September Messenger 2019

Table of contents

Medical Matters

Annual physician fee of $2,150 approved by Council 1

Fatality inquiry-judge makes recommendations as a result of child’s death from chloral hydrate. 2

Last chance! CPSA Council nominations close tomorrow.. 3

Are you up to standard? Charging for after-hours phone calls

PRP therapies-avoiding the risk of disease transmission

. Not accepting new patients? Please make sure your physician profile is up-to-date6

The patient perspective: one chronic pain patient’s experience with prescription opioids. 6

Fighting burnout earns Dr. Lindsay Hubenig physician health award. 8

Avoiding a personal directive faux pas. 9

Alberta’s Strategic Clinical Networks report series. 11

Discipline report

Optimized Prescribing with Seniors. 12

Annual physician fee of $2,150 approved by Council

Being fiscally responsible is important to CPSA and its Council, and it is an expectation of Alberta physicians.

At its September meeting, Council approved an annual fee increase from $1,960 to $2,150. The increase will ensure CPSA can carry out:

• the strategic directions of Council;
• planned priority work for 2020;
• ongoing operating activities; and
• new rules under Bill 21: An Act to Protect Patients.

Physician fees are CPSA’s primary revenue source

Physicians have been paying CPSA $1,960 annually since 2012. This included a building fund of $150 collected annually from 2012 to 2016 to buy a building in the future. Physician annual fees remained at $1,960 for 2017, 2018 and 2019, making the fee increase roughly one per cent per year over the last eight years.

“No one wants a fee increase,” says CPSA Registrar Dr. Scott McLeod, “but physician fees match the work we need to do, especially work to meet Council’s strategic plan and provide programs and services that support physicians in providing good care to patients.”

The Finance and Audit Committee are projecting the new fee will remain at $2,150 for three years.

What your fees pay for

Some of the work physician fees will support in 2020 include:

• Creation of a Patient Relations Program and fund, as required by Bill 21, to provide treatment and/or counselling to patients affected by sexual abuse or misconduct by a regulated health professional.
• Streamlining complaints work and addressing the current back log of complaint files.
• Increased education and supportive interventions for higher risk physicians through CPSA’s Physician Health Monitoring Program, Practice Reviews and a new external competence enhancement program (being developed with the University of Alberta and University of Calgary). This work aligns with CPSA’s shift toward proactive prevention to reduce discipline.

More information on what your annual fee pays for and other CPSA priorities for 2020 is available on cpsa.ca.

Fatality inquiry: judge makes recommendations as a result of child’s death from chloral hydrate

On Sept. 4, 2019, the Ministry of Justice published the report of a fatality inquiry into the death of Nevaeh Michaud, an eight-year-old girl who died in January 2014. The autopsy report indicated the cause of death was trichlorethanol toxicity based on an accumulation of trichlorethanol, believed to be the result of receiving chloral hydrate as a long-term treatment for insomnia. The case is complicated, and interested physicians can learn more by reading the full report.

The judge made the following recommendations in her report, based on testimony from a clinical expert:

1. Chloral hydrate can be used as a short-term measure, to assist with sleep in children transitioning to different care situations. The usual dose is in the range of 50 mg/kg to a maximum dose of 1,000 mg. Given that tolerance to the hypnotic effect of chloral hydrate is known to develop within 10 to 14 days, this should be factored into the treatment plan and consideration should be made to wean or stop chloral hydrate shortly after the transition is accomplished. Chloral hydrate is not an appropriate drug for long [term] use to assist in sleeping in children.
2. Chloral hydrate should be prescribed with this in mind and for a defined period of time. It would be prudent not to have an automatic refill order for chloral hydrate, but rather to thoughtfully assess the need and safety of prescribing before re-filling a prescription for chloral hydrate.
3. Chloral hydrate therapy should be monitored on a regular basis to evaluate dose, efficacy and safety. The therapeutic plan for chloral hydrate should include considerations as to when therapy should be weaned/stopped.

