The Health Professions Appeal and Review Board
confirmed a decision by the Inquiries, Complaints and Reports Committee (ICRC) of the College of Physicians and Surgeons of Ontario (CPSO) to advise a physician that his focus should be on clinical care and a sick child rather than on a clinic’s rules and procedures and a families perceived failure to follow those rules.
What Happened?
The physician in question worked at a Walk-in-Clinic. The mother who filed the complaint visited the clinic with her two daughters seeking medical attention for a respiratory infection that one of the girls was suffering from. The physician examined the child, prescribed antibiotics for suspected pneumonia and ordered chest x-rays. A follow up appointment was scheduled for the following day.
The next day, the mother went to the clinic on her own to obtain the test results. She was informed that because she had not brought her daughter with her, a $69 fee for a missed appointment would be charged. The mother explained that she was a single mom and her daughter was out of town visiting family. She inquired whether the child’s father could bring the child back to the clinic the next day. Another appointment was booked for 10:00am the following day.
The physician then met with the mother to provide the test results, which indicated that the daughter had pneumonia.
When the daughter and her father missed their scheduled 10:00am appointment the following day, the clinic called the Children’s Aid Society (CAS). The daughter and father eventually arrived at the clinic, the daughter was evaluated on an emergency basis, and was sent to the hospital where she remained for 24 hours.
The Complaint
The mother filed a complaint, alleging that the physician had behaved unprofessionally by:
- Failing to adequately explain the clinic’s missed appointment and cancellation procedures;
- Refusing to withdraw the $69 missed appointment charge; and
- Threatening to inform “Child Services” when the mother complained.
The Physician’s Response
The physician responded to the mother’s complaint claiming:
- The mother had understood the child’s treatment plan, which included an x-ray, antibiotics, and required a follow up visit within 24 hours;
- The mother was given a specific follow-up appointment time. If she knew the daughter would not be available at that time, she should have informed the clinic;
- On the initial visit, the mother had signed intake sheets which clearly explained the clinic’s policies. This information was also clearly indicated on the patient appointment cards as well as signs placed throughout the clinic;
- The mother was not initially charged the $69 fee for the missed appointment but was told that she would be charged if her daughter did not attend the next discussed appointment with the father;
- On the first follow-up visit, the physician had clearly explained that the x-ray confirmed pneumonia and that he wanted to physically examine the daughter by 10:00am the next day in order to provide instructions on symptoms;
- At no time during the initial follow-up visit did anyone at the clinic threaten to call CAS. Staff did call CAS when the daughter and father did not arrive for the scheduled appointment as the clinic has reasonable grounds to believe that the daughter was in need of protection given the failure to bring the child in for the requested appointment, the mother’s statements that the daughter’s symptoms were getting worse, the fact that the mother had not yet filled the child’ prescription, and the fact that the daughter was out of town visiting family;
- As soon as the daughter arrived at the end of the day, the physician arranged for her to be seen urgently by the on-call paediatrician.
The ICRC Decision
The ICRC observed that it was questionable whether it had been reasonable to have charged the mother with a missed appointment fee in the circumstances and was understandable that the mother may not have been expecting this to have occurred. Office records showed that “an altercation of sorts” had occurred when the mother attended the follow up appointment, and this altercation was largely due to the undue focus that the physician and his staff placed on procedures and rules to the detriment of patient care.
The Committee further emphasized that this type of “rigid and confrontational” approach creates circumstances in which conflict occurs and the ICRC expected “a more courteous and sensitive approach to patients and patient care” than that which was demonstrated by the physician and his staff.
The ICRC also found that the physician’s record in this case had been inadequate and his notes were extremely brief and illegible. The ICRC noted that this too showed that the physician placed far more focus on process and rules than the clinical care being provided. Overall, this was indicative of “the problematic manner in which the Applicant was running his practice”.
The Committee did note that it had been reasonable, in the circumstances, for the physician and his staff to contact the CAS with concerns about the child. The physician had a professional obligation to make a report to the CAS where he had concerns that a child was in need of protection, and there was no indication in the information before the ICRC that he had exercised his judgment inappropriately or for an unrelated motive or acted unprofessionally in this regard.
The ICRC ordered that the physician complete a specified continuing education or remediation program (SCERP) in medical record-keeping, and to undergo a reassessment in which an assessor selected by the CPSO would review 25 of his patient charts within 6 months of completing the SCERP.
The HPARB Review
The physician requested the HPARB review the ICRC decision.
The Board considered the reasonableness of the ICRC’s decision to advise the physician that his focus should be on clinical care and a sick child rather than clinical policies and procedures and a family’s failure to follow them.
The Board found that there was reasonable support for the ICRC’s finding that the altercation and tension that arose were largely attributable to this undue focus on procedures and rules. The Board further noted that while the physician’s primary concern was the child’s care, this was carried out in a manner that escalated the confrontation. Further, the ICRC’s concern about this rigid approach were reasonable, with the Board noting:
Approaches which fuel rather than defuse altercations in patient care settings, create additional stresses and are not conducive to positive patient care.
Overall, the Board found that there was support for the ICRC’s decision to advise the physician as they had, and that this advice had been reasonable.
The Board further noted that the physician’s overall complaint history supported a decision to require remedial action related to patient relations.
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