatory testing. While a College representative advised me that most emergency physicians answer “Yes” to question #H2a, my own experience in talking to colleagues is the exact opposite. And diminishing the respect and authority of the College may be the most harmful consequence of this misbegotten policy.
P.S. I agree to the posting of this comment on the CPSO website even though my identity cannot be anonymized.
A bilingual version of the commentary that has been cited in an earlier post:
It should not be mandatory.
As surgeons we do not test all our patients for these disease. To be fair, if the surgeons are tested then all patients must be tested.
I would not make it mandatory but now that there is treatment for Hep C, surgeons should be aware of their status but it should not influence their ability to practice.
There is little evidence of the transmission from doctor to patient
Worldwide, the documented number of health-care worker to patient transmissions of blood-borne infections since 1991 has been exceedingly low.
The Canadian Medical Association, the National Institutes of Health and the Centers for Disease Control in the U.S. recommend against mandatory testing of doctors.
Patients pose a significantly greater risk to physicians, than physicians do to patients in terms of transmission rates of blood-borne pathogens. This is evident from even a cursory review of the literature. Yet there are no guidelines for patient testing prior to exposure-prone procedures.
Presumably a significant number of physicians who ultimately test positive for blood-borne pathogens have contracted their infection from a patient-related exposure – wouldn’t it make sense to test patients prior to exposure prone procedures? This would ultimately potentially protect the physician/surgeon, and that physician’s future patients.
Interestingly, in the case of needlestick injuries, one needs explicit written patient permission to test for blood borne pathogens when a physician has been put at risk. Patients can decline to have their blood tested in this setting.
In principal the College’s mandate to protect the public is appropriate; however the current policy is an example where the pendulum has swung too far from fairness, evidence, common sense, and basic human rights.
It is completely unacceptable to request physicians to do routine (yearly) testing for blood borne pathogens. It is extremely discriminatory and will alienate individuals! Frankly this borders on a violation of human rights.
It will affect physicians opportunity to participate in their field and having gainful employment. Will the college be supplementing income lost for those physicians? Doubtful.
Furthermore there has never been a case report of a physician infecting a patient with a pathogen. Many cases have been documented of physicians being exposed and infected by patients. Doctors are the people at risk NOT the patients. If routine screening is being requested it should be of the PATIENTS, NOT the physicians. The current policy of asking physicians to complete routine screening is unjust!
This policy should be completely removed.
I disagree with the policy but if it is going to remain the CPSO should facilitate the tests being done. When I get bloodwork done for insurance applications I don’t have to track down my family doctor to order it and a nurse comes to my house to draw it.
In this era of ministry cost cutting and up swing of quality based funding programs, it would seem a colossal waste of funds requiring “at risk” physicians to undergo HIV and Hepatitis testing every year. Particularly when there is absolutely no evidence to support this program. As a compromise, perhaps every 3 to 5 yrs would be more reasonable although once again there is in fact no evidence to support any testing at this point.
the costs to the taxpayer for each physician being assessed include a visit to a physician to order the tests followed by costly blood work and potentially a follow up visit to review results. There remains the risk of false positive testing adding additional costs not to mention the devastating effects on the practitioners and their patients.
I would stress that, in particular,the evidence supports that the risks and costs of false positive tests far outways the benefits of identifying the rare true positive results
Further, there remains no program in place to deal with positive results.
thank you for your attention in this matter
Dear Colleagues ….. While not objecting to the annual testing, I am not convinced that we are significantly serving the Public or the Profession because the transmission of HIV and HEP virus from Physician to patient is insignificant ….. I am for testing if one is concerned about exposure ( eg: needlestick injury ), and remain convinced that all persons in the Health Delivery Services should have the same concerns , expectations , and rules of engagement.
Physician do not know the Sero-positivity or negativity of the patients they operate on with regards to blood born pathogens.
Protections measures should be bilateral.
If physicians must undergo annual testing to protect patients, then all patients undergoing any form of surgery must have their status determined either in advance or in case of emergencies after the surgery. Hep C is prevalent in some communities and who stands to suffer the consequencies more? The patient or the surgeon?
Universal precautions for surgical procedures can not be considered adequate for one group, and inadquate for the other
Transmission risk from patient to physician is higher than the other way round. Hep C is more prevalent in some communities..
