September 2005

• To Dr. Chander Gupta on having received the Order of Manitoba award.
• To Dr. Krish Sethi, College Councillor, who has been designated Physician of the Year by the Manitoba Division of the College of Family Physicians of Canada. 
• To the 2005 MMA Awards Winners:
  • Dr. Oscar Domke – Physician of the Year Award
  • Dr. Henry Friesen – Distinguished Service Award
  • Dr. Philip Katz – Scholastic Award
  • Dr. Bruce Martin – Administrative Award
  • Dr. Gilles Pinette – Health or Safety Promotion Award
• To the following physicians who were inducted as Honorary Members of the Canadian Medical Association: Dr. Robert Abel, Dr. Victor Chernick and Dr. Peter Warner.
• To Dr. Rudy Danzinger, who received the Certificate of Merit Award from the Canadian Association of Medical Education at their Annual Meeting in 2005.
• To Dr. Estelle Simons, elected President of the American Academy of Allergy, Asthma and Immunology.
• To Drs. David Rush and Ken Van Ameyde, who were elected Clinicians of the Year 2004-2005 by the Graduating Class of Medicine.
• To Drs. Malek Kass and Suma Shastry who were elected the Resident Clinicians of the Year 2004-2005 by the Undergraduate Class.

1. By telephone:  772-4984 (same number as before)
2. By fax:  237-3468 (goes directly to Manitoba Pharma-ceutical Association), and
3. By e-mail:  mppp@mpha.mb.ca
   

	Q.	The last Disciplinary Report implied we must tell patients the results of all tests that we order.  Is this correct?
	A.	No.  The Code of Ethics requires that a patient has a right to know why a test is indicated and the right to know the results.  This can be accomplished without calling the patient with every test result. Some tests used to screen out disease can be dealt with by saying, “We will let you know if there is a problem with the results”. You must, of course, set up a mechanism to ensure that you do so.  Other tests clearly may be a source of anxiety to the patient who wishes to be advised regardless of the results.  You have two options.  You may undertake to advise all patients directly, or you may suggest that the patient follow up by contacting the office.  In the latter situation, you must put in place a notification for those with abnormal results who fail to call.  An example of such a test would be a biopsy.  In the case of consultations, your patients should know the reason for the consultation, what feedback to expect and from whom to expect it.  It is a standard of practice that patients have a right to know why a test is being done and the results. This standard has been reinforced by the courts and should be incorporated into practice. Publication in this newsletter does not create a new expectation.

