Family Physicians with Focused Practices Must Ensure Patients Have Access to Primary Care
Family physicians (FPs) and general practitioners (GPs) are most often a patient’s first point of contact with the health care system and they are usually seen as the patient’s “medical quarterback”, managing a patient’s overall health care through prevention, diagnosis and treatment.
Some FPs and GPs, however, choose to focus their practice in a specific area of medicine – such as mental health, palliative care, obstetrics & maternal care, or complementary medicine – as opposed to carrying on a general practice in which they care for all parts of the body and all diseases for patients of all ages and genders. While the medical profession allows for physicians to follow a path of this nature, a decision of the Discipline Committee of the College of Physicians and Surgeons of Ontario (the “College”) from earlier this year makes it clear that there are certain obligations that must be met in order to comply with the standards of practice of the profession in these circumstances.
Specifically, all FPs and GPs who provide specialty care are required to ensure that their patients have access to proper primary health care.
The Discipline Committee found that a physician, who was a general practitioner with a special interest and additional training in environmental medicine, committed an act of professional misconduct by failing to maintain the standard of practice of the profession in respect of a young female patient (“Patient A”).
The physician, who had focused her practice on environmental medicine, saw and treated Patient A, who was 19 years old, at the request of her mother. Patient A’s mother reported that Patient A had experienced cognitive decline, seizures and mental health issues, including two previous suicide attempts and several prior hospitalisations. Patient A had previously been treated by another physician practising environmental medicine, which had led to considerable improvement. Over a period of several months, the physician administered a regime of IV Vitamins, treated Patient A with minerals and amino acids, and lowered Patient A’s thyroid medication in response to tests. One month after the patient’s last visit with her, the physician learned that Patient A had committed suicide.
A College investigation into the physician’s care of Patient A was initiated following the receipt of a report from the Office of the Chief Coroner about Patient A’s death.
The physician admitted that she had failed to meet the standard of practice of a general practitioner by failing to consider the patient’s needs as a whole. The physician had focused solely on Patient A’s chemical sensitivities, to the exclusion of Patient A’s mental health issues. Specifically, although the physician had proposed only to focus on Patient A’s environmental medicine needs, the Discipline Committee noted that the physician took no steps to investigate or treat Patient A’s psychiatric symptoms or seizures, to assist Patient A in finding a primary care physician or other specialist, or to refer Patient A to a psychiatrist, psychologist or other mental health professional.
The Discipline Committee ordered that the physician appear before it to be reprimanded and placed a number of terms conditions and limitations on her certificate of registration, including that she:
practice under supervision for one year and undergo a reassessment of her practice six to nine months after the completion of the supervision;
only see patients who are also under the care of a family physician or other appropriate specialist; and
pay to the College costs in the amount of $4,460.
The main lesson to take away from this decision is that FPs and GPs who are unable to provide care to a patient in a certain area, must refer that patient to another physician for assistance in that area. The requirement for concurrent primary health care is particularly important where general practitioners choose to specialize in one specific area of medicine.
This recommendation is applicable even where a physician is prepared to provide general primary care to patients but the patients see her only for a specific type of care. For example, the Medical Psychotherapy Association Canada has published Guidelines for the Practice of Psychotherapy by Physicians, which advises that “[i]t is preferable that in the role of family physician, physical medicine and psychotherapy not be combined because of the risks of misinterpretation of touch and examination.” The Association notes that this risk is significant due to the additional role of emotional intimacy and trust that is formed in a psychotherapeutic relationship. In our view, this risk can be mitigated by ensuring that physical examinations and psychotherapy not be undertaken at the same appointment. When both roles must be performed by the same physician, clear communication and policies are extremely important.In any case, if GPs or FPs restrict their practice to psychotherapy or any other type of care, it is imperative that they communicate this fact to their patients and refer their patients to another physician for primary care.
If you have questions about your professional obligations as a family physician or general practitioner who has a special interest or focused practice in a specific clinical area, please contact us for assistance.
