2013 Education Day and Annual General Meeting
Acknowledgements
Dr. Ailve M. McNestry
Dr. A. Jack Burak
Dr. W. Robbert Vroom
Dr. J. Galt Wilson

Overview
• Introductions
Panelists:
– Ms. Lori Charvat
– Dr. Marjorie A. Docherty
– Mr. Graeme Keirstead
Presenter:
– Dr. Galt Wilson, Deputy Registrar
• Audience response – using your i-Clicker
• Case studies
College of Physicians and Surgeons of British Columbia

Using your i-Clicker
1. Turn your i-Clicker on using the on/off button at the bottom of the panel; a solid blue light indicates power is on.
2. Select your preferred answer using the corresponding buttons: A, B, C, D or
E.
3. If your answer was received, the vote status light will be green; if your answer was not received, the vote status light will be red.
4. You can only register one answer per question.
5. Let’s do a trial run.
6. Please don’t forget to return your i-Clicker at the end of the session!
College of Physicians and Surgeons of British Columbia

Trial Run
The i-Clicker can also be used as:
A. An entry fob to the College offices.
B. A next generation multimedia smartphone.
C. A hand-held device to access my electronic medical records.
D. All of the above.
E. Absolutely nothing – I’ll leave it on the table following the session.
College of Physicians and Surgeons of British Columbia

Trial Run
The i-Clicker can also be used as:
A. An entry fob to the College offices.
B. A next generation multimedia smartphone.
C. A hand-held device to access my electronic medical records.
D. All of the above.
E. Absolutely nothing – I’ll leave it on the table following the session.
College of Physicians and Surgeons of British Columbia

Format
1.
Present scenario
2.
Questions – first glance, ponder
3.
Considerations – resources
4.
Questions – i-Clickers
5.
Results, panelist discussion and questions
College of Physicians and Surgeons of British Columbia

WARNING
College of Physicians and Surgeons of British Columbia

1
Assisting with community fundraising
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising
Dr. Smith is a heart surgeon, highly regarded by colleagues and recognized nationally for his exceptional career. He was recently awarded the Order of
Canada. The hospital has a file bulging with unsolicited testimonials from grateful patients. Similar letters regularly appear in the local newspaper.
On the cusp of retirement, Dr. Smith learns from the hospital foundation that a new post-operative unit will be named in his honour. The CEO of the foundation has another request: would Dr. Smith be prepared to assist in fundraising efforts to ensure that the new unit has the best equipment available? Specifically, given the many public declarations of gratitude from patients, would the heart surgeon be willing to endorse a letter to former patients?
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising Question to ponder
Dr. Smith and his colleagues may:
A.
Promote the campaign with patients, as long as treatment is finished and the outcome was satisfactory.
B.
Promote the campaign with patients and offer to have office staff accept contributions in sealed envelopes for delivery to the foundation.
C.
Promote the campaign with patients but insist that contributions be sent directly to the foundation office.
D.
Limit promotional activities to the distribution of brochures and display of posters in the office.
E.
Decline to communicate directly with patients, limiting the physician’s involvement to allowing their names and photographs to be used in promotional materials.
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising
CanMEDS roles:
• Health advocate
• Manager
• Communicator
• Professional
Considerations
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising Considerations
College standard: conflict of interest
• 17 authoritative references cited
• Speaks mostly to financial conflicts
“It is not always easy to identify and manage the wide-ranging circumstances where conflicts of interest might arise in the course of a physician’s professional duties and activities.”
• Suggests contacting the CMPA
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising Considerations
CMA Code of Ethics
1. Consider first the well-being of the patient.
2. … [treat the patient] with dignity and respect.
7. Resist any influence that could undermine your professional integrity.
11. Recognize and disclose conflicts of interest…
13. Do not exploit…
43. Recognize the responsibility of physicians to promote equitable access to health care resources.
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising i-Clicker question
Dr. Smith and his colleagues may:
A.
Promote the campaign with patients, as long as treatment is finished and the outcome was satisfactory.
B.
Promote the campaign with patients and offer to have office staff accept contributions in sealed envelopes for delivery to the foundation.
C.
Promote the campaign with patients but insist that any contributions be sent directly to the foundation office.
D.
Limit promotional activities to the distribution of brochures and display of posters in the office.
E.
Decline to communicate directly with patients, limiting the physician’s involvement to allowing their names and photographs to be used in promotional materials.
College of Physicians and Surgeons of British Columbia

Giving back
Assisting with community fundraising
Discussion
College of Physicians and Surgeons of British Columbia