1. The patient, (“X”), born in 1947, was a known diabetic. When Dr. Rich first saw X on October 25, 1999, his blood pressure was elevated (162/80) and his blood sugar was 17.6. Dr. Rich’s note includes: “Needs to look after his diabetes”.
2. X saw Dr. Rich on October 28, 1999, January 18, 2000 and March 12, 2000 for unrelated problems.  On March 22, 2000, X’s blood pressure was 140/75.
3. On August 8, 2000 X’s blood pressure was 150/80.  Diagnostic tests which were ordered that day showed a urea of 9.0 and a Hgb A1C of 8.4.
4. Dr. Rich discussed these results with X on October 10, 2000, and ordered further tests, which showed a creatinine of 205, urea of 10.5 and Hgb of 131.  On October 10, 2000, X’s blood pressure was 186/96.  Dr. Rich prescribed Monopril, at a dose of 10 – 20 mg PO od.  His note included: “confirm protein loss from diabetes” and his impression included “diabetes with hypertension and early renal problems”.  The record indicates that X was asked to return the next week.  X next attended on December 20, 2000.
5. On December 20, 2000 X’s blood pressure was 188/92 and Dr. Rich prescribed Hydrodiuril, 25 mg.  The note of X’s visit includes: “definitely has renal disease secondary to diabetes” and Dr. Rich’s impression includes: “diabetes with renal disease”.   The note indicates that X was asked to return in the new  year.   X next attended on February 14, 2001.
6. In February 2001, X developed retinopathy while on vacation. He sought out and consulted ophthalmologists in this regard.  At a February 14, 2001 visit,  X advised Dr. Rich that he had discontinued his medication while he was on vacation, and had just started it again.  His blood pressure was recorded as 178/93 – 169/96 – 168/88.
7.  X saw Dr. Rich for a series of appointments at which his blood pressure was recorded as follows:
   - February 21, 2001 - 170/92 - 172/86
   - March 13, 2001 - 154/82
   - April 14, 2001 - 180/90
   - August 3, 2001 - 164/88
   - September 10, 2001
8. On September 24, 2001, X’s blood pressure was 170/108. The note states that he went off all medication but insulin when the eye problems developed.  Congestive heart failure was noted at this visit and Dr. Rich prescribed Lasix.  Dr. Rich ordered tests which showed an elevated urea of 24.7.
9. On October 3, 2001, X’s blood pressure was 200/100 – 180/80.
10. Another doctor changed X’s medication to Vasotec on October 19, 2001.
11. On October 30, 2001, X’s blood pressure was 182/88. Dr. Rich prescribed Vasotec and Lasix.
12. On November 22, 2001, X’s blood pressure was 196/110 – 186/92 and Dr. Rich prescribed Vaseretic.  Dr. Rich ordered  tests, and results showed a creatinine of 812, Hgb of 86 and urea of 26.3.
13. On November 29, 2001, X’s blood pressure was 189/96 and Dr. Rich prescribed Altace.  The note includes “going towards renal failure” and Dr. Rich noted his intent to refer the patient to a nephrologist. 
14. By letter dated December 3, 2001, Dr. Rich referred X to a nephrologist.
15. X attended at the Nephrology Department of St. Boniface Hospital in January 2002, at which time he was diagnosed with end stage renal disease.
16. In response to the questions of testing at regular intervals and follow-up Dr. Rich stated that:
    1. his usual practice is to provide diabetes patients with a requisition for blood work that should be repeated at regular intervals for up to a year and he believes that he would have provided this to the patient.  There is no record that repeat testing was ever performed on the patient at the intervals requested.
    2. he had no system in place in his office to enable him to know whether a test that he ordered had in fact been completed and the results reported to him.  Consequently, he was unable to say whether the patient actually had repeat tests.
    3. his standard practice is to remind patients to attend for tests and he believes that he would have addressed that with the patient.
    4. he felt that the patient was non-compliant with his recommendations with respect to his own care.  However, he did acknowledge that he could have been more aggressive with him and could have referred him to a nephrologist sooner.
17. The consultant retained by the College opined that:
    1. X’s hypertension was not managed to acceptable standards.  He stated: “Follow up seems to have been quite frequent, but the increase in hypertension was not recognized to be possibly related to a decrease in renal function, as follow up renal function was not evaluated closely.  This despite the use of NSAID’s, and ACE inhibitors, which are known to affect renal function, the former of which may also increase blood pressure.”
    2. The consult with nephrology should have been initiated in October 2000. 
    3. It was inappropriate to prescribe NSAID’s without knowing X’s renal function, knowing that he had been a diabetic for some years.  Prescribing ACE inhibition, while very appropriate for hypertension in diabetes, was also not accompanied by close observation of kidney function. 

	a.	He failed to take adequate steps for follow up on X’s proteinuria and abnormal renal function.
	b.	He failed to aggressively manage X’s hypertension when he obviously had renal disease.
	c.	He prescribed medication known to possibly aggravate renal failure, but he did not closely monitor renal function.
	d.	He failed to maintain an adequate medical record with respect to his care of X.

	1.	The physician’s licence is suspended for a minimum period of six months.
	2.	The physician’s licence will remain suspended until he has undergone an assessment by an individual or program acceptable to the College, (herein “the assessor”) for the following purposes:

		i.	to establish an understanding of why the physician violated boundaries;
		ii.	to determine the risk of further boundary violations by the physician and what, if any, terms and conditions the assessor recommends should apply to the physician’s practice to minimize that risk;
		iii.	to determine what, if any, remediation plan the assessor recommends the physician should follow either before returning to practice or while he practices medicine.

		The assessment will proceed in accordance with the terms of the physician’s undertaking to the College, setting forth details of the process.
	3.	If the assessor opines that a problem exists such that the physician should undergo specified remediation before re-entering practice, the physician’s licence will remain suspended until such time as he has demonstrated to the satisfaction of the assessor that any such problem has been overcome.
	4.	If the assessor opines that a problem exists such that the physician should undergo specified remediation while he practises medicine, the physician’s licence will be issued subject to the term and condition that he comply with all aspects of the remediation plan stipulated by the assessor, within such time frame as may be fixed by the assessor.
	5.	If the assessor opines that a problem exists such that terms and conditions should apply to the physician’s practice of medicine to minimize the risk of further boundary violations, the physician’s licence will be issued subject to such terms and conditions.
	6. 7.	The physician will pay costs of $7,935.46 to the College on or before the date of the Inquiry.  There will be publication of the facts and disposition, which will not include the physician’s name.

	i.	deviation from the obligation of physicians to maintain appropriate boundaries.  X appears to have been much more emotionally vulnerable and fragile than the physician appreciated and, in any event, maintenance of appropriate boundaries is the responsibility of the physician.
	ii.	There was no evidence of conscious manipulation by the physician of X for his own needs.  However, the assessment of the physician’s personality and psychological adjustment will address the question of potential risk to the public of further boundary violations.
	iii.	The physician had no disciplinary history with the College.
	iv.	The physician took steps to obtain his own treatment under the care of a psychiatrist.
	v.	The physician was cooperative in the College investigation.
	vi.	Following the College involvement, the physician sought the advice of experts to assist him in addressing the matter, and accepted the advice of the experts in having a period of no contact with X.
	vii.	The physician and X have stated that they are in a committed personal relationship, and X is adamant that she makes no complaint with respect to the actions of the physician.

