KINGSTON, AUSTRALIA

ACCREDITATION OF TRAINING OF THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS

The Australian Medical Council (Council) has granted accreditation of the training of the Royal Australian and New Zealand College of Psychiatrists, following a review in August–September 2005. The Council has resolved:

  1. That the AMC grant accreditation of the education and training program and the continuing professional development programs of the Royal Australian and New Zealand College of Psychiatrists (College) until June 2009.

  2. That before the expiry of this period of accreditation (i.e. June 2009), and at a time suitable to the RANZCP, the AMC review the College’s progress in relation to the key issues raised in the Accreditation Report with particular reference to implementation of the new Training and Assessment Regulations. The review will be undertaken with a view to extending the period of accreditation to the maximum period of six years.

  3. That in the usual annual reports to the Specialist Education Accreditation Committee, the RANZCP comment on its response to the other recommendations in the Accreditation Report. The first annual report should specifically address:

    • progress in addressing trainee concerns about the examination eligibility requirements, and access to clinical examination places;

    • the College’s overarching principles for engagement with trainees;

    • the progress in relation to the examination for overseas-trained psychiatrists.

To assess the College’s training program, the AMC set up an expert team which reviewed the College’s accreditation submission; and submissions from bodies such as health departments, health consumer organizations, other health professions that are part of the mental health care team. In addition, the team interviewed medical schools and other colleges and interviewed College committees, doctors who are completing specialist training in psychiatry, and College Fellows who supervise and assess doctors completing the training programs. In addition, the team visited large and small hospitals in urban and rural sites across Australia and New Zealand.

Beginning in 1998, the College has implemented a major review of its training, examinations and continuing education, resulting in the introduction of new training and assessment regulations on Dec. 1, 2003. When the team was assessing the College’s education and training programs, many issues relating to the transition to the new regulations were still be addressed by the College. As well as identifying the strengths of the College’s training and professional development programs, the team’s detailed accreditation report identifies areas where further work is required. The detailed accreditation report was available as a public document beginning February 2006.

PRIMARY SOURCE VERIFICATION OF MEDICAL QUALIFICATIONS

Beginning January 2006, all applicants for the AMC examination (for non-specialist registration) and the AMC – Specialist College assessment pathway (for registration as a specialist) will require primary source verification of the medical qualifications though the International Credentials Service of the Educational Commission for Foreign Medical Graduates of the United States (ECFMG).

Applicants will continue to apply to the AMC for initial assessment. Subject to the vetting of their documents by the AMC, applicants will be able to continue with the AMC examination or the specialist assessment as a “provisional candidate.” The documents will be forwarded to the ECFMG for verification through the original issuing university or institution. When confirmation of verification is received by the AMC the candidature will be confirmed. The AMC will not be able to issue a final AMC Certificate until the verification has been confirmed.

As of Jan. 1, 2006, the document verification assessment fee of $225 AUD applies to all applicants. This replaces the previous assessment fees for general (non-specialist), specialist and combined (general and specialist assessment). NOTE: Primary source verification is now a requirement for registration in Queensland and other states are expected to follow.

Reprinted from the Australian Medical Council website.

BRITISH COLUMBIA, CANADA

SEXUAL BOUNDARIES IN THE PHYSICIAN/PATIENT RELATIONSHIP

Introduction

Physicians must maintain professional boundaries in their interactions with their patients and not exploit them in any way. The following is a general discussion of the issues pertinent to situations where the professional physician/patient relationship may be compromised by sexualized behaviour.

Principles

  • Trust is the basis of the physician/patient relationship.

  • The patient is considered to be the vulnerable individual in the professional relationship in which assistance and treatment are sought from a professional individual with knowledge and training to make diagnoses and treatment decisions.

  • Power imbalance exists in the physician/patient relationship.

  • Transference may develop as a result of the power imbalance.

  • Sexualized behaviour in the physician/patient relationship is never acceptable.

  • A breach of sexual boundaries has potential for significant harm to the patient.

  • The physician cannot provide objective care when a sexualized relationship exists.