While CPSA accepts the recommendations of the fatality inquiry report in principle, we urge physicians to consider these recommendations in conjunction with the advice in the peer-reviewed literature that suggests pharmacotherapy for insomnia in children should be limited and that chloral hydrate in particular should not be used for insomnia,^1,2 or its use should be substantially limited due to safety, side effects and tolerance concerns.³

Any time there is a loss of life, especially when it’s related to how health care was provided, it’s devastating to everyone involved. It’s up to all of us to learn from this and do everything we can to prevent it from happening again.

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1 Owens, Judith A. “Pharmacotherapy for insomnia in children and adolescents: A rational approach.” In A. G. Hoppin (Ed.), UpToDate (2019). https://www.uptodate.com/contents/pharmacotherapy-for-insomnia-in-children-and-adolescents-a-rational-approach#H655649244 (accessed August 27, 2019).

² Owens, Judith A. “Pharmacotherapy of pediatric insomnia.” Journal of the American Academy of Child and Adolescent Psychiatry 48, no. 2 (2009): 99-107.

³ Felt, Barbara T. & Chervin, Ronald D. “Medications for sleep disturbances in children.” Neurology Clinical Practice 4, no. 1 (2014): 82-87.

Last chance! CPSA Council nominations close tomorrow

We are accepting nominations for four physician members of Council for just one more day! Still on the fence about running? Here are some reasons you should consider joining Council:

• Move the medical profession forward. As a Council member, you’ll meet other physician leaders and take part in the conversations that will ultimately shape the way you and your fellow physicians deliver patient care.
• Bring your perspective. Every physician has unique successes and challenges that shape how they view and practise medicine. Different outlooks around the table contribute to well-rounded decisions.
• Health care is changing every day. From telemedicine to team-based health care, the medical profession is evolving. By joining Council, you can be part of the evolution.

In short, serving on CPSA Council means making a difference-to patients and to other physicians.

You have until 4:15 p.m. on Friday, Sept. 13 to submit your nomination. Don’t miss out on this challenging, engaging and rewarding opportunity!

And remember, voting in the CPSA Council Election opens on Friday, Sept. 20-watch your inbox for your ballot and cast your vote by Oct. 18!

Questions? Email elections@cpsa.ab.ca.

not accepting new patients? Please make sure your physician profile is up to date

Log in to your physician portal to update your information

Recently, CPSA heard from a number of Albertans who accessed the Find a Physician tool in hopes of finding a family doctor. In many cases, these prospective patients found that physicians were often incorrectly listed as accepting new patients-leaving them to continue their search for a new physician. To ensure all Albertans are accessing accurate information, please visit your physician portal to ensure your information is up to date.

Updating your information is as easy as one, two, three!

1. Log in to your physician portal and click “My Practice Status.”
2. Select whether or not you’re accepting patients, specifying any limitations or patient selection criteria.
3. Click “Submit.”

While you’re in your physician portal, please take a moment to verify that your other information, such as email address, phone number and practice address, are also up to date.

Having difficulties? Contact us at memberinquiries@cpsa.ab.ca for assistance with updating your information.

Fighting burnout earns Dr. Lindsay Hubenig physician health award

At the start of her third year of medical school, Lindsay Hubenig was studying, volunteering, living away from her husband and training for a marathon. Her physical fitness was at a high, and she was succeeding in all she took on. However, her mental health was suffering.

Lindsay was experiencing burnout.

This personal experience sparked Lindsay’s interest in physician health. Her goal was clear: to help others-and herself. She co-founded a physician interest group at University of Saskatchewan’s College of Medicine, and later became a wellness representative for postgraduates at the University of Alberta. She also got involved in developing the Resident Doctors of Canada Resiliency curriculum-a tool that teaches residents practical skills to mitigate stress and optimize performance.

