Ms Soapbox has been in a quandary all week. She was troubled by what she’d observed at the meeting of the College of Physicians and Surgeons governing council. Finally the penny dropped. The College is deadlocked and incapable of living up to its mission which is “Serving the public by guiding the medical profession”.*
It’s become painfully obvious that the College is extremely reluctant to regulate doctors who provide uninsured services; let alone discipline physicians who breach the Standards of Practice and Code of Ethics by taking advantage of the public’s ignorance of how insured and uninsured services should be provided.
Sounds harsh, but consider this. There are roughly the same number of doctors as lawyers in Alberta (approximately 7000 doctors and 7800 lawyers) but over the last five years there were twice as many complaints resulting in disciplinary action against lawyers than doctors—50 actions against the lawyers including 18 disbarments and 5 resignations and just 22 actions against the doctors.**
There are two possible explanations for this anomaly: Doctors are more ethical than lawyers or doctors’ patients are less likely to complain than lawyer’s clients.
Are doctors more ethical than lawyers?
I have three words for anyone who thinks doctors are more ethical than lawyers: Queue Jumping Inquiry! Given the revelations surrounding the Helios clinic and what turned out to be a well-established queue jumping protocol, I find it hard to believe that doctors are more ethical than lawyers.
To further complicate matters, doctors have the challenge (and the luxury) of being able to charge for insured (government-paid) services and non-insured (extra fee) services. This confuses patients and gives doctors even more wiggle room under the Standards of Practice and Code of Ethics.
Lawyers on the other hand don’t have one foot on the pier and the other in the boat. Virtually all lawyers work in private practice or in-house for corporations or government. The question of who pays their bills is easily determined and there’s no opportunity for double-dipping.
Are doctors’ patients less likely to complain?
I left the meeting of the College of Physicians and Surgeons convinced that doctors’ patients are less likely to file a complaint because they’re not properly equipped to do so.
When a lawyer messes up, his client finds out pretty quickly. The deal goes sour, the client loses his deposit, etc. Clients are furious and fire letters off to the Law Society at the drop of the hat.
A lawyer’s client knowns what he wants to get accomplished, he just needs the lawyer to help him do it. Doctor’s patients on the other hand, don’t know what’s wrong with them, let alone how to heal themselves. This makes it difficult for patients to know when they’re receiving inadequate medical care. Furthermore, the nature of the doctor/patient relationship requires patients to trust their doctors. Consequently patients will endure a great deal of substandard care before they raise the alarm or switch doctors.
Given this state of affairs, the College must do everything possible to protect the public by enforcing the Standards of Practice and Code of Ethics. Does it?
The College’s duty to protect
The Code of Ethics states that it is a doctor’s fundamental responsibility to “consider first the well-being of the patient”. This principle alone would prohibit a doctor from limiting his patients to only one ailment per visit, thereby forcing patients to book three separate appointments on three separate days. This may enhance the doctor’s ability to bill the system but it’s certainly detrimental to the patient’s well-being.
The Standards of Practice prohibit the tying of uninsured services to insured services. (This may be illegal under competition law as well). So a doctor can’t close his practice, ditch his patients, re-open his practice in a concierge clinic and demand that his old patients pay him an annual fee of $3000 to $10,000 for uninsured services before he’ll agree to provide them insured services.
The College is well aware of these and other abuses. And yet it is reluctant to amend the Standards of Practice to make it crystal clear that such practices will not be tolerated. Instead it sends the staff back to the drawing board to “clarify guiding principles that would frame any future discussions surrounding” amendments to the Standards of Practice.***
This is deeply troubling because the problem isn’t a lack of clarity. It’s a lack of fortitude. The College must deal with the elephant in the room. Will it fight for public healthcare by enforcing the existing Standards of Practice and adding amendments to stop the incremental privatization of healthcare or not?