  • The onus is always on the physician to maintain professional boundaries with a patient and not to exploit the patient in any way.

  • The nature of a fiduciary relationship makes a consensual sexual relationship between physician and patient impossible.

The Code of Ethics

The 2004 Canadian Medical Association Code of Ethics states:

  • Paragraph 1

    “Consider first the well being of the patient.”

  • Paragraph 2

    “Practice the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.”

  • Paragraph 13

    “Do not exploit patients for personal advantage.”

Inappropriate Behaviour in the Physician/Patient Relationship

The following are examples of behaviour that are considered inappropriate:

  • Altering or removing a patient’s clothing while an examination is taking place without express patient consent.

  • Not allowing the patient the privacy to undress or dress and not providing appropriate gowns or drapes.

  • Sexually demeaning or suggestive comments.

  • Requests for “dating”.

  • Sexualized touching, fondling, hugging, kissing, and petting.

  • Sexual intercourse.

It is not unusual for a patient to consider the behaviour of a physician to be sexually motivated, even in circumstances where the physician had not consciously considered the behaviour to be sexualized. This most frequently occurs during examinations conducted without adequate explanations or without expressed patient consent.

Precautions in Practice

Consideration should be given to the following:

  • A physician should be careful to ensure any remarks or questions asked cannot be construed as demeaning, seductive or sexual in nature.

  • When sensitive subjects, such as sexual matters, have to be discussed, the physician should explain why the questions have to be asked, so that the intention cannot be misconstrued.

  • Hugging and kissing a patient is considered high risk behaviour that can be misinterpreted. Any touching that is not part of the physical examination must be of a type that cannot be misconstrued.

  • Although chaperones are not mandatory, a physician should consider carefully whether a chaperone would contribute to an individual patient’s feeling of comfort and security. Also, a chaperone may protect the physician from unfounded allegations. If a patient asks to have an appropriate support person in the room, that request must be honored. Signage indicating a chaperone is available or a printed policy regarding the provision of chaperones may be helpful.

  • The scope of the examination and the reasons for examination should be explained to the patient.

  • A physician must provide complete privacy for a patient to undress and to dress.

  • A patient must be provided with an adequate gown or drape.

  • The physician should not assist with removing or replacing the patient’s clothing, unless the patient is having difficulty and consents to such assistance.

  • A physician should be aware and be mindful of the particular cultural preferences in the diverse patient population.

  • A physician should avoid crossing non-sexual boundaries such as dual roles and self-disclosure, as these may accumulate and take the physician down the “slippery slope” into the realm of sexual misconduct.

  • Every physician should minimize personal vulnerability by appropriate recognition and attention to personal illness, stressors, emotional neediness and professional isolation.

  • When any questions or concerns arise, the physician should feel free to contact the The College of Physicians and Surgeons of British Columbia (College) for advice or direction.

Ethical Duty To Report

As indicated in the Medical Practitioners Act (Section 65), and subject to the requirements outlined below, physicians have statutory responsibilities regarding the reporting of sexual misconduct by another member to the College. Subject to the patient’s consent, the physician has an ethical responsibility to report to the College if a patient discloses information that leads the physician to believe that another physician may have acted improperly with the patient. To assist in such instances, the following guidelines are provided:

  • The physician must inform the patient that such alleged behaviour by any physician is unacceptable to the College and the medical profession.

  • The physician must provide the patient with information on how to file a complaint with the College.

  • If the patient does not wish to file a formal complaint immediately, then the physician must offer to file a third party report with the patient’s written consent.

  • If the patient does not give permission to proceed, then the physician has fulfilled the ethical duty. The physician should document the event, indicating that the patient does not wish a complaint or third party report to be made to the College.

Adjudication of Sexual Misconduct Complaints

All allegations of sexual misconduct must be carefully investigated and reviewed by the College.

Complaint Process and Procedure

Each situation is considered on its own merit, carefully taking into account such factors as:

  • The nature of the physician/patient relationship.

  • The duration of the physician/patient relationship.