Dr. Hubenig with family members of the late Dr. Marnie Hinton
(L to R: Melinda and David Dry, Dr. Lindsay Hubenig, Peter Dry)

In recognition of her dedication and advocacy for physician health, the University of Alberta honoured Lindsay on June 28, 2019, with the Dr. Marnie Hinton Award for Resident Physician Health.

Congratulations, Lindsay!

Practising what you preach

Now a mother of three young children (five, two and two) and completing her Royal College year, Lindsay’s engagement and advocacy for physician health is temporarily on hold. “This year took a lot out of me, and I’m hoping to re-engage in those activities I put on the back burner: travelling with my family, healing studying injuries and educating myself on the science of sleep.”

As she regains some balance in her life outside of medicine, we look forward to Lindsay’s future in physician health. She has already started a free online course called The Science of Well Being through Yale University and is looking at how to incorporate sleep counselling into her medical practice.

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Dr. Marnie Hinton, a long-time Alberta physician, dedicated her life to physician health. For nearly 25 years, she worked with doctors struggling with addiction through the CPSA’s Physicians Aftercare Program, sharing her wisdom about healthy sobriety and even taking members to recovery meetings in her off hours. The Dr. Marnie Hinton Award for Resident Physician Health, jointly funded by the College of Physicians & Surgeons of Alberta and the Alberta Medical Association’s Physician and Family Support Program, is awarded annually to a medical resident with a demonstrated interest in physician health.

Avoiding a personal directive faux pas

Dear colleagues,

CUPO. Looking up this acronym on Google, you’ll get results for a Canadian-Italian actor; a term of endearment for someone living in Cupertino, CA; a dance studio in Brisbane, Australia; and a term indicating “quota” in Spanish; among other results. But the meaning that I am looking for here is capacity until proven otherwise (CUPO).

A case of CUPO

Recently, Mr. A was moved into a long-term care facility based on his activated personal directive (PD). But there are a number of concerns with his case:

1. The personal directive was signed by him one day prior to activation. He was competent enough one day to sign his PD, but the next day was not. How does this happen?
2. He was not actually interviewed because there was the concern that it might create stress for his spouse who was already stressed with caregiving.
3. Now Mr. A is in long-term care and expresses that he wishes to return home.

What would you, as his physician, do?

It is crucial for us to not just know what forms are required to be completed in these situations, but actually understand the purpose of each form. For example, can an enduring power of attorney (EPA) be used to make medical decisions? Can a personal directive be used to help a relative sell the patient’s home? If a family member comes to you with an EPA asking for medical information, can you release that information?

What would you do?

Providing the best care for patients by understanding our legal requirements

We all need to understand the legal requirements of these important documents and be diligent in their completion. These days, no physician would go ahead with surgery without the proper consent forms being signed. Similarly, we need to take care to understand the modern legal requirements for ensuring these patients are properly protected and cared for-according to their wishes-through careful completion of these forms. We need to pay attention to the capacity of our patients and assume that they have capacity until proven otherwise: CUPO.

As physicians, we have the ability to change the direction of people’s lives. Most of the time, we are right in our decision-making. But we can also be incorrect, such as with the above case of Mr. A, which can cause distress for those to whom we provide care and their loved ones and embarrassing for us as a profession if we do not demonstrate that our profession takes these legal forms earnestly. Other provinces recognize the seriousness of this issue, to the point that only capacity assessors can assume the role of determining whether a PD should be activated. Some of us might feel this is the correct approach, but the reality is that we need to consider if we are comfortable-by default-giving up a responsibility that I believe is well within our capacity as physicians.

The Office of the Public Guardian and Trustee provides lectures and seminars to help physicians gain a better understanding of this area, and I highly encourage all my physician colleagues to engage these sessions. Whether you are a family doctor, a surgeon, a hospitalist or interventional cardiologist, we all face these issues, and failure to handle these situations properly can then create a situation we will need to support-legally.

