Ontario Trial Lawyers Association (OTLA)

Please find OTLA’s submission attached.

Response in PDF format:

Ontario Medical Association (OMA)

Response in PDF format:

Ontario College of Family Physicians (OCFP)

Response in PDF format:

Threatening to file a complaint against a physician signals to me irreparable damage to the patient-physician relationship. It does not matter if the patient is unaware of just how anxiety-provoking and life-disrupting even the potential of a complaint is for physicians. There is no way for any physician to provide objective care toward a mistrusting patient. CPSO needs to stop micromanaging physicians and this is just another example of trying to tell us how to act.

I think this policy needs to take account on the physician side:

1. Administrative abuse. Patients use regulatory and other complaints to get what they want and to try to coerce physicians. A physician needs to protect their own mental health by being able to without having to worry about administrative abuse. Some patients are clearly vexatious and mentally ill with personality disorders. There needs to be repercussion and consequences for manipulative behaviour and intimidation by patients.

2. Physician burn out is contributed to by not being able to enforce no abuse policies.

Note: Some content has been edited in accordance with our posting guidelines.

I work in a large Clinic [redacted] which provides services to several communities around Ontario and Canada. For each patient I have informed them that I am going to retire soon, and I have documented in their medical records that I will give up my practice this year and I have given enough repeats in their prescriptions. Patients who have complex medical problems I have referred them to consultants within our clinic (mostly in Internal Medicine), other patients with more simple problems I have told them to continue with their own Family Doctors. I don’t mind extending my practice to another extra year to be sure that all my patients have continued care.

I have a few comments:
1) One common reason to end physician-patient relationship in specialists' clinics is when a patient does not require follow up in the clinic anymore. For example, patients are often sent to a cardiology clinic for work up of s suspected clinical problem. If it turns out negative, there is no need for follow up. Similarly, even if they have a chronic problem that has been well managed and stable foe years, e.g. CAD or AF, there is no need for ongoing follow up, as GPs are more than capable of managing cardiac RFs, like HTN or lipids. Not needing a specialist care is not listed among the reasons to end a P-P relationship. 

2) It is mentioned that ending P-P relationship needs to include a letter to patient. If I end it in the clinic for reasons listed above, or if patient is abusive in the clinic and I tell them in person that I am ending a P-P relationship, why is there a need for a document issued to the patient?

3) I don't understand why the CPSO insists on keeping noncompliant patients. As a cardiologist, if a patient refuses the evidence-based care, and chooses to live a risky lifestyle with smoking, inactivity and alcohol abuse instead, what is the point in keeping them at the expense of compliant patients who can't get to see me as my clinic is full? Is this not discrimination of compliant patients by mandatory keeping the noncompliant ones? Why is CPSO so rigid about this? Bringing those patients to my office to do what? Isn't it waste of precious clinic and OHIP resources? CPSO needs to get off their green tables in the ivory tower, come to our trenches and get a real sense of the struggles we deal with.

Every time a patient contacts the CPSO or threatens to do so, the physician should immediately declare that it caused irreparable harm to the doctor-patient relationship, then terminate the patient. There is no way the College can argue that it didn't cause irreparable harm unless they start dictating the personal feelings of physicians. 

The CPSO should realize that this policy is more impactful than it appears. It brings up broader issues that strike at the heart of the complaints process. It also casts further light on the College's problematic trend of trying to micromanage every facet of a physician's practice.

Every time a complaint is lodged or threatened by a patient, the College should act on the default assumption that the physician-patient relationship is over. Eliminate the requirement of three months continuity. The only requirement should be that the physician complete any remaining clinically necessary tasks before parting ways. If that only takes a day or two, so be it.

Obviously, nothing of common sense ever comes from the CPSO. Why do the useless CPSO burocrats go and do treat patients who abuse and threathens you?