  • The patient’s vulnerability:

    • The presence of a disorder likely to impair judgment or hinder independent decision-making

    • Psychotherapy in the physician/patient relationship

    • Age under 19

  • Physician factors:

    • Previous sexual misconduct

    • Degree of exploitation

    • Impairment

    • Actual or threatened bodily harm or violence

Termination of a professional relationship in order to pursue a sexual relationship has always been considered to be unethical.

Reprinted from The College of Physicians and Surgeons of British Columbia website.

ONTARIO, CANADA

COLLEGE’S HPRAC SUBMISSION PRESCRIPTION FOR CHANGE

The College of Physicians and Surgeons of Ontario (College) has been asked to provide recommendations for change to the legislation that governs the College to the Health Professions Regulatory Advisory Council (HPRAC). In the previous issue of Dialogue, we discussed some of our suggestions for improvement. Here, we continue our prescription for change. The Health Professionals Regulatory Advisory Council (HPRAC) has been charged with the responsibility of providing advice to the Minister of Health and Long-Term Care on a number of issues respecting the regulation of health professionals under the Regulated Health Professions Act (RHPA).

When the RHPA was proclaimed in 1993, it envisioned a regulatory system unlike any other in Canada. While there are many good things to say about this act, the College’s 12 years of experience working within the legislation have also revealed some weaknesses. In the November/December issue of Dialogue, we outlined some of our recommendations for improvement. The following is part two of our prescription for change.

The full submission is on the College website at http://www.cpso.on.ca under the What’s New button.

Recommendations – Complaints Committee

Investigation Time Frames

We have made several specific recommendations about Complaints Committee processes. We recommend the RHPA be amended to increase the time frame in which complaints investigations are to be completed. The College notes sometimes completion within the stipulated period will not be possible. When the statutory time frame cannot be met, colleges should be required to give notice to the parties advising them of the reasons for the delay and the revised time frame for the disposition of the complaint.1

Frivolous and Vexatious Complaints

While changes to the original legislation have permitted the colleges to deal with complaints that are frivolous and vexatious in a more efficient fashion, we recommend the colleges be permitted the discretion not to investigate complaints that are frivolous and vexatious. The process could be simplified if the Committee were permitted to issue a summary decision based on the initial letter. An appeal to the Health Professions Appeal and Review Board of the decision to decline such investigations should continue to be available.

Interim Suspension and Practice Limitation Orders

In the rare case where the College has information a member is a threat to patient safety, it cannot suspend the member or place restrictions on his or her practice immediately. Although this does not happen often, we need the ability to act more quickly when it does.2 The College is concerned, however, about ensuring procedural protections for the physician subject to such orders. If this authority is granted to the proposed Screening Committee, the College has submitted that it must be subject to the following procedural safeguards:

  • The Committee must have formed the opinion that the member’s conduct exposes or is likely to expose the public to harm or injury or the member must have refused to cooperate with a practice assessment (or in the case of an investigation into the member’s capacity, a mental or physical examination);

  • The member must be provided with notice of the intended impending suspension together with disclosure of all of the information relied upon by the Committee and its reasons for making the order;

  • The member must be given an opportunity to reply to the notice of intended suspension prior to it being put into effect;

  • The member must be given an opportunity to request a review of the suspension, once made; and

  • Once the suspension is in place, the matter must be referred to, and disposed of by, either the Fitness to Practice or Discipline Committee on an expedited basis.

Public Information about Undertakings

Many complaints or concerns about physicians received by the College are resolved to the satisfaction of the physician, the complainant and the College without recourse to Complaints or Discipline Committees. Sometimes such resolutions entail undertakings by the physician. Undertakings generally reflect a physician’s commitment to upgrade his or her skills or to refrain from an act or an area of practice. Providing this information to the public for the duration of its term, but removing it once its requirements have been fulfilled, would demonstrate the College’s and the subject physician’s commitment to continued quality improvement.

Discipline Panel Chairs

The College recommends the quorum for the Discipline Committee should be amended to allow a retired judge or experienced lawyer to chair discipline panels and to form part of the quorum in the place of one of the public members of Council.