If universal precautions are considered safe for protection of these blood born pathogens why then the worry about patient safety and NO CONCERN about physicuan safety?
We are care givers and not politicians running for election? we are guided by statistical evidence and not anacdotal evidence.
I appreciate the concern- “physician to patient” but what about “patient to physician” and who really is at greater risk in this senario?
Annual testing would be an overkill and not an effective way of utilizing our limited resources and unless the plan behind the curtain is to prohibit those that test positive from the continuing the surgical specialty , I don’t see the point
I have rummaged thro CDC’s recommendations on blood borne pathogens and I have not seen anything about annual testing for health care providers.I would be grateful if you point me towards any regulations or suggestions that CDC may have on this matter.
This policy is reminescent of the routine wasserman that was required of all patients admitted to hospitals in the US in the sixties. That policy was abandoned a long time ago,when they realised that too many people with pos. wasserman were being treated unneccessarily until the treponema pallidum test came along.
Annual testing for BBP should be discontinued, it is highly discriminatory,expensive to the public purse and does not in any way protect the public since the general patient population is not being concomitantly tested.
I would appreciate some information from the College regarding the results of the Blood Borne Pathogens policy. This is a screening program, and the members of the College who participate in this screening program will be interested in whether it is an effective screening program. I feel that the Blood Borne Pathogens policy should be held to evidence based standards. Therefore, I feel it is needed that an appropriate specialist review the results from the past two years, and provide feedback to all members interested. This review would, of course, be done while protecting individual member privacy concerns.
I would be interested to hear whether a review of the program would justify yearly testing. Personally, I would be in favour of testing every two or three years.
Thank you for the opportunity to comment on the policy.
annual testing is a waste of everyone’s time and health care resources. It is also based on little or no evidence. What kind of health care are we practicing here?
This is not a policy based on evidence. If the CPSO is going to continue to engage in this practice, then it should be simultaneously be studied with comparison to regions in which this policy is not in place to determine whether there is actually a risk reduction. Otherwise, it is a massive waste of resources that has ethical harms to aspects of non-maleficence, autotomy and justice that do not justify the benefits, which is the primary foundation of medical intervention–benefits must outweigh harms.
These seem like reasonable recommendations – they appear to adhere well to the CDC guidelines
These seem like reasonable recommendations with one exception – they appear to adhere well to the CDC guidelines with the exception of the requirement for annual testing, the evidence for which is not clear
I am uncertain why we are using SHEA when we have Ontario expertise at Public health Ontario regarding Infection Control. Were they consulted on this document?
There are several problems with mandatory testing – lack of evidence, lack of a real policy as to what to do if a positive test is obtained, the creation of false positives, and the stress resulting from that. I also question the definition of exposure prone procedures – generally if working in a confined area, we keep our fingers out, and use instruments – fingers take up too much space, quite aside from the risk it entails. I would say the risk of needle injuries is greater from a needle being left on a driver on top of the patient, or from Sens retractors, which are used in many of the procedures considered to be low risk, so the division into high and low risk is artificial.
I would like to pass comments through the gross route like:
1) all blood borne diseases are not the same as were in existence policy that they need to be categorised separately according to their course and current evidence and their implementation should be individualised according to the physicians specialty and sub specialty.
2) some blood borne diseases (HCV) are labeled as cured on the basis of testing/blood markers and their repetitive testing is useless and there monitoring should be done as per current literature evidence inspite of on six monthly or yearly.
3) college also needs to make policy for how to conduct the policy specialy for IMGs. When and what the tests and physicians input is required from their own country and from here (CANADA), to make sure that the IMGs once they are arriving in CANADA, their training should not be delayed because of this reason.
If college needs physicians consultation in CANADA for IMGs then college should arrange their appointment for them because in CANADA minimum waiting time is month and then some blood tests they are also taking two to three weeks for test result and finally with the follow up the two months are required in CANADA if college needs physician’s consultation.
I agree with majority of comments. This is not a policy based on evidence. This is a policy based on an opinion that is not supported by any facts. It creates costs and inconvenience without any additional protection for the public which is in the College’s mandate. Testing on a less frequent basis like every 4 to 5 years would still lack evidence but would be a compromise that would be more acceptable.
