Trevor’s Take: On limiting billing numbers, reporting unfit drivers and authorizing use of marihuana for your patients

Dina Baras CPSA, Messenger, Trevor's Take On 10 Comments

Will limiting billing numbers improve patient care?

In the March 2017 essays published on Longwoods.com, Graham Dickson PhD wrote a piece titled Leadership “Inaction” or Leadership “in action” – the Change Dilemma.

Dr. Dickson wrote:

The old adage that everyone wants change but no one wants to change is alive and well in Canadian healthcare. Governments call for transformation, yet are not willing to transform their own behaviour. Everyone wants collective efforts to be patient centred, but don’t want to partner with each other or patients because they are afraid of losing control of the agenda. Everyone wants a well-honed, integrated system of patient care but wants to retain independence and autonomy from that system. We all want collaboration, shared visions, and collective action to achieve change, but when pressed to deliver, we often revert to demands of ego, turf, and combativeness. It seems that we intellectually “buy” the notion of transformation, but aren’t ready to accept the personal demands associated with its success. Instead of leadership in action – championing and orchestrating change – we have leadership inaction: lots of talk and no action…

“We all want collaboration, shared visions, and collective action to achieve change, but when pressed to deliver, we often revert to demands of ego, turf, and combativeness.”Dr. Graham Dickson

In Alberta we have a physician resource planning process underway that may fundamentally change the relationship between physicians and the health system.

If the Minister of Health follows through on the Ministry proposal to limit the number of physicians in Alberta (and address the maldistribution of the physician workforce) by tying new billing numbers (practitioner IDs – PRACIDs) to AHS appointments, physician resources would then be controlled by AHS.

I understand there is some urgency to getting healthcare costs under control – the medical services budget is rumored to be about $300 million over budget, and AHS is rumored to be in a deficit position. Each net new physician adds upwards of $400,000 to the cost of the healthcare system. One can see, therefore, the attraction of limiting physician numbers as one cost control mechanism; doing so would also provide AHS a tool to try to address the distribution of physicians in Alberta.

I have previously argued that Alberta has a sufficient number of physicians but that the mix, distribution and activities (what physicians choose to do in practice) does not meet the global needs of Albertans and our healthcare system. Putting in place a physician manpower plan (as part of a more comprehensive health human resource plan, tied to an operational vision – how healthcare should be delivered) makes sense and has been advocated by the CPSA for some years.

However, what is currently on the table is a proposal to limit billing numbers.

Will doing so change the relationship between the medical profession and the health system (AHS)? Absolutely. Will it achieve the effects intended? Perhaps (it will likely control the rise in costs in the physician services budget). Will it have unintended consequences? Almost certainly, but those have not been publicly identified and mitigation strategies have not been implemented.

More importantly, will such an approach address what I see as a fundamental problem in medical service delivery in Alberta: the absence of oversight of what services physicians provide and the appropriateness and effectiveness of those services? I think not.

A fundamental change in the relationship between physicians and the health system is required that is not just about cost, although we cannot ignore costs.

I worry that just focusing on cost, which is what I see the current physician resource planning process as about, will fail to fix what really needs fixing.

In our present system there is simply too little oversight of what services physicians provide, whether they are indicated or not, whether they are beneficial to patients, and whether they result in harm. In addition, physicians largely choose where they work and what work they will provide, especially in community practice. Physician choices also drive the majority of costs in our health system. These are not novel thoughts, and while we talk about them, we’ve not done much to address them.

In Alberta, arguably, we have gone beyond talk: we have action and leadership on the clinical information system (CIS) for Alberta Health Services (kudos) and on physician resource planning (concerns noted above). Oversight of medical services? We’re not there yet, although a new governance structure for PCNs is in the works. Are we really prepared to alter the relationship between physician services and the health system? Do we have the skill set needed? As Graham Dickson writes:

“The scope and breadth of behaviour change, time required, and sophisticated leadership needed to transform healthcare is vast. Healthcare exists in a volatile, uncertain, complex and ambiguous world; a world that demands strategic, distributed, innovation, authentic, adaptive and complexity leadership approaches. This skill set is very different from the skill set that created the health system we now wish to change.”

Reporting unfit drivers

You may have seen news reports and editorials around the province’s Fatality Inquiry into the death of Megan Wolitski, a girl who died from injuries suffered when she was hit by a vehicle driven by a man with untreated severe epilepsy. The judge leading the inquiry made the case that the CPSA’s guidance to physicians on their duty to report potentially medically unfit drivers was incorrect and that reporting of unfit drivers was, in fact, mandatory.

The relevant legislation (Alberta Traffic Safety Act) is clear that reporting unfit drivers is discretionary, not mandatory. While this is not in dispute, the judge argued that section 35 in the CMA Code of Ethics (which the CPSA has adopted) makes such reporting mandatory. (Section 35 states Disclose your patients’ personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others…).

