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To whom it may concern.
I read with interest your policy statement on physician services during disasters and public-health emergencies. My comments to the policy are as follows (quote in italics, changes in bold):
Lines 32 to 34
A public health emergency is an occurrence or imminent threat of an illness or health condition caused by biological and/or chemical terrorism, endemic/pandemic disease, or a novel and highly fatal infectious agent or biological toxin that poses a substantial risk to human life.
I suggest should be rewritten as:
A public health emergency is an occurrence or imminent threat of an illness or health condition caused by biological and/or chemical terrorism, endemic/pandemic disease, a novel and highly fatal infectious agent or biological toxin or environmental disaster that poses a substantial risk to human life.
The rationale for this change is as follows:
This correction is meant to cover other situations such as famine or extreme weather that can lead to public health emergencies. The view as written is extremely narrow and focusing on toxic or infectious events only, ignoring the public health emergencies that can stem from disruption of services. The WHO definition the draft is quoting stands as is in the WHO documents because, within the framework of other documents, they address the issue of health care facility resilience to natural disasters. Out of context it is too narrow a definition, hence the correction.
Lines 48 – 51
A physician’s practice setting may afford access to additional sources of information. This may include, but are not limited to, hospital protocols, directives from community settings where medical services are provided, or organizational plans and/or policies.
I suggest should be rewritten as:
A physician’s practice setting may afford access to additional sources of information. This may include, but are not limited to, hospital protocols, Public Health and other directives from community settings where medical services are provided, or organizational plans and/or policies.
The rationale for this change is as follows:
Public Health may be a key player in, for example, a pandemic and may provide directives for physicians in both community and hospital settings. Within the aforementioned example these directives could include the establishment of vaccination or triage clinics.
I feel this section is highly problematic and requires serious revision. The text:
There may be reasons related to the physicians’ own health, that of family members or others close to them which may place limits on the physicians’ ability to provide direct medical care to people in need during a disaster or public health emergency. In those instances, physicians who have a personal health and/or ability limitation must lend support during disasters and public health emergencies. This support can include performing administrative or other support roles, as well as increasing capacity in one’s practice to offset the increased strain placed on physician resources during disasters and public health emergencies.
There may be reasons related to the physicians’ own health, that of family members or others close to them which may place limits on the physicians’ ability to provide direct medical care to people in need during a disaster or public health emergency. In those instances, physicians who have a personal and/or ability limitation should make themselves available to provide support during disasters and public-health emergencies within the context of the relevant disaster response and the best of their ability. This support can include performing administrative or other support roles, as well as increasing capacity in one’s practice to offset the increased strain placed on physician resources during disasters and public health emergencies.
The rationales for this change are as follows:
(1) Any functional disaster plan should have defined roles and personnel allocated to those roles a priori. Furthermore forcing people into roles are not accustomed to is counter to the basic rules of disaster response. Thus making it obligatory (“must”) for a physician to become involved in the delivery of support could actually pose a problem by disrupting the existing human resources plan placing physicians in roles for which they are not trained and with which they are not familiar. This is similar to the problem of convergent volunteers in disaster settings. Physicians should make themselves available but not be obliged to push themselves onto the disaster response process.
(2) I am assuming that the College has sought legal advice with regards to whether it can compel physicians to put themselves at risk. As a profession we have historically exposed ourselves to risk as part of our culture of helping others. This has always been voluntary. Making it compulsory is counter to the ethos of our profession, may be challenged in law and may expose the College to legal risk should a physician suffer an untoward outcome because of having been obliged to comply with the College’s dictate. The rewrite I propose above should help with this issue.
(3) Finally, on a non-scientific note, hard to enforce and counter-productive statements like this paragraph run the risk of playing into preconceived opinions of the College as heavy-handed, uncaring for the well-being of physicians and divorced from the realities of frontline care leading to antagonism towards this policy as a whole and limiting compliance.
I hope these comments are of use to you. I would appreciate if you could acknowledge receiving them. Please feel free to contact me if I can be of any further help.
Agree with the concern to line 62-68
Given that we will be expected to provide care in a potentially dangerous environment with significant risks, we should be offered compensation both for our services and for any illnesses or deficits that may occur as a result of providing this care. This would include a compensation plan for death or disability. For example if myself and a nurse attended to a patient with a SARS like condition, followed by our deaths from contracting this disease, would not be appropriate that our families both be offered compensation for our deaths. This of course should also include disability and not just death.
Ultimately I believe it would be highly inappropriate not to ask for this compensation especially given that other emergency providers will be given and offered such compensation.
A physician has duties towards his family and his patients. Usually there is no conflict between these duties: you go to work and see patients in order to earn money to support your family. All the duties are in alignment. However, if there is a disaster which “seriously disrupts the functioning of a community or society and results in human, material, economic or environmental losses that exceed a community’s or society’s ability to cope” and which causes these duties to come into conflict with each other, then a physician’s primary duty is towards his own family, not other people and their families. If that means evacuating himself and his family from the area, then that is what he must do.
The current policy reflects this, saying that “…physicians also have obligations to themselves and their families, which may need to be balanced with their obligation to provide care to patients. The College is confident that physicians will use professional judgment when balancing these obligations.” That is a reasonable policy.
The new draft policy says “physicians must provide physician services during disasters and public health emergencies” but qualifies this slightly by indicating that the health of a family member may limit the physician’s involvement to “performing administrative or other support roles”. This is both unreasonable and unrealistic. The main effect of the new wording would be to facilitate complaints by patients and relatives after the disaster is over, that the physician should have prioritised them over his own family.
In this response, for “he and “his” please read “she” and “hers” etc.
Agree with this comment
“There may be reasons related to the physicians’ own health, that of family members or others close to them which may place limits on the physicians’ ability to provide direct medical care to people in need during a disaster or public health emergency. In those instances, physicians who have a personal health and/or ability limitation must lend support during disasters and public health emergencies.”
While I appreciate that the policy recognizes that there will be circumstances when physicians cannot provide direct medical care, it strikes me as harsh that they MUST still lend support. In a public health emergency, there should be some accommodation of professional expectations when a physician is coping with the severe illness or death of a child or spouse. I do not know how it serves the public good if a physician in such a situation is forced to do administrative work.
I am comfortable with this policy and think the way it is written allows some flexibility (in public health emergencies) for physicians wrt documentation and practicing outside of scope (and clear guidelines as to when we would be expected to do this). Thank you.
Given that British Columbia declared a Public Health Emergency in April of 2016 (i.e. 18 months ago) regarding the opioid crisis, that there is no sign of it being cancelled any time soon, and that there is pressure on Ontario and the federal government to follow suit, the CPSO policy should anticipate such extended (and “no exit strategy”) uses of PHE powers. It remains unclear to this reader whether the opioid crisis even meets the WHO definition as listed in the Terminology section of the policy, but it would be problematic to require physicians to continue to provide services (or allow physicians to practice outside their scope) for *years* in response to political gestures, including for example long queues for essential services triggering a PHE declaration.
Agree with this concern
I support the articulate comments made by the physician on Oct 16 at 4:20pm. Otherwise the draft appears reasonable to me.
Response in PDF format.
Response in PDF format.
Thank you for the opportunity to comment. In general the policy is well written and organized, focusing on duties and obligations of physicians. Acknowledgement of the reciprocal duties of society in the form of government policy to support and protect responders and caregivers would be a welcome enhancement.
“Reciprocity requires that society support those who face a
disproportionate burden in protecting the public good, and take
steps to minimize burdens as much as possible. Measures to
protect the public good are likely to impose a disproportionate
burden on health care workers, patients, and their families.” (Upshur R et al. Stand on Guard for Thee, University of Toronto Joint Centre for Bioethics. 2005. available at: http://www.jcb.utoronto.ca/people/documents/upshur_stand_guard.pdf
lines 32-34: This definition is too narrow. The definition of Emergency, as defined in the Emergency Management and Civil Protection Act of Ontario is: “any situation or an impending situation that constitutes a danger of major proportions that could result in serious harm to persons or substantial damage to property and that is caused by the forces of nature, a disease or other health risk, an accident or an act whether intentional or otherwise.” Physicians may be called upon to treat patients who suffer health effects from these events.
lines 46-48: in reference to provincial emergency management plans, you may wish to include the Ontario Ministry of Health and Long Term Care Emergency Response Plan (MERP), available at: http://www.health.gov.on.ca/en/pro/programs/emb/pan_flu/docs/emerg_resp_plan.pdf
lines 49-50: suggest editing to “This may include, but are not limited to, hospital protocols, directives from PROVINCIAL PUBLIC HEALTH AUTHORITIES, AND community settings where….”
Medico-Legal Society of Toronto
OMA section of General and Family Practice