There’s a lot of money to be made in providing uninsured services. The College will face fierce headwinds if it disciplines physicians who provide these services improperly. But, hey, someone has to do it. Shouldn’t that “someone” be the College of Physicians and Surgeons, the self-regulating body empowered under the Health Professionals Act to discipline wayward physicians?
Time to get militant
At this point the College is deadlocked. The amended Standards are under review (again). We can’t afford to wait for the College to decide whether it will support public healthcare or turn a blind eye to the physicians sneaking privatized healthcare into Alberta through the back door.
So let’s force the College’s hand. Let’s stand up for ourselves. Let’s take a lesson in militancy from my little physiotherapist who challenged her doctor for writing her a prescription for over-the-counter vitamins. (She also challenged her dentist for charging $400 for a cleaning and an X-ray and a waiter for charging her dinner companion a $10 split-meal charge when her friend only had a beverage).
The next time you visit your doctor take the Standards of Practice and Code of Ethics* with you. Ask your doctor to explain his fees and whether he’s charging you for an insured service. If he insists you book a second appointment to describe some of your symptoms ask him how that’s consistent with the Code of Ethics.
And if you don’t get a satisfactory answer file a complaint with the College of Physicians and Surgeons. If we don’t stand up for ourselves who will?
**These are high level statistics based on information available on line. Additional information from doctors or lawyers is welcome.
***Council Meeting Highlights, May 2013, CPSA website
Susan on the Soapbox 
I am fascinated by your added blog item on the CPSA. Having attended the March meeting, I was gobsmacked then by the arrogance (or was it blind indifference?) that the physicians in attendance seemed to show to the members in the public gallery, including some rude behaviour by one doctor, as was discussed at the time.
Frankly, I really admire your physiotherapist and wish that more people would follow her proactive example! We need to stand together and challenge the CPSA (and other governing bodies) that appear to be wilfully negligent, in not enforcing their own Standards of Practice and Code of Ethics. (It probably should be expected that Justice Vertes will have some comments to make on this issue, when he presents his final report on the queue jumping inquiry.)
Your question at the end, about who will stand up, reminds me of the famous poem attributed to the German pastor, Martin Niemöller.
“First they came for the Socialists, and I did not speak out–
Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out–
Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out–
Because I was not a Jew.
Then they came for me–and there was no one left to speak for me.”
That really says it all for me, in a very profound way.
Liz, the Niemöller poem says it beautifully. So many things have gone off the rails here in Alberta that people are giving up. Some think the problems are overwhelming, others hope that someone else will fight the battle for them and worry that if they make a fuss they’ll suffer reprisals. Frankly the fear of retribution is legitimate or it wouldn’t have been included as one of the recommended changes to the Standards.
I went back to the very first version of the CMA Code of Ethics (created in 1868 and revised 19 times). It contains an interesting provision that prohibits a wealthy physician from giving free medical advice to the affluent, “because his doing so is an injury to his professional brethren. The office of a physician can never be supported as an exclusively beneficent one; and it is defrauding, in some degree, the common funds for its support, when fees are dispensed with, which might justly be claimed.”
And now almost 150 years later we’ve got exactly the opposite problem, some physicians are demanding extra fees from the affluent in order to provide services that they’re required to provide under the Standards of Conduct to everybody. This is so wrong. We must never give up.
A terrific analysis, Susan. We lawyers have to stick together.
Thanks Phil (I believe that was a tongue-in-cheek comment). On a more serious note, as much as it pains me to admit that twice as many lawyers as doctors were disciplined over the last 5 years at least we know the Law Society is doing its job!
For anyone interested in penning a strongly worded letter on the issue, the http://www.ombudsman.ab.ca/ Is allegedly ‘Focused on Fairness’.
Goinfawr, thanks for providing another mechanism to lodge a complaint. This fits nicely with the “never give up, never say die” philosophy; if we can’t get through on one path, we’ll find another!
