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I think this policy is fine.
I find however it doesn’t go far enough in another area that perhaps it should. There are physicians that routinely engage in business with their patients. They use their trade in office improvements, or they may engage in purchase and sale transactions with them. Clearly there is a conflict of interest in such instances, especially in long-term relationships, psychiatric or addiction medicine situations.
There is only general policies on this and nothing specific. While there is very specific policies dealing with conflict of interest of a sexual nature and with family members, there is no specific policy on the issue of engaging in business or service transactions with those under physician’s care.
On the notion of business.. what exactly is the “conflict of interest”? If a physician truly provides WORSE care to a patient because he/she is providing a business service for them that may not have gone as expected, that should be dealt with as a disciplinary problem, and not by a blanket policy that prohibits doctors to hire people in a certain industry (who may be the best in their field) because that business person is their patient. Trouble occurs when a patient asks for medical advice during off hours when the physician is dealing with the industry/business decision at hand. Ensuring proper documentation and categorizing treatment plans would be a solution to that. However, to provide a blanket policy that physicians can’t have anyone in their practice who may also provide a business service to them is nonsense– physicians in small communities then won’t get any service! This entire policy assumes that physicians really have poor judgment and what is reasonable and what is not.. In my opinion, examples of troubles that have arisen potentially should be provided on a sheet to educate on types of situations to avoid, and stop policing the entire connected world that is getting smaller and smaller from engaging in business. If the business relationship interferes with the patient care, then the policy on ending the doctor-patient relationship apply. There is a way out of a bad situation, and if poor medical care is given, then the disciplinary committee deals with this also. So, why do we need another policy on restricting physicians who may be routinely engaging in business with their patients? If we provide more and more restrictions on access, then the problem of ‘physician access’ will get worse and the risk of NO MD access will hurt society much more than ensuring patients have employment and allow them to feed their own families. Again, provide examples of situations on what situations have occurred that were brought to the attention of the CPSO and doctors can learn from those to avoid repeating them.
There are rare circumstances when prescribing opioids in palliative care i(malignancy) may be reasonable, to patients who are family or friends, only when there are no palliative care professionals or family doctors willing to immediately take over. The prescription & care would be temporary until a replacement physician could be found. Maybe especially true in Northern Ontario or in areas of extreme physician shortage, such as extreme southern Ontario. When the alternative is uncontrolled or untreated suffering, one must act according to our physician oath, while perhaps reviewing all orders with MD or RN colleagues.
I totally agree with this. Even in busy city hospital, when a family member was dying of cancer with such excruciating unrelenting pain, on a visit to ER for URI, the ER doc prescribed 2mg morphine q4h prn for their pain, when on 60mg a day (given by oncologist)! We begged the ER physician who ignored our plea completely- he would not even come near us. What was I to do? Have you ever seen a loved one cry with pain and beg to be gone from this world? I had to go home to get their bottle of med to give at the hospital. My family member was dying but didn’t need to suffer the excruciating pain in their last days. As physicians we may be clouded by some emotions but always keep in mind that we are hardwired and encoded to be responsible physicians too. In a palliative setting there should be consideration in allowing physicians to intervene when there is no other alternative.
I agree with the previous two points. We need to remember that our purpose is to serve people and relieve suffering, not live in fear of a policy that although set for the greater good will be so rigidly interpreted that it will counteract the ability for beneficence. Treating acute pain or treating an infection should be allowed, as the prescription immediately benefits the patient (relieves pain and avoids doubling time of bacteria) while SAVING OHIP funds (providing that the MD did not bill for the family member) and decreases waiting time for other members of the public to access care. Remember that OHIP was over $500 million short (and so taken from the doctors fees), and ironically, treating in such circumstances and not billing will save the system money, and hence keep it viable for everyone longer. This treatment policy has to be thought through in all components, and so I would argue that treatment in minor or emergencies should stand alone as a condition, and remove the “AND other professional should not be available”, because technically, many professionals are available in the province, but within how many kilometers, and in what time frame is reasonable?… this would also have to be spelled at out clearly. Minor issues, acute emergencies or as the physician below states (simple SHORT term refills of chronic meds if regular MD is on vacation) would be in the best interest of the patient and qualify for the Principle of Beneficence.