Let’s all do our part to ensure we understand our legal requirements and the purpose of these documents so we can provide the best possible care for all Albertans.

Respectfully,
Dr. T. Dusang
Palliative Care Physician

Do you have an idea or article you’d like to submit to Messenger? Please email messenger@cpsa.ab.ca.

Alberta’s Strategic Clinical Networks report series

Alberta’s Strategic Clinical Networks (SCNs) have released the first of two reports as part of their SCN Report Series. The series paves the way for an exciting journey for the SCNs over the next five years and highlights great examples of successful projects that demonstrate the breadth, scope and impact of their work.

The SCN Report Series includes:

• Alberta’s SCNs: Past, Present, Future – A 10-page report explaining who the SCNs are, their partnerships, mission and role within the health system and the processes by which they enable health system improvement and transformation. It identifies seven areas of focus and provides a high-level overview of the five-year action plan for the networks.
• Improving Health Outcomes: SCN Retrospective | 2012-2018 – This report looks back on the SCNs’ work in Alberta and profiles 10 key projects. It explains how these networks are making a difference across the care continuum by enhancing the experience of patients and families and improving health outcomes for all Albertans. Featured projects include:
  • The Surgery SCN’s 2013 creation of a standard Safe Surgery Checklist, for use in every operating room in Alberta. Since implementation, the checklist has prevented errors in four per cent of surgeries, equating to more than 10,000 operating room errors avoided in Alberta each year.
  • The Cancer SCN’s 2016 integrated care pathways to address gaps and improve breast cancer care. The pathways were created using Alberta data, best practices and input from breast cancer survivors.
  • The Cardiovascular Health and Stroke SCN’s development of Stroke Care Alberta-an overarching strategy that aims to provide best-in-class stroke care, especially for Albertans living in rural areas.

Please read through these important reports and share them with your teams to spark ideas and solutions. For more information, visit their website or contact the SCNs.

Congratulations to the SCNs for their accomplishments throughout their first six years working with clinicians, zones and provincial programs. CPSA looks forward to working with them as they embark on their five-year action plan.

Discipline report

Dr. Habeeb Tunde Ali’s practice permit reissued after stay granted by Alberta Court of Queen’s Bench

Madame Justice M. E. Burns of the Court of Queen’s Bench of Alberta ordered a stay of the cancellation of Cochrane family physician Dr. Habeeb Tunde Ali’s 2019 practice permit. The Court’s decision allows Dr. Ali to practise medicine until his judicial review application is heard on Oct. 2, 2019.

Background

In May 2018, Dr. Ali’s registration and practice permit were cancelled by the College of Physicians & Surgeons of Alberta (CPSA) under section 43 of the Health Professions Act, due to his failure to pay outstanding discipline proceedings and Court costs related to his conviction for unprofessional conduct.

The cancellation decision was stayed by Order of the Alberta Court of Appeal pending Dr. Ali’s application to seek leave to appeal to the Supreme Court of Canada. The Supreme Court of Canada dismissed the leave application on March 14, 2019, which meant that the previous cancellation decision took effect, resulting in the cancellation of Dr. Ali’s 2019 practice permit.

Dr. Ali was found guilty of unprofessional conduct in 2014 after facing three charges, including failure to pay annual monitoring fees to the CPSA, failure to cooperate and meet with the Assistant Registrar as required under his Continuing Care Agreement with CPSA and failure to comply with his obligations as a bankrupt person. Dr. Ali unsuccessfully appealed the hearing decision to the CPSA’s Council in May 2016 then appealed to the Alberta Court of Appeal, which dismissed his appeal in December 2017.

Commentary

While Dr. Ali’s practice permit has been reissued, he is expected to continue to adhere to the same practice conditions that were on his practice permit prior to cancellation, which include a chaperone for all appointments with a female patient and a restriction from practising psychotherapy or counselling.