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 11 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

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

George Tulle said : Subscribe Jul 11, 2017 at 6:22 PM

I was recently made aware of Dr. Theman’s essay on medical cannabis in his April 11, 2017 post to the Examiner, and specifically the use of the terminology, “consider yourself warned”. I believe this was applied to the use of surrogates in place of the physician treating the patient.

I feel compelled to communicate my perspective in the hopes it causes positive discussion on the subject of medical cannabis and how the patient care process works. I am not a doctor but I have huge regard for the medical profession; my late father was a radiologist, my mother a registered nurse, my sister in law in Calgary a nurse (B.Sc.), and my wife is presently recovering from a stem cell transplant. It is her third fight with cancer. I am humbled by what the medical community has done to save my wife’s life, truly so I am trying very hard in this essay to focus on the perspectives facing the medical community and to make suggestions. There are enough people criticizing things out there, ideas and answers are a different story. Part of my perspective is based on the fact I have a decent historical understanding of cannabis.

If I can try to examine Dr. Theman’s perspective when he wrote his essay on the subject I believe it would reflect that the medical community is constantly trying to provide the best possible health care for all citizens of Alberta and is a self-regulating body (I am guessing similar to APEGA and the engineering community which I have been a member with for 34 years). There are constant changes going on, and there are people involved, a lot of people. Where engineers reach for technical studies to support change, so does the medical community rely on technical studies before implementing a change; i.e. a new drug that can be safely administered to patients. I think it is safe to say both agencies are designed to protect society from non-standard and non-safe practices. Engineers have building codes to adhere to and doctors have approved methods of treating patients; the approved playbook so to say. When my wife’s treatments this past winter began failing and another chemotherapy drug was studied, recommended, and decided to be tried, the hematologist had to apply for government approval for the drug to be used as a treatment for that particular form of leukemia. It just could not simply be prescribed, the case had to be communicated and studied before approval (thank you) was given. It also worked, causing the reaction the hematologist was seeking, and that gave my wife the window of remission to receive the stem cell transplant. So to restate, I am humbled and forever thankful to the medical community.

So, to continue the perspective of the medical community it would seem the vast majority of the treatments come from brilliant young minds performing university and corporate research for patenting and commercialization of the treatment by the pharmaceutical industry. It is an understood process with a long historical perspective and that counts for a lot.

Then the Supreme Court of Canada comes along and passes judgement permitting Canadian citizens to have access to medical cannabis. I can imagine the entire medical community was caught flat footed and un prepared. There is no information that even comes close to what the medical community and the pharmaceutical industry is used to generating and having access to before setting the regulations of good practice. That is not fair. It could be analogous to the court ruling a new type of steel is safe to build a bridge with and contractors must have access to it. There would be no data, the engineering community would be horrified and would make it very hard for the contractor to have access to the new steel.

The reason for no data is no studies have been done because cannabis is a Schedule 1 drug, deemed to have zero potential for medical benefit. It is a political decision. For support to this statement please read Chasing the Scream by Johann Hari. It is an amazing history on the war on drugs, and shows clearly the political influence on cannabis prohibition. So it is entirely logical to derive and table the process Dr. Theman communicated in his newsletter. But here is where I take issue with the wording and overall tone of the essay. It is wrong because it is simply unacceptable to communicate to fellow professional in this manner and as importantly the words offers no means of moving forward.

There is actually a tremendous amount of data available on this subject, you just have to go look for it from a different set of sources. Please go the clinics, see the people that have appointments. I am betting none of them will have an issue with discussing the subject with you, and you will be amazed. These folks will be all ages, from all walks of life, and they will all tell you first-hand what benefits they are receiving. Go to the hospices where I am told first hand by a close friend who works there that a huge percentage of the patients are coming in with cannabis oils. Go to the Tom Baker and see the people waiting for chemotherapy filling out the medical cannabis survey. When we had our meeting with the psychologist as part of the process before my wife’s stem cell transplant we were invited to attend the main talk of weekend symposium on stem cell transplants. The subject was medical cannabis. Speak with my step father in law who has horrible back pain and used to consume large quantities of opioids. He no longer takes those pills and uses cannabis oil exclusively. So, there are many situations where medical cannabis is a superior alternative to the pharmaceutical approaches.