I totally agree with the above comment.
I agree that there are times when it would be appropriate for a physician to prescribe /administer opioids to a family member or friend.
I would like to see specific guidelines related to a simple refill of daily meds for self or family member, I.e Thyroid replacement , anti-hypertensives, NSAID’s especially when primary MD is not readily available
Also please review administering care to family members for simple acute conditions like cold, flu or strains, as well as administering vaccinations and immunotherapy and b12 injections
From the policy introduction: “The overwhelming majority of the responding physicians objected to the policy’s position that physicians should not provide treatment for themselves or their family members except in the limited circumstances of minor conditions or emergencies, and where no other physician is readily available.” If we are a self-regulating profession, then the expressed opinion of CPSO members (Ontario physicians) should prevail over the views of stakeholders groups and published articles, although these should of course be respectfully considered.
I think, as other comments made so far have implied, that the term “minor condition” needs to be defined further. It is written in too vague of a manner currently.
The policy as it stands is much too restrictive. There are so many instances when one could help a friend or family member with a refill, known medscape for a simple condition, acute pain, any medication within scope of practice that would obviate a trip to ER or walk in clinic. Doctors should be given much greater responsibility and trust than this policy allows.
We have years of schooling and experience, surely we have learned how to prescribe. College catering to the most conservative position as usual.
I see nothing wrong with treating immediate family members initially for basic conditions and referring them on to suitable consultants for ongoing management. Also we should be allowed to refill scripts for ongoing therapy to save time and keep the offices of the prescribing physician free for more urgent care.
some other specific sensible exceptions could be addressed:
1. non-patient (friend/family member) on long term medication forgot to get a renewed prescription before the holidays, expecially if missing a couple or a few days can be a major problem.
2. When we travel, especially foreign country or off grid camping, I take a full emergency kit for higher risk events (age considered): two antibiotics, one anti-arrhythmic, one serious pain medication, one sleeping medication, topical antibiotics, as well as non-prescription drugs for stroke, allergic reaction etc.
(I have twice had the experience of not treating a family member while abroad and trusting the local physician, only to have dangerous medication prescribed for the wrong diagnosis, having to throw this out and do it myself)
3. Antibiotics for major respiratory ailments, UTI’s, anti-virals for shingles, safely alleviating missed opportunities to catch the problem early, prevent infecting others, and clogging the emergency wards.
4. Emergency and temporary treatment for an acute psychiatric illness when either the person will not attend anyone else, or the family physician will make a referral to a psychiatrist with a 9 month waiting list, or going to an emergency will prove to be a traumatizing and fruitless experience.
The policy does provide for the conditions listed. These are all temporary and/or short term situations. The temptation to continue to do this on an on-going basis must be resisted to ensure your family member is getting appropriate long term care by their physician.
For treating family and self it would be useful to give a few examples of emergencies eg prescribing antibiotics for an elderly relative with a recurrent bladder infection Friday evening of a long weekend etc
There needs to be greater clarification in regards to what a “minor condition” is.
Acute cases such as URTI, UTI, otitis media where a quick assessment and treatment can be prescribed should be allowed. What about travel vaccinations and treatment while abroad?
My honest belief is that this is an unduly restrictive proposal that many of my colleagues would deem not sensible. In particular, I think there should be consideration of when appropriate treatment is defined, and that definition of “minor” should be more clearly stipulated.
I agree with other comments that the wording “limited circumstances of a minor condition”
needs to be clarified and expanded.The CPSO should trust Physicians to Treat myself or a family member for episodic conditions such as Urinary Tract Infection, cellulitis and renewal of medications.
The draft policy on treatment of self, family members and others close to members is clearly intended as a restrictive one and its underlying purpose is sound. I have three comments, however.
(1) Not all jurisdictions in North America appear necessarily to be highly restrictive in this matter.
