The College recently received correspondence from a regional hospital stating that from time to time patients without a family doctor are admitted to hospital, and that these patients, when not being admitted to a specialty service, are admitted to a member of the hospital’s family practice department. The question was asked whether that member of the family practice department has any responsibility for the ongoing outpatient management of such a patient on discharge from hospital.

In addressing the enquiry, the College noted that it was the College’s understanding that when referring to ongoing outpatient management, the hospital was referring to ongoing care concerning the condition for which the patient was admitted to the hospital.

The College would also note that similar circumstances may arise when a patient is seen by a family physician practicing in an emergency department or in a walk-in clinic, if the patient has no family doctor to follow the patient for ongoing patient management.

The College stated the view to the regional hospital that the College believed that an alleged failure to provide ongoing outpatient management, in the circumstances outlined above, might potentially give rise to an allegation of conduct deserving of sanction, under the Medical Act, 2005, against the family practice department member.

The College cautioned that it could only provide general advice on this issue, and that any particular allegation of conduct deserving of sanction received by the College would have to be considered and decided on its own facts.

Having said that, the College stated the view that members of the family practice department, who are aware that they are discharging a patient who does not have a family physician and who requires ongoing outpatient management, do have certain responsibilities to that patient. These responsibilities may not be simply deemed to terminate on discharge from hospital.

The College noted that Section 19 of the CMA Code of Ethics (2004 Update) states:

Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted; until another suitable physician has assumed responsibility for the patient; or until the patient has been given reasonable notice that you intend to terminate the relationship.

The College also noted that the College’s Guideline on Ending the Doctor-Patient Relationship may also have applicability to this type of situation.

The College stated that if the College were to receive an allegation from a discharged hospital patient that no or insufficient arrangements had been made for their ongoing post-discharge care, the College in the first instance would look to whether the applicable provisions of Section 19 of the CMA Code of Ethics and the College’s Guideline on Ending the Doctor-Patient Relationship had been followed. A key issue which would arise, from the scenario, presented to the College, is whether there had been “reasonable notice to terminate the relationship.” In the College’s view, what is “reasonable notice” cannot be established arbitrarily or without due consideration for the health and well-being of the patient.

The College advised that patients should be informed of reasonable limitations on the ongoing care that may be able to be provided by members of the hospital’s family practice department following discharge from hospital. However, the College cannot say that a notice to the patient, deeming a medical practitioner’s responsibility to come to an end upon discharge or after a certain period, when there is no likely prospect of the patient being followed for necessary ongoing out-patient management by another physician, would necessarily insulate a member of the family practice department from an allegation or finding of conduct deserving of sanction. Even if a patient’s express agreement was obtained to such a limitation on responsibility for outpatient management, the College would likely still have to consider whether any such agreement reflected the truly informed and voluntary consent of a patient.

The College recognizes the difficulty encountered by many patients in this province in obtaining family physicians, and the valuable service provided by hospital’s family practice departments to address that concern for patients admitted to hospital. However, the College would not feel comfortable in saying that the consequences of this difficulty in obtaining family physicians fall solely on these patients post-discharge. The College would recommend that hospitals work with the family practice departments to determine how their coverage may be extended to provision of necessary ongoing outpatient management for these patients.

The College also noted that a similar circumstance may arise when a patient is admitted to a specialist, if upon discharge from hospital that patient has no family doctor to follow the patient for ongoing outpatient management.

The College is not in a position to comment on the question of potential civil liability of family physicians or for specialists, who find themselves in the above situation. If this is of concern, the College can only suggest that this aspect of the matter be referred to the Canadian Medical Protective Association.

January 30, 2008 – 4:37 p.m.

Updated 2:50 p.m. – Feb. 4, 2008