It has been the College’s experience the discipline process is becoming more intricate and procedurally demanding. Hearings are prolonged as discipline panels confront issues and arguments that are increasingly complex and highly contested. Panel chairs with adjudicative expertise will enhance Discipline Committee proficiency in conducting hearings and writing decisions, while preserving the principle of self-regulation. This model is being used in other jurisdictions with success.

Access to Information and Confidentiality Concerns

It has been previously recommended the confidentiality provisions in the RHPA be amended to allow a college to acknowledge its dealings with a member when it is in the public interest to do so. Regulatory imperatives such as procedural fairness and the effectiveness of college programs must be carefully balanced against the desire to ensure maximum access to information for health care consumers.

Currently, when allegations of misconduct or incompetence against a physician are referred to the Discipline Committee, the referral is public information, the notice of hearing detailing the specific allegations is publicly available, and the hearing itself is open to the public. Furthermore, the findings and the reasons of the Discipline Committee are in the public domain and easily accessible on our website. Recently, physician reprimands delivered by the Discipline Committee have been made public. At the Complaints Committee level, any individual who makes a complaint (as well as the physician) receives a copy of the Complaints Committee’s decision and reasons. It is also our practice to provide regular progress reports to both parties throughout the investigation.

Under the present system, if the Complaints Committee refers a matter to the Quality Assurance Committee, the College cannot provide information about the outcome to the complainant. If the concern comes to the College through another mechanism (coroner, hospital chief of staff, mandatory report, for example) the College cannot share information with the source that raised the concern. The existence of a complaint or an ongoing investigation is not public.

We believe part of the foundation of the new committee structure we have recommended would be to permit the College to provide progress reports about investigations and the Committee’s decision and reasons to the source of the concern. This would help to make the system more accountable. We don’t believe, however, that this goes far enough.

In both of our previous submissions we recommended legislative direction be established to govern when information about dealings with members could be disclosed. The circumstances under which we recommend it is appropriate to disclose the fact that we are investigating a member are as follows:

  • The member has made the investigation a matter of public record.

  • There has been an alteration in the member’s hospital privileges in connection with the same issue as is being investigated.

  • Criminal charges have been laid against the member in connection with the same issue as is being investigated.

Public Register

In 2001, HPRAC made several recommendations about information it felt ought to appear on the public register. HPRAC suggested all referrals to Discipline and Quality Assurance Committees be placed on the public register. We noted all discipline referrals are already a matter of public record, so no change is required. As to referrals to the Quality Assurance Committee, if our recommendations about a single committee were adopted, such referrals would be eliminated. While it is true the secrecy required by the RHPA in connection with Quality Assurance referrals creates a tremendous barrier in a variety of ways, we are persuaded the critical repair needed is to change the structure.

If, however, the current referral structure is maintained, we agree greater transparency is required. At the least, complainants should be entitled to receive progress and outcome reports for matters referred to the Quality Assurance Committee and the Committee must be permitted to share its investigative materials with other College Committees should the matter possibly require referral to the discipline stream.

Endnotes
1.

The College notes our desire to increase the statutory window for completion of an investigation is motivated by a desire to create realistic expectations rather than to introduce delay. We have been working to improve our complaints completion timelines: since the 1980s we have reduced our average completion period by more than 70 percent. On an ongoing basis, we are developing tools and benchmarks to continue to improve our turnaround time.

2.

Such authority would not be unprecedented in the name of public safety. Under the Health Protection and Promotion Act, 1990, Medical Officers of Health have the authority to close a business or temporarily quarantine an individual if there is evidence of a health hazard for the public.

Reprinted from the College of Physicians and Surgeons of Ontario website.

SASKATCHEWAN, CANADA

REPORT FROM THE COMPLAINTS COMMITTEE

The College of Physicians and Surgeons (College) has a statutory obligation to investigate complaints registered against physicians. Complaints are accepted when a complainant has a concern about the care or conduct of a physician. If the complaint is verbally reported to the College and is amenable to resolution by enhanced communication or by providing information, the College staff resolves these concerns in an informal manner. If the complaint cannot be resolved by that type of interaction, the complainant is asked to identify their concerns in writing using the Complaint Reporting Form and the Authorization Form provided by the College.

