College of Nurses of Ontario (CNO)
Hello,
Thank you for the opportunity to review and provide feedback on the Accepting New Patients policy and Advice to the Profession companion document. Overall, we found both documents to be clear, comprehensive and relevant. The information shared in both documents provide important accountabilities for physicians that will serve to protect the public from harm.
Please see below a few considerations that may support your update of these resources.
Accepting New Patients policy
On page 2 (line 63) there is reference to ‘priority populations’. You may want to consider defining this term directly in the policy. While this term is elaborated on in the Advice to the Profession companion resource, it may be helpful to include a definition in the policy to ensure common understanding. You may also want to consider the employer accountabilities physicians have when registering priority populations to their rosters.
Note: Some content has been edited in accordance with our posting guidelines.
As a mature member of the public I am responding briefly and perhaps a bit off topic.
In [redacted], I have been a grateful patient in a well established Family Health Team (FHT) practice since 2003. The local larger FHT administration and other FHT physicians are members of a local FHT walk in clinic patient service with hours each weekday evening and w/end mornings. Outside those hours it would be up to patients to make decisions to either wait or go to [redacted] Hospital ER. I have not used this after hours service however family members infrequently have.
The practice has an outgoing voice mail phone message that they are not accepting new patients.
De-Rostering: If this was well defined in the advice document, I missed reading it. I know patients who attend walk in clinics outside their practice may be de-rostered. The drafts implied more than one option by the practice physician in future with the patient. Clarity might be helpful in preparing definitions and final policy.
The Globe & Mail medical journalist, Andre Picard, who I do not always agree with, in a recent feature mentioned the many Internationally educated doctors not yet eligible to practice in Ontario.
Two distinct international medical graduates include:Ontario students not accepted so they chose an international medical education in a country with comparable medical degree. They should be fast tracked to return with minimal delay.
Doctors educated in a second language and/or a country without equivalent medical degree. With screening for any requirements included English fluency (for safety and comprehension) and for areas of medicine requiring further training they should be supported to achieve completion of requirements, with supervision, mentorship. Since patients and family members often having one of many languages but not fluent in English, the internationally trained doctors might be matched with patients from similar background (in a large multicultural community, Toronto, Mississauga, elsewhere) with potential for enhanced experience by both physician and patient. In a smaller practice setting in less populated Ontario communities, this would likely not be practical.
Perhaps Dr. Jane Philpott might consider this option.
The third draft policy documents were read with appreciation for the complexity of treating self, family, others will require common sense, the situation, many other considerations beyond my ability to contribute. The reality of timely access when care is required as well as the long list of pharmacist ability to consult and treat (which I don’t agree with) somewhat validates occasions for physician treating self, family, others within guidelines.
Professional Association of Residents of Ontario (PARO)
Dear CPSO Policy Department,
Thank you for the invitation for PARO to provide feedback on the following policies:
Treatment of Self, Family Members, and Others Close to You
Ending the Physician-Patient Relationship
Accepting New Patients
We have reviewed the policies and overall find them to be thorough and provide clear direction.
We do have questions about the Ending the Physician-Patient Relationship Policy, with respect to working with patients that do not follow medical advice. If a patient is to refuse all treatment, and a physician has no further options to offer, should it be considered that the space be provided to another patient? Would it be beneficial to specify that the patient-physician relationship cannot be terminated due to a patient's refusal of preventative medical advice?
We once again appreciate being included in the CPSO's consultative process.
Ontario Trial Lawyers Association (OTLA)
Please find OTLA’s submission attached.
Response in PDF format:
Ontario Medical Association (OMA)
Ontario College of Family Physicians (OCFP)
Ontario Medical Association (OMA) Section on Plastic Surgery
-Accepting patient based on language should not be considered as discrimination. Communication is a key component of medicine. - There must be exceptional circumstances, even for those who are no longer accepting patient, such as a family member in need, or a pt require needed care due to language barrier. I do know a FP who would consider taking on patient if referred by such as Oncology due to language issues, or referred by a family member, or a colleague.
