Comment

Honestly quite ridiculous to have to jump through all these hoops, when it is difficult enough get medical care in Ontario. 

Even moreso, so many of the references to support statements in the "Advice to the profession: treatment of self, family members, and others close to you" don't even seem to be relevant or support the claims being made. 

For example, in reference #1 "Research demonstrates that your objectivity and the quality of care you provide can be compromised when treating yourself or people close to you", they list a personal narrative of a son who needs to make a DNR decision with respect to his father. This is wholly unrelated to the topic of a physician providing treatment to a close family member/friend.

Overall this is advice misses the nuances of real life situations and attempts to paint the situations as black or white

I find this section somewhat black and white when the reality is that there is a degree of reasonableness that should be applied to what is and what is not acceptable. For example, for minor ailments, should this be included in this definition. Probably not. Should you include Surgery and making diagnostic conclusions? Probably yes, but what if you're in a rural part of the province, where you're the only care provider? What about a clear cut laceration that needs repair that you can easily fix? I appreciate that there is greyness in this area and we're trying to set rules that govern physicians across the province, but some things need to be adjudicated around the reasonableness of the request. I think we need to think about every circumstance and apply a degree of reasonableness to the policy. Otherwise, it threatens care.

Let's follow the logic of these policies and see where it takes us. Doctor A and Partner B are a happily married couple. They go on vacation to cottage country. While there, they encounter one of the following circumstances: - Partner B forgot their blood pressure medications or puffers at home. - Partner B gets a cut while swimming which becomes obviously infected. - Partner B develops a classical sinusitis which is a condition Doctor A treats routinely. Options for medical care for Partner B are: - Go to emergency room, waste a space and the emerg nurse/doctor's time, waste 8 hours waiting for a 5 minute issue. - Drive 1+ hours to a walk-in clinic, again wasting a space, and spending 3-8 hours there. - Doctor A simply gives the acute prescription that is obviously needed and problem is solved. Are you honestly suggesting that in such circumstances it is likely or reasonable for Doctor A to refuse to provide the needed nasal spray, puffer, antibiotic, or BP med refill to Partner B? Are you honestly believing that a married couple in this circumstance is likely going to drive 1 hour to an emergency or walk-in and spend 8 hours there rather than take the more obvious solution? Really? Furthermore, are you then suggesting that Doctor A if they do what every couple will do this circumstance is guilty of "sexual abuse of a patient"? You are just creating absurd standards with zero context that will lead to weaponization and abuse of your policies. I seem to recall a case like this, where a doctor had prescribed asthma puffers to their child and some refills for their partner several times, and upon divorce, the partner reported the doctor to the CPSO for sanctions. The CPSO then sanctioned the doctor for "sexual abuse of a patient." You are creating a circumstance where any doctor is now open to threats against their license by any partner or family member who has ever gotten a single prescription from them under such a circumstance. And their CPSO page will then forever read they "sexually abused a patient" which is insanely disproportionate and not representative of what anyone would think should they read this. I have a hard time believing this is truly the intention of the policy. This policy should be written with common situations families encounter in mind and with expectations for the most reasonable course of action that should be expected for normal doctors to most likely follow in those situations.

The CPSO has always had, and continues to have, a terrible blindspot for this ethical and moral complexity of this subject. I am not sure if one should interpret it as willfully malicious, the desire for an easy and simplistic checklist framework that sounds good on paper, or ignorance based on the likely reality that many CPSO staff may prefer to work in administration rather than the real world where they might experience actually challenging situations. 

I will provide you with some "hypothetical" scenarios and you can please tell me honestly, clearly, and fully why the CPSO would seek to intimidate and punish this "hypothetical" doctor, say "Dr. H", for his actions in these cases.

1) Patient A is a 25 year old woman who suffers from chronic intellectual disabilities. She is now also suffering from a severely painful and potentially dangerous physical medical condition. She has a family doctor, with whom she has a good relationship. However, she reports she is too embarrassed to tell her doctor about the severity of what she is experiencing. Months go by and she is continuing to suffer with constant 5-10/10 pain daily due to this treatable condition. She is becoming dangerously underweight and her function is declining. Dr. H offers to accompany her to see her family doctor and explain, join a conference call, or go to a walk-in with her. Patient A declines all such offers, but asks Dr. H if he can refer her to a specialist for it. Seeing the worsening trajectory, Dr. H sends a referral. Had she been Dr. H's patient, he would have placed this referral months ago. Dr. H would never allow an ordinary patient of his to suffer this long.

