Accepting New Patients Draft Policy – General Consultation Discussion Page (Consultation Closed)

Posted on December 6th, 2016

Show Comments

Posting Guidelines

To ensure transparency and encourage open dialogue, the feedback we receive is posted on our website in accordance with our
posting guidelines.

Provide your feedback in comment box.

*

60 Responses

  1. Physician (including retired)

    we have many patients who already have family doctors and would like to switch to our clinic. we have been prioritizing the ones without family doctors. Can we continue to do this?

  2. Physician

    Thanks for the opportunity to comment on this draft policy.
    I welcome the first come first served and no discrimination approach. I think the policy should be written in clear language so that there is no confusion about how to interpret the policy. For example Family physicians have a broad scope of practice and should not discriminate on the basis of scope of practice, ever! A family physician can always provide primary care services even for patients requiring specialized care. Appropriate referral and coordination of care is a family physician role regardless of how specialized the condition is. I find it hard to understand how there can be a refusal on the basis of scope of practice for a family physician. Focussed practice family physicians are different and can turn people down on scope of practice.
    Another example around language – in the section on family members you have chosen to keep it vague by saying “it may be acceptable” . This is hard to interpret. Why not make that clear? In otherwise closed practices it will be acceptable to accept family members of an existing patient.
    I hope these comments are helpful.

  3. Physician (including retired)

    I am delighted to see this policy in place. I worked in a family health team for 7 years. There I saw MD’s require applications from the patients and then exclude complex patients whom they felt would take too much time. This was a rostered setting and some MD’s would do “strategic rostering” ie take on many health young people with the expectation that they would rarely come.
    I always myself took on everyone included refugees in my practice and gave my name to hospital specialists if they needed to refer a patient who was lacking a family MD.
    Thank you for this. Equitable access to care is our duty

  4. Physician (including retired)

    I say this as a family doctor in a small town who is the only one willing to take care of patients in the local nursing home, is one of the few who still has hospital privleges and has a much older than average practice. While well intentioned I feel more and more like I am living in a big brother state when I read this policy. One would think that if we had a well resourced well constructed health care system with adequate numbers of doctors, doctors would be looking for patients and if one doctor did not want the patient another would. If doctors were adequately funded to take care of high needs patients one would think they would want them as patients. It seems we have rationing and a stand in line way of operating. If you were a patient would you want a doctor who wants to take care of you or one that has too because of some policy? I am not talking about seeing a specialist once or twice but a family doctor with whom you would like to have a long term relationship. What is next the government maintains the list and then assigns the patients to individual doctors? Or the college insisting to see the lists doctors maintain of potential patients? I am as upset as anyone that certain doctors cherry pick easier patients and some even might discriminate. I just don’t see this is the way to address the problem. Are we going to see patients taking doctors to human rights boards because they wouldn’t take them on? This policy may also have unintended consequences. More doctors will likely close their practices to new patients rather than expose themselves to the accusation that they are not using a first come first serve model. Doctors will be unlikely to locate in certain places of high need because they may have disproportionately high numbers of high needs patients. I feel very sad for a young doctor who locates in a high need area who is forced to take on all sorts of patients who are very difficult to care for. Quite a number of patients who don’t have a doctor do because they have been discharged by their last doctor for legitimate reasons like lying to get extra narcotics or habitually not showing up for appointments. The reason a lot of family doctors don’t want to take on new patients is they know that it is difficult to justify discharging a patient. It is very time consuming to build the case to discharge a patient in the meantime it saps you ability and enthusiasm to take care of others. Imagine starting you medical career doing alot of that. I’d locate somewhere else if I was starting over.

    • Physician (including retired)

      I agree. What if a patient is rude and demanding on the first visit? The doctor is told everything they must do and what drugs are necessary. Taking on a substance abuser that expects you to cooperate with their demands is already a problem.

    • Physician (including retired)

      Points well made. I am near the end of my primary care career and am not taking new patients although I could. I have had medical issues and no longer have the energy to engage in complex patient care. The patients I have, I know well and have a good sense of their risk, health, mind set whether well adaptive or not and they are a challenge at times and I welcome it. Also I know many younger doctors who load up their capitation practices, generate awesome revenue but don’t have a hope of providing regular care. Many patients never ever see their MD because they are deflected to IHPs. Don’t forget the system is well and truly broken and making me care marginally for patients because of lack of resources is bad medicine and health care window dressing..

  5. Physician (including retired)

    Primary care pediatricians face an interesting dilemma. Many do a combination of primary and consultation care. They may be closed to primary care but open to consultation referrals. Some pediatricians may also be affiliated with a particular hospital and may feel it necessary to see newborn babies from his/her own base hospital although the practice is closed. Is this discrimination ? That pediatrician may not be able to see all who want to come to the practice from different areas in the city. Also if a child already has a pediatrician or family doctor and the parents just wish to change doctors, are pediatricians obligated to take on that child?
    The policy also needs to have some mechanism/ wording to protect doctors who may determine a patient is doctor shopping to get certain medications or procedures. (The phone call of ” I want to a new doctor because my present doctor does not want to do my MRI”)

  6. Physician (including retired)

    Thank you for tackling such a difficult issue.

    In the ED we see, first hand. the effects of “cherry picking” patients, both by primary care and specialties. We see countless patients disadvantaged and left to fend for themselves for many reasons, especially ones that make them have a perceived high burden of care. In fact, those are the patients that need us most.

    The difficulty is not going to be in passing this policy but in educating our profession to the value of equal access. Declining care to such patients is narrow minded and only serves to make our collective care less effective.

    My only caution is on how we, as a system, are going to support this policy in a manner that does not push physicians, especially new graduates in Primary Care, from Family-Medicine-Proper to Walk-in-Medicine practice. A problem already pervasive in our medical culture.

    Thank you again.