My opinion of lawyers has taken a knock as a result of your blog and your colleagues comment (Phil Elder). Any nincompoop should understand that “promotion of public healthcare” is a political issue and not a regulatory one. It is the College’s function to ensure that physicians are in compliance with current legislation. Where the legislation is vague the College Council gets to apply professional, moral and ethical principles, not necessarily aligned with your thinking. The College Council consists of individuals of varying political persuasion and therein lies its strength. To its credit, the College Council decided that it requires ‘more information’ before making a binding and enduring decision.
While it is the College’s expectation that physicians will treat patients, irrespective of their ability to pay, there is no reason why those willing and able to pay should be denied access to timely medical care – but that is a topic for a whole other debate. Strangely enough, access to justice under the law should also be considered a basic human right but lawyers aren’t confined to “public legalcare” funded by taxpayer dollars. Lawyers get to charge for everything and anything, and consultations are ‘time-based’, whereas doctors are largely prohibited from charging for anything where the patient is not sitting directly in front of them.
A lawyer promoting militant behaviour and actions is also disturbing!
Clearly we won’t see eye to eye on this issue but here’s my logic. The College’s mission is not a political one, it’s one of service. See the CPSA mission statement, “Serving the public by guiding the medical profession” and its 4 point vision statement. http://www.cpsa.ab.ca/AboutUs/MissionVisionValues.aspx
The College is a self-regulating body under the Health Professions Act. The CMA Code of Ethics (adopted by the CPSA) recognizes that self-regulation is a “privilege” and notes that each physician has “a continuing responsibility to merit this privilege and to support its institutions”. This would explain why the College wanted “assurance” that its Standards would address “issues arising from private concierge-style clinics”. Dr Mazurek’s memo to Council May 8, 2013.
Dr Mazurek’s memo set out four guiding principles: (1) equal access for family physicians and specialists for all Albertans, (2) no barriers, financial or otherwise, to insured medical care, (3) equal access to a physician’s time, timely access to care and timely referrals “commensurate with medical need and not [a patient’s] ability to pay for other services offered by the practitioner or clinic” and (4) clarification that a physician leaving a practice to set up another practice in the same community is not “closing a medical practice” if he offers the same services.
Council staff did not ban block fees. They simply made a number of recommendations to enhance transparency of block fees. These were: (1) indicate whether fees were for “insured” or “uninsured” services, (2) indicate what’s included in the block fee and what’s an extra charge, (3) allow a patient to opt out of the block fee program without repercussion, (4) prevent physicians from billing patients for uninsured services before they’ve provided them, (5) prohibit preferential treatment to patients who pay block fees and (6) ensure patients are not abandoned if a physician moves to a concierge clinic.
Sounds reasonable, but some Council members pushed back hard. The strangest comment came from the physician who wanted to collect the block fee upfront in order to cover the extra staff providing uninsured services. Well you can’t have it both ways. If you want to offer uninsured services then you bear the risk of underutilization. That’s how it works in business—greater risk, greater reward.
I stand behind the use of the term “militant”. The dictionary defines it as having a combative, aggressive character, especially in the service of a cause. It fits Ms Soapbox like a glove.
One last point, here on the Soapbox we exchange ideas and points of view. Sometimes we disagree, but one thing we don’t do is fling silly names around. So while I welcome the feedback, any name-calling comments will go into “moderated” limbo.
A much more reasoned and balanced point of view. I do agree with much of what you have to say and apologise for the name calling. You touch on an important point in that “that’s how it works in business.”
A medical practice is a business but the practice of medicine is not. Many of the practices these days are owned by mini corporations who have bought into the ‘business of medicine’. Physicians are contracted to these ‘chain’ practices and are pressured to see as many patients as possible, thus increasing the profit margin of the holding company. Patients are the victims in terms of poorer quality of care and communication. Because of the reduction in ‘real incomes’ we will see an increase in innovative ways to increase the profitability of traditional practices. Is this the fault of physicians or is it more the result of outside pressures?
Oh good, I’m glad we found some common ground. Your comment about the pressures of working for a “chain” practice brought in an interesting dimension. I’m not familiar with that business model. Your question at the end of your comment is a difficult one to answer. I take Carol’s point that ultimately each physician must decide for himself how he will practice medicine, however I would temper it with the following questions. Does a physician fully understand what he’s signed up for when he joins a chain practice? Does the quality of care that he delivers deteriorate gradually? Is he clear about what’s expected of him in the first place? In other words does he fully realize that he’s compromising his standards?
All of this brings me back to the College which has been given the responsibility to guide the profession and is reluctant to do so. I fear that the College will be even less willing to take dramatic action given today’s announcement that Fred Horne fired the entire AHS Board. Just what the system needed–another shockwave.
Welcome to the Soapbox
Susan the College is reluctant to regulate the doctors and it will not regardless of what is right. Again in a society where what is right is now debateable, it is not a surprise that doctors are jumping on the bandwagon. This government on the other hand seems to be fine with confusion as it brings the possibility of no regulation and that is the point of neo-conservatism.
As far as your question about ethics I do not not know statiscally but as far as public perception, right now doctors win hands down. Lawyers have a very low reputation. Justice these days depends greatly on what kind of lawyers one can afford and the problem is that many times people get extremelly upset on cases that seem almost obvious and bad people get away with murder. MP Oldring is just the last example. The joke in my office was that he got out on the fact that the tube he was supposed to blow into was too dirty for an MP clean mouth and so he refused to do it. 🙂
I personally still trust doctors more than I do lawers.
The idea that it is wrong for a lawyer to be militant, whatever the meaning is in Realistic’s note, is surprising to me. I thought that lawyers are the majority in parliaments around the world, lawyers are behind most of the most famous revolutions and lawyers are involved in political and social events that I consider dubious. Even if it is against the lawyers ethical standards, it is widespread and I am not sure why they should not be militant. Alison Redford right now is a strong militant for neo-conservative ideology, is a guest of groups like the Bilderberg group which is an extremelly elite militant association and she is a lawyer. I did not understand this view point. Maybe correct but in today’s world irrelevant.
I agree with you Carlos, doctors are perceived to be more ethical than lawyers and there may be good reason for that. But I think we’d all agree that politicians are the least ethical of the bunch! Fred Horne’s dramatic decision to fire the entire AHS Board (a decision he would not have made without Ms Redford’s blessing by the way) is a classic example. Sure, Mr Horne was frustrated by the Board’s refusal to follow his “directive” that no bonuses be given out to AHS staff, however wasn’t that decision solely within the purview of the AHS Board? Mr Horne’s decision to fire the lot of them brings into question just how “independent” this independent PC appointed, arm’s length board really is. Three guesses on what the topic of this week’s blog is going to be….!
PS I loved your comment that Alberta is getting to be more exciting that Turkey…well said.
“Is this the fault of physicians or is it more the result of outside pressures?”
I can’t resist. Surely the benchmark for responsibility is still the Nuremberg position that an individual, regardless of rank, was responsible for their own actions. Are “outside pressures” a better justification than “just following orders”?
Carol
Carol, I take your point, but I’d temper it just a little with the questions I posed in my response to Realist. Over the years I’ve noticed that sometimes people slide into unprofessional conduct so gradually that they don’t realize they’ve crossed the line until it’s too late. Not noble, but a fact of life. Hence my view that the College needs to step up and do its job of guiding physicians in ethical practice by clarifying the Standards and disciplining those who refuse to get with the program.
wow Alberta is getting more exciting then Turkey
http://www.huffingtonpost.ca/2013/06/12/alberta-health-services-board-fired_n_3428652.html
Carlos, I can’t wait to see what they pull tomorrow!
Well Susan what about a bet that tomorrow somehow Alison Redford is sick or some family member is. After all the experience with this and previous governments and knowing very well how spin doctors work, I bet something will happen. Also it is possible that she will just ignore it. She is very capable of that.
