CMPA Perspective December 2014 - Cmpa

CMPA
THE RISK MANAGEMENT MAGAZINE OF THE CANADIAN MEDICAL PROTECTIVE ASSOