Practice Guide – Preliminary Consultation (Discussion Page) (CLOSED)
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As a physician, who finds himself working in facilities, owned by other business entities (i.e. clinic owners) I find myself occasionally in conflict where the clinic owner may be putting profitability above the patient’s interest.
I have seen this result in unnecessary testing being carried out as well as suboptimal working conditions where the technical staff is forced to carry out more tests than they are comfortable with and in some instances more than they can properly carry out. This can result in subpar testing and lead to incorrect results and adversely impact patient care and well-being.
It would seem that there is NO ENFORCEABLE CODE OF CONDUCT to which non-medical individuals and entities that own/run clinics must adhere. This is a potentially serious problem and is growing in certain sectors of healthcare where opportunists see a system that can be “gamed” for profit.
I have seen NO INDICATION that the CPSO is aware of this or is doing anything about it. I believe this GROWING BEHAVIOUR to be a significant contributing factor to the increasing cost of healthcare and results in decreased patient access to legitimate testing.
principles sound good and of course are needed and desired, one fear is that we dont confuse being sensitive to patient’s values (which is important to do with agreeing with any and all values. ” Dr I think in my opinion its ok to take one of my kids kidneys for my transplant so i want to consent for them as that is in my value system” may sound extreme but smaller similar situations could lead to requests for more extreme situations based on our prior examples. We can do our best to support patients but should not state that we support them at all cost.
Overall, the practice guide is excellent. I believe that it would be great to incorporate the EDI lens into the New Practice Guide for all physicians in February 2023. We need to rise to the challenge of the application of EDI in everyday clinical practice, especially for patients who have been historically underrepresented and discriminated against due to their ethnicity, socio-economic background, gender, disability, etc. It would be important, to keep EDI at the forefront of what we do, every day.
Discriminating against people and seeing them as nothing more than their skin colour, gender, and sexual orientation is inherently wrong. DEI is designed around doing exactly that, and then providing preferential treatment for some at the expense of others based on those inherent traits.
The only correct response to racism, sexism, and other discrimination is to treat everyone in a blind fashion irrespective of their immutable superficial traits.
That was the Martin Luther King way and it is still the only correct answer now. DEI institutionalizes racism and discrimination. Two wrongs don’t make a right.
As an expression of idealized sentiments, the guidelines are lengthy, sometimes defensive, and possibly in conflict with existing regulations. The stated intent of the Guidelines is to provide overarching principles. In effect, the Practice Guidelines constitute a contract between physicians and the public. A good contract should be fair and enforceable. The proposed guidelines are enforceable but hardly fair. As overarching principles, the Practice Guidelines are neither practical nor balanced and therefore lack credibility.
Service may mean working for the benefit of another but many services regulated by The College are of uncertain benefit. Assisting, aiding, and helping are terms that capture the sentiment in a manner that reflects the current social reality while including the concept of benefit.
Altruism is a lofty goal but impossible in the real world. Altruism may apply, somewhat, to those working in publicly funded institutions but for everyone else, the bills must be paid. Humanitarianism better describes the intent of medical practice without excessive idealism.
The notion of trustworthiness is unquestionably a component of any service. I recommend going silent beyond a simple statement.
Ensuring that practice matches the level of competence conflicts with a world of limited resources. Many physicians practice well beyond their level of competence striving to help patients simply because those with an acceptable level of competence are not available.
Where the guidelines are acceptable are in those sections that present a concise requirement with a caveat – Maintaining Confidentiality and Reporting. The remainder require pruning and thoughtful revision
You really do not understand the principle of altruism, and you twist it. Altruism is certainly important, but most people, including probably most physicians, do not have it. Just cut the whole paragraph about it out. (Altruism is nothing to do with putting an individual’s needs before a doctor’s or population needs, etc. It is a much more basic concept, mostly lacking everywhere).
I would suggest that a 15 page document is unlikely to be read by most busy residents/clinicians. This kind of document contributes to admin fatigue. Though it may be helpful to offer this lengthier version for those in teaching settings, I would recommend the following for the busy physician: adding a one page synopsis or ‘cheat sheet’ at the beginning of the document and a simple ‘Take Home points’ at the end.
I concur with the author of another ‘reply’ here that CPSO has no control currently on non-medical persons owning, clinics for profit; A classic example is a large pain clinic that closed abruptly at the beginning of last year leaving hundreds of patients, their referring physicians and the physicians working there in the dark. There were no consequences for the owners, and apparently after declaring insolvency, they have opened a new ‘medical business’ on virtual care. Where is the accountability?