       The Investigation Committee emphasized that it was only prepared to recommend publication without the physician’s name because the Committee was persuaded that there was a serious potential of harm to the innocent children if the physician’s name was publicized.  The Investigation Committee also emphasized that this was based upon the peculiar facts of this case and is not intended to detract from its general policy of publication including the physician’s name.

• serious medical conditions,
• a history of life-threatening illness, or
• a history of refusal to seek appropriate health care services, all of which may put the family member at increased risk.  However, if the individual does not require rapid medical intervention (or delegated acts) to save life, limb, or function, it is not an emergency.

1. Dr. Janzen’s prescribing to a member of her immediate family (herein “X”) first came to the attention of the College after she issued a prescription which appeared to be for a very large amount of medication. The prescription was acknowledged to be an error.  In November, 2002, the Medical Consultant to the Manitoba Prescribing Practices Program stated to Dr. Janzen that it was inappropriate to prescribe this medication to a family member.
2. On May 8, 2003, in an interview with the Investigation Chair, Dr. Janzen acknowledged that she had permitted X to continue to obtain medication on the basis of refills of prescriptions issued by her.
3. On the point of prescribing the medication to a member of her immediate family, Dr. Janzen explained X’s multiple medical issues.  She stated that she researched the issue and determined that X should take a particular medication.  Dr. Janzen stated that she was unable to find another physician comfortable prescribing the medication to X for X’s particular symptoms, and so she began prescribing, and also began monitoring for side effects of the medication.
4. By letter dated May 14, 2003, Dr. Janzen stated that she would not prescribe for X or remain involved in X’s care.
5. DPIN searches revealed:
   1. Dr. Janzen first provided to X a prescription for this medication in June 2001, and continued prescribing this medication to X until 2003.
   2. In addition to the medication referred to above, Dr. Janzen wrote several other prescriptions for X, including sleeping aids.
   3.  X was continuing to obtain medication based upon refills of prescriptions signed by Dr. Janzen.
6.  On May 23, 2003, upon the direction of the Investigation Chair, Dr. Janzen cancelled refills of the prescriptions issued by her to X.
7. By letter dated July 4, 2003, Dr. Janzen stated that she and X were searching for a “suitable” family physician for X, which she defined to be one that understands the complexity of X’s medical conditions and is comfortable with prescribing and monitoring the medication she had initiated for X.
8. In response to the point that she was acting as X’s family physician, Dr. Janzen provided explanations for the other medications she had prescribed.  She stated that she had attempted to refer X to a specialist, but X had refused to attend.  Dr. Janzen attempted to characterize these services as emergency services, stating that X’s past history put X in a “life-long emergency state”.
9. A further DPIN check revealed that effective June, 2003, other physicians were issuing prescriptions for X.
10. Dr. Janzen later advised that, upon reflection, she acknowledged that the care provided to X was not emergent care within the meaning of that term in the Code of Conduct.

1. Dr. Janzen acknowledged having initiated medication for X in June 2001 and having initiated further medication for X in April 2002, and continued prescribing these medications or allowing X to obtain refills based on her authorizations until May 2003. 
2. When confronted with the fact that her prescriptions to X amounted to providing care to a family member beyond minor or emergency care, Dr. Janzen initially attempted to justify her actions by characterizing X as being in a “life-long emergency state”.  Later, upon reflection, she acknowledged that the care she was providing to X was not emergent care.

• in counter-signing prescriptions for American patients in violation of College Statement  805,
• in practising without ensuring that he had professional liability insurance coverage that extended to all areas of his practice as required by Regulation 25/03, 
• in failing to maintain medical records with respect to his counter-signing practice in breach of Article 29 of By-Law No. 1 of the College.

1. a documented patient evaluation by the Manitoba physician signing the prescription, including history and physical examination, adequate to establish the diagnosis for which the drug is being prescribed and identify underlying conditions and contra-indications;
2. sufficient direct dialogue between the Manitoba physician and patient regarding treatment options and the risks and benefits of treatment(s);
3. a review of the course and efficacy of treatment to assess therapeutic outcome, and
4.  maintenance of a contemporaneous medical record that is easily available to the Manitoba physician, the patient, and the patient’s other health care professionals.