Below is my letter to CPSO on this matter:
Re: Confidentiality of medical status of physicians
In response to your letter of July 29, 2009 directing me to advise you in writing by September 29 of my “personal serological status with respect to HIV, HBV and HCV…” I wish to inform you that I do so under protest. As a Canadian citizen and as a patient with rights to privacy and confidentiality that are equal to those of the patient public I feel the College has no right to demand of me this information.
There is absolutely no documented scientific evidence of transmission of the above pathogens from surgeon to patient. The transmission of Hep. B which occurred in an EEG lab was due to lack of sterilization of equipment and in fact represented transmission between a technician and a patient. It is of course curious that the serological status of the technician would not be known even if that of the physician running the lab would be. Or does the College expect physicians to demand serological status from their employees? This would of course be illegal, as I personally believe the same to be the case as it relates to physicians. Should all applicants for medical school be screened for these conditions and be denied entry based on these results? After all it is pointless to train someone and then deny them the ability to practise fully. Will the CPSO urge government to demand serological status disclosure from nurses? After all they are frequently in situations of potential exposure to needle punctures, especially in emergency departments, operating rooms, labour rooms, etc. Will the CPSO urge the College of Dentistry to institute the same illogical policy? All dentists would be considered performing “exposure-prone procedures”.
There have been many cases of transmission from patients to surgeons. The surgeon who is exposed to many potentially infected patients has no right to demand of these patients their serological status as a precondition to treatment even in an elective situation. How can the CPSO demand of doctors information about their medical status that has no scientifically documented bearing on the patients they treat but will potentially devastate their personal and professional lives? Will the College insure their livelihood and look after their families if they are unable to practise surgery following the finding of positive serology?
I believe that the demand by the College for this information is not at all in the material interest of the profession or the patient public, but rather is aimed at promoting the image that the College is acting in the public’s protection. I view the demand for this information as a breach of my rights as a Canadian and a patient. I have discussed this matter with several colleagues some of whom are politically involved in the medical profession. They agree with me but urged me to save myself a headache and provide the information you demand. This is truly a reflection of the opinion many physicians have of the CPSO. It is viewed as a coercive body, frequently acting against the interests of the profession and sometimes only creating the impression of acting in the public’s interest.
As a surgeon, who performs all surgical procedures with direct view of sharp instruments, I am not sure whether I fall into the category defined as performing “exposure-prone procedures”. I very rarely excise minor lesions in the mouth or lip. I tried to clarify this matter with the College but was simply referred to the explanatory pages mailed out. Because of that I had myself recently tested and proved negative for all 3 pathogens.
Again I wish to reiterate my disappointment and anger at the College of Physicians and Surgeons of Ontario for demeaning itself and its membership with this illogical, discriminatory and humiliating policy.
what is the incidence of patients in Canada getting HIV or other blood born pathogen from a doctor or surgeons If we do not have that data how can you restrict surgeons practicing on patients? you need to see all the surgeons practicing in Canada that have HIV or other blood born pathogens and see what percent of their patient have contracted the disease before you can pass a law
As a physician personally affected by this policy I understand the rationale, however I agree that testing physicians annually for Hepatitis B surface antigens when they have already been immunized against Hepatitis B is not productive and is a waste of resources.
With regard to Hepatitis C, the current guidelines should not be in place. For both Hepatitis B and HIV there is a protocol for post-exposure prophylaxis which does not exist at this time for Hepatitis C. In the case of exposure all the person can gain is the knowledge that they have or have not been infected. Most persons exposed to Hepatitis C are unaware and asymptomatic. Granted new treatments are becoming available and those infected should be able to access them, however this choice should be between the patient (whether or not the patient is a physician) and their personal physician, not the officials of the College. As stated by other physicians commenting, the adoption of universal precautions and testing after a needle-stick or other body fluid exposure should be sufficient. Annual forced testing is draconian and should be abandonned.
My primary issue is with the way physicians who test positive for antibodies to Hepatitis C are treated. Being forced to enter into an undertaking with the College with deadlines (some of which are extremely onerous) and having to undergo annual (or for the first year every 6 month) testing for viral RNA should not be required. A single test showing negative RNA should be sufficient and then the physician should be treated like other physicians, not like a criminal with a duty to report to the College. Personally I have found the process demeaning, invasive and disrespectful.