In Pennsylvania, for example, the application for renewal of a medical license offers 3 choices: (1) a full unrestricted license, (2) inactive status, and (3) active-retired status. The renewal form refers to active-retired status as follows:
“I will be retiring from practice but desire to place my license on active-retired status which will allow me to treat immediate family members.
I am exempt from the CME requirements. Renewal must be completed and fee is required.”
I was somewhat surprised to find this option, but I mention it to illustrate that there is a spectrum of opinion on this matter.
(2) The policy states that treatment by members of themselves of family members is not permitted “except for a minor condition or in an emergency situation and when another qualified health care professional is not readily available”.
The College might consider incorporating into this statement language appearing earlier in this draft policy, specifically, in reference to “circumstances where the risks associated with treatment in this context are either minimal or are outweighed by the benefits of providing the treatment”.
(3) Item 1c seems excessive and severe in reference to a spouse. In the case of a spouse, a sexual relationship is clearly not arising out of a patient-physician relationship. The policy appears to “put the cart before the horse” and the threat of application of sexual abuse provisions of the RHPA seems inappropriately severe. It is difficult reasonably to construe that the RHPA was intended to apply to this situation.
I agree with this document as it relates to treating medical conditions. I notice you have added the word “cosmetic” along in a long list of items. However, I feel cosmetic treatments should be in their own category. Currently, most physicians with cosmetic practices treat their own staff with fillers and Botox. I personally feel that this should be allowed. I have a cosmetic practice….I have chosen to not treat my staff because the guidelines are unclear. However, this has created great difficulty in my clinic. My staff resent the fact that they cannot choose me as their injector and threaten to quit so that they can come to see me for filler and Botox. My staff cannot afford to fully treat themselves but want treatment. It puts me in the difficult situation of trying to arrange for another injector to come and treat them. Frankly, I have difficulty finding an injector who can provide the level of skill and experience that I have after many years of injecting. Even so they constantly ask for my opinion, advice right down to where I would place the Botox and how many units for example. I might as well be doing their treatments.
I certainly do not feel that a doctor should be operating on their own staff or carrying out major or invasive procedures like endoscopy or procedures requiring sedation. But, minor procedures like Botox, filler or laser hair removal….I do not see this as a conflict of interest. We are not treating illness. I suggest creating a document that outlines the risks of having a doctor do minor cosmetic treatments on staff to ensure that staff have received full informed consent. However, I feel staff should have the freedom to choose who does their injections.
Agree with many comments.
Agree overall with this policy’s intentions but lack of definitions problematic.
I feel documentation is the main issue that will limit how often physicians treat family members as this simply can’t be avoided or does not meet the standard of care.
As others mentioned simple medication renewals if not done on a regular basis should be reasonable to do and I would like a statement specifically about this issue.
Agree with comment that the complete ban on narcotics etc could potentially be an issue in very remote areas. This could be investigated. While the legal responsibility in the event of a bad outcome would fall on the college in these rare exceptions it still doesn’t prevent bad outcomes which should be the primary issue. The college needs to address this issue.
I liked the comments about business transactions someone mentioned (although a side issue). This is more important with the expanded scope of pharmacists who have no restrictions of engaging in business with clients. I would like to see a level playing field one way or the other (MD, ND, pharmacist, chiropractor, OT…..). Either we can all do business and sell stuff or we all can’t.
Thanks to all contributing to this.
The ethical physician is expected to always act in the best interest of the patient and physicians need every possible support to act in the best interest of their patients – including support from the CPSO.
There are unforeseen circumstances when physicians encounter family members and others close to them in need of medical care. We spend our days – our whole life, really – making decisions about what is in our patients’ best interest. As professionals, we constantly reflect on what we should do to meet that standard.
After external consultation, the College is presenting a draft policy on “Treatment of Self, Family Members and Others close to them” that informs physicians that when they provide treatment for themselves, family members and others close to them, there is a risk of compromised objectivity, which may impact their ability to meet the standard of care.