Assuming personality disorders in at least 10-12% of the population, how can the College assume that frivolous complaints wouldn’t be a way for some patients to control and abuse their physicians? And now, you’re proposing that doctors continue to treat when patients have initiated complaints or threatened so or signaled intent to do so. I cannot see how this will not lead to physicians giving in to patient demands, or being abused by their patients. I should hope you’re ready for lawsuits from physicians who could argue, rightly so, that you’re forcing them to work under duress and in abusive conditions. We’re already sick of providing free care to uninsured patients who are at times too lazy to go to Service Ontario. Now, you want us to continue to treat people, many of whom I can probabilistically say are personality disordered and perhaps even sociopathic? 

Sorry, but your overreach is getting tiresome and increasingly appearing to be grossly uninformed. 

The notion of the noble patient needs to be thoroughly exorcised from the regulatory sphere.

The weaponization of college complaints is increasingly being used by patients as a blunt instrument to get what they want. This fact should already be 100% apparent to the CPSO.

Patients who threaten a complaint if their demands are not met do not deserve service or protection. It can and should be considered the same as other aggressive or threatening behavior, and justifiably met with little to no tolerance.

This specific scenario should be addressed by the college. Aside from physical violence, making a complaint, or threatening to do so, is a surefire way to immediately and irrevocably damage the physician-patient relationship.

The statement, "physicians should not automatically end their relationship with a patient in response to the patient’s contact with CPSO" is out of touch with reality. It was written by someone who either doesn't practice medicine, or has never had to face the scenario where they were on the receiving end of something vexatious. Otherwise, they would understand how ridiculous that line actually is. Resolution of the complaint can go forward, but the patient’s therapeutic relationship with the doctor should be over at the doctor’s discretion.

Don't like your lawyer? Change your lawyer. Don't like your accountant? Change your accountant. Don't like your doctor? Change your doctor. The college's mistake is thinking physicians are different compared to other professionals. The doctor is not forcing the patient to stay, nor should a patient want to stay under circumstances as severe as those leading to a complaint.

A patient who complains clearly feels their doctor is either not serving them adequately or appropriately, so therefore should move on anyways. It is not in their interest to stay, so why are you compelling both parties to remain together? If your answer is because it would be difficult for the patient to find another physician, then that is a system issue the doctor has no control over, which means it would penalize the doctor unjustifiably. 

The obligation to provide medical services for at least 3 months once the physician-patient relationship has ended is also non-sensical. If you're still providing service, then the relationship hasn't truly ended. For the same reasons mentioned above, the doctor should not be obligated to continue care. Continuation could also confuse the patient. Remove the time requirement for continuity once all necessary tasks have been completed (e.g., prescriptions renewed, labs followed up etc.). 

Also, why 3 months? Why not 3 weeks? Those extra nine weeks in between might look “better” on paper as policy, but not practicality. Either the patient has a new doctor lined up, in which case those 3 months are unnecessary. Or, the patient doesn’t have another doctor, in which case it will take longer than 3 months to find a new one anyways. We should all agree this number is based off nothing and just be transparent about it. Don’t drag the time on needlessly.

The CPSO needs to understand that many, if not most, physicians will mentally put a college complaint on the same level as a lawsuit, even if the issue is regarded as "minor" by the regulator. Trust with the patient will be diminished or completely gone. Things will never go back to exactly what they were before. College complaints are a direct threat to a physician's livelihood. They are a direct threat to the doctor's continued ability to provide service to their other patients, of which there could be thousands. This is high stakes and needs to be respected as such.

If not already being done, whenever a patient contacts the College, they should be told upfront of the chance that this could irrevocably damage the physician-patient relationship, and that the outcome of termination is a possibility if they wish to pursue this. This is not meant to dissuade them from complaining. It’s just a matter of fact. Ask if they still want to proceed. Some will reconsider. If they feel very strongly that they’ve been wronged though, they should still want to continue.

