The establishment of trust between a physician and a patient can begin as early as when patients begin seeking care. A patient’s perception about whether a physician is accepting new patients in a manner that is fair and transparent can support the establishment of a trusting physician-patient relationship and foster trust in the profession.

The Accepting New Patients policy sets out physicians’ professional and legal obligations when accepting new patients and helps to ensure that decisions to accept new patients are equitable, transparent and non-discriminatory. This companion Advice document is intended to help physicians interpret their obligations as set out in the Accepting New Patients policy and provide guidance around how these obligations may be effectively discharged.

What’s the rationale behind the first-come, first-served approach?

The first-come, first-served approach helps to ensure that physicians fulfil their legal obligations under the Ontario Human Rights Code (the ‘Code’).¹ The Code entitles every Ontario resident to equal treatment with respect to services, goods and facilities, without regard to race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity, gender expression, age, marital status, family status or disability.

Under the Code, all those who provide services in Ontario, including physicians providing health services, must do so free from discrimination on any of the above-listed grounds. The first-come, first-served approach helps to ensure that all patients receive equal treatment with respect to health services.

Accepting new patients in a manner that is fair, transparent, and respectful of the rights, autonomy, dignity and diversity of all prospective patients reinforces public trust in the profession, and fosters confidence in the physician-patient relationship.

What does the College expect when patients want to change physicians within the same group practice?

In keeping with the principles of medical professionalism as set out in the Practices Guide and the spirit of the Accepting New Patients policy, it would be inappropriate for physicians to practice medicine in a manner that hindered patient autonomy and denied patients’ freedom of choice of health care provider. Practice policies that prohibit patient movement between physicians in the same practice group/team, may compromise a patient’s autonomy and ability to determine who provides their care.

If a patient requests a change, physicians are advised to discuss with the patient their reasons for seeking an alternative care provider and to make patients aware of circumstances where the structure of the practice (e.g. physician coverage arrangements) may necessitate care by and/or contact with their former physician.

The policy sets out specific instances whereby physicians must make decisions in “good faith”. What does this mean?

The term “good faith” is a legal term that means an intention to act in a manner that is honest and decent. In other words, the term may be characterized as a sincere intention to deal fairly with others.

For instance, physicians act in good faith by:

• closing their practice when it has reached capacity, not as a means of refusing patients who may be perceived as less desirable;
• assessing, in a fair and honest manner, whether their medical knowledge and clinical skills will meet a patient’s health care needs, and not using a lack of medical knowledge or clinical skills to unfairly refuse patients with, for instance, complex or chronic health needs; and
• prioritizing access to care because a patient truly has higher and/or complex health care needs, and not because a patient is perceived as “easy” and/or requiring less time or resources.

What should a physician do if they feel that treating patients with a history of prescription opioid use is legitimately outside of their clinical competence and/or scope of practice?

As stated in the Accepting New Patients policy, physicians, or those acting on their behalf, must not refuse patients because they have a history of prescribed opioid use. Such refusals may cause the patient harm. This may result in patients experiencing discrimination in the provision of care, even where this is not the intention of the physician, and/or may lead to the abrupt cessation of a patient’s medication. If a dose is not reduced gradually, it may cause the patient increased pain, decreased function or opioid withdrawal, which can be dangerous.

Physicians who feel that treating patients with a history of prescription opioid use is legitimately outside of their clinical competence and/or scope of practice are reminded of the following:

1. Prescribing narcotics and controlled substances is part of good clinical care, and refusing to prescribe these drugs altogether (e.g., through ‘no narcotics’ policies) may lead to inadequate management of some clinical problems and leave some patients without appropriate treatment.²
2. There are relevant resources that can assist in managing the care of patients with a history of prescription opioid use, including the ‘2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain’, and the ‘Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain’.
3. Where elements of a current patient’s care needs are legitimately outside of a physician’s clinical competence and/or scope of practice, the College requires that the patient be provided with a referral for those elements of care that the physician is unable to manage directly.

Physicians are further reminded that given the broad scope of practice of primary care physicians, there are few occasions where scope of practice would be an appropriate ground to refuse a prospective patient and determinations about whether a patient’s health care needs fall within their clinical competence and/or scope of practice must be made in good faith.

Where a practice is otherwise closed, the policy permits primary care physicians to prioritize the family members of current patients. How do I determine in what circumstances prioritizing patients’ family members is appropriate?

When determining whether to prioritize access to care for a current patient’s family member, physicians must take into account whether accepting that family member would reasonably assist in the provision of quality care. For instance, caring for the current patient’s spouse or partner, parent, child, and/or sibling may allow physicians to gain a clearer picture of family history.

It may also be appropriate for physicians to prioritize access to care for extended family members when doing so would reasonably assist in the provision of quality care. For instance, caring for family members who share a household and/or have the same hereditary health condition may contribute to better health outcomes.

How do wait-time targets for specialist consultations and surgeries that are set by the province fit with the first-come, first-served approach?

Physicians are permitted to depart from the first-come, first-served approach to accommodate patients requiring priority access to care. The College acknowledges that there are a number of factors, some of which are outside of a physician’s sole discretion, that determine when a patient is provided priority access to care. These factors include, for instance, wait-time targets set by the province for cancer consultations and surgeries.

Endnotes

^1. Human Rights Code, R.S.O. 1990, c. H.19.

^2. Please refer to the College’s Prescribing Drugs policy for expectations regarding the use of “no narcotics” prescribing policies.