The draft policy completely fails to reflect that this risk of compromised objectivity – seen as detrimental for treating self, family and others close to us – exists potentially in every patient encounter; we constantly examine, diagnose and treat patients who we may have a very close, caring, emotional, and worried relationship with. I explain to every expecting parent during the prenatal interview that I “always will treat their child exactly as I would want my own child to be treated”.
Every physician has to judge at each and every patient encounter if his or her decision-making is impaired by compromised objectivity and then act accordingly. I do not see the categorical difference portrayed in the College Policy between our regular patients and our family and those close to us when they have medical needs. (It goes without saying that I am not talking about controlled substances and the like). I am thus troubled that the College takes the responsibility of making this professional decision away from us when the person in need is “close to us”. It worries me that the College thinks that physicians are not able to judge for themselves what is considered ethical, appropriate and according to standard of care. I do not believe that goodness can be legislated and I do not appreciate a nanny-society approach.
The draft policy proposed by the College does not reflect the input given by so many physicians in the external consultation. The College stands to be criticized as conducting an external consultation pro forma but without listening to members critical of the policy and without reflecting this feed-back in the revised document.
-The policy guidelines appear sound.
-I think it`s ok,to treat family members for minor condition,emergency situation or when regular primay care service is not available etc.
-When my primary care physician is not available,usually they leave a no.to call in case of emergency,or on w/e.We were able to access this service,rarely,when needed(may be 4-5 times in the last 10 yrs).
-Rarely,I also have treated a family member(2-3 times in the last 10yrs),for simple-straight condition,with excellent recovery in a short period.
I fully support this physician’s points. Well said. I agree we always act in the best interest of patients, and to be forced not to act in the best interest of our family members in emergencies and for minor situations to ensure proper and TIMELY care (even if ‘another professional’ is available – who may not have the same knowledge of all medical conditions of the family member or all allergies for that matter which may be too complex for a short first time walk-in visit) would be a slap in the face for devoting our lives to serving society. I think the ‘studies that show that physicians are emotionally involved’ need to be dissected as to the nature of the illnesses being treated and for what length of time, before it is extrapolated to all physicians for most circumstances if we indeed keep the “AND no other professional available” clause in this policy. I fear that the “and” policy would result in basically being interpreted that there really are no situations of when a physician can treat a family member, especially in saturated Toronto, as many other professionals are available. Please be fair. Indeed, show me a car mechanic that does not treat his own car? Show me a painter who does not treat his walls to a fresh coat of paint? Show me an accountant who does not do file his own taxes? The rules for physicians are often imbalanced, and we could argue that we are not being afforded the human rights that other members of society enjoy – using your skill set for helping loved onces. What about preventive treatment? So are we going to police doctors for self prescribing iron supplements for iron deficiencies or for increasing their own vitamin D dosage or self treating with a multi-vitamin because they may be too emotionally involved in their own care? Who writes these policies? ? What about the fact that most physicians are burnt out taking care of patients, that they have no time to take time off from their practice to wait to see another professional for their own urinary tract infection? Would ordering a urine test on themselves become illegal? This would be an example of an acute situation and present NO emotional consequence. Emotional involvement would be possible for a physician operating on themselves or treating their own psychiatric problems. I fail to see how fixing a rash, an infection, or a biochemical imbalance acutely presents a burden on emotions. Each physician has different levels of skill in various areas, and if you are the ‘expert’ in an area how is the best interest of a family member served to make it illegal to treat since ‘some other physician in that specialty does exists’? So it appaears that we are creating INEQUITY in that the rest of society can benefit from a particular diagnostic skill of physician X but your own family should not have access to the same? This does not seem fair when you treat members of the public with the concept that you would not give them anything that you would not give to your own family, except that the CPSO rules then say, you can’t give it to your own family….
physicians should be able to provide out-pt care to self and first degree relatives even if they are retired similar to rules in Michigan and Pennsylvania for example. Not allowing an internist to give self a prescription for GERD or Hypothyroidism is unfair just like telling carpenters that they cannot fix their own cabinet because studies have shown that they will be more emotionally involved….!!
with respect to treating minor conditions the section should be changed to “or” not ‘and ” re: when another qualified physician is not readily available.
in most areas there is always an emergency dept or walk in that would fulfill the criteria of readily available but would seem a waste of resources, health care dollars and time for a family member to go there for a simple refill e.g a blood pressure medication, if they ran out on a weekend when their family doctor was not available when you could simply provide them with a prescription and the family doctor be notified the following week.