Also if a complaint is made against the physician by a patient, this would imply that the patient physician relationship has broken down and thus the physician can then end the patient's enrollment. This should be explicitly written in your statement, 

Kind regards

If the patient moves out of the physicians physical location, the Physician should be able to end the relationship on the grounds, that they may not be able to deal with all queries on the phone and the patient is not in a reasonable period able to come to see the physician in person (Obviously if the patient moved for school and intends on returning back to the vicinity of the physician then this should be ok)

Few patients are abusive and demanding and we are uncomfortable with them
Few who have complained to the college its is not possible to maintain a cordial and effective physician patient relationship and we need to deroster them.
We do follow the college policy in this process

I disagree with the requirement to provide 3 months of continued medical services after termination a relationship. While I would generally offer 3 months of continued medical service if possible for the benefit of the patient, there are some circumstances where I do not agree. For example, I would not be able to safely provide medical care under duress or following any threat; under these circumstances I disagree with the requirement to provide continued care.

Emergency Physicians are often in a uniquely vulnerable position. They encounter patients in crisis, some of whom may exhibit aggressive or violent behaviors due to medical conditions, mental health issues, substance use, or other factors. 

The safety of the physician, staff, and other patients is paramount. A policy that doesn't explicitly acknowledge the right to end a relationship with an abusive patient who is not in immediate medical distress could put people at risk. 

: The current policy mentions that physicians can end a relationship if there's a "significant breakdown" in the relationship, but it could be more explicit about what constitutes a breakdown in the context of an abusive patient encounter.

Emergency Physicians need clear guidelines and support from the CPSO when dealing with abusive situations. This includes protection from potential complaints or repercussions when they prioritize safety. How the policy could be improved: Specific language: Include language that explicitly addresses abusive behavior towards Emergency Physicians and staff. 

Immediate termination: Allow for immediate termination of the physician-patient relationship in cases of severe abuse or threats, even if the patient is not in a medical emergency. 

Safety protocols: Provide clear guidance on safety protocols, including when to involve security personnel or law enforcement. 

Documentation: Emphasize the importance of detailed documentation of abusive incidents.

Greetings – thank you for the revised Guideline document. I wanted to bring to your attention that it continues to stay silent on the ‘Ending’ process for specialists who are providing a consultation opinion to the primary caregiving physician. The physician-patient relationship is fundamentally different. In cases, where the consultant opinion takes 3-4 visits, the distinction remains clear. In cases of chronic disease, where the PCP has requested ongoing consultant guidance and the relationship might continue for months or years, the question of relationship arises. Patients often come to assume that the specialist is taking a primary caregiver role and the eventual separation can become challenging.

It would be helpful to have the document provide input on the consultant role, and its distinct type of physician-patient relationship.

With thanks

I’m not a masochist so no thanks. I have worked hard on my self worth to not associate myself with people who want my downfall. I value myself. 

I don’t think the policy accurately represents reality. I think the wording is clear but I don’t agree with it. I think it’s very idealist. I think it’s an over reach (common theme I think). Did the CPSO consult practicing physicians before even brainstorming or proposing this idea? Or was it suggested by non practicing health care workers / employees? And I disagree with it with ever fibre of my being.

Try and come for my job, but also be forced to treat them! no thanks.

 
It seems risky. I wouldn’t want a doctor I complained about to treat me yikes.

That’s like staying with my bf after I called the cops on him. No thanks. Just bc the cpso tried to mandate it, it doesn’t mean it’s possible or practical.

By requiring to provide care for patients that launched a complaint to the CPSO, the College is in effect instructing the physicians to commit assault and battery. The issue of informed consent is not mentioned. Let’s think about it. College complaint in effect means that the fiduciary duty is broken. By responding to the complaint a physician is following their own best interests. This is the right of the accused. Patients know that, and usually deny consent based on the “loss of confidence in the physician”. Battery by definition is touching without consent. Assault is treating without consent. So the College is violating its own mandate to protect the public by instructing physicians to provide care under the circumstances.

I’d consider agreeing to your policy if you allow the MOH to give an add on billing code E666 that pays per visit (maybe like $45.00). This may allow docs to handle the complex needs and nuances required to deal with said patients who threaten the treating physicians livelihood. It obviously requires extra time, care, and dedicated time to remove all biases on either side. Wouldn’t you agree cpso?

My human brain won’t allow me to objectively treat someone without bias if they threaten to take away my livelihood. I’m only human. Don’t come for my job but also expect that things can go on as before. There is obviously no malice, but there may be subconscious bias which may impair quality of care for better or for worse. It’s precisely why I don’t complain about restaurant staff service until AFTER I received all the food. I’m not coming to complain to the manager then eat the food there.