2
A physician is named as the beneficiary in a patient’s will
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate
Dr. Kind is a full-service family physician in a well-established practice. She is respected and valued by her patients. (She scores 5.0 on a widely used physician rating website.) At holiday time, Dr. Kind receives many cards and baked goods from patients. She appreciates these gestures and always expresses her gratitude.
When one such elderly patient, Mrs. Jones, dies, Dr. Kind is surprised by a call from a lawyer who identifies herself as the executor for the estate. The deceased patient has left Dr. Kind $10,000 in her will, which includes a testimonial to Dr. Kind’s unwavering reliability.
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate Question to ponder
Dr. Kind should:
A.
Decline the bequest outright citing the traditions of the medical profession.
B.
Insist that the bequest be donated to a charity chosen by Mrs. Jones’ family, based on their knowledge of her favourite charities.
C.
Insist that the bequest be donated to a charity of Dr. Kind’s choosing.
D.
Graciously accept the bequest, giving honour to what was clearly a sincere expression of gratitude. The fact that Mrs. Jones is dead negates any concerns about boundaries.
E.
Accept the bequest, but only if there is no objection amongst surviving members of Mrs. Jones’ immediate family.
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate Considerations
College position concerning gifts:
1.
A power differential always exists…. This does not mean that the physician holds power over the patient, but the physician occupies special status in the patient’s eyes.
2.
The importance of gifts is not measured by the cost. However, the cost needs to be considered in the context of the patient’s circumstances….
3.
The meaning of the gift can be complex.
College Quarterly (March 2012)
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate Considerations
GMC, Good Medical Practice, 2013.
Gifts, bequests and donations
• You must not encourage patients to give, lend or bequeath money [to you].
• You may accept unsolicited gifts from patients or their relatives [provided there was no coercion].
• However, if you receive a bequest from a patient, you should… refuse … where [it] could be perceived as an abuse of trust.
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate Considerations
CMA Code of Ethics
1. Consider first the well-being of the patient.
2. … [treat the patient] with dignity and respect.
7. Resist any influence that could undermine your professional integrity.
11. Recognize and disclose conflicts of interest…
13. Do not exploit…
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate i-Clicker question
Dr. Kind should:
A.
Decline the bequest outright citing the traditions of the medical profession.
B.
Insist that the bequest be donated to a charity chosen by Mrs. Jones’ family, based on their knowledge of her favourite charities.
C.
Insist that the bequest be donated to a charity of Dr. Kind’s choosing.
D.
Graciously accept the bequest, giving honour to what was clearly a sincere expression of gratitude. The fact that Mrs. Jones is dead negates any concerns about boundaries.
E.
Accept the bequest, but only if there is no objection amongst surviving members of Mrs. Jones’ immediate family.
College of Physicians and Surgeons of British Columbia

Healthy boundaries
Physician as beneficiary to an estate Discussion
College of Physicians and Surgeons of British Columbia

3
And the busy family physician
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician
Dr. Ernest has been a busy family physician in a growing suburban community for 25 years. He sees patients from infancy to old age. His patient population is quite stable. Many have been with him since he took over the practice.
While going through his in-tray one morning, Dr. Ernest comes across a faxed request on the letterhead of a UBC clinical division. The handwritten subject line says “Request for Patient Information” and provides the name of the patient and her date of birth. The note below describes a twenty-year retrospective chart review of patients who had suffered an acute illness, with potential for future recurrence. Dr. Ernest is asked to provide
“notes/labs” from a specified date “to help clarify her relapse course.”
The physician/researcher provides his phone number and email address.
Dr. Ernest is inclined to pass the request on to office staff.
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician Question to ponder
Dr. Ernest should:
A.
Direct clinic staff to copy and send in the patient information.
Retrospective reviews by UBC clinician scientists fall under the auspices of the UBC Office of Research Ethics. Release of information do not require patient consent.
B.
Insist on being provided with a copy of the ethics approval document and release the information only if provided for in the approved protocol.
C.
Advise the researcher that he cannot release the information without the signed consent of the patient.
D.
Have staff call the patient, explain the circumstances and ask whether she consents to the release of the information.
E.
Scan the documents to the patient’s EMR and take no further action.
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician Considerations
Provincial and federal privacy legislation affirm the privacy of personal health information and define the terms under which it may be released.
Court decisions give special status to personal medical information and the confidentiality that must be maintained.
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician Considerations
Personal Information Protection Act, SBC 2003, c.63 (PIPA)
Consent required
6 (1) An organization must not
(c) disclose personal information about an individual.
(2) Subsection (1) does not apply if
(a) the individual gives consent to the collection, use or disclosure,
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician Considerations
Office of the Information and Privacy Commissioner Guidelines
Get consent for collecting, using and disclosing an individual’s personal information, except where PIPA excuses consent (such as employee personal information reasonably needed for the employment relationship; in an emergency; for an investigation where consent would compromise the availability or accuracy of the information).
Get consent in a form appropriate to the sensitivity of the personal information.
If an individual modifies or withdraws consent, comply with the change… explain the consequences of withdrawal.
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician Considerations
CMA Code of Ethics
39. Inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of your participation including any compensation.
40. Before proceeding with the study, obtain the informed consent of the subject, or proxy, and advise prospective subjects that they have the right to decline or withdraw from the study at any time, without prejudice to their ongoing care.
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician Considerations
Freedom of Information and Protection of Privacy Act, RSBC 1996
(FOIPPA)
Disclosure for research of statistical purposes
35 (1) A public body may disclose personal information…for a research purpose…, if
(a) the research cannot reasonably be accomplished unless that information is provided in an individually identified form….
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician
Dr. Ernest considers all these things. He calls the researcher’s office and gets voice mail. He leaves a message asking whether the consent of the patient is required. Another fax arrives:
“Due to the retrospective nature of our project and relationship with the patient, UBC Office of Research Ethics, which approved this project, does not require patient consent.
Thank you once again for your time.”
College of Physicians and Surgeons of British Columbia