  7. Physician (including retired)

    Patients who already has a family physician should not be included under this policy.

  8. Physician (including retired)

    I am a specialist and,see patients for consultation only on referral basis.when a referral is received,we advise the referring physician,the specific date or approximate time-frame we`d be able to see the patient.We also try to prioritize,depending on the urgency/elective as noted by the physician.we advise the physician,if more urgent/expedient service is required,they should seek another available specialist or go to the Hospital emergency service in the community.

    • Physician (including retired)

      I totally agree. This policy should not deny the physician the right to screen and prioritize the patients.
      FIFO service assumes all the patients have the same difficulty level and time and care requirement which is not the case.
      we have limited resources and booking for procedures and office visit completely depends on available tesources, OR booking availability, government funding, rtc.

  9. Physician (including retired)

    Your policy needs to include several other factors

    As you age your patients age with you and your ability to manage more complex patients may in some cases decline. This policy would make it more difficult for a doctor to manage this issue in a responsible manner

    As a group doctor we are expected to manage our patients as a population. That has to include keeping balanced demographic profile. At times that means adding older patients and at times younger patients. WHile this would not be discriminating to a specific patient it may be to a group. As a rule younger patients that move around are more likely to leave but the older ones are yours forever.

    It is unclear from the policy (see line 151) whether you were talking about discriminating against complex pts or in favor of them

    The meet and greet is an essential part of the patient – doctor contract. It is after all a partnership You have looked at it from only 1 side and have neglected the patient side. When I tell a patient that I only work part time and what my on call arrangements are or that I have little knowledge of their illness or treatment concern I am giving them the information to choose whether they want me. This should happen before they are required to sign a committment to me. I would agree that there are few occasions where I would refuse a patients but a patient should clearly understand where I am coming from before the relationship begins

  10. Physician (including retired)

    The first-come first served policy has always been in the past and is probably the fairest. I have many patients who have not been able to get a new family doctor for over TEN years because they are complex. Doctors unfortunately have an “out” if they say s/he is “not competent” in managing patients with multiple issues or such. I think that patients should be allowed to make a “report” to the College if they encounter such treatments. As a specialist, I am stuck being the one consistent care giver for these patients and it is really not fair.

  11. Physician (including retired)

    Regarding focused practice and complex patients; sometimes these patients are best served in a hospital setting as opposed to community setting. The focused clinician/specialist in the community should have the right to notify the referring physician that this route is preferred so that the patient does not end up waiting when their care is better served in the aforementioned setting. This would prevent delays. This should not be construed as discrimination. This is a form of recognizing scope of practice. For example, a cancer pain patient referred to a non-cancer out of hospital pain clinic. Or a patient with multiple co-morbidities sent to an out of hospital interventional pain clinic when they would be best served in a hospital setting for monitoring and better co-management in the event of an adverse event. This needs to be made clear in the document. Thank you.

  12. Physician (including retired)

    I tell my patients a dr-pt relationship is A TWO -WAY BUSINESS. For this to work it needs a strong partnership of both parties. What ever we can call the first visit it will give both the pt and the dr a chance to know about each other and make a joint decision of taking the patient on into the practice. At the end of the day it is the patient’s care and patients should be able to ask questions and able to have a say if my practice will be able to serve them.
    At the same time emphasis should be put on public responsibility in terms of expecting a reasonable and practical service. As gate keepers of the resources we have we can’t dispense every test, referral, or treatment just because the patient requests – the reason some patients leave their family doctors.

  13. Physician (including retired)

    I do not believe this is a regulation that is required. We have more & more regulations, rules, cutbacks, and utter loss of control of our practices. This is NOT NECESSARY at this time.

  14. Physician (including retired)

    Surgical specialists are responsible for maintaining their wait lists. There cannot be a stipulation that you must accept all patients if your wait list and resources will not allow you to intervene in an appropriate time. There must be a right to refusal if it is timely and doesnt interfere with care. There also has to be a stipulation for procedures that are out of a practitioners scope of practice. It cannot be a blanket statement to accept all patients referrerred in a time of major resource shortages.

  15. Physician (including retired)

    To whom it may concern:

    My understanding is that this was always supposed to be the case. First come and no “cherry picking”. This is not a huge change from what I understood to be the case previously and is of course supposed to get rid of cherry picking.

    BUT I feel it will, as in the past, be completely ineffective. I must say looking at our clinic and the other clinics in our community, this is never followed except by our clinic. Further, people with chronic complex conditions are accepted by these other clinics, but then they are not seen and eventually leave and try to get in with our clinic. Why? Too many patients are rostered to the family doctors in the other clinic. Those with chronic complex conditions, the old, the ones with limited resources are weeded out because once they are accepted, the physicians practice in a same-day-only model of making appointments. Allowing only same day appointments, requires that the patient call in the morning to get an appointment. This only works if the size of practice and number of appointments available are equal to the needs of the population. Otherwise within 30 minutes all the appointments are filled up. This works for people who are highly organized and know how to call and call and call until someone picks up. The elderly and the ones who have challenges never get an appointment. People with diabetes and COPD and those requiring regular f/u can’t function in this type of system (one patient called every day for a diabetes f/u appointment and had to stop work to do it and if he got an appointment, he would go, but if not, he would have to do the same day after day until he finally got an appointment. It took him over a month at one time to get such an appointment). In the end these people get fed up, and so leave the doctor. This effectively means the docs are still cherry picking their patients by leaving them as orphans in a rostered practice. Until you deal with forcing doctors to provide an environment of access for all the patients that have been accepted and that access doesn’t discriminate against the type of patient that is rostered to them, this system of cherry picking will continue and your policy is in reality ineffective.

    Nice piece of paper but in practice doesn’t work!

  16. Physician (including retired)

    This policy is turning medicine in Ontario into a “big brother” state. Patient care will be very poor if a physician is forced to interact/care for problems that he/she is not interested in. There are now so many regulations that it’s hard to follow. Such a policy is just not realistic.

  17. Physician (including retired)

    Concern with “respecting autonomy in choosing physician”. In a limited resource environment where there are many patients that do not have a Family Physician, first priority should be given to patients without a family physician. Otherwise, the patient should first have to de-roster and inform their current physician that they are no longer going to be a patient BEFORE applying to other physicians in the community. There should not be “doctor shopping” on the taxpayers dime.

  18. Physician (including retired)

    Exceptions should be made in this policy for physicians doing psychotherapy – M.D. psychotherapists. When a therapeutic alliance begins between an M.D. psychotherapist and the patient it is important that the therapist be able to determine whether they are competent in a particular area of treatment. Many psychotherapists are trained in certain areas, and to treat certain diagnostic categories but not others. Being unable to refuse to see the patient because you do not have the credentials or training does not serve in either the patient’s interest all the physician’s.Perhaps the college should consult with MDPAC the Medical Psychotherapy Association Canada for a more reasonable approach to this problem.

  19. Physician (including retired)

    Fortunately I am near the end of my primary care career. I could easily work for many years as I love caring for my patients with whom I have built up a relationship over 35 years. I do not take new patients due to recent health problems and a system that is badly broken and leaves physicians out on a limb with less and less specialist support. I spend more time with the computer and in meetings about data management and rules and regulations. In my large clinic of family doctors we all face the same issues. Some younger doctors see the process as a business and roster as many patients as possible and punt to IHPs. Awesome revenue but deflected care. Some regions have patients that despite requests NEVER see their FD who generates out of basket revenue in the ER. Just an example of how far we have come from the days when we were expected to by both colleagues and patients, and did, all of our in hospital, OB, nursing home, office work , Or assists and hospital committee work gratis. The system is broken and forcing doctors to unwillingly treat patients is bad medicine. Psychology 101 states reward the behaviours you want to see to get positive results. This applies to both patients and caregivers.

  20. Physician (including retired)

    I do not support the last point about accepting patients of family members. I think that many people DO NOT want their family members to be cared for by the same doctor due to privacy . I feel if a doctors practice is closed even if they choose to take on others it should NOT be family members of existing pts but people whom they deem high needs or appropriate . Many times in a FHT we have a geographically area and how I am I to care for extended families outside of my catchment area?

  21. Physician (including retired)

    I feel that MD should have the right, just like patients to NOT accept patients if they feel that the fit is not right. I think that if you practice in such a way that is NOT as the patient would want it that is grounds to NOT accept. Not everyone gets along or trusts each other. I think that both patient and doctor have the right to end their relationship if they do not work well together, whatever the reason.

  22. Physician (including retired)

    The the following language requires clarification:

    “With an injury, medical condition, psychiatric condition or disability that may require the physician to prepare and provide additional documentation or reports.”

    A clear distinction has to be made between patients with actual needs for medical care (i.e. medical necessity) and persons who are in a third party dispute and are shopping for an ally to advocate on their behalf. Third party issues here refers to insurance claims, workers’ compensation issues, civil litigation and similar matters. Many consultation requests to my specialty concern matters in which there is no clear objective diagnosis. In many such cases, claims have been initiated but that information is withheld from the referral. In my experience, the reason underlying the nondisclosure is the referring doctor’s expectation of transferring documentation responsibilities to another physician.

  23. Physician (including retired)

    While I agree with the College concerning equal access to all patients, I have some concerns.

    My family practice is closed, but on occasion, I will accept a patient that is new to town that I meet in the ER. I do organize an initial appointment at my office to describe how our office operates. This is more for the patients’ benefit than mine.

    Also, there is no portion in the policy that comments on geographic limitations. Currently, if I refer a patient to a specialist in another city, I often get a response that the patient is outside of their geographic area. Is this restriction allowed? If so, can there please be some reference to this in the policy?

    Thank you

  24. Physician (including retired)

    Does “higher needs” patients reflect the ability to triage based on acuity?

    For example, I work in a general consulting pediatric group where acuity of referrals varies greatly, from urgent infections to potentially significant congenital anomalies to difficulties in school. Generally for each referral, the physician on call triages that the patient needs to be seen within x Amount of time. The secretaries then work within these parameters to book everyone in, urgent referrals squeezed in with the physician who was on call, non urgent referrals booked first come first served.

    Would this continue to be acceptable? If not, please consider clarifying that urgency of medical need should be a priority in accepting consults for specialists.

    Thank you for your consideration

  25. Physician (including retired)

    To Whom It May Concern:

    I have one suggestion regarding the new draft policy about accepting new patients.

    As a current family medicine resident soon to graduate, I hear about thousands of people who do not have a family physician due to the lack of family doctors; our region is classified as underserviced by the Ministry of Health. However, your policy as it is currently written, could make the situation more difficult to meet that need because it does not allow priority being given to individuals that do not currently have a family physician.

    I understand the importance to avoid discrimination in which you highlighted appropriately in the current draft policy. However, I do think it’s crucial to have an exclusion whereby physicians, like myself, who will be graduating residency and starting a practice, can quickly address this the dire need of thousands without a family doctor.

    Why is this important? The individuals without a family doctor may have gone years sometimes decades with no standard preventative care, whereas those who are already patients of a family doctor at least have access to the system through their current physician. Also, these patients without a family doctor are more likely to use the ER for unnecessary reasons or issues that could have been avoided by having access to a family doctor. The ER is overwhelmed here for unnecessary visits due to not finding a family doctor.

    In summary, I advise that an exception be made that physicians can prioritize accepting new patients only based on if these individuals do not currently have a family doctor. That way new grads like myself can quickly meet this dire need without having to navigate taking on patients that already have a doctor due to this policy as it’s currently written. You can add criteria for “having no physician” as: those currently not rostered by another physician, they’ve moved and require a local physician, current physician has stated retirement etc.

    Thank you for reading and considering my suggestion.

  26. Physician (including retired)

    Overall looks good:
    - Should highlight triage based on priority for all specialists – it does talk about priority access, but I think this should be highlighted

  27. Physician (including retired)

    State-employed GPs (e.g. Community-Health Centers..) who have all the benefits of salaries, pensions & vacations, should have different standards than regular self-employed MDs, who perform & are being treated as independent contractors, in terms how they have to run their business. Ultimately the policies/regulations should focus on voluntary rather than coercive methods, encouraging/motivating MDs to take & retain more complex patients & providing them with the resources (e.g. spinal & pain centers), rather than force the MDs to do more work for less compensation.
    As any type of relationships in a free democratic society, it should be a mutually-respectful & beneficial partnership of doctor & patient, and if the parties do not feel satisfied with their relationships, there should be little barriers to move to the more productive/fulfilling ones.

  28. Physician (including retired)

    About providing access to complex patients:
    -Is triaging consultation requests based on clinical information (for a specialist) consistant with the exception set out in the policy?

    Does this policy also apply to an emergency department physician since all patients are triaged and seen by priority and not on a first-come first-served basis?

    Also, can patients be refused by a physician based on geographic origin, specifically out-of-province patients?

    Thanks you for the attention to these questions.

  29. Physician (including retired)

    Putting too many restrictions on selecting patients will antagonize the medical profession. Rather, go after those doctors who are blatantly racist.

    Just as the patient has a choice of which doctor to choose, that the doctor should have a choice of which patients fit into his type of practice. Patient care will be enhanced if if there is a fit between the doctor and the patient

  30. Physician (including retired)

    The guidelines are very concise and clear particularly the section on “first come, served basis”.

  31. Physician (including retired)

    First come first served is the most reasonable approach. Prevents “cherry-picking” of healthy patients only, unless it is the physician who has health issues and cannot care for complex patients.

  32. Physician (including retired)

    Consider this option: physicians are humans who may want to avoid unpleasant or time-consuming work and may cherry-pick. I would suggest that capitation be reserved for those over 65 and for established medical/psychological problems such as chronic medical disability and psychiatric diagnoses.

    As second issue is the problem that when a patient cannot access the doctor, he/she should be able to attend walk-in clinics without penalizing the primary care doctor, rather than patient being advised to go to Emergency which is already overburdened and the wrong place to assess many kinds of problems.

    I am sure you also have considered how difficult it would be for prospective refused patient to prove lack of good faith, or have help of a tribunal, since a physician could always fall back on “the problem is outside my competence”

  33. Physician (including retired)

    Thank you for the invitation to offer comment upon the College of Physicians and Surgeons (CPSO) draft policy for accepting new patients:

    I am an old man, a widower and retiree on a fixed income living in rental accommodation and without any family support in the Province.

    I have experienced increasing mobility issues over the past 4 years and have reported my concerns to my family physician on a number of occasions.

    I have been dismayed by the cursory manner in which my office visits have been conducted since I have never been examined comprehensively in terms of an assessment of my gait: I have for example never been asked to walk, never asked to undress, never asked to display range of motion and never given a diagnosis.

    I have been x-rayed, and referred to an orthopaedic specialist (who also failed to asses my gait or examine me when disrobed in a manner which would have determined, for example, my existing peripheral neuropathy or considerable unilateral muscle wasting or scoliosis.

    I accordingly sought acceptance at a hospital-based Family Practice Teaching Unit where I felt that I might expect a comprehensive physical exam from a Family Practice Resident from whom I might anticipate an objective (and somewhat time-consuming) assessment that was not almost solely reliant upon the extent and limitations of any medical history that I was in a position to volunteer.

    Regrettably my request was denied on the basis of an explanation that I “already had a Family Physician”. This concerned me, for it leads to a stagnation in that no patient would be at liberty to choose a different doctor once that patient was deemed to have a Family Doctor. That “second Opinions” from one Family Doctor and another is forbidden. Further to change doctors does not reduce the opportunities for any other patient to seek a doctor within the community since a vacancy would have been created in the practice I wished to leave.

    The problem would seem to be that I am unable to change physicians without ending my relationship with my present Family Doctor, a measure I am hesitant to undertake without some assurance that I would indeed be accepted into a new practice. That I would have to declare myself “orphaned” before consideration to join a different practice could be extended to me, no matter what the circumstances.

    My query for favour of your consideration is: Can a patient be refused transfer to another practice in circumstances where the patient feels that he/she is not receiving individualized care? (In fact I feel that my level of care has been second rate in that I feel that I have been characterized as a standardized ageing patient in whom “aches and pains” are to be expected and treated symptomatically as a means of efficiently moving on to the next patient…but in doing so, effectively leaving me to feel that the quality of care is found wanting.

    I am saddened to feel that my own family Doctor has not felt it necessary to dedicate the time and care which I feel is needed, instead employing referrals, or issuing requisitions for x-rays and venipunctures to “kick the can down the road”. I had asked for a disabled drivers certificate which was denied. A (self-referral) Physiotherapist, following a gait assessment, did procure this for me. I had asked for a referral to a Rehabilitation Specialist a year earlier…which was also denied…only to be referred to the same specialty a year later (and a few months from now) with the given reason that “You are worse now”.

    In the course of my clinical journey, I have seen five health care professionals; My Family Doctor, an Orthopaedic Surgeon, and self-referrals to a Physiotherapist, a Chiropractor and Registered Massage Therapist. Of those five, only one, the RMT, had asked me to disrobe in order to examine me. (That exam fortunately resulted in a referral for a skin biopsy for a suspicious lesion).

    All I have really sought is a comprehensive assesment, leading to a diagnosis upon which would be based any treatment plan. And that this would form the basis for a high level of confidence in the care extended by my Family Doctor.

    Was I wrong to question this? Was I wrong to seek to change my Family Doctor,? Am I correct in therefore believing that it is wrong to seek a set of fresh eyes, to seek a second opinion, to change to a new medical practice in that this option has been denied to me?

    I certainly do not wish my experience to become the basis for a formal complaint of professional negligence. (Or, heaven forbid, believing that some professional “Old Boy” network is at play). Rather I see this as a sad reflection of practice fatigue in a world in which “one size fits all” medical care is increasingly being determined if not constrained by the momentum of bureaucratic demands within the publicly funded Health Care System and in which the freedom to choose in the best interests of patient health is being compromised by the imposition of decisions not directly related to the individually determined need and indeed the choice of the patient.

    I would value your kind commentary and advice of course, and more especially would hope that a resolution of my dilemma might be reflected in any revision of your forthcoming guidelines for accepting new patients.

    And in the absence of being denied the chance to change family Doctors, I wonder if I might expect a more comprehensive physical assesment were I to transfer my care to a Nurse Practitioner on the assumption that this might be “allowed”?

    • Physician (including retired)

      Thank you for your sincere commentary it brings up a number of important points.

      With regards to your family doctor, I am not sure why they have not agreed to refer you to a rehabilitation specialist or other health care professionals as you have requested. One could argue they are fulfilling their role as gatekeeper to finite publicly funded healthcare resources but as a patient you are being denied your right to pursue improvement to your health and quality of life.

      Would you pay out-of-pocket for this right? Would you as citizen of Canada, endorse the development of a parallel private system which would enable faster access to health professionals but at an additional cost to yourself?

      The fact is specialists are leaving the province because there’s not enough publicly funded positions here, open it up to a free enterprise and I would argue the number of doctors and health care facilities would rapidly expand to much better accommodate your healthcare needs and wants.

      You mention you had not received a comprehensive assessment from your family doctor. Had you been in for a physical? Did you directly and specifically ask for a skin check and gait assessment or did you assume your doctor should do this as part of routine care?

      As a family doctor myself who spends 1 full day in office for about every 400 patients I have rostered, I taken only 1 week holiday over the last year yet each day my schedule is full and I constantly feel time-pressured not only during patient visits but with all the administrative work, reviewing results, reports, taking phone call, completing forms etc. It helps when a patient is direct and specifies the reason for their visit and is respectful of the duration of the appointment and what can reasonably be accomplished in that timeframe.

      Booking longer appointments for multiple or more complex issues and specifying your expectations early in the visit may help. Having said that, the renumeration model for family doctors favours faster appointments and the difference in payment for a 5 minute visit versus a 30 min visit is negligible. It has been difficult to address these disparities through the publicly administered fee schedule.

      As our population ages, it is increasingly challenging to deal with ever more complex patients, particularly elderly patients, with multiple co-morbidities, not only are time and resource considerations a factor, but also limits in knowledge and training.

      Some patients are fortunate enough to be rostered within a family health team with access to multiple allied health professionals including occupational therapists and physiotherapists which may help fill gaps with the assessment and care. Unfortunately, this is not available to all patients and points to disparities in our system.

      Nonetheless, I believe you should have the right to attempt to access such a team and rules that prohibit your autonomy as a patient should be removed. Similarly rules that restrict access to walk-in clinics should be removed. Overall, I believe you or any other patient should have the freedom to navigate the healthcare system as you see fit BUT I would argue you should also bear some of the financial responsibility, above and in addition to your tax payments, for its use i.e. co-payment or out-of-pocket private payments.

      I believe this is the only way for our system to be sustainable long-term while effectively meeting the health care needs and expectations of our population, particularly the aging demographic.

      There is a need for accelerated development of health care facilities and resources and this I’m afraid can only come from the private sector. Holding patients somewhat financially responsible for their use of the public system especially for second or third opinions and non-urgent expensive tests like MRI’s can also help as well as reducing the bureaucratic waste in healthcare management.

      Thank you for raising key points, I believe issues like yours should be part of a wider public debate and discussion if we are to meet our population’s healthcare needs moving forward.

  34. Physician (including retired)

    I think it’s fair for a doctor to have a meet and greet with a prospective patient as an opportunity for both to talk about whether the doctor can meet their expectations. If not, it’s better not to start than to enter into a relationship doomed to failure. As a new doctor starting my practice not too long ago, I was faced with many patients who had expectations for controlled substance prescriptions that did not fit with clinical guidelines. I had the expectation that such patients receive a formal assessment before I would renew their prescriptions; some accepted this and some did not. Starting in a small town relatively saturated with doctors, I found I inherited a disproportionate number of drug-dependent patients, and these were not habits I created but that I was forced to deal with and which put me into many awkward and difficult situations with patients to start my career. Eventually I had to dismiss a couple patients due to abuse after failing to meet their unreasonable expectations and then I had to deal with unfounded complaints from these same patients, further perpetuating the abuse. Hence the first come first serve policy can force new doctors into difficult situations that were facilitated by doctors before them. Giving doctors autonomy to decided whether to enter into a relationship can be better for both everyone long-term.

    • Member of the public

      So what about those of us who take a “controlled substance” that don’t abuse them being turned away by a physician with a sign in his lobby “No Controlled substances prescribed here”. I need a doctor. I take nucynta which probably shouldn’t be controlled in the first place. I am repeatedly turned away. I am not an addict. Where can I find a doctor?

  35. Physician (including retired)

    The first come first served requirement is an effective deterrent to setting up an office practice. I might have considered opening an office practice to render medical services to older patients with complex medical problems with whom I could establish a therapeutic alliance, and would gladly let other more ambitious physicians see the minor untreatable ailments of easier young patients, all the more power to them. This policy left me quietly deterred from considering opening an office in Ontario.

    Though I recognize that selection of patients with whom to establish a therapeutic alliance needs to be done in a professional manner and communicated well, I see that a first come first served policy is counterproductive and unduly restrictive of the autonomy of both partners in the doctor-patient relationship.

  36. Physician (including retired)

    Hello,

    I am a family doctor who works in a family health team (over 30 mds). Our group feels strongly that family doctors should be able to accept “orphan patients” preferentially. The Ministry of health has always made it very clear that we should first be accepting people who do NOT currently have a family doctor. The priority should be to ensure access to care for everyone. Our group also felt that as physicians who work in a shared on call model that the physicians should have the option of declining to accept a patient who was previously seeing another doctor in the same on call group. The situation could arise where the patient might end up seeing their previous doctor in an on-call setting. If the previous physician-patient relationship was terminated because the physician felt unable to continue to provide care to that patient then patient care is compromised. Also if the patient no longer wants to see that particular physician then he/she may not feel comfortable using the after hour services.

  37. Member of the public

    My comment is that I did not realize a patient of a doctor in a family practice may provide feedback on choice of specialist when referral is needed.

    With wait lists, limited choices in many regions of Ontario, referral to a dermatologist or ophthalmologist for example, may mean an appointment at a date well over 6 months or a year.

    I am grateful for a fine family doctor who practices in a FHT in Guelph.

    This feedback is being submitted after my having had the experiences of power of attorney then executor for two family members – complicated cardiac care in Hamilton, brain tumour surgery followed by cancer Centre referral for chemotherapy & radiation.

    Respectfully submitted as a member of the public and with appreciation for the quality of medical care during a very challenging time for physicians in Ontario and while the federal government negotiates future terms for health care funding with the provinces.

  38. Physician (including retired)

    1. physician -patient relationship is where both parties are willing. Hence physicians need to explain patients there hours of operation , there level of comfort in managing certain conditions and then give patient option to accept or decline being accepted as new patient

  39. Member of the public

    At one time, this on-line register showed which physicians were accepting new patients. It would be very helpful to have this information available again. Thank you.

  40. Physician (including retired)

    Hello, I think that this is a fair policy, and I can say as an ER physician in the busiest emergency department in the country that there is quite a bit of confusion as to where a patient goes to find a family doctor who is CURRENTLY taking new patients.

    1. The CPSO website should maintain an index by postal code of family physicians who are taking new patients. That way there is no doubt, and the College knows at any given time the status of this situation by area and practitioner. This is more useful than a policy – much more useful.

    2. Patients in Ontario need to understand that we are always there for them, but THAT THERE IS A CLEAR EXPECTATION THAT THEY TAKE THE INITIATIVE TO HAVE A FAMILY DOCTOR. Frankly, this social norm in Ontario has BROKEN DOWN. This is deleterious to continuity of care and the ability of hospital emergency departments to provide care to the community. Patients must understand that the emergency department is not designed to be their initial source of routine primary care.

    3. Similarly, family physicians office vary widely in accessibility to patients:
    A. Many offices do NOT answer telephones properly during business hours, or have intolerable hold times, ridiculous recorded messages, and so on. Even when an ER physician calls to update the family physician, we can’t get through.
    B. There need to be RULES about having your practice covered when you will not be available (vacations, etc). This is a BIG problem.
    C. Appointment slots must be kept available for sick patients. I routinely here about waits of 2 and 3 weeks for appointments. That is unacceptable. Even more, literature questions the value of “routine checkups.” Given that, the lack of timely appointment slots for sick patients is forcing patients to dodgy “walk in clinics” where the quality of care is at best questionable, or to overcrowded emergency departments.

    4. I like to see patients! That said, the system is NOT working properly today.

    • Other health care professional (including retired)

      “Appointment slots must be kept available for sick patients. I routinely here about waits of 2 and 3 weeks for appointments. That is unacceptable. Even more, literature questions the value of “routine checkups.””

      I agree, but this requires a level of patient accountability that the government has never been willing to endorse. Healthcare is like hunger: the issue isn’t that we don’t have enough resources, it’s that those resources are not being distributed effectively.

      I work in medical administration for a family practice clinic. And while I’m not sure what the ER environment is like, I can say with some certainty that family medicine is a textbook example of the Pareto principle: 20% of the patients use 80% of our time and resources. It’s not that the 20% are necessarily more medically complex, either – they’re just more demanding, more insistent on being seen, and more aggressive about pushing for imaging and referrals, even though there’s usually nothing medically wrong with them in the first place.

      “Routine checkups” are actually a great example of this. Many patients think they need annual physicals, and nobody has told them otherwise. When a completely healthy 30something calls the clinic and says “I want to book an appointment for my yearly checkup,” I can try as tactfully as I can to dissuade them by pointing out that they’re up to date on all of their immunizations and preventative health screenings, but if they insist, I don’t have the medical authority to say “No, you don’t need a physical.” So, they get booked in, and the doctor wastes half an hour going through the CPX checklist with them and asking them if they smoke and exercise and go to the dentist, and I have three fewer appointment slots available on that day for minor acute issues: a teenager with strep throat, an elderly woman who slipped and fell at home, a boy with a rash.

      If a family physician had a roster of 1500 patients, each of whom wanted a “routine checkup” once per year, that would be 750 hours spent doing nothing but largely unnecessary physical examinations. Assuming the physician’s office was open to patients for 30 hours per week (allowing the physician to spend another 20-30 hours per week on charting, prescriptions, referrals, etc), it would take 25 solid weeks just to do physicals. Half the year gone, and that’s if the doctor did doing nothing but physicals, all day, every day – and that doesn’t even take into account things like wellchild visits (4-6 visits during the first year), prenatals (every month for 4-5 months), diabetic visits (3-4 per year per patient), or anything else someone might need to see their family doctor for. Is it any wonder that so few physicians are taking on new patients? They don’t have time to deal with the patients they have!

      Want to improve access to family doctors? Stop allowing patients to waste time and resources on unnecessary appointments. If I could tell patients “Sorry, but OHIP only covers one ‘routine checkup’ every five years,” that would free up hundreds of hours in the schedule that could be used for more acute visits. (Or, indeed, for new patients).

      But, of course, no government wants to be the one to tell people that they can’t have the comfortable placebo of the “yearly physical” anymore.

  41. Member of the public

    I am a complex patient that takes a narcotic drug, Nucynta. I have been without a doctor since mine retired with three weeks notice last September. I have been repeatedly turned down by prospective physicians based solely on the fact that I need a script for a narcotic. How is this not discrimination and why is this not covered in the new policy please?

  42. Physician (including retired)

    I am accepting new patients regularly.Doing 2 to 4 consults a week.Some weeks doing two consults a day if urgent.I agree take new patients seen before or request for patients relatives. worked for emergency calls for hospitals for 48 years till March 2014 .I also worked as emergency psychiatrist two days a week besides my regular day calls and weekend calls. I miss hospital work very much.I enjoy doing consults working now in office 3 to 4 days a week only due to health problems.

  43. Member of the public

    I am considered a “complex” patient and take a narcotic, Nucynta. I have been without a doctor since September 2016. I have seen several doctors in a “meet and greet” appointment and have continually been turned down as a patient for the simple reason that I take a narcotic.

    The new policy should have a paragraph included that it is discriminatory to turn down a patient based on the medication that they take.

  44. Organization

    The Access To Care (ATC) program has been working on access to specialist consults for surgery. ATC has worked closely with our provincial clinical experts (Provincial Clinical Leads) who are practicing surgeons in their respective specialties to provide a framework for surgeons. Through the Clinical Leads, we have engaged their various Communities of Practice to develop prioritization categories for benign and malignant surgical diseases. These categories are applied based on the best information available at the time of the referral and allow the accepting surgeon to categorize (triage) the referred patients based on the clinical need for service, which supports the fundamental principles of our health care system. We believe that this process is also consistent with the principles that are outlined by the CPSO and wanted to ensure this information was available to you.

  45. Physician (including retired)

    As a specialist. What if a certain GP or clinic routinely refers patients who are consistently no-shows.
    For example. The Dr or clinic book appointment in my office. It is a 3 month wait. The same patient then takes the referral and sees the “convenient but not very thorough” specialist in short order. The contact information from the referral for the patient is outdated. Therefore there is no actual confirmation of the appointment from our end.
    The GP’s and the patients and the walkin clinics are all booking and shopping around due to the fact that we have a “free” system. The individuals making these choices are not the same people paying upwards of 100,000-500,000$ of income taxes into this broken system.
    Can’t we have a system whereby patients hold a spot with their OHIP info or a credit card. And no shows are tracked. Or credits deducted for blatant disregard and abuse of the system.

    Also. This would be a better way to monitor for the horrific abuse of our medical system. With OHIP card holders allowing visiting relatives to use their cards and appointments.

    My clinic had over 1,000 no shows last year!!!!

    Who’s paying for all the administration that is incurred without any income?

  46. Physician (including retired)

    “First Come, First Served”

    Sirs

    This letter is in response to the request for comment on the CPSO draft policy.

    I understand the fundamental tenet of the profession — that the practice of medicine is about serving the needs of the patient.

    I understand the CPSO policy of “first-come, first-served” approach helps to ensure that physicians fulfill their legal obligations under the Ontario Human Rights Code (the ‘Code’). From the current draft I excerpt the following as it seems relevant.

    The Code entitles every Ontario resident to equal treatment with respect to services, goods and facilities, without regard to race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity, gender expression, age, marital status, family status or disability.

    Under the Code, all those who provide services in Ontario, including physicians providing health services, must do so free from discrimination on any of the above-listed grounds. In keeping with this legal obligation, physicians must not refuse prospective patients based on any of the prohibited grounds of discrimination.

    In applying the “First-Come, First-Served” approach physicians may limit the health services they provide based on their own clinical competence and/or scope of practice. Further, some physicians have limited or focused practices based on specific clinical areas such as geriatrics, psychotherapy or adolescent health. If a patient’s care needs do not align with the physician’s clinical competence and/or scope of practice, this would be permissible grounds for refusing a prospective patient.

    Similarly, if a patient’s care needs do not align with the physician’s focused practice area, this would also be permissible grounds to refuse to accept a patient into the practice, however refusal must be made in good faith.

    Physicians, and those acting on their behalf, must not use clinical competence and/or scope of practice as a means of discriminating against patients as defined by law, or to refuse patients:

    - With complex or chronic health needs;

    - With a history of prescribed opioids and/or psychotropic medication;

    - Requiring more time than another patient with fewer medical needs; or

    - With an injury, medical condition, psychiatric condition or disability that may require the physician to prepare and provide additional documentation or reports.

    Setting

    I will provide the following working example to guide the discussion. A Neurologist is before the ICRC of the College of Physicians and Surgeons of Ontario after a complaint of discrimination by an office policy of not undertaking elective consultations of individuals involved in a Motor Vehicle Accident (MVA).

    I draw to the CPSO attention that the referral patient is a litigant. It is become common practice to request assessments through OHIP when there is an alternative mechanism in place designed to address them. In addition, litigants may be seen after an Independent Medical Examination was undertaken through the SABS process to answer specific questions, or as a back door second opinion.

    In current practice Neurologists have diverse approaches to the request for elective consultation. I will address them sequentially. They all have in common the “Catch 22” that places the Neurologist in jeopardy.

    Firstly, some decline MVA elective referrals outright by office policy. Those that are rejected or inevitably slip through the screening process are informed that MVA-driven encounters lie beyond the capacity of the Neurologist’s office.

    The reasons are various:

    Some simply wish to avoid the possibility of subpoena to attend proceedings in the matter as a civic duty.
    Some doctors feel they can not do justice to the presentation or the patient without full knowledge of the setting.
    Some may be of the opinion that it is an unnecessary exposure to personal and professional jeopardy.
    Some may be unprepared to deal with litigious questions that will be settled in an adversarial arena.
    Some prefer to simply avoid the acrimony which arises disproportionately in this setting.

    I draw to the reader’s attention that important issues are likely to be vetted through subpoena of the encounter or appearance of the doctor. Yet the salient information is not found among the descriptor of requirements listed in the OHIP schedule of benefits and as such is not a medically necessary service.

    Not uncommonly the patient will say, “My lawyer told me to ask my family doctor to get testing / see a specialist/ get an MRI , etc.” Frequently patients fail entirely to mention the MVA and subsequently correspondence requests answers to specific questions of functional capacity: “Are the patient’s headaches from the MVA? Would you consider the patient to be disabled as a result of the MVA”, etc.

    Thus a referral “involved in MVA – rule out …… ” is unlike others and may be instigated by the setting. Patients not placated at this stage may be outraged and do complain to the CPSO. In the past this has been seen as a reasonable course of action by the CPSO.

    Doctors choosing the avoidance approach typically do not bill OHIP to avoid future audit when billings are discovered during the legal process.

    Secondly, some Neurologists accept all referrals. Paradoxically the most well intended may feel that they are patient advocates not knowing their role in serving the justice system.

    Of this group some strictly limit the encounter and say to the patient that the only aspect of the presentation that is to be addressed is the specific component such as “possible pinched nerve in the neck”. No discussion of the MVA is recorded in the chart as the information is reiterative and recollection is heavily influenced by practice through repetition.

    This approach balances ignorance versus deniability of knowledge. “Willful blindness” is a concept that recognizes that if one intentionally fails to be informed about matters, one does not avoid responsibility under the law.

    The difficulty inherent in this selective approach to MVA-driven encounters is also discussed in the CPSO publication “one issue per visit” policy. As stated by Dr. Thurling , “It is safer and more effective for physicians to triage and prioritize patient complaints than to ask patients to do it themselves”.[1]

    Some recognize the presentation is complex and uncorroborated. However, the setting of the MVA is distinct. The majority of individuals involved in a MVA have minimal or no injury.[2]

    Some may recommend a more detailed or fulsome assessment in a setting by a provider for that purpose.

    Some tell the patient to have his lawyer or the Insurer seek an IME.

    Summary

    Applying the CPSO policy of ”first come first served” and discrimination under the Code to the MVA setting will be difficult for the practitioner. Complaints have and will be triggered by litigant dissatisfaction rather than discrimination of an injured or disabled individual.

    Mandatory acceptance of elective referrals for those involved in an MVA will now become a duty with sweeping implications, not all of which I will address in this response.

    Firstly, OHIP billing will rise as they are merely a cover, if not a misuse, in the legal process. The General Manager of OHIP may be required to broaden the definition of medically necessary to include compliance with this policy.

    Secondly, doctors screening patients are likely to be ensnared by complaints of discrimination unless the patient is accepted. Effectively one can no longer triage or decline nonmedically necessary referrals arising in this setting.

    Thirdly, presuming all involved in an MVA to be disabled under the Code, is a reliance on self determination that is demonstrably inaccurate. The CPSO is aware that Ontario is the staged collision capital of Canada. [3]

    One possible solution is to have the referring physician indicate clearly the expectations of the referral and to allow the Neurologist to determine if they have the capacity to undertake the referral and accept the follow through consequences.

    Failing this, a period of grace and transition is recommended during which the implications are addressed. Necessary education is to be provided. The responsibility to provide education in nonmedical presentations is unclear. Such knowledge should be a requirement for accepting the referral.

    For the benefit of the CPSO, Financial Services Commission Ontario (FSCO) accredited disability Designated Assessment Centres (DAC) under took examinations under Statutory Accident Benefit Schedule (SABS.) Issues of impairment, disability, causality and apportionment were thereby expertly addressed without exposing the doctor to personal and professional jeopardy. There was a relative immunity from vexatious complaints and subsequent subpoena for clarification of opinion.

    [1] Ref
    http://www.cpso.on.ca/cpso/media/uploadedfiles/members/resources/practicepartner/patientsafety/patientsafetyarticles/safety-1issue_1_2011.pdf

    [2] Ref Preliminary 2014 Ontario Road Safety Annual Report Selected
    Statistics

    [3] Ref
    http://business.financialpost.com/personal-finance/the-auto-fraud-squad-how-canadian-insurance-companies-are-trying-to-crack-down-on-fake-claims

  47. Organization

    Response received from the ‘Ontario Medical Association’ is available in PDF format.

  48. Organization

    Response received from the ‘Professional Association of Residents of Ontario (PARO)’ is available in PDF format.

  49. Organization

    Response received from ‘Health Care Connect Program, Provincial Care Connectors’ available in PDF format.

  50. Other health care professional (including retired)

    I am past retirement age but one point that I have come across with my pain patients is that some physicians within
    the guidelines of freedom of action refuse to prescribe any medications with any amount of narcotic in it. After a
    consult, has been sent back suggesting Tylenol 3 or Percocet, a number of physicians refuse to write any narcotic
    prescription even if it is just during my absences. A number of pain physicians are asking the referring physician to
    guarantee they will continue narcotic medication.

    In the past I have noted that patients have been to many clinics filling out application forms and provided a list of
    their medication. They have been declined acceptance because they are on narcotics. This leaves a new patient in a
    difficult position because the CPSO accepts the right of the physician not to prescribe narcotics if they feel unhappy
    with this and thus they will not accept these patients.

  51. Organization

    Response received from ‘OMA – Section on General Family Practice’ available in PDF format.

  • Share