1. In or about July 2003, Dr. Hoy entered an arrangement with a pharmacy that he would counter-sign prescriptions for American patients who were customers of that pharmacy.
2. Subsequently, he entered similar arrangements with at least thirteen additional pharmacies to counter-sign prescriptions for American patients who were the customers of those pharmacies.
3. Although the precise arrangements varied slightly from pharmacy to pharmacy, generally Dr. Hoy received from the pharmacy the patients’ prescriptions and patient information forms.   Dr. Hoy reviewed these documents and, if the prescription was acceptable to him, he counter-signed the prescriptions. 
4. Dr. Hoy had no direct patient contact with the patients before counter-signing the prescriptions.
5. Upon receipt of correspondence from the College questioning his counter-signing practice, Dr. Hoy ceased counter-signing using his Manitoba licence, but continued to counter-sign using his Nunavut license.  Dr. Hoy’s explanation for not immediately ceasing counter-signing or taking appropriate steps to ensure that the pharmacy did not use his counter-signed prescriptions for any renewals or refills was that:
   1. Based on advice from pharmacies, Dr. Hoy understood that this was justifiable given the “virtual” nature of the business.
   2. Dr. Hoy understood he was bound by contractual arrangements with one or more of the pharmacies to continue to counter-sign until a replacement physician was hired, and was faced with civil litigation if he did not meet this commitment.
6. In his response to the College, Dr. Hoy stated that:
   1. He was not aware of the College’s position on counter-signing prescriptions without direct patient contact until December 2003 when he received the College’s letter questioning his role in counter-signing prescriptions.  
   2.  For the reasons set forth above, he continued to counter-sign prescriptions using his Nunavut licence until mid-January 2004.  Dr. Hoy has not counter-signed prescriptions since that time.
   3. He had not seen the items published in the College newsletter respecting Statement 805.
   4. He acknowledged having breached Statement 805.
   5. He understands the College’s concern that counter-signing prescriptions without direct patient contact fails to meet an acceptable standard of care.
   6. On reflection, he accepts the validity of the College’s position, and accepts responsibility for his actions in failing to meet an acceptable standard of care when he counter-signed prescriptions without direct patient contact.
   7. At all material times he had CMPA coverage, and thought that this would provide him with liability coverage for counter-signing.  However, he made no inquiries of CMPA in this regard.   He now understands that CMPA is not prepared to provide coverage for counter-signing for American patients.
   8. Dr. Hoy has no medical records with respect to any of the patients for whom he counter-signed prescriptions, having either destroyed or returned to the respective pharmacies all of the material provided to him by the pharmacies.
   9. He has not counter-signed prescriptions since January 2004.

1. Counter-signing prescriptions for American patients in violation of Statement 805 of the College and in violation of the requirements of the Code of Conduct.
2. Practising without professional liability insurance coverage that extended to all areas of his practice in violation of Regulation 25/03.
3. Failing to maintain patient records in accordance with the requirements of By-Law No. 1 of the College.

• Friday, November 18, 2005
• Friday, March 17, 2006
• Friday, June 16, 2006. 

	President:	Dr. R. Graham
	President Elect:	Dr. H. Domke
	Past President:	Dr. M. Roy
	Treasurer:	Dr. B. MacKalski
	Investigation Chairman:	Dr. L. Antonissen
	Registrar:	Dr. W. Pope
	Deputy Registrar:	Dr. T. Babick
	Assistant Registrar:	Dr. A. Ziomek
	Assistant Registrar:	Ms. D. Kelly
	Chair of Council:	Dr. R. Graham

	Central Plains	Dr. L. Antonissen, Portage
	Interlake	Dr. C. Chapnick, Gimli
	Interlake	Dr. R. Graham, Selkirk
	Northman	Dr. K. Sethi, Flin Flon
	Parklands	Dr. D. O’Hagan, Ste.Rose
	Winnipeg	Dr. A. Alvi Dr. N. Goldberg Dr. J. James Dr. A. MacDiarmid Dr. S. Sharma Dr. R. Onotera         Dr. K. Saunders Dr. S. Sharma Dr. E. Stearns  Dr. R. Suss
	University of Manitoba	Dr. W. Fleisher
	Public Councillor	Mr. W. Shead
	Public Councillor	Ms. S. Hrynyk

	Brandon	Dr. B. MacKalski
	Eastman	Dr. B. Kowaluk, Oakbank
	Northman	Dr. N. Nwebube, Thompson
	Westman	Dr. S. Chapman, Neepawa
	Winnipeg	Dr. A. Arneja  Dr. H. Domke Dr. S. Kredentser Dr. R. Lotocki
	University of Manitoba	Dean D. Sandham
	Public Councillor	Mr. R. Toews
	Public Councillor	Mr. W. Crawford
	Clinical Assistant Register (expires 2006)	Mr. Y. Abdulrehman