Now let’s consider the perspective of going to your family doctor and asking for a medical cannabis prescription. The general response will be reluctance to write the prescription. They have no training, no access to data, not even a sales rep from pharma to call on. The elephant in the room is liability, the potential to lose their license to practice, and that makes it easy to say no to writing the prescription. So what happened in Calgary? My wife got a recommendation to go to a clinic started specifically for patients who wished to have access to medical cannabis, and started by a doctor. This is not a grow operation, not a pot culture shop, not a public company trying to cash in on the looming financial bonanza of legalized cannabis. No, this is a place where patients like my wife, my step father in law, myself, and many others from various walks of life can not only get access to medical cannabis, but can also get real information, and real feedback to questions. And there are many questions. The answers are supplied by the licensed providers who are tapping in to any medical research that can take place, the study of the plant and the derivation of different types of plants (people raise their eyebrows when they hear about cannabis that does not get you high, but helps you sleep, the CBD properties), and empirical knowledge. While empirical knowledge might raise an eyebrow, how many doctors would swear off experience in favour of a pharmaceutical report? The family doctors now have a means of pointing their patients to the medical cannabis clinic and freeing themselves from the decision to write the prescription. That is sweet for the family doctors, but what about the medical cannabis clinics. In the oil and gas industry we have the term “so and so is doing the heavy lifting”.

So, the vast majority of the patients seeking medical cannabis are going to a small number of providers for their prescriptions. Essentially they are the experts and pioneers of this approach to health care. It is real and it will grow. This is an opportunity for the Alberta medical community to capitalize on because the number of clinics is small and is staffed by medical professionals who are dedicated to this stream of health care, and nothing else, in hindsight this is exactly how it should have been designed in the first place. Simply consider the perspective again of the family doctors and their limited time to actually learn; consider the opioids and anti-depressant epidemics. These are a result of not enough education and suspect business models. And perhaps insufficient data? With the clinics the education is there and the business model is much simpler and is contained within Alberta, not to the multinationals.

So the real challenge for The College of Physicians and Surgeons of Alberta is to consider communicating with the clinics, and specifically the patients and asking for their feedback. I think you will hear there will be situations where a visit is recommended every 3 months, and with the physician. But I am willing to bet there will be a huge number of situations where the process can be different, such as every 6 month, or annually. And there will be situations where the surrogate can be utilized. Let me just say when I see what nurses actually do, they are perfectly capable of meeting with the vast majority of cannabis patients.

I would be horrified if the real motive to these regulations is to make it as hard as possible to have access to the medical cannabis, especially when it is now legislated as a legal substance across Canada? I refuse to believe that is the foundation for the regulations. So would it not seem logical to pursue an educational approach? If the time was spent to follow up on these ideas, the answer would be very clear and positive that these clinics should have a much larger say in developing the regulations. There should be a steering committee of 6 people who are interested in volunteering some time that helps evolve the regulations.

Am I correct that 7 provinces do not have this set of regulations that calls for 3 month visits and to see the physician face to face? Only Alberta, Saskatchewan, and Quebec? Am I correct that the time period between visits was recently shortened to 3 months from 6 months. I find that very interesting. At least why not Skype or Facetime, are there not also the time and money perspectives?

In closing, I wish you a happy retirement Dr. Theman, and to Dr. Scott McLeod I congratulate you on your new job as the registrar. I read that you are heavily invested in the mental health of our armed forces and the huge issues many of them face. Thank you. If either or both of you wishes to meet and discuss my thoughts further over a coffee I would be happy to spend the time.  

Sincerely,

George Tulle

 

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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