I found the policy contradictory. The first stem list techniques of blind needle passage in confined spaces guided by digital palapation. The second lists procedures that automatically indicate risk (i.e. Renal Transplant)
I submit that the digital palpation technique described is almost never appropriate in contemporary surgery. Secondly transplant recipients are one of few patient groups that universally have pre-op hep C and HIV status determined which greatly reduces risk of incidental unknown exposure. The transplant scenario is probably lower risk!
Lastly, the policy is far too vague regarding the pathway for physicians with positive tests. I understand the approaches differ significanly between provinces, notably Quebec vs Ontario. I would encourage all the provincial colleges to create a national evidence based pathway.
I strongly agree with most of the comments made by my colleagues. I feel the mandate of annual testing is wasteful, especially in an era of evidence based medicine and the increasing need for fiscal restraint. As a tax-payer I would rather my health-care dollars be spent on essential and evidence based laboratory investigations (i.e. d-dimer to rule out PE) than on hundreds of physicians’ HIV tests. The requirement for HBV testing is redundant in the face of widespread vaccination, especially since proof of immunization is required for admission to medical school and for granting most hospital privileges.
Most physicians act responsibly and after an exposure event, such as NSI, will follow the standard PEP protocols at their institution, including appropriate testing, pharmacologic prophylaxis and follow up blood testing. No further monitoring aside from what is medically necessary should be required.
To the best of my knowledge, other regulated health care professionals do not have the same expectation of testing, despite similar risks of exposure.
My last concern is regarding human resources. As a surgeon in a smaller community, my assistants are family physicians. Finding assistants can be challenging and further barriers to my primary care colleagues . I know that many colleagues have made a conscious decision to not undergo testing, despite meeting the vague and over-inclusive criteria of EPP. What happens if any/all of them lose their privileges or licences because of this? All surgical care in my community would stop, or operating days would be cancelled, and this is a greater harm to the public than the exceedingly remote chance of a positive blood test.
I strongly urge the CPSO to change the focus of this policy from monitoring asymptomatic physicians who are already doing everything mandated by Universal Precautions, to encouraging appropriate investigation and monitoring after exposure events.
This policy is abusive, discriminatory, ill conceived and unsupported by ANY evidence. Mandatory testing of physicians would not pass a challenge of any scientific review or legal review. The regulatory bodies for the rest of the operating room team members do not require such testing including the scrub nurses, RFNAs, or PAs. In my institution it is much more common for one of the non physician team members to have a penetrating injury in the OR. This is a situation where the physician policy makers at the college need to educate the lay people on the panels and get rid of this wasteful, discriminatory, invasive yearly testing policy that serves no useful purpose but costs a tremendous amount and causes significant anxiety.
This comment is in regards to the policy of BBP as it pertains to Emergency physicians:
The belief that this policy will protect the public is misguided. The literature reports that transmission of BBP from physician
to patient is exceedingly rare – only described in case reports. The inclusion of many procedures considered high risk for exposure is not
based on good evidence and some are performed only in very rare circumstances. In 2012, there were 16.9 million emergency visits in Canada (ICES).
If in each of the past 6 years there were an average of 16.7M visits, then 100 million Canadian ED visits have taken place in this time period in
which there have been no reports of transmission of HIV from an emergency physician to a patient. It has also been estimated that the
number of Ontario emergency physicians that need to be tested to prevent one case of HIV transmission exceeds 1 billion. (95% CI 300million to
infinity). (Sivilotti CMEJ 2013 15(3) 127-129)
Also, emergency physicians are well educated in regards to the risks of BBP transmission. It is doubtful that the mandatory requirement for annual testing would identify any additional infected physicians. This policy is alarmist, greatly exaggerates the risk of transmission
of BBP in the public eye, and undermines the scientific foundation of the
It would be superfluous for me to re-state what has been particularly well argued by my colleagues here, and in CJEM 2013;15(3):127-129, which has also been cited here.
The CPSO needs to reconsider this policy, whose intention seems to be good optics, rather than rational governance.
The CPSO policy on Blood Borne Pathogens is well balanced and adequately documented.