Canadian Medical Protective Association (CMPA)
I wanted to share a perspective from a Radiation Oncologist who has been disabled most of his professional work life. My clinical oncology practice was focused in gastrointestinal and CNS malignancies, chronic cancer and non-cancer pain, and palliative care.: I have a few concerns that the CPSO fails to interpret or apply the Ontario Human Rights Code (OHRC) appropriately after having reviewed these draft documents. I have considerable experience working with two prominent human rights attorneys, one who became an Ontario Superior Court Justice. I completed the online survey but wanted to express my remarks in context.
People with chronic medical conditions that require medication, frequent medical appointments, or who experience any impairment whatsoever may be considered as having a “disability" under the OHRC. This includes patients with diabetes, chronic pain, mild COPD, and even osteoarthritis. Therefore, it is important the CPSO use the term “disability” in the most expansive use of the term, so physicians understand what practices are likely prohibited under the Code.
In considering procedures for recruiting patients to a new practice, a first-come, first-served policy may be inherently discriminatory against marginalized populations including those with some disabilities. A physician in Walkerton recently offered a first come-first serve, in person registration one cold morning. People queued for hours in the extreme cold for a spot. Such a process obviously discriminates against those with complex medical problems, disabilities and the elderly. The College should NOT recommend such an approach unless it clearly includes accommodations for these marginalized populations. Offering them telephone registration the same day or online applications (at least for those with medical problems or disability) for example, would be more inclusive. The irony of course, those in greatest need of a family physician are those people who are likely to miss a new physician announcement and those unable to queue for hours (I place myself in the latter category). I would urge the College to clarify in greater detail, the possible equitable approaches in which a physician can recruit new patients for enrolment. The Ontario Human Rights Code is often skimmed over in medical school curriculum, if covered at all. I confirmed this via questioning senior medical students and residents in my role as an educator.
I proposed developing an online registration tool for new physicians. Prospective patients could complete a survey uploaded to a secure server, with access controlled by the physician. A first-come, first served policy would be more fairly applied. However, even in this arrangement I would recommend a phone number for those without internet access or poor computer skills (elderly). I am sure there are a number of practices not mentioned that could be adopted to achieve fair enrolment of new patients.
The process of screening patients for acceptance into a mature practice especially must be cautioned (for reasons other than determining the patient is suitable for an individual’s scope of practice). While it may appear intuitive for physicians to add low acuity patients to their mature practices at variable intervals, such a practice appears inherently discriminatory. It prefers enrolment of well patients versus those with significant medical problems (disability) and/or the elderly. Both are prohibited grounds under the OHRC. Discrimination need not be intentional to have occurred. It is not clear to me that a physician attempting to balance out the acuity of his or her practice would be considered as not violating the Code. If one only accepted patients under age 40, then it would be clearly discriminatory in my opinion. Nevertheless, my impression is this practice is generally accepted by practising physicians. To that end, perhaps the CPSO could seek out a legal opinion from a human rights attorney if not done so previously? A fairer approach would be to alternate between a younger patient without significant medical issues with an elderly patient or one with chronic medical problems.
In respect to the Advice document, I was surprised to see missing from Line 27, “Priority populations”:
1. Those with chronic disability (including complex medical conditions) and,
2. Chronic non-cancer pain patients including patients requiring chronic opioid therapy.
You have addressed, quite well, accepting patients with opioid use later in the document. However. both patient groups experience great difficulty in attempting to find replacement family physicians when their doctors retire or move, and were commonly orphaned when I practised clinically. I would recommend they be added to the Priority Population list.
I hope my comments are constructive.
I have reviewed your draft policy "Accepting New Patients." In general it looks fine, however it is confusing - is this only for primary care physicians? Line 52 states: " Given the broad scope of practice of primary care physicians, ..."
I don't see that the document is titled Accepting New Patients - Primary Care Physicians
So, is this intended for specialists too? If so, line 52 is confusing.
Something not mentioned in this policy, which I believe should be is the practice of what techniques are used to invite patients to apply for acceptance to practice. One example that I have seen locally multiple times is physicians requiring patients to lineup on specific days in person waiting many hours to apply. This has a discriminatory effect on persons with disability who may not be able to wait.A separate concern I have is relating to the provision regarding rejecting patients that may require extra documentation. A trend I’ve noticed as a specialist is sometimes being asked to see a patient in consultation for completion of workplace disability forms that the family physician does not feel comfortable to/does not want to complete despite not having previously been involved in the care of the patient. This not being a provincially billable service (as the consultation is solely for completion of uninsured documentation). I would hope that the policy would clarify that physicians are allowed to refuse consults made solely for the purposes of uninsured services.Finally I have noticed certain specialist practises refuse consults from patients without family physicians. Personally, I think this practice should be banned. I take on many patients without family physicians, and while this is additional work, ultimately these patients still need care and refusing to see them just because they do not have a family physician seems to me to be highly unethical.
You should be able to decline accepting a patient if they are outside your region i.e. one Works in Toronto, but the patient lives in Ottawa (Obviously if the patient was registered with you and has moved for school, and they plan on moving back then this would be ok)
I will take on a patient with no family doctor and medical problems needing constant careThe problem arises when patients are criticizing their own doctor in same geographical area and Family doctor shoppingIt’s difficult to enrol these patients so I politely refuse to enrol such patients They can visit me for issue based care .a
For a referral to a specialist from a Family Physician which needs to be declined, it is not appropriate for the specialist to then be responsible to refer the patient to another physician having never assessed the patient. (If the patient is seen by the specialist then it is entirely reasonable to expect the specialist to be responsible for further referral). It is, however, reasonable to expect the specialist to provide the names of alternate specialists who may be able to accept care to assist the Family Physician in referral to a more appropriate individual.
The draft looks fair, well done for putting it together.
The new policy is fair and equitable
I have never used an introductory meeting in my career. The only purpose is to decide if you want to take on a patient. This is discriminatory.
Another issue that needs to be addressed is you have a much better chance of getting a physician if you know somebody who already sees that physician. There are a significant number of people who do not have these contacts and thus would have no chance of getting a physician.
A possible solution would be that for every new patient that you roster, you also have to take on a patient who is on some centralized list looking for a doctor.
I am a family physician working at a community health centre in Toronto. A significant proportion of my clients have coverage under interim federal health (IFH), and many of my referrals to specialists have been rejected specifically on the grounds of the specialist “Not accepting IFH-insured patients”.
Upon reviewing the draft policy I am now wondering if this practice of denying patients care based solely on Refugee status is:
I have two requests in light of this.
I have passed on my practice so I have not taken new patients for over two years. I have not done any patient relationships in over two years. And I am well aware to not treat family which includes not looking in charts for results.
The following policy should be added
If a physician is taking over a practice from a retiring physician they must automatically accept all patients who were previously in that practice
This is not always feasible. Some retiring providers have extremly large practices, which impairs the ability to provide quality care for all patients. This will also lead to burnout of physicians. This responisbility is on the retiring physician to attempt to find replacement(s), however, the physician taking over should not be required to take all patients. Otherwise, I expect retiring physicians will have an even harder time finding replacements.
Overall agree with the policy. It can sometimes be a challenge to accept new patients with multiple complex problems, solely due to the limited time and resources physicians and their offices have in the case where they are close to capacity and are accepting patients on compassionate grounds. In these instances it would not be fair to either the physician or prospective patient if the proper amount of time needed to manage and follow up with their health issues cannot be adequately allocated without sacrificing care from the current patient population.
While I appreciate the concern on time constraints, burn out etc., the selection of patients according to the complexity of health problems is prohibited under the Ontario Human Rights Code. This is an element of disability i.e. any chronic medical condition is likely to be considered a disability, a protected ground under the OHRC. Physicians must consider their usual practice for adoption of new patients and not make decisions based on particular conditions or anticipated number of office visits, for example.