Just like other provinces (such as BC) persons with a non-medical background should not be allowed to own or operate a medical facility. Its time for CPSO to stand up and safeguard the public, and the physicians against such persons.
This practice guide is good reading to reinforce certain principles of a physician’s basic interactions with the patient’s putting the patient first, altruism and being sensitive to diversity.
There remuneration provided to FFS family physicians requires them to see more patients in their time so that they can cope with the overhead which is always increasing in terms of minimal wages increased rent and increasing inflation. The college should work towards a policy that the government should be paying a part of the overhead cost for running clinics.
The current Ontario government PSA for virtual and phone care and the cuts that have been made make it difficult to provide continuous care. Walk-in patients also want to have phone calls and virtual calls and to pay a doctor only $15 or $20 is totally unjustified when a consultation has been done.
Many patients in the older age group are unable to do video calls and like phone calls which prevents them from traveling long distances and paying for car parking and I do not see why a reduction has been made for phone calls.
The college needs to look into these aspects as well otherwise family physicians will find this clinic practice outside hospitals and outside funding models very difficult to pursue.
I find the guideline very easy to understand and comprehensive but a little long so make it brief so we can easily finish reading it.
Prof Assoc of Residents of Ontario (PARO)
Note: Some content has been edited in accordance with our posting guidelines.
Thank you for the invitation to provide feedback on the CPSO Practice Guide.
Overall we found it to be clearly written and to provide useful guidance.
The “Wellness” section is focused on ensuring one’s own wellness and fitness to care for patients, which is certainly very important. We wonder if there should be an added section about being cognizant of the wellness of one’s colleagues and learners and ensuring that they have the support they need to step back from patient care if needed. Certainly for learners, our ability to step away from care is often facilitated or limited by our supervising staff. In addition, residents may not be as well equipped to recognize when one is not fit to provide patient care and may need assistance with this being early in their medical careers. It would however similarly apply to clinical staff, who may benefit from their peers helping them to see when they are unwell and take over some of their tasks if needed.
As Equity, Diversity, and Inclusion are increasingly recognized as key values in medical practice, we suggest identifying these values, perhaps within the Advocacy section.
Finally, there are multiple typos throughout where there is a dash in the middle of the word eg. page 8 column 2 “responsibili-ties”, page 9 “effec-tiveness”, page 10 “appropri-ately”, and page 12 “compet-ing”.
Thank you for the opportunity to contribute to the review of this policy.
Canadian Medical Protective Association (CMPA)
Response in PDF format.
Ref. to the CMPA’s suggestion to use language like “patient safety incident”:
Although this may be helpful for a CMPA-represented client, to encourage a productive outcome in a tort proceeding, CPSO may risk obscuring the intent and undermine the public’s faith and trust by using this language.
Possibly at least one section is talking about actively contributing to driving out systemic failure. So words like this may be considered (reference at bottom):
Systematic failure invariably occurs under specific conditions of handling, storage, or use of equipment or drugs. One of the characteristics of systematic failures, as opposed to random failures, is their ability to reproduce themselves by deliberately applying the same conditions that have generated them. The systematic failures are considered to originate from people and processes being involved during the care life cycle, either in the specification, design, manufacture, installation, operation or maintenance phase of the equipment, system, or facility. Thus: a lack of requirements specification, incorrect or non-robust design, manufacturing quality deficiency or problems, software errors, incorrect installation, incorrect maintenance, acceptance of product literature or academic papers in presence of conflict of interest, etc.
It may be helpful to name at least some of these for concreteness:
◾ Errors of substitution—turning on hot water instead of cold during a shower.
◾ Errors of selection—such as selecting carbon dioxide for a patient instead of oxygen
◾ Errors of reading—a nurse may read 1.0 mg as 10 mg.
◾ Errors of oversight and omissions—a practioner may simply forget to give an antibiotic after a
◾ Errors of irritation—a caregiver may perform a task wrong when irritated with too many
alarms and interruptions.
◾ Errors of alertness—the dangers of residents working on multiple shifts are obvious.
◾ Errors of interchangeability—such as connecting an oxygen hose to the nitrous oxide source
in anesthesia equipment, because the fittings on both the sources are same.
◾ Errors of lack of understanding—an improperly trained staff is likely to make mistakes
◾ Errors of haste—a caregiver unable to perform the tasks in an allocated time is likely to
skip seemingly minor tasks as hand sanitization prior to surgery; a surgeon leaving a sponge
inside a patient.
◾ Errors of sequencing—a practitioner may not perform the work in the given sequence
of a checklist and overlook an activity.
◾ Errors of overconfidence—this happens in diagnosis when a physician sees a very familiar symptom.