It should be noted the committee’s review of cases extends beyond the calendar year. In 2005, the committee met on seven occasions and reviewed cases registered in 2004 and not completed by the end of the calendar year in 2004 (51), and those cases registered in 2005 (66). As the work cycle does not match the calendar year, for statistical purposes the committee reports on the most recent completed year of review.

In the 2004 calendar year, the College received approximately 1,054 expressions of concerns, the majority of which were dealt with by the administrative staff. There were 150 formal complaints registered in 2004 and which were managed by the College’s Complaints Resolution Advisory Committee process.

In the 150 written complaints, there were 417 allegations, the most common allegations being inadequate treatment, inappropriate medication, incorrect or missed diagnosis, insensitive care, rudeness, unethical conduct, failure to refer, delayed diagnosis, or communication error/lack of communication. Of these 417 allegations, 132 were founded, 56 were partially founded, 178 were unfounded, three were withdrawn, 12 were found to be patient responsibility, and in 39 there was no determination. With respect to the no determination code, this code is used when the committee is unable to determine with any degree of certainty what the situation was. This includes such allegations as rudeness, inappropriate comments and roughness.

The purpose of the committee’s review of complaints is to provide educational suggestions to physicians in cases where their care or conduct could be improved. The committee also attempts to provide the complainants with a better understanding of the care provided. The committee hopes the review of these types of complaints is educational, both to the physicians and to the complainants. The process is confidential and at the present time complaints through the Complaints Resolution Advisory Committee process do not form part of the physician’s personal record and are not reported on a Certificate of Good Standing.

It is hoped this process is viewed as an educational exercise by physicians and assists them in understanding that it is often the patient’s perception of the interaction that leads to a complaint rather than any care issue. Thoughtful reflection by physicians often results in changes to their practice or communication style, therefore often resulting in avoidance of similar complaints in the future.

Feedback in the complaints process is confidential and is provided to the complainant if the complainant is the patient, or to a third party with appropriate legal authorization to act on behalf of the patient or the patient’s Estate. The same feedback is provided to the physician.

The committee does raise systemic issues (nonnominally) to the attention of the appropriate authority, such as the Regional Health Authority, when there are issues identified within the complaints process that need to be addressed by a different authority to make quality improvements. The committee views this as part of an overall continuous quality improvement strategy.

The committee also provides information by way of the College Newsletter to raise physicians’ awareness to certain problems and/or potential educational tools. In the last year, the committee provided information on the evidence-based preventative care checklist forms, an alert with respect to the possible magnitude of interaction between the fluoroquinolines and Warfarin, information regarding risk factors for osteoporosis, and guidelines for bone mineral density testing for osteoporosis.

The College has mailed satisfaction questionnaires to both complainants and physicians for cases closed in the years 2002, 2003 and 2004. These questionnaires are mailed out a number of months after the completion of the committee’s review.

There were 200 questionnaires sent to physicians involved in cases closed in 2004, with 104 questionnaires returned (52 percent), and 140 questionnaires sent to complainants, with 52 questionnaires returned (37.14 percent). Comparison of the responses over the three years was found to be fairly consistent. Based on these responses, some changes have been made to assist complainants and physicians in understanding the complaints review process. One concern raised was whether it was reasonable to have the College request the feedback on their process rather than having an independent organization manage the summary. The College continues to look for alternative ways of obtaining feedback on the complaints process.

The Complaints Resolution Advisory Committee members consist of Dr. L. Baker (family practitioner, Rosthern), Dr. M. Harington (general surgeon, Saskatoon), and Chair, Dr. J. Kriegler (family practitioner, Saskatoon). The public members are Mrs. A. Brayshaw and Ms. V. LaCroix of Saskatoon, and Mrs. S. Lougheed of Pinehouse Lake.

Reprinted from the Volume 21 Number 63 issue of College Newsletter, published by the College of Physicians and Surgeons of Saskatchewan.