Community-based research
And the busy family physician i-Clicker question
Dr. Ernest should:
A.
Direct clinic staff to copy and send in the patient information.
Retrospective reviews by UBC clinician scientists fall under the auspices of the UBC Office of Research Ethics. Release of information do not require patient consent.
B.
Insist on being provided with a copy of the ethics approval document and release the information only if provided for in the approved protocol.
C.
Advise the researcher that he cannot release the information without the signed consent of the patient.
D.
Have staff call the patient, explain the circumstances and ask whether she consents to the release of the information.
E.
Scan the documents to the patient’s EMR and take no further action.
College of Physicians and Surgeons of British Columbia

4
In search of a consistent approach to language proficiency assessment
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment
Dr. Krebs is a 35-year-old specialist, new to British Columbia and to
Canada. She attended medical school in a country where English is not the first and native language. Dr. Krebs went on to complete 10 years of postgraduate training in an English-speaking country.
To date, Dr. Krebs has failed to meet expected standards on the TOEFL iBT and the IELTS examinations a total of four times.
Despite this, the College has received numerous letters from physicians attesting to her English language skills (variations on “even I can understand her!”). She recently passed his Royal College examinations and has published 75 articles in English language peer-reviewed journals.
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment Question to ponder
The Registration Committee of the College should:
A.
Accept the evidence of Dr. Krebs’s English language proficiency
(testimonials, Royal College certification, training in an English speaking country) and waive the formal ELP requirements.
B.
Waive the requirements, but only if Dr. Krebs commits to a return-ofservice period in an underserved remote community.
C.
Waive the requirements, but only if Dr. Krebs agrees to limit her practice to group settings, in the interest of patient safety.
D.
Decline to provide a licence until established ELP requirements have been met. To bend the rules would be unfair and leave the College vulnerable to a human rights challenge for its inconsistent approach.
E.
Test Dr. Krebs’s English language skills at an interview to determine whether standardized tests underrate her particular performance.
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment Considerations
College Bylaws
General registration and licensure requirements
2-3 (2) An applicant for any class of registration, except for emergency registration, must
(d) have the ability to speak, read and write English to the satisfaction of the registration committee,
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment Considerations
College English language proficiency requirement:
Candidates are considered to have met the proficiency requirements if:
1. the language of instruction at medical school was English, and
2. the primary language of patient care was English, and
3. the first and native language of the country where the candidate was granted their medical degree is English.
Candidates who have not met the above requirement will require either a
TOEFL iBT (internet-based test) or the Academic IELTS examination.
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment Considerations
Our shared commitment to national standards:
Federation of Medical Regulatory Authorities of Canada
September 2013
STANDARDS FOR
MEDICAL REGISTRATION IN CANADA
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment i-Clicker question
The Registration Committee of the College should:
A.
Accept the evidence of Dr. Krebs’s English language proficiency
(testimonials, Royal College certification, training in an English speaking country) and waive the formal ELP requirements.
B.
Waive the requirements, but only if Dr. Krebs commits to a return-ofservice period in an underserved remote community.
C.
Waive the requirements, but only if Dr. Krebs agrees to limit her practice to group settings, in the interest of patient safety.
D.
Decline to provide a licence until established ELP requirements have been met. To bend the rules would be unfair and leave the College vulnerable to a human rights challenge for its inconsistent approach.
E.
Test Dr. Krebs’s English language skills at an interview to determine whether standardized tests underrate her particular performance.
College of Physicians and Surgeons of British Columbia

Dr. Krebs
…language proficiency assessment Discussion
College of Physicians and Surgeons of British Columbia