As a self regulated profession, we need to assure the public we are protecting their safety. The best way protection is to diagnose and treat infected practitioners early so that their viral loads become / remain undetectable. CDC recommends that infected practitioners disclose their status to patients (MMWR 40(RR09), 1991) however, this will incent physicians not to get tested or treated and puts them at greater risk to the public (Gostin JAMA 284(15) 2000). I support the CPSO policy as it encourages the right behaviour. There is strong evidence of under-reporting, testing and prophylaxis of sharps injuries. Physicians simply don’t do it and therefore will be unaware when they get infected.
I believe the definition used for Exposure Prone Procedures is cumbersome. I would recommend that it be replaced by a definition that encompasses ALL procedures involving physicians where there is contact with either mucus membranes or open tissue. Whenever there are surgical tools in use, regardless of whether the work is superficial or deep, there is a risk of inadvertent self injury
I think that HepB vaccination should not be strongly encouraged; rather it should be MANDITORY for all physicians having physical patient contact, unless there is a medical exemption from vaccination.
I have reviewed the CPSO policy and have also reviewed the on-line commentary as of July 22 and would like to offer the following comments:
Regarding the policy:
• I believe the CPSO Blood-borne Pathogen (BBP) policy is a necessary and important contribution to patient safety. There is ample published literature to demonstrate that there is risk to patients from physicians who perform exposure-prone procedures (EPPs). However, I believe that the policy would benefit, and possibly be somewhat more acceptable to the CPSO membership, with some modifications.
• With regard to screening for hepatitis B virus (HBV), once immunity to HBV has been documented, i.e., antibody to hepatitis B surface antigen is documented after receipt of a full course of HBV vaccine, there is no need for annual screening for hepatitis B surface antigen. All physicians should be required to have a full course of immunization against HBV and have seroconversion documented.
• There is little evidence to justify mandatory screening for HIV infection. Lookbacks on patients of HIV positive surgeons have not demonstrated transmission; in the 30+ years since HIV was discovered, there have only been a couple of documented transmissions from surgeons and these have been when the surgeon’s status was unknown and they were not yet on anti-retroviral treatment.
• Hepatitis C virus (HCV) is somewhat more complex. Transmission during EPPs has been documented, but is at a much lower rate than HBV. If mandatory screening continues, annual screening (i.e., testing for antibody to HCV) for those physicians who perform EPPS may be reasonable. For physicians who are identified with HCV infection, if they have a sustained virologic response to antiviral treatment (usually defined as 6 months virus free after treatment is finished) monitoring is no longer necessary.
• The current policy applies screening and interventions to “physicians who perform and who assist in performing EPPs”. I am unaware of any published reports of transmission of BBPs from physicians who assist in, as opposed to perform, EPPs. If this policy is fully applied, it would mean mandatory testing of all medical students (albeit not covered by CPSO) and virtually all post-graduate medical trainees since most PGY1 trainees will have rotations through surgery where there may be EPPs. This extension to physicians who assist in EPPs should be reconsidered. If this policy is retained for physicians who assist in EPPs, there should be a better definition as to whom it applies, e.g., post-graduate trainees entering surgical specialties including obs/gyn? physicians who devote a large part of their practice to being surgical assistants?
Regarding the on-line comments from physicians:
• The physician knowing their status for HBV, HIV and HIV is of personal medical benefit to the physician. There are anti-viral treatments for all these infections that will extend life and improve quality of life, not to mention protecting the physician’s partner. Usually, viral loads can be reduced to below the threshold for practice restriction, so the physician will be able to continue practice. Any continued monitoring by their physician will, again, be of medical benefit to the physician.
• Testing of patients to know their status before a surgical procedure will not protect the surgeon. With Routine Practices applied to all patients, there should be no difference in risk between the patient known to have a BBP and those of unknown status.
• Physicians have an ethical obligation to know their status for BBPs, to seek appropriate care if infected and to follow-up on any “sharps” injuries.
• Physicians who perform EPPs have an ethical obligation to report to the CPSO if they are aware they are infected with a BBP so their medical status and practice can be assessed by an Expert Panel. Any recommendations made by the Panel must be evidence-based.