You can read the College’s advice document on reporting unfit drivers, but the take away is this:

There is no mandatory requirement in Alberta for a reporting an individual’s fitness to drive. However, physicians are encouraged to report all instances where a patient fails to meet the medical standards for operation of a motor vehicle.

The advice document notes  a physician that does report is protected from legal action. The Traffic Safety Act, Section 60, states “No liability accrues to a physician, optometrist or other health care provider by reason only that the physician, optometrist or other health care provider provides to the Registrar under this Act information respecting a person’s medical condition that may impair that person’s ability to operate a motor vehicle in a safe manner.

The Canadian Medical Association has published a comprehensive list of medical fitness standards. A physician should be familiar with the spectrum of medical conditions that may affect a patient’s ability to drive. Standards are written to enable a physician to be as objective as possible in conducting a clinical assessment. Some examples of medical conditions that may affect safe driving include stroke, seizures, dementia, syncope and double vision.

A physician is not required to declare a patient to be unfit to drive: there is an exercise of discretion left to the physician. Should a physician have concerns, he or she may choose to report a failure to meet a published medical standard to the Driver Fitness and Monitoring Branch of the Alberta Ministry of Transportation. This office reviews every driver’s medical form and report. Where a clinical condition fails a medical standard, the driver will be notified of restrictions on his or her driving or required to surrender his or her driver’s licence. There is an exclusion of liability if the physician does report medical concerns under Section 60 of the Traffic Safety Act. Section 60.1 of that statute also ensures the physician can report this information confidentially.

Until legislation is changed making reporting of unfit drivers mandatory, physicians are encouraged to familiarize themselves with the CPSA advice and, while using their discretion, to err on the side of reporting. Protecting the public from drivers who may be unsafe should be our paramount goal.

Authorizing the use of marihuana for your patients? Know the rules

“The physician who authorized the patient to use marihuana is personally responsible to directly and in-person evaluate the patient’s status and progress and to provide ongoing care for the patient’s underlying medical condition.”

The CPSA’s standard of practice on Marihuana for Medical Purposes states, in part:

A physician completing a patient medical document must:

  1. evaluate the patient on a regular basis to determine the benefits and risks of marihuana as treatment for the medical condition or symptom(s) stated in the patient medical document,
  2. at minimum see the patient every three months following stabilization [1],
  3. provide ongoing care to the patient for the underlying medical condition or symptom(s) for which marihuana is the treatment, including a process to identify misuse or abuse of marihuana,

Anecdotally, I have heard that some physicians have interpreted this direction as allowing the use of ‘surrogates’ to both evaluate the patient’s status on a regular basis and to follow up the patient ((a) and (c) above).

A correct interpretation of this section of the CPSA standard is a literal reading: 

The physician who authorized the patient to use marihuana is personally responsible to directly and in-person evaluate the patient’s status and progress and to provide ongoing care for the patient’s underlying medical condition. No other interpretation is acceptable or allowed.

There was a clear purpose in writing this standard of practice in this manner. Considering the paucity of high quality evidence for the medical use of cannabis, we wanted and expected physicians who authorized its use to take responsibility for their decision by personally monitoring and evaluating patients using this drug. Cannabis is not a panacea and is not first line treatment for any medical condition.

If you have authorized or plan to authorize the use of marihuana for medical purposes, consider yourself warned. You are personally responsible to monitor and evaluate patients on an ongoing basis.

As always, I welcome your comments.

Trevor Theman

10 Comments on Trevor’s Take: On limiting billing numbers, reporting unfit drivers and authorizing use of marihuana for your patients

Elizabeth Samson said : Subscribe Apr 27, 2017 at 9:28 PM

You might want to look at other jurisdictions, specifically Ontario, regarding mandatory reporting.  The Ontario Heath Insurance Plan also has a Fee Code for such reporting.  

Das M said : Subscribe Apr 21, 2017 at 3:43 PM

Thank you Trevor for creating a platform to debate about the cannabis. Couldn't agree more with Martin Scanlon and Zealot. Tim Jordan has a valid point. With the risk of delaying reaction time, there could be more traffic accidents , and when charged the court hearing excuses that it was 'medical' marijuana.  It is unfortunate that the meek medical profession allowed the political ransom to marijuana by promoting it as 'medical' to lure the unsuspecting ( and suspecting) customers of cannabis.  In late 50's and 60's when alcohol was formally prescribed in hospitals, especially for expectant mothers, no one used the term 'medical beer / alcohol' ( still it created far too many FASD's ). If the governments needed a solution for the illicit business of marijuana, why not sell it in open market like alcohol and cigarettes?