Absolutely under no circumstances should I be required to continue providing care for a patient that either threatens me with a CPSO complaint or pursues one. Complaints are the single most stressful and soul destroying thing a physician can go through and no way would I be able to objectively care for a patient afterwards. CPSO is actively against physicians.

Whose idea was it to change the current status? Who does it benefit? It certainly does not benefit physicians who have to deal with negative consequences (emotional, and yes PHYSICAL) when it comes to ongoing care for patients who are unhappy with the care they recieve. Patients are welcome to complain to CPSO (and sometimes those complaints are very valid) but you cant have your cake and eat it too. They must understand that proceeding with a complaint comes with valid consequences -- i.e. ending the relationship. No other profession would encourage their constituents to continue to see such patients/clients. And yet physicians are asked to do so? why? who does it benefit? the patient... surely its detrimental to the patient too

If a patient threatens to file a complaint, that should automatically terminate the physician-patient relationship. That's just common sense.

You are encouraging poor biased patient care with this policy by placing a barrier to a physician from objectively removing themselves from a patients care due to breakdown in trust. Any CPSO report will likely result in loss of trust of at least one side of the complaint regardless of the content or outcome of the complaint. Even without contacting CPSO, patients will use CPSO as a threat to force their physician to comply to their wishes and even that should warrant grounds to dismiss.

If patient complains to college, that means they do not trust their physician. the patient and physician relationship has been broken by the patient once they chose to purse this action. they should not expect to be able to cont the same relationship with their physician that they just complained about as if nothing happened. "Physicians should not automatically end their relationship with a patient in response to the patient’s contact with CPSO" is coercive and abusive to the physician, and this sentence needs to be removed.

This policy will not serve to protect patients. If a patient does not trust a physician enough to bring their complaint to them directly (and instead brings the complaint to their regulatory body), then there is insufficient patient-physician trust. This will ultimately lead to worse patient care and further erosion of family medicine within Ontario if physicians cannot discharge patients that complain to their regulatory body from their practice. This sentence specifically should be removed: "Physicians should not automatically end their relationship with a patient in response to the patient’s contact with CPSO".

If patient is unsafe (violent, threatening, racist/ sexist) towards other patients or community members on clinic grounds (including parking lot), that should be grounds for ending relationship. If patient makes cpso complaint , physician should be able to end relationship on basis of termination of therapeutic relationship, without further discussion with patient. Physicians should be able to decline a patient transfer from someone in the same physician group, even if they are still accepting new patients externally and internally.

I believe a threat to file a complaint is an automatic breakdown in trust which is required for a good physician patient relation. It's very difficult to provide good and objective care to someone who would not trust our medical expertise and threaten a complaint against a physician. It's absurd to continue a physician patient relation when there is no trust.

It might be difficult for a doctor to provide care to a patient who has launched a complaint against the doctor. I think this very step makes it difficult for a physician to be objective in their care; they may feel coerced into making decisions that aren’t necessarily warranted in an effort to not upset the patient further. Also, how is this not an automatic breakdown of trust in the patient-physician relationship? Most doctors are devastated by a complaint even if frivolous and it is a major source of stress for them and takes a toll on their mental health. To then put them through this mental gymnastics is not fair.

Implying that patients can approach the College to discipline their doctor without consequences fosters an abusive dynamic toward physicians. If you trust your doctor, there should be no need to escalate concerns to their governing body in an attempt to modify their behavior. This policy risks empowering inappropriate patient behavior and contributing to a culture of disrespect. Shame on those who proposed this approach. While it is every patient’s right to contact the College, they should not expect to return to a doctor-patient relationship unchanged after taking such action.

Hello,

The following is my feedback about the proposed language for the updated policy about terminating the doctor-patient relationship.

Specifically, the verbiage “Physicians should not automatically end their relationship with a patient in response to the patient’s contact with CPSO”.

In my opinion, this is absurd. There's no way you could maintain your objectivity about a patient who's made a complaint against you, especially if the complaint is seemingly ridiculous.