Again, I believe this an important patient safety issue and occupational safety issue for physicians. I have spent considerable time reading and thinking about the issue. I hope these comments are of use to you in your review of your policy. Please let me know if you have questions or wish to discuss any of the above.
College of Medical Laboratory Technologists of OntarioResponse in PDF format.
This is another unnecessary policy.
If the evidence does not show that doctors are infecting patients with blood borne pathogens, what purpose does this policy serve other than increasing the cortisol levels in doctors’ blood?
Is there a policy for drug and alcohol testing of doctors? Doctors with high cortisol levels can turn to alcohol and drugs, and this policy, along with others, only serves to add to a doctor’s overwhelming stress possibly leading to alcohol and drug abuse. If the College wants to keep this policy, they need to consider adding one for routine drug and alcohol testing.
If the doctor turns to drugs or alcohol, that is a mental health concern, and legislation is in place to fully protect the doctor. However, there are no “universal precautions” to protect a patient from a doctor who has drugs and alcohol in their blood. A policy to protect patients is needed.
When harm has happened due to pathogenic blood alcohol and/or drug levels, the patient suffers secondary harm from complaining to the College because the doctor’s CMPA approved response and “doctored” notes are considered to be the truth.
And no, my statements are not based on any evidence I have uncovered, but is one logical explanation for the unnecessary harm I and others have suffered.
I must agree that the current guidelines for physicians involving in invasive procedure for surgeons and physicians practicing critical care invasive cardiology must follow the guidelines as recommended for safety of patients coming under their care.Similarly must make an effort to not expose themselves from Pathogens discussed and others known to cause unhealthy situations to themselves.
OMA - Section on Emergency MedicineResponse in PDF format.
I agree with the comments that yearly testing makes no sense. I agree that after a baseline test, we should only have to have testing when there is a needle-stick or other high risk injury.
Annual testing should not be mandatory if M.D is contagious with BBP expected to report and go to standard precautions and treatment.
In my opinion College should list all specialities which are exposure prone and all physicians of these specialities should be tested. If any physician think that he does not need testing, he should provide explanation to the College.
e.g College should say that all General Surgeons, Orthopaedic Surgeons, ER physicians, Gynaecologists, Urologists etc etc should go for blood test every year Rather than giving all physicians a freedom to interpret the definition of Exposure prone procedures.
I am ER physician and I feel that according to definition of exposure prone procedures, All of them should be tested, but I was surprised to see many ER physicians who do not feel that it is necessary according to the definition.
College of Physicians and Surgeons of SaskatchewanPlease find herewith feedback from the CPSS:
I wonder about the paragraph:
Physicians who have been exposed to bodily fluids of unknown status through a specific incident, such as a needle prick, or splash must seek appropriate expert advice regarding the frequency of testing that is required to determine if they have been infected with one or more blood borne pathogens.
Is it reasonable to expect that a physician will be required to seek expert advice every time they may be splashed with blood or another bodily fluid such as urine or vomit?
If this was being looked at for Saskatchewan, I would want a stronger statement permitting broader disclosure than the statement:
If the College does impose restrictions on a physician’s practice, it will share the details of the restrictions with the institution(s) at which the physician works. Whether broader notification of the practice restrictions is required will depend on the circumstances of each case. When evaluating whether broader notification is required, the College will strive to protect physician privacy to the greatest extent possible.
I would want something like the following statement. I recognize that there is a balance to be achieved between reasonable public protection and privacy interests.
If the College does impose restrictions on a physician’s practice, it will share the details of the restrictions with the institution(s) at which the physician works. The College may, if it concludes that it is in the public interest to do so, provide additional information to others, including the public. Whether broader notification of the practice restrictions is required will depend on the circumstances of each case. When evaluating whether broader notification is required, the College will strive to protect physician privacy to the greatest extent possible.
With regard to the above comment about ‘bodily fluids’ I see that bodily fluids are defined in the glossary and note that the policy only applies to physicians performing exposure prone procedures. I think that the paragraph is reasonable and presume that the expert advice will weigh the risk of infection depending on the degree of exposure.
I agree with the above comment on strengthening the paragraph on sharing of details.