I think the criteria for prescribing marijuana should mandate ( 1) no history of cannabis addiction, (2) no history of psychosis and (3) a second opinion from an independent physician. Royal college of Psychiatrists have some evidence-based info, especially " how does it work... Its effects...Work... Mental health problems...

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/cannabis.aspx

Trevor Theman said : Subscribe Apr 24, 2017 at 9:58 AM

Comment *Thanks Dr. Das The medicalization of cannabis in Canada was a result of a couple of court cases where Health Canada was told that patients (who brought the suits) benefited from the use of cannabis and, therefore, Health Canada was directed to ensure cannabis was available for medical purposes. Trevor Theman

Dr. Anil Rickhi said : Subscribe May 05, 2017 at 8:45 AM

Thank you for your comments Dr. Anderson. I completely agree with what you mentioned, and to Dr. Theman, thank you for brining up this topic. As you know I was employed at a sleep institute and resigned because even the CPSA and Heath Canada did not know the regulations. I phoned health Canada and was just passed on to 5 people who essentially have no idea. As physicians we need to know the law. If anyone is inclined I would suggest reading about the Apollo project thttp://apollocannabis.ca

Ian Anderson said : Subscribe Apr 13, 2017 at 6:02 PM

I appreciated your comments on reporting unsafe drivers. I believe the first responsibility is that drivers have an obligation to report themselves and to initiate the discussion with their doctors. I would like to point out that there is also existing mandatory reporting of aircrew and train operators who are medically unfit. This is federal legislation and the reporting requirement is mandatory.

Trevor Theman said : Subscribe Apr 13, 2017 at 3:00 PM

Thanks to the above authors for their comments.

To Martin Scanlon's point I chose my language purposely. If a physician is going to offer this drug for patients then that physician must personally follow the patient, as the physician is now responsible for treating and monitoring the condition for which cannabis is being used. The College's direction in the Standard of Practice on cannabis use is meant seriously; the physician is responsible and will be held accountable, and may not delegate this important task to a surrogate. 

Trevor Theman

Tim Jordan said : Subscribe Apr 13, 2017 at 1:23 PM

Reporting Unfit Drivers: The Government must re-enact the legislation to ensure that reporting an unfit driver is mandatory, particularly by doctors. Unfortunately, much of the care patient's receive is substandard, and I am concerned whether many doctors, have the skills to make a satisfactory judgement in this regard.

Use of Marijuana: Would the use of such a drug preclude a person from driving? My opinion is that may well be the case. Therefore, should every person prescribed marijuana also be made unfit to drive, as should happen to those persons on narcotics, tranquillisers, anti-psychotics etc. I hope that all prescriptions or authorisations for marijuana usage be policed by the College for conformity with the law. Too many doctors have become ill-disciplined and ignore their duties toward society and the patient, by not preventing harm. If the College is unable to manage any problems, then we should expect trust in our profession to continue its downward trend.  

Zealot said : Subscribe Apr 13, 2017 at 12:24 PM

I really like your comments on medical marijuana Trevor. It has been difficult for me to attempt to address marijuana abuse in my patients when they can point to medical marijuana use in the community and their impression that there  is little medical oversight of such use. I do not actually know if there is little medical oversight, but it is the impression of some of my patients that this is so. Thank you!

Martin Scanlon said : Subscribe Apr 13, 2017 at 12:20 PM

Regarding medical marijuana, there is insufficient evidence to support 

any of those management standards, just as there is insufficient evidence to guide us in its use.  Most will agree that there is tremendous potential though, and I hope will want to maximize this.  I would prefer to see our governing body helping to guide us in learning more about this potentially very useful option rather than issuing what sounds to me like threats regarding its use.  "Consider yourselves warned"?  That tone does not promote advancement of our learning.  To me it sounds like bullying.  Perhaps the word "advised" would have been better.

 

Adeleye 'Lemi ADEBAYO said : Subscribe Apr 30, 2017 at 9:09 PM

I agree with Martin, there are potential benefits of Medical Marijuana when appropriate history taking, screening for drug seeking behavior and risks of addiction and dependence taken in to consideration. Such cases include multi drug resistant Epilepsy, Drug Resistant Depression ,Anxiety and PTSD , Cancer Pain where conventional medications either failed or are associated with unacceptable side effects. Trevor's choice of words sounds intimidating but I believe it's appropriate in this context, it's to warn physicians of their duty to do their due diligence before prescribing Medical Marijuana,the truth is most physicians are opposed to it and in case of a related investigation, with significant potential that there might be some bias (at subconscious level) against the prescribing physician, the only saving grace is to provide evidence that you did your due diligence prior to prescribing it and also you provided appropriate follow up care.

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