LONDON, ENGLAND

GMC PUBLISHES MANAGEMENT FOR DOCTORS

Management for Doctors is a new booklet that develops the essential elements of good standards of practice and care described in Good Medical Practice with a particular focus on management in health care. It will be particularly relevant for physicians who have a management role, but should be helpful for all doctors.

The General Medical Council (GMC) organized a seminar in April 2004 to seek views and generate ideas about existing guidance publications and how they could be brought up to date in a way that would be helpful to doctors and in line with expectations of patients and current management practice. Following nearly two years’ further work, the GMC presents new guidelines, Management for Doctors.

All physicians on the specialist and GP registers should have received a copy of the new booklet with the February issue of GMCtoday. Management for Doctors replaces Management in Health Care: the Role of Doctors. Management for Doctors can be found online, along with all GMC-published materials, in the GMC’s Guidance Library on its website at http://www.gmc-uk.org.

GMC STATEMENT ON HIGH COURT JUDGMENT MEADOW AND GENERAL MEDICAL COUNCIL

Justice Collins’ judgment has important implications for the GMC and all professional regulators and will need to be studied carefully. The courts have previously ruled the GMC is under a duty to investigate any complaint potentially capable of reaching the relevant threshold. Before today, no judge has suggested that there were exceptions to this.

The GMC has consistently argued, except where there has been criticism by a court, as in this case, the GMC’s procedures should not be used to challenge evidence given in, or for the purpose of, civil or criminal proceedings. The GMC agrees with Justice Collins that it cannot be in the public interest if doctors and other professionals are inhibited from giving evidence, honestly and truthfully. However, where there has been serious judicial criticism, we have sought to act to protect the public interest from experts who fall significantly short of accepted standards.

In today’s judgment, Justice Collins has extended the principle of immunity, so that it would apply for the first time to the bringing of disciplinary proceedings by regulators. The effect is to grant an immunity that, hitherto, has not been recognized in law. Such immunity would place doctors, and other professionals, beyond the reach of their regulator, when writing reports for the courts or giving evidence. This would be true even when they, or their evidence, have been criticized by the court. The only exceptions would be if the judge complained to the regulator.

This judgment seeks to address a very real problem. It has far wider implications than the particular case, not just for doctors but for all professionals. The GMC is carefully considering the judgment which it recognizes to be a welcome contribution in a very vexed area of the law.

GMC REVISES THE GUIDELINES FOR MANAGERS

The General Medical Council is publishing new guidance for doctors who are managers, as well as those who work in managed environments.

The new guidance sets out the standards that are expected of doctors working in a management role, as well as those who are managed. It explains that doctors remain responsible to the GMC for their actions even when a non-doctor could perform the management role.

One of the areas that has been considerably enlarged compared with the previous/existing guidance is the definition of the competencies and standards that define a good manager. These include:

  • The ability to make sound decisions in difficult situations.

  • The ability to manage resources and plan work to achieve maximum benefits.

  • A knowledge of what is affordable and achievable.

The guidance advises doctors that when they do not have the resources to provide the best treatment for all patients, they must make judgments on the basis of sound research information as to efficiency and efficacy and in line with their duty to protect life and health, respect patients’ autonomy and to treat justly. They should also be sure to “take into account the priorities set by government and the NS or your employing or funding body.”

It also details the responsibility a doctor has to raise concerns if they believe that patients may be at risk of serious harm and the option to whistle blow if risks are not made safe. The guidance states that “If you have good grounds to believe that patients may be at risk of serious harm, and you have done all you can to resolve the problem by raising your concerns within the organization in which you work, you may consider making them public, provided that patient confidentiality is not breached.”

The review of the guidance was launched in April 2004 with a seminar, during which Chief Medical Officer for England, Sir Liao Donaldson gave the keynote address signalling the importance the DoL attaches to this issue. During his speech he praised the guidance for being ‘innovative’ when it was first issued.

To receive a copy of Management for Doctors, e-mail publications@gmc-uk.org or call 0161-923-6315.

LET US HEAR FROM YOU

Would you like for information from your board to be considered for publication in the Journal? If so, e-mail articles and news releases to Edward Pittman at epittman@fsmb.org or send via fax to (817) 868-4098.