Re: College of Physicians and Surgeons of Ontario (CPSO) Blood Borne Pathogens Policy
Thank you for this opportunity to comment on the Blood Borne Pathogen (BBP) Policy. I have reviewed the policy and over the last several years engaged in discussions surrounding this with urologists and surgeons in the province.
The purpose of the policy should be made clear beyond vague and general principles such as “protecting the public”. Clarity in the purpose of the policy will help direct development of an appropriate policy. Members of the profession, in my experience, are unclear as to what insinuations are to be understood in the policy.
Is the contention that by the nature of their work (e.g. surgery) that some members of the medical profession are at increased risk of acquiring a BBP? Is this a substantial risk greater than that of the population in general? My impression is that the policy exists to protect the patient from the risk of receiving a BBP from their doctor. The CPSO deems this to be a substantial risk, worthy of a policy. However, in most cases the typical exposure such as a needle stick is greater to the healthcare provider. An example would be the typical needle stick injury, where a doctor is poked by a needle which has already been used on the patient. The injury is immediately identified and the needle is not reintroduced to the patient. The doctor takes appropriate action to deal with her/his injury.
I am not aware of any information, actuarial, statistical etc. suggesting that doctors who perform these procedures are at increased risk for a BBP related infection. As example to my knowledge there is no preclusion for a doctor engaged in this work to donate blood.
It would be well and good if one of the intentions of the CPSO policy were to protect the health of the doctors (which in turn could help protect the patients). The limitations on achieving this goal are well recognized, such as restrictions on preoperative testing of patients and ethical questions potentially raised by such testing, as well as the need for patient consent for testing.
Should testing be stratified by individual doctor risk of carrying a BBP not related to the practice of medicine such as history of transfusion, risky sexual behaviours, i.v. drug abuse etc.? These factors are well recognized as being associated with increased risk of having a BBP (unlike surgery itself), yet the policy does not address them, or suggest a modified schedule for testing doctors with any such risk factors.
Is the inference therefore that doctors engaged in this type of work would be expected to harbor the background population risk of carrying a BBP? In fact doctors presumably being medically savvy and responsible individuals most likely have a lower risk of harboring a BBP. If this is the case, then the issue that the policy would wish to address is that by its very nature, certain procedures have a risk of body fluid contamination from doctor to patient, and with that comes a (lesser) risk of the patient contracting a BBP.
What procedures or practice types are at risk for transmitting a BBP? This has been a source of much confusion in the medical profession and the current policy is confusing. The policy provides the following definition:
*Exposure Prone Procedures are defined as follows:
1) Digital palpation of a needle tip in a body cavity (a hollow
space within the body or one of its organs) or the
simultaneous presence of the health-care worker’s fingers
and a needle or other sharp instrument or object in a
blind or highly confined anatomic site e.g., during major
abdominal, cardiothoracic, vaginal and/or orthopaedic
2) Repair of traumatic injuries, or
3) Manipulation, cutting or removal of any oral or perioral
tissue, including both tooth structures, during which
blood from a health-care worker has the potential to
expose the patient’s open tissue to a blood borne
This is extremely confusing, and by a literal read would not include most surgery. This is presumably a definition lifted directly from elsewhere. It seems however that the CPSO’s intention is that essentially all surgeons are performing exposure prone procedures. Further examples have been given:
General surgery, including nephrectomy, small bowel
resection, cholecystectomy, subtotal thyroidectomy, other
elective open abdominal surgery;
• General oral surgery, including surgical extractions, hard
and soft tissue biopsy (if more extensive and/or having
difficult access for suturing), apicoectomy, root amputation,
gingivectomy, periodontal curettage, mucogingival
and osseous surgery, alveoplasty or alveoectomy, and
endosseous implant surgery;
• Cardiothoracic surgery, including valve replacement, coronary
artery bypass grafting, other bypass surgery, heart
transplantation, repair of congenital heart defects,
thymectomy, and open-lung biopsy;
• Open extensive head and neck surgery involving bones,
including oncological procedures;
• Neurosurgery, including craniotomy, other intracranial
procedures, and open-spine surgery;
• Nonelective procedures performed in the emergency department,
including open resuscitation efforts, deep suturing to
arrest hemorrhage, and internal cardiac massage;
Obstetrical/gynecological surgery, including cesarean
delivery, hysterectomy, forceps delivery, episiotomy, cone
biopsy, and ovarian cyst removal, and other transvaginal
obstetrical and gynecological procedures involving handguided
• Orthopedic procedures, including total knee arthroplasty,
total hip arthroplasty, major joint replacement surgery,
open spine surgery, and open pelvic surgery;
• Extensive plastic surgery, including extensive cosmetic
procedures (e.g., abdominoplasty and thoracoplasty);
• Transplantation surgery (except skin and corneal transplantation);
• Trauma surgery, including open head injuries, facial and
jaw fracture reductions, extensive soft-tissue trauma, and
• Interactions with patients in situations during which the
risk of the patient biting the physician is significant; for
example, interactions with violent patients or patients
experiencing an epileptic seizure;
• Any open surgical procedure with a duration of more
than three hours, probably necessitating glove change.
