May 25-26, 2017

Dr. Gary Smith Receives Council Award

Dr. W. Gary Smith, a nationally recognized authority on pediatric medicine, received a Council Award at the May Council Meeting.

In a career that has spanned almost 40 years, Dr. Smith has played a principal role in the development of a regional maternal, child and youth program in Orillia that today is an acknowledged centre of excellence for pediatric patient care, academics, research and training.

He has done this in his roles as a pediatric consultant, as Chief of Pediatric and Neonatal Medicine and the Family and Community Program Medical Director at Orillia Soldiers' Memorial Hospital, as a researcher, teacher, and in countless other leadership positions.  Along the way, Dr. Smith has firmly established himself as an expert in neonatal intensive care, pediatric asthma, diabetes and sports medicine.

"He is a builder," says Dr. Nancy Merrow, Chief of Staff at Orillia Soldiers' Memorial Hospital. "His patients and thousands of patients across the province have benefited from his contributions through his work and research. His colleagues have had a mentor and a reliable practice partner, and the hospital has had a visionary leader."

Opioid Strategy

Council has launched a wide-ranging strategy addressing the opioid crisis that puts public and patient safety at the forefront.

It has taken 20 years for the current crisis to develop and quick fixes and easy answers will not work. Council's strategy recognizes that resources, data, collaboration with different groups and a steadfast commitment to improved patient and public safety are necessary in order to prevail.

Council's strategy will see several of the College's key responsibilities — guidance of the profession, assessment and investigation — play significant roles to advance efforts to ensure appropriate prescribing.

The overall objectives of the College's opioid initiative are to:

• Facilitate safe and appropriate opioid prescribing by physicians to patients,
• Protect patient access to care, and
• Reduce risk to both patients and the public.

Key to this strategy's success will be providing physicians with the information and guidance they need. This will include updating our Prescribing Drugs policy to incorporate elements of the recently released Canadian Guideline for Opioids for Chronic Non-Cancer Pain. These guidelines address much more than just dosage amount; they also include guidance on tapering and what to do before initiating opioid therapy, such as ensuring the patient knows what to expect.

The strategy will also see the College continue focused methadone assessments via the methadone program and will work toward expanding the focus of assessments to opioid prescribing through the Quality Assurance Committee. To ensure that the College is able to consider all opioid issues within a quality assurance focus, Council directed, as part of the strategy discussion, that the role of the Methadone Committee be transitioned to a specialty panel of the Quality Assurance Committee. This change in governance structure provides the opportunity to better align assessments of methadone prescribers with the general approach of peer assessments for physicians. Changes to the current process will be phased in over time and communicated to prescribers and stakeholders prior to implementation.

The College will also continue to identify, investigate and monitor high-risk opioid prescribing. This work is underscored with the awareness that while investigations may identify instances of risk of harm to patients of continued prescribing, there is also a very real risk of harm to patients of discontinuing prescribing. In order to balance the risks in these situations, the goal of investigations is to support continued prescribing when it is appropriate and informed by guidelines. The College's preferred approach, when appropriate, is remediation.

The Minister of Health and the Chief Medical Officer of Health and Provincial Overdose Coordinator have asked us to send this letter with important information about opioids to all members. In addition to information about the new prescribing guidelines which we have already shared, they have also provided information about additional resources that are available or that will be available in future.

Dr. David Juurlink

The medical profession must seriously re-evaluate the role and limitations of opioids in the management of chronic non cancer pain if Canada has any hope of emerging from its public health epidemic, an expert on drug safety told Council.

"We need to re-think how we treat pain and how we treat people with addiction and if we do those things correctly, then hopefully we can prevent more people from losing their children," Dr. David Juurlink, a medical toxicologist from the Hospital for Sick Children, told Council during a meeting in which much of the agenda was devoted to discussions on the opioid crisis.

More than 20 years in the making, Canada's opioid crisis has been fueled by corporate interests, well-intentioned doctors, and patients with expectations for quick relief, said Dr. Juurlink. The absence of affordable alternatives to pain relief within the health-care system has only exacerbated the situation, he said.

"The culture around opioids today has been shaped by the pharmaceutical industry and its agents, and while these drugs have a place in the management of chronic pain, it is nothing like the one that they have enjoyed for the last 20 years," said Dr. Juurlink, who has trained as both a physician and a pharmacist.

The goal of prescribing pain medicine is to afford patients more benefit than harm. And yet, the benefits of opioids decline with time as the analgesia wanes due to tolerance, while the harms persist and even increase as patients are put on higher doses, he said.

He urged doctors to prescribe less readily and start fewer patients on opioids, keep doses low and prescribe sensible quantities after a surgical procedure. He also urged empathy for patients who are currently on high doses of opioids. "These are people whose lives revolve around their next dose ... you can't take them off suddenly, it's a very dangerous thing to do.  You need to engage in a very gradual taper. They didn't get to this point overnight — so treat it as a marathon not a sprint."

Preliminary Consultation Underway

The College's Confidentiality of Personal Health Information policy is currently under review. The policy sets out physicians' legal and professional obligation to protect the privacy and confidentiality of patients' personal health information. It also outlines the limited circumstances where the disclosure of personal health information without a patient's consent is permitted or required by law.

To assist with this review, we are inviting feedback from all stakeholders, including members of the medical profession, the public, health-system organizations and other health professionals on the current policy. Comments received during this preliminary consultation will assist the College in updating the policy. When a revised draft is developed, it will be recirculated for further comment before it is finalized by Council.

Two Policies Updated

Accepting New Patients and Ending the Physician-Patient Relationship

Council approved two updated policies that provide guidance on related issues of practice management — one on the acceptance of new patients into a practice, and the other detailing the considerations to be taken into account before deciding to end a physician-patient relationship.

The Accepting New Patients policy sets out physicians' professional and legal obligations when accepting new patients, and emphasizes that physicians must accept new patients in a fair and professional manner.

The updated policy:

• Retains the expectation that physicians accept new patients on a first-come, first-served basis.
• Clarifies that the first-come, first-served approach does not prevent physicians from determining when their practice is "closed" and not accepting new patients, as long as this is done in good faith.
• Clarifies that medical questionnaires and meet and greet appointments can only be used after a patient has been accepted into the physician's practice. Examples of appropriate use of such questionnaires and meetings include identifying a new patient's needs and expectations or determining whether the terms of the physician-patient relationship are acceptable to the patient.

The revised Ending the Physician-Patient Relationship policy retains much of the key content and many of the central principles of the former policy, but it has been substantively updated to further emphasize physicians' obligation to act in the best interest of their patients, and to provide more explicit guidance with respect to when it may or may not be appropriate to end the physician-patient relationship.

More specifically, the policy has been updated to:

• Emphasize that the policy applies equally to all physicians, including specialist physicians and those practising outside of primary care;
• Clarify that physicians must apply good clinical judgment and compassion in every case to determine the most appropriate course of action; and
• Always undertake reasonable efforts to resolve the situation affecting their ability to provide care in the best interest of the patient prior to ending the relationship (except where the patient poses a genuine risk of harm).

We have articles about both policies in the next issue of Dialogue.

Other News

MAID Update

At its May meeting, CPSO Council was updated on the passage of Bill 84 — Ontario's Medical Assistance in Dying Statute Law Amendment Act. The Bill, which came into force on May 10, 2017, aligns with federal MAID legislation and addresses areas relevant to MAID that fall under provincial jurisdiction. The CPSO will review Bill 84 carefully, and consider what changes may be required to the Medical Assistance in Dying policy to ensure consistency and alignment.

This letter from the Ministry of Health and Long-Term Care (MOHLTC) to all Ontario physicians provides an overview of Bill 84 and highlights revised MAID-related protocols that flow from this new legislation. These revised protocols include, but are not limited to, updated instruction on completing the Medical Certificate of Death for MAID patients and the establishment of a MAID Care Co-Ordination Service (CCS). Physicians who are interested in participating in the CCS are asked by the MOHLTC to complete the registration survey.

Compensation Committee

The Compensation Committee has been eliminated as a standing committee of Council. The Executive Committee will be assuming the tasks previously performed by the prior Compensation Committee in reviewing Registrar performance and compensation.