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APPENDIX A
Selected CPSO Investigations
and Referrals to Discipline Statistics
APPENDIX A
Selected CPSO Investigations and Referral to Discipline Statistics
Table 1: Annual Data (1993 - 1997)
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APPENDIX A
Selected CPSO Investigations and Referrals to Discipline Statistics
Table 2: Five Year Summary (1993 - 1997)
| 1993 Carry-over Investigations | 1,777 | ||
| 1993 New Investigations | 2,165 | 1993 Investigations Referred to Discipline | 72 |
| 1994 New Investigations | 2,338 | 1994 Investigations Referred to Discipline | 7 |
| 1995 New Investigations | 2,396 | 1995 Investigations Referred to Discipline | 14 |
| 1996 New Investigations | 2,076 | 1996 Investigations Referred to Discipline | 34 |
| 1997 New Investigations | 1,444 | 1997 Investigations Referred to Discipline | 19 |
| Total Investigations | 12,196 | Total Investigations Referred to Discipline | 146 |
| Total Investigations Referred to discipline as a Percentage of Total Investigations | 1.2% |
APPENDIX A
Selected CPSO Investigations and Referrals to Discipline Statistics
Observations
1. The CPSO reports that roughly 2,200 new investigations are
commenced each year.
2. Investigations referred to discipline each year number in
the "tens" rather than the "hundreds". They average 29 per year.
3. The percentage of investigations referred to discipline is
extremely low (approximately 1%).
4. Not all referrals result in discipline. Hence, the number
and percentage of disciplinary actions (of any kind) taken by the CPSO
are even lower than those stated above.
5. The low rate of referral to discipline and disciplinary action
taken is inordinate. It is indicative of a systemic problem whereby
health professionals are not being held accountable.
6. The number of carryover investigations (not closed or referred
within two calendar years) is very high. In three out of five years,
carry-over investigations exceed the number of new investigations.
This points to a timeliness problem.
APPENDIX B
Kluge, Eike-Henner W., "Informed consent in a different key: physicians' practice profiles and the patient's right to know", Canadian Medical Association Journal, 4 May 1999, 160(9), 1321-1322.
APPENDIX B
Informed consent in a different key: physicians' practice profiles and the patient's right to know
Eike-Henner W. Kluge, PhD
CMAJ 1999;160:1321-2
Dr. Kluge is Professor and Chair, Department of Philosophy, University
of Victoria, and a member of the Minister's Advisory Committee on Ethical
Issues in Health Care, British Columbia Ministry of Health, Victoria, BC.
Reprint requests to: Dr. Eike-Henner W. Kluge, Department of Philosophy,
University of Victoria, Victoria BC V8W 3P4; fax 250 721-7511; ekluge@uvic.ca
© 1999 Canadian Medical Association
See also:
· Letter: Debating the patient's "right to know"
· Editorial: Reporting medical mistakes and misconduct
In 1997 the State of Massachusetts enacted legislation that makes the
practice profiles of its physicians available to the public. These profiles
include such information as the physicians' education, the honours and
awards they have received, their hospital affiliations and the insurance
plans with which they are affiliated. They also report whether successful
malpractice suits have been brought against the physicians, whether they
have received any criminal convictions and whether they have been the subject
of disciplinary actions by hospitals or medical officials within the last
10 years. The profiles do not list malpractice awards under appeal or complaints
that have never resulted in legal or disciplinary actions. These practice
profiles can be requested from a central clearing house and are then faxed
on demand. They are also available electronically on the Internet (www.docboard.org/ma/df/masearch.htm).
The law that allows the dissemination of this information is a trimmed-down
version of a proposal that would have required the disclosure of all complaints
and all malpractice claims, whether proven or not. Massachusetts is not
alone in having such a law. Several other US states have similar legislation,
including Arizona, California, Iowa, Ohio, Texas and Vermont.
Massachusetts is not Canada, and the physicianpatient relationship
here is not quite what it is in the United States. However, the Massachusetts
initiative raises an interesting question for this country. Should Canadian
provinces follow the lead of Massachusetts and adopt similar legislation?
The arguments in favour of doing so are powerful. They are based on
2 concepts central to Canadian medical practice: informed consent and public
accountability.
The informed-consent argument goes something like this: Informed consent
relates not only to a procedure or an intervention being offered to a patient
but also to the person offering it. Traditionally, informed consent has
been construed as having applicability beyond a specific procedure or intervention.
The Canadian Medical Association itself has stated on many occasions, the
last time being in 1990,1 that patients have a moral right to seek out
the physicians of their choice. However, patients cannot make an informed
choice if they know nothing about a prospective physician beyond the fact
that this person completed a medical degree at this or that university
or that he or she has acquired further specialist training.
Of course, patients could be guided by word of mouth. In fact, earlier
versions of the CMA Code of Ethics stated that word of mouth should be
the physician's only means of advertising. This approach may have been
effective when people lived in small communities and knew each other. In
those circumstances, it might well have yielded an accurate picture of
the abilities and practice patterns of a physician and might have been
sufficient to allow patients to make an informed choice about which physician
to see. However, in the modern urban environment word of mouth is an unrealistic
means of obtaining such information, because few people know each other
well enough to feel comfortable about sharing such sensitive information.