There is no specific mention of urology which has been a source of confusion for our specialty. Nephrectomy is mentioned with general surgery (for some reason), as well as transplant and open operations lasting more than three hours. A nephrectomy can be done without using any sharp instrument with the exception of sutures to close the wound which does not seem to be itself an exposure prone procedure. Is laparoscopy or percutaneous renal surgery an exposure prone procedure?
It is strongly advisable that the CPSO clarify their definition and we would suggest this be defined by each specialty, and as necessary by procedures done in that specialty. We would also question the risk associated with other practice patterns with frequent exposure to bodily fluids (e.g. anaesthesia), and question how this compares with the surgical specialties.
We should be mindful that there is a cost associated with this type of screening.
It seems odd that in an era of cost constraint and increased scrutiny, with an emphasis on evidence based medicine and avoiding testing of unproven merit, that the medical profession via the CPSO’s BBP policy would mandate annual testing. The motivation here seems to pertain more to the optics of what is being done rather than any significant risk. This is contrary to our mandate as responsible physicians.
In summary we would request greater clarity on the intended purpose of the policy, a better assessment of risk of BBP acquisition by health care workers and patients and a clear definition of which doctors are deemed to be engaged in exposure prone procedures. Furthermore we request that the policy be based in fact, and those facts may change over time and the policy must be adaptable. Annual testing in particular appears to be unnecessary unless the individual doctor appears to be exposed to an increased risk.
Public Services Health & Safety AssociationResponse in PDF format.
We suggest moving the Policy statement section. The policy statement should be the first section encountered
Currently the Public Health Agency of Canada is developing a policy and standards for health care professionals infected with blood borne pathogens (Management of Health Care Workers Infected with Blood Borne Pathogens). The College might insure their policy and chosen definitions align with PHAC’s.
Are students subject to CPSO policy? It is stated that physicians are subject to CPSO policy, but it is unclear if medical students are expected to adhere to CPSO policies. The CPSO should state whether students are subject to this policy.
It seems contradictory to state this policy “does not apply to physicians who do not perform or assist in performing exposure prone procedures” and then subsequently state “[routine procedures] must be followed when caring for all patients at all times regardless of the patient’s diagnosis.” Is Appendix C – Routine Practices also a “stand-alone” policy? If not perhaps it should be. Cross referencing Appendix C in the routine procedures section would be helpful.
BBP does not mention of risk of transmission b/c of drug diversions. Drug diversion is unethical, immoral and illegal.
Referring to the CMA’s Code of Ethics and cross referencing with the Behaviour policy could be beneficial. Physicians’ ethical obligations underpin knowing one’s serological status and reducing risks of exposure.
There is no mention of concerns around adequately informed consent, reasonable person and idiosyncratic needs of a patient who may require disclosure of infected health care worker’s status. At minimum, disclosure would require a notice that a member of the health care team has a blood borne pathogen. The institution could include notice the health care worker is not infectious since their viral load meets Public Health Agency of Canada’s standards.
If an exposed health care worker has the right under the mandatory testing laws to have a patient tested, do patients have the reciprocal right to have health care workers tested if the patient is exposed? If not, this is a double standard.
Canadian Medical Protective AssociationResponse in PDF format.
Professional Association of Residents of OntarioResponse in PDF format.
Toronto Academic Health Science NetworkResponse in PDF format.
Ontario Medical AssociationResponse in PDF format.