◾ Errors of unintentional activation—a caregiver may inadvertently flip a life support switch to OFF instead of ON.
◾ Errors of mental overload—a practitioner commits an oversight or error because his or own workload had increased due to Covid conditions
◾ Errors of physical limitations—a short person may not be able to reach out to an object at an inconvenient height and cause an accident after climbing on a chair.
◾ Errors of casual behavior—sometimes a caregiver may not take a task seriously. A surgeon may not go through a scrub process when touched by another person. Or a surgeon may not mentally prepare a patient for a surgery.
And to provide concrete examples of system improvement:
◾ To prevent a surgeon’s leaving a sponge in a patient, some hospitals use bar-coded sponges so they can be accounted for before and after each surgery.
◾ In the case of the anesthesia equipment in which the oxygen and nitrous oxide fittings are the same, many hospitals have equipment in which the fittings are unique for each supply. They cannot fit in a wrong place.
Reference: Safer Hospital Care : Strategies for Continuous Improvement, 2nd Edition
Raheja, Dev ISBN : 0-429-05804-7
Ref. to the CMPA’s comment about “Limited Resources:”
Perhaps some symptoms and causes of the phenomenon present in every profession, of performance without passion, or without due concern or done diligently in a substandard manner could be mentioned for concreteness:
Symptom 1: Performance without passion
Not learning from mistakes
Inattention to the voice of the patient
Making premature judgments without critical thinking
Lack of teamwork
Lack of feedback and follow-up
Symptom 2: Performance without due concern
Lack of accountability
Encouraging substandard work
Reacting to unsafe incidences instead of proactively
Inattention to clinical systems
Difference between management and caregivers
Poor risk management
Symptom 3: Performance diligently done in a substandard manner
Doing substandard work, knowing it is substandard
Ignoring bad behavior
Inattention to quality
Safer Hospital Care : Strategies for Continuous Improvement, 2nd Edition
Raheja, Dev ISBN : 0-429-05804-7
College of Nurses of Ontario (CNO)
CNO had the opportunity to review the current Practice Guide posted on your consultation page. Overall, the guide is clear, easy to understand and relevant. The duties that are set out in the guide are helpful for articulating the practice expectations of the profession.
We have shared some specific feedback below to support the evaluation of the Practice Guide.
• In the Practice Guide there are a few different references to using the term “his or her” or “himself and herself”. From a diversity, equity and inclusion lens, you may want to consider revisions to be more inclusive. For example it may be more inclusive to use the terms “they, them and their”. We have shared a few examples where this language was used:
o On page 9, under the third duty (Collaborating with Patients and Others), instead of using the term “his or her care” to be more inclusive we would suggest using “their care”.
o Another example is on page 11 (Participating in Self-Regulation), you may want to consider removing “his or her colleagues” in the third sentence and revise to “their colleagues”.
• We also noticed a few dashes in the middle of the words. For example, on page 9, under the third duty (Collaborating with Patients and Others), in the second paragraph instead of “effect-tiveness of collaboration” I believe it is meant to say “effectiveness”.
• Lastly, you may also want to spell out some of the acronyms when they are used for the first time (e.g., WSIB on page 11 and CMPA on page 14).
Ontario Medical Association (OMA)
The OMA does not have feedback on the Practice Guide at this time. We appreciate the opportunity to participate in this preliminary consultation, and we look forward to reviewing the next iteration of the guide and providing additional feedback at that time.
The OMA appreciates the opportunity to provide feedback on the College’s Conflicts of Interest and Industry Relationships policy and Practice Guide before they are finalized. Please contact us if you have questions or require additional feedback.
Comments and suggestion on Trustworthiness
Trust is a nebulous concept, close for many people to “good and honest,” “will not harm you,” or “safe and reliable-looking.”
I would encourage clarification of what is meant by the term “trust” or “trustworthiness,” in this regulatory context, in order that patients and carers may have a common understanding.
I can propose these words for consideration/discussion:
“Trust is an emergent property of the carer/careseeker relationship. It can neither be demanded nor asserted. The carer’s trustworthiness and the value of the offered advice is mainly a function of track record, taking into account all previous interactions, recommendations, and what resulted when the careseeker took the decision to accept/act on the advice. If there have not been many previous interactions, indicia of professionalism can help. (organization, accuracy, a clean/organized work environment, checklists, and so on.)
Trust is also supported by being candid about the level of uncertainty that is present for the carer. And not offering advice outside of the carer’s true knowledge and experience domain, in case it turns out to be unsupported.”
Reference: Burgman, Mark A.. Trusting Judgements (How to Get the Best out of Experts) (p. iv). Cambridge University Press. ISBN: 9781107112087