As far as your comment that Fred Horne would not have made this decision without the premier’s approval, I agree 1000%. No way Fred would make a decision of this magnitude on his own. He does not seem to be able to make a decision period, never mind one like this.
Knock, knock, Who’s there? CPSA. CPSA who?
Hi all – I just can’t resist adding this example of Dr. Fong’s view of the world to this discussion on regulation – from the Preferential Access Inquiry transcripts with a little additional info I have in my files.
Page 2684-2687 – Transcript 19Feb. 2013 (Volume 32) Preferential Access Inquiry
Dr. Fong: “I’ve been in the public sector for a long time, and I have. . . you know, if you will, I’m sorry to say this, but I have an aversion for policy and procedures. We [Helios] are a very small shop. We don’t need policies and procedures. . . ”
Inquiry Counsel: ” Have you ever had any discussion with your doctors and the staff at Helios about what it means to be a patient advocate and where the lines are between advocacy and running afoul of the system?”
Dr. Fong:. “I have – – – as I mentioned earlier, I left the medical component to the doctors because they have ownership of the patients and their well being. So long as I’m not getting complaints, I don’t talk to anyone.”
Inquiry Counsel: “Have you. . . did you ever go over the CPSA regulation with them.”
Dr. Fong: “No”
Inquiry Counsel: “Was anyone within Helios in charge of making sure that nobody was outside of the regulation?”
Dr. Fong: “I do not know that. I’m actually embarrassed I don’t know what is the CPSA regulation.”
Inquiry Counsel: “It’s the College of Physicians and Surgeons of Alberta and their guidelines for advocacy and what doctors can do. Are you familiar with their guidelines?”
Dr. Fong: “No, I’m not familiar with that. As I may have explained to you before, when I was practising, I was a radiologist, I never practised family medicine.”
Note also (from my files) From 1996 to 2006 Dr. Fong was head of the Division of Radiology in the Faculty of Medicine and head of Clinical Radiology for the Calgary Health Region. He is one of the founding partners in Elliott Fong Wallace (EFW) Radiology Partnership (established in 1966) – one of three dominant radiology companies in Calgary http://www.efwrad.com/home/home.html which has enjoyed many lucrative contracts with the Region as well as FFS billings. He retired and left the Partnership in 2006/2007 at which time he was beginning to get Helios off the ground.
Dr. Fong was also instrumental in setting up the first private MRI in Canada in 1993 without worrying about the illegalities of it all.
Ignoring legislative restrictions (AHCIP), some influential Calgary businessmen and a consortium of 21 radiologists open the doors of Canada’s first private-pay MRI clinic – the Western Canada MRI Centre. [1] In a 1993 Canadian Medical Journal article, Dr. Chen Fong is identified as “the clinic’s initial medical director, one of its investors, and acting director of radiology at the Calgary’s Foothills Hospital” [2] Three weeks later, Shirley McClellan, the Minister of Health, gives hospitals permission to send patients to this investor-driven clinic and pay for these services out of hospital budgets.[3] The same Directive states that radiologists who charge either patients or third party insurers for MRIs beyond those MRIs contracted by hospitals “will not” be required to opt out of the Alberta Medicare Plan {AHCIP]“at this time.”
[1] MR Imaging Corp. was registered July 8, 1992. It becomes Canadian Diagnostic Centres in about 2002 and the partnership with EFW appears to end.
[2] (Janet Brooks, Canada’s first private MRI clinic: Does it signal a shift to two-tiered medicine?, Can Med Assoc J, October 15, 1993; page 1156, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1485489/pdf/cmaj00276-0105.pdf)
[3] Fearing runaway costs with this new and untested technology, the province restricted MRIs in 1990 to hospitals and refused to provide a fee-for-service code for radiologists in the community to offer these tests outside hospitals similar to the fee-for-service arrangements for traditional X-rays.
Wendy, this is a classic. Not only does the head of Helios (the private clinic that perfected the art of queue jumping) have an “aversion” to policies and procedures; he’s never heard of the CPSA standards because he’s a radiologist and not a family practitioner (who apparently doesn’t talk to anyone). I wonder if Dr Fong understands that ignorance of the law (or procedures) is no excuse, in fact it’s more damning. Wow.
It was truly breathtaking to watch Dr Fong’s testimony at the inquiry. Despite portraying himself as well intentioned, he presumably hoped that his personal charm could overcome his lack of attention to details……..and the very significant matter of his aversion to following standards and procedures!!
Well said Liz – and it gets even better Susan.
These same guidelines dealing with appropriate/inappropriate advocacy also apply to practicing radiologists and their decisions about who gets priority access to MRI and CT . And such decisions did come under scutiny in the Inquiry in relation to the hospital radiologist who provided a same-day MRI to triathelite Paula Findlay. I also have to say that Dr. Bill Anderson’s testimony of his investigation into the incident and his own personal/professional views on why “weekend warriors” (not just professional athletes) should get expedited access to radiology exams was more than a little disturbing. These views appeared to be based on some incredibly biased and flawed assumptions about how other people who injure themselves behave compared to those injured doing sports. My advice to friends: “Even if you injure a knee or hip by tripping on a curb or jumping off a truck, put on a pair of neoprene shorts and runners before heading to the ER.” What I found most troublesome though was how someone like Dr. Fong – with such a boldly stated lack of knowledge or interest – could be the “guy in charge” in both the Division of Clinical Radiology in the Faculty of Medicine and Calgary Region for so long.
The issues around physicians charging privately is that they are compensated by the province for care. Obviously no one should be compensated for a service that they are contracted to provide services by another entity for. That said, what if services are not being provided? The only reason that a business exists for private MRI’s is that the queue is too long publicly. Our present registrar of the college is maneuvering to shut down private MRI. They believe that a quicker diagnosis leads to quicker access. Technically this is true but the logic is perverse. Do we really believe that the public good is better served by slowing down the ability to understand your health? Yes, the poor can’t necessarily afford a private MRI but the wealthy will always be able to travel for it. It is the middle class that looses choice and speed of treatment. Are we really looking after the public good if we are limiting the ability of the middle class to understand their own health. Uggh, I think that’s a stretch. Either we dramatically increase health funding or we allow people the ability to control their own health fate. This is not a radical point of view it is consistent with our own Supreme Court’s ruling in Chaoulli.
Before we get militant, let’s consider if we have alternatives. Let’s consider that physicians net far less money than most people assume in fact they are generally netting meaningfully less money than those lawyers and working longer hours. Let’s consider that their life expectancies are lower than the population at large (stress perhaps?). Let’s consider that most of us claim that there are not enough of them and that we are having trouble finding them when we need them. We need to consider whether we can pay them more and make their job rewarding such that they can spend adequate time with us in an environment where health care is already 50% of most province’s budgets or alternatively whether we need to narrow the public system such that they are only dealing with the acute matters in a national health system and whether chronic issues and preventative issues etc that are not presently working well in the public system should be open to them providing services in a private manner. In fact if we agree with the latter, we need to become less militant with the college.
I’m just not at all sure that the stick is the most effective way to manage human beings. I doubt your physiotherapist’s dentist or waiter is interested in providing especially good care to her. I know her doctor will regardless but I really don’t know if her doctor will recommend the profession to students as really they only lose in public perception and they aren’t compensated adequately to deal with anything but routine care. I definitely know that your physician doesn’t want to hear from you if you have fibromyalgia. It would be nice if those people who suffer from chronic disease aren’t blocked from the option of paying for their own care as I doubt the rest of us are going to pay significantly more taxes and I don’t see why physicians are going to do work they are not compensated for when they are already at their limits.
Too bad the answer isn’t easy but please let’s not legislate and demonstrate away the ability and the tools of those around us to care for their own health.