2) Patient B is a 70 year old man who has spent his entire life avoiding medical care. He has never had a family doctor. He distrusts anyone he does not know well. He has refused to follow up with any doctors. He has smoked heavily and drank heavily his whole life. He has been recently now discharged from a 3 week stay in hospital and ICU after heavy drinking almost killed him. He is now trying to maintain alcohol abstinence with success. However, without alcohol, it is evident to him and his family that he is suffering from depression and this has likely been a background driver for his substance use. He wishes to take something for this as he now fears relapse. He trusts Dr. H and says he will only take something if Dr. H gives it to him. He refuses to see any other doctor. He has already stopped following up with the hospital specialists he was referred to post-discharge. Dr. H prescribes escitalopram as he commonly does in routine practice. Patient B shows improvement in his mood and continues to maintain his abstinence going forward.

In such cases, Dr. H must balance:

(i) The probable outcome and harm of not acting.
(ii) Any potential bias that might affect judgment. (ie. Is he providing the same basic treatment he would provide any patient under his care?)

Is it the intention of the CPSO policy to sanction Dr. H for helping these individuals in these ways? Both patients had ample opportunities for other medical care but actively refused it. Neither were facing acute or minor medical conditions. Both already had suffered considerable harm due to their refusal for other medical care and would have likely suffered far worse harm had Dr. H not then done as they requested. Dr. H provided them both with the same management he would any routine patient under his care.

Ethical principles must be managed in order of importance. Would it be medically or ethically correct for Dr. H to allow Patient A to continue to go without treatment until they ended up hospitalized or worse? Or to allow Patient B to go untreated despite his requests for help and the threat of death from a potential subsequent relapse?

Ethical guidelines should be general, brief, open-ended, and focused on basic guiding principles. It is impossible to write an overly specific "checklist" that encompasses all possible ethical scenarios, and you have clearly failed to cover all ethical scenarios in this guideline, as evidenced by the examples given above. 

Your continual threats of punishment of doctors when doctors are already trying to make the most moral and ethical choices are not helpful and just open up doctors to risks for wasteful and frivolous malicious complaints.

If you do not understand what I am explaining, then I suggest you speak to doctors who have large or extended families with complex personal and social histories, such as those described above. Let them tell you privately off the record of similar stories where they felt morally and ethically obligated to help those around them who have asked for their help, all the while knowing that one day they might be punished by their overly aggressive and disconnected regulatory body for doing so.

According to your guidelines, Dr. H should be sanctioned because: (i) These were not acute (<24 hour) issues, (ii) These were not "minor" conditions, and (iii) Both individuals had alternative options for care available, but refused to take them for personal reasons not described as acceptable based on your guidelines. No one involved was an "indigenous person", which seems to be one bizarrely specific exemption you are providing from these regulations. Apparently, if patient A or B were "indigenous" no ethical problem would suddenly exist (?).

Is that the intention of the policy? Based on the details of the "hypothetical" cases above, what should Dr. H's action have been to avoid sanction? Why would those actions have been more or less moral or ethical? Specifically what do you imagine would have been better for Patient A & B in these situations?

I would appreciate a clear and specific reply if you believe your guidelines are morally and ethically sound and have been thought through thoroughly. If not, then I suggest you re-evaluate your guidelines as they are continuing to manifest the same ethical blindspots and overly simplistic thinking your organization has unfortunately become notorious for in recent decades.

Any ethical guideline should be written by starting with the challenging real world ethical scenarios and cases a doctor may commonly encounter. If your guideline cannot be applied fairly or reasonably to the best choices a person can make in those scenarios, then it is not a well considered guideline and needs to be re-written accordingly.

If you want honest and useful feedback on this matter, you should consider first surveying doctors for their experiences in situations like this and then working backwards based on what you believe those doctors should have done in those circumstances to craft guidelines that can be applied fairly from there. 

I hope you will try to understand what I am trying to sincerely convey to you here, and write a more thoughtful, open ended, and better balanced policy. 

Any such policy should reflect and prioritize the fundamental ideals of our profession. The suggested policy unfortunately does not.

Common sense is key. If a family member has a minor condition, the physician should absolutely be allowed to treat their family member. This should not even be a question. Examples include: ear infections for their kid, a cough, a rash, etc. It's not logical to go and sit many hours in a walk in clinic, or wait days for a family doctor appointment or wait 6-8 hours in an emergency room ; for a condition that the doctor in the household can manage in just moments.

The draft should be changed.

A physician should be able to treat their family member for all the minor ailments items that a pharmacist can now prescribe for in addition to minor conditions at their discretion and in emergencies. If a patient is able to diagnose themselves and seek care for a minor illness from a pharmacist a physician should be able to do the same for their family/friends and spare the medical system the additional costs.

The proposed changes outlined in the draft policy "Treatment of Self, Family Members, and Others Close to You" are welcome. These updates are appreciated as they seek to clarify expectations for physicians in Ontario. However, further clarity is needed regarding the definition and scope of "minor conditions."

Currently, the policy defines "minor conditions" as those manageable with minimal, short-term treatment that usually do not require ongoing care or monitoring. While this is helpful, the definition remains open to broad interpretation. For instance, in Ontario, pharmacists are permitted to prescribe medications for minor conditions, which include certain infections or other health issues. Examples such as otitis externa or cellulitis in a child could reasonably fall under this category. Can physicians, under this policy, provide treatment for such conditions?

In the current healthcare environment in Ontario, it is impractical and resource-intensive to require patients to attend walk-in clinics, emergency rooms, or schedule primary care appointments for some of these minor conditions that physicians could address responsibly. Unfortunately, the lack of clear guidance on what constitutes a "minor condition" may discourage physicians from providing care due to concerns about regulatory repercussions.

Ideally, the CPSO could provide detailed examples or a more comprehensive explanation of "minor conditions" to alleviate this ambiguity. Clear guidelines would support physicians in making confident decisions while ensuring alignment with CPSO expectations.

We should be allowed to treat ourselves and family members for minor episodic illness

Given the scope of the family physician shortage, I fear for family members who may not have a family physician and yet require someone to renew ongoing medications or investigations for chronic diseases, as well as routine screening tests that require a signature. I wonder if the following thoughts could be considered, to be reconsidered when the HHR situation is much improved. This is in the context of "protecting the public" - and in this case, the "public" is a family member of a practicing family doctor. 1. reordering of medications that are for chronic conditions. At this time, pharmacists can do this and the risk benefit to the "public" is much greater for benefit. 2. ordering of routine bloodwork or other screening diagnostics for chronic diseases (e.g. HbA1c) or for preventative screening (FIT requisitions, Rx for Shingrix, etc). 3. Minor procedures such as cryotherapy, cerumen removal, etc. 4. Many specialists require a consult note for ongoing follow up after a certain timeline. I would hope that a family physician would be able to provide this in order to maintain continuity of care. I believe the CPSO should protect the public from physicians. By withholding care in the context of a serious shortage of family physicians, this policy may do the opposite and preclude care.

Thanks for the section on rural areas. That is an important distinction. Where we have a single specialist or few family doctors , we can end up providing an opinion or seeing colleagues, friends and family members of our colleagues. Sometimes we have to provide an opinion on a test for a family member or colleague. Agree that we may also have to and should be able to treat conditions that are not minor ( emergency) or advocate for family members on non minor conditions ( and emergency) where timely care is not available and then transfer care. Appreciate that the policy indicates that need to transfer care.

The section on treatment of minor conditions requires further revision.
As per the draft policy: "A 'minor condition' is a health condition that can be managed with minimal, short-term treatment and usually does not require ongoing care or monitoring. In addition, the treatment of the condition is unlikely to mask a more significant underlying condition. ... Physicians must only provide treatment for minor conditions to themselves, family members, and others close to them when no other qualified health-care professional is readily available." [And in 'Advice to Physicians':] "The permitted care is limited to emergency treatment or treatment of a minor condition AND when no other qualified health-care professional is readily available, requiring the transfer of treatment to another qualified health-care professional as soon as is practical."

Particularly in these days of immense pressure on family physicians and primary care clinics / ERs, it seems quite unreasonable that a physician can only treat such minor conditions as insect bites, conjunctivitis, minor lacerations, bruises and sprains in themselves, a family member or other person close to them, if the person is unable to "travel to another community within a reasonable distance where they could obtain care (even if less convenient)". These sorts of minor conditions are essentially basic first aid and it is highly unlikely that the physician's judgement will be impacted by their relationship with the person. (I don't imagine my family physician, or her after-hours covering team, would appreciate me sending along my husband to have Steri-Strips applied to a cut... or myself, for assessment of apparently minor soft tissue injuries when I fell off my bike!) Additionally, in the case of a physician's spouse/partner being the patient, the 'Advice' section implies that treating even minor conditions in a common-sense manner, if the spouse/partner could somehow manage to get to a clinic or PCP elsewhere, could be considered inappropriate and in fact may fall under the umbrella of 'sexual abuse of a patient' ... this is, quite frankly, ridiculous. I completely agree that family members should primarily receive their medical care from an unrelated family physician (IF one is available ... I have family members who have been waiting years for their own PCP), but our basic skills should be available to them for minor conditions, vs. adding to the primary care system burden (and OHIP costs). 

It also appears that, in determining whether 'sexual abuse of a patient' may have occurred, the spouse/partner becomes a 'patient' if we contribute to their medical record (does that include sending a note to the PCP to be included in their file?) or if we write a prescription (does that include 'emergency' renewal of longstanding and needed prescriptions if forgotten while traveling, e.g.?) 

While the intent of the policy is to prevent harm, the way the details play out in the real world is at times quite unhelpful. The guidelines need further revision, with common sense in mind, along with respect for (a) our health care system's limited resources and (b) our ability to use sound judgement in managing basic, minor conditions within our skill set, if we deem that the relationship with the patient will not adversely affect that care.

If a pharmacist can “diagnose, prescribe and treat” in certain clinical situations then it should follow that any physician can diagnose prescribe and treat” those same situations their own family at any time.