Absolutely under no circumstances should I be required to continue providing care for a patient that either threatens me with a CPSO complaint or pursues one. Complaints are the single most stressful and soul destroying thing a physician can go through and no way would I be able to objectively care for a patient afterwards.

Completely disagree with: "Physicians should not automatically end their relationship with a patient in response to the patient’s contact with CPSO" This usually constitutes a breakdown of physician-patient relationship and trust, and if a physician is forced to continue the relationship despite that, it’ll be to the detriment of both the physician and the patient.

Physicians should have the right to end a doctor-patient relationship if the patient has filed a complaint against them with the CPSO. The therapeutic relationship relies heavily on mutual trust and respect, and this trust is inevitably compromised when a complaint is lodged. Continuing care in such circumstances risks undermining the quality of care and could harm both parties. Just as patients have the unrestricted ability to file complaints, physicians should retain the ability to assess and maintain the integrity of the therapeutic relationship, ensuring it remains conducive to effective care.

The policy update regarding termination of patients after a complaint is not reasonable. After a complaint by a patient, it would be impossible to maintain a patient physician relationship built on trust. Therefore, it almost certainly should result in the end of the therapeutic relationship.

The notion that a physician should have to retain a patient who was made a complaint to the CPSO (most of which are groundless/vindictive) is really quite absurd as there is no way a physician would be able to maintain objectivity under these circumstances.

The absurdity of this update is beyond me. There is clearly a breakdown in physician patient relationship when the patient chooses to approach CPSO to complain about the physician. This will decrease my willingness to take on new patients and increase my reason to leave Ontario to practice elsewhere.

Please consider simplifying and rewording the document for easier comprehension and integration. This is easily achieved with help from AI large language models and appropriate prompting. I will advocate striking a balance between patient care and physician burnout.

‘Ending a physician-patient relationship is a significant decision that requires careful consideration to ensure patient care continuity and to mitigate physician burnout. The College of Physicians and Surgeons of Ontario (CPSO) provides guidelines to navigate this process effectively. 

Key Considerations: 

1. Assess the Situation: 

- Evaluate the Relationship: Determine if the relationship has deteriorated to a point where effective care is compromised. 

- Patient Welfare:Consider the potential impact on the patient's health and access to care. 

2. Attempt Resolution: 

- Communication: Discuss concerns with the patient to seek a mutual understanding. 

- Support Services:*Utilize mediation or counseling services if appropriate. 

3. Decision to Terminate: 

- Justifiable Reasons: Ensure reasons align with CPSO guidelines, such as persistent non-compliance, abusive behaviour toward the physician or health care team member, or irreparable breakdown of trust. 

- Prohibited Reasons: Do not terminate based on discriminatory factors or patient decisions regarding their care that do not pose a risk to others. 

Steps to End the Relationship: 

1. Provide Notice: 

- Written Notification: Inform the patient in writing, clearly stating the decision and the reasons, if appropriate. 

- Notice Period: Allow sufficient time for the patient to find alternative care, typically at least three months. 

2. Ensure Continuity of Care:

 - Emergency Care: Continue to provide urgent medical services until the patient secures a new healthcare provider. 

- Referrals: Assist the patient in finding another physician or healthcare facility. 

3. Transfer Medical Records:

 - Patient Access: Inform the patient of their right to access their medical records.

- Timely Transfer:*Expedite the transfer of records to the new healthcare provider upon patient consent. Documentation: 

- Record Keeping: Document all communications, reasons for termination, and steps taken to ensure continuity of care in the patient's medical record. 

Preventing Physician Burnout: 

- Set Boundaries: Maintain professional boundaries to prevent overextension. 

- Seek Support: Utilize peer support networks and professional counseling when needed. 

- Workload Management: Delegate tasks appropriately and consider practice adjustments to manage workload. 

- Self-Care: Prioritize personal health and well-being to sustain professional performance. 

By following these guidelines, physicians can ethically and professionally end a physician-patient relationship while safeguarding their well-being and ensuring patients continue to receive necessary care.