Furthermore, in our society both patients and physicians are highly mobile,
and word of mouth does not travel well from one city to another. Physicians
who have been disciplined or who have lost a malpractice suit in one locale
need merely move and set up shop in another to escape the effects of a
bad reputation. Public disclosure of practice records, as in Massachusetts
and many other US states, would address this problem.
Physicians cannot argue that, because no other profession is required
to disclose the practice profiles of its practitioners, the disclosure
of such information about physicians would be unfair and unjust. As a matter
of logic, the fact that the members of other professions do not have to
disclose their practice records does not establish that physicians should
not disclose theirs. At best, it demonstrates that other professions share
Canadian medicine's perspective on professional secrecy. The fact that
people agree on something demonstrates only that they agree. The correctness
of the subject of their agreement must be demonstrated on independent grounds.
On the subject of accountability, the other basis for arguments in
favour of public disclosure of practice profiles, it is relevant that medicine
is a service-provider monopoly, which puts it in a very special position.
Society confers monopolies not for the sake of the holders of those monopolies
but because it believes that only by restricting services in this fashion
will the interests of society be properly served. Therefore, the primary
consideration that should guide the relationship between the medical profession
and the rest of society is not the welfare of the individual practitioner
but the welfare of health care consumers and of society as a whole. In
this situation, physicians should reject the disclosure of practice profiles
only if such disclosure would make it impossible for physicians in general
to carry out their professional duties. The example of Massachusetts and
other US states makes clear that this is not the case. Disclosure may make
physicians practise more carefully, and it may even make it impossible
for certain practitioners to earn a living, yet that happens even now when
the provincial licensing bodies fulfil their mandate.
Then why not leave the issue up to the licensing bodies, given that
they are society's duly constituted watchdogs over the practice patterns
of the medical profession? Isn't it their role to make certain that the
welfare of patients is not threatened by incompetent physicians or by physicians
who have shown criminal or otherwise inappropriate tendencies? In other
words, isn't the public interest well served by the existing quality assurance
mechanisms?
To paraphrase a legal saying, proficiency and quality must not only
exist but must also be seen to exist. Canadian medical-licensing bodies
are staffed mainly by physicians. By and large, their operations are poorly
understood by the public. They may even function behind closed doors. All
of this fosters the perception that the licensing bodies tend to favour
physicians.2 This perception can be countered only by making all disciplinary
proceedings open to the public, by making sure the majority of members
on disciplinary bodies are non-physicians - or by making practice records
publicly available, as in Massachusetts.
Finally, there is the matter of trust. Physicians operate within a
fiduciary relationship with their patients. This entails more than a requirement
that they do the best they can for their patients. It also means that physicians
and patients should come together in an atmosphere of openness and mutual
trust. It may reasonably be asked whether such trust is possible when significant
information is withheld by either side. Physicians justifiably object when
patients withhold or falsify relevant medical information about their lifestyle
or habits and then expect to receive appropriate medical care. By the same
token, the practice profiles of physicians - their experiences, their background
and the like - reflect how they practise medicine and the quality of care
they provide. Therefore, this information is relevant for health care consumers.
In Reibl v. Hughes,3 the Supreme Court of Canada stated that a physician
has a duty to disclose, unasked, what the objective reasonable person in
the patient's position would want to know before agreeing (or refusing)
a particular medical intervention. Reibl v. Hughes did not deal with the
disclosure of practice profiles because that was not at issue. However,
would the objective reasonable person in the patient's position not want
to know whether her or his physician had been disciplined for inappropriate
or incompetent behaviour or had lost a malpractice suit? If the practice
profiles of physicians reflect their proficiency as practitioners, does
the logic of Reibl v. Hughes not support the disclosure of such information?
And, to take a more positive view, would a prospective patient not want
to be able to select a physician on the basis of past training and qualifications,
instead of mere word of mouth?
[Editor's note: The On_the_Net column (page 1353) provides addresses
for 9 Web sites in Canada and the US that provide information about individual
physicians.]
Competing interests: None declared.
References
1. Canadian Medical Association. Code of ethics. Ottawa:
The Association; 1990. Clause 5.
2. McPhedran M, Armstrong H, Edney R, Marshall P, Roach R, Long
B, et al. The final report of the Task Force on Sexual Abuse of Patients.
Toronto: College of Physicians and Surgeons of Ontario; 1991.
3. Reibl v. Hughes [1980] 2 SCR 880, 14 CCLT 1, 14 DLR(3d)1,
33 NR 361.
APPENDIX C
Belza, George S., "Professional Ethics - Self-Regulation: Physicians
and Surgeons", York University Centre for Practical Ethics, 1 August 1996
(updated to 1 May 1998), as edited by HPRAC for public examination on HPRAC's
website, www.HPRAC.org.
Referred by the Minister of Health to HPRAC for comprehensive consideration
as part of the RHPA Review.