I am a physician. I know many but not all specialists. I think I often have a reasonable idea obout which specialist may be best suited by skill and personality to deal with my fmaily members. Certainly there may be other specialists that may be better suited than those that I know, but I would like to be able to refer my family members to certain specialist. I think this may be precluded in the current policy.
In Dialogue, Volume 11, Issue 2, 2015, page 11 it states, ” Advises physicians that treating spouses or sexual/romantic partners beyond the limited exceptions … is sexual abuse under the RHPA.
Treating an individual is not sexual in nature and should not be under the umbrella of sexual abuse. It should be categorized differently such as ‘assault’. The current proposal is too heavy handed in my opinion.
I have read this article with interest.
I,like so many others,have on occasion treated family members both for cosmetic and non-cosmetic medical concerns over the years.
You refer to “research” clearly showing that this is not a good thing.However you do not give a peer reviewed literature reference or the evidence based research that validates this claim.
Before I can make an informed decision about how I will continue to practise in the future ,I would like to review the medical literature you are referring to.I would like also to know whether the researchers differentiated between cosmetic and non-cosmetic issues.
Physician should not be treating self and family members.
With respect, this kind of absolute pronouncement is not helpful to the discussion. Please read some of the posts. Much harm can result from overly strict policy.
I have just finished reading the Dialogue, Volume 11, Issue 2, 2015. I have two questions regarding the six “things” you quote on Page 11.
1) How does the College define “ others close to the physician”? My family physician has been a close friend for many years and my wife and I and he and his wife often attend social functions, dinners, etc., together. Is the College saying he should not be providing my care?
5) In this section you state that treating spouses or sexual/romantic partners beyond the limited exceptions is sexual abuse! I can understand that such treatment would be unethical, but sexual abuse???
Personally I have been rebuked on 2 separate occasions by 2 separate physicians when seeking care for my children.
Both times was berated for not personally treating my children and for wasting other physician time in seeking independent medical assessment and treatment .
Timely article to address the need for independent medical care for family members as well as guiding physicians to provide care for other physician family members without prejudice.
Even though the CPSO is inviting input from its members concerning this new draft policy, it should be clear to all members that all comments will be studiously ignored, save where they happen to agree with the policy makers. Those who disagree will be dismissed as not having understood clearly the intent of the policy, or as opposing the policy, which of course is intolerable. After such a preamble, it may seem paradoxical that I wish to share my opinion, but the fact is I have strong personal reasons to do so.
For the past several months, I have had to play a very active role in the care of a loved one. If I had not done so, there is a very high probability that person may have died as a result of misdiagnosis and mismanagement. As soon as a severe medical problem manifested itself, I sought medical care. The correct diagnosis was missed on the first occasion, an honest mistake. On the second hospital admission, my concerns — and that of the patient, more importantly — were casually brushed off. Obviously, I was “too emotionally involved to be objective”, and I was worrying about irrelevant issues due to my “preconceived notions about the individual’s health”. Well. Such irrelevant issues included serious symptoms. My loved one’s trust in the medical system was shattered.
It took me a few more weeks to get my loved one to accept to see another physician — I made the referral as no one else would — and at last our concerns were heeded, and a test I had asked to be done was finally ordered. The diagnosis? A very serious disease.
So. Following the policy put forth by CPSO, my loved one would presently continue to have episodes of uncontrolled serious symptoms, with the risk of death or severe harm. Not to mention untreated disease. Had I felt empowered to take control sooner, diagnosis would have been made months earlier.
A better policy should simply state: “Physicians should not engage in a therapeutic relationship with ANYONE if, in their judgment, they believe their objectivity may be in any way compromised, and should at all times practise within the boundaries of their expertise. Temporary infringement of this rule can be allowed for cases of minor conditions or emergencies where appropriate medical care is not available in timely fashion.”
This policy statement would be less restrictive, and protect not only relatives, but any one under the care of a physician.
There are a number of concerns arising from the revised draft policy that need more reflection before this policy is finalised. My perspective comes from many years of experience as a clinician, teacher of medical students and as a patient.
I am aware that the research regarding medical care of those close to physicians tends to support the notion that some objectivity is lost. This must be respected, but this research only reflects part of the true picture. Many factors are involved in achieving excellence in medical practice. I was raised in a small community where our physician and his family were our closest family friends. This physician administered medical care to all of us. It worked very well for decades, ending only with death of the physician. This kind of thing is very common in small communities and despite the learned opinion of some there is nothing wrong with that; and much to say in favour of it. I suspect that if the right kind of studies were done, the so-called loss of objectivity would not be nearly as significant as a number of other factors that impact the quality of care.
The last thing that the public wants is cold, distant relationships with their physicians. They want their physicians to know them as people and to truly care about them and for them. The draft College policy is antithetical to achieving and even maintain this. My own measure of how well I am delivering care is to ask myself “If this person was a member of my own family, would I do the same?” If not, then why not? There is nothing, absolutely nothing, that reassures patients like being told that I would treat a member of my own family exactly the same way I am treating them. And it’s true. With regard to achieving “clinical objectivity” over humanity, there is an old adage, “Be careful what you wish for, you might get it.”
It goes without saying that family members should not rely on other family members to be their regular physicians, perform surgery or administer psychiatric care, that billing should not occur if treating self or family members, and that controlled substances must not be prescribed to self or family members. Boundary issues exist and we have standards of practice that almost all physicians agree upon, unlike the draft policy.
Nevertheless, whether or not a physician treats someone close to them should be primarily determined by the level of comfort in the physician-patient relationship and the scope of practice. The primary consideration should obviously be the comfort of the patient, but the comfort of the physician in delivering the care is also very important. The point is that this level of comfort is different for every circumstance and trying to impose a blanket prohibition is not only fraught with difficulties, it is harsh and could easily be detrimental. When a close person says, for example, “I would not be comfortable with anyone else taking care of this.”, and the physician is comfortable and competent to deliver the care, there is no place for the College to institute a comprehensive ban on acting in that capacity irrespective of the unique circumstances. Even if it is not an emergency. Until there is an agreed upon definition of a “minor condition”, this has no place as Policy. The definition of “minor condition” similarly depends on the training and experience of each physician. If by minor condition, the College means “not immediately life threatening” then that should be the wording. The level of comfort is obviously not an issue in self treatment. Within the provisos outlined in the previous paragraph, the rationale for penalties for self treatment is questionable. Such issues should be between a patient and their doctor.
The RHPA characterization of treatment of spouses or sexual/romantic partners as sexual abuse equates coming to the aid of a loved one with seeking, or establishing romantic liaisons in your patient roster. This comparison is inappropriate under most circumstances (non-psychologically controlling situations, surely the majority of non-psychiatric instances),
In summary, this document should be primarily a guidance document rather than a prohibitive one.
In the past, most Ontario physician respondents opposed aspects of earlier versions of this draft policy. Practising physicians are capable of critical appraisal. There is a quote which has been attributed to Albert Einstein and Yogi Berra, but is probably from Dutch mathematician Jan van de Snepscheut: “In theory, theory and practice should be the same. In practice, they are different.” If we are truly a self-regulating profession, then the power of the College to deliver its mandate of protecting the public must ultimately derive from the rank and file members. With respect, College representatives must not knowingly vote contrary to the expressed wishes of the majority of College members, irrespective of their own personal feelings or the rationale proffered in the policy proposals before them.
College of Physicians and Surgeons of AlbertaResponse in PDF format.
Professional Association of Residents of OntarioResponse in PDF format.
Ontario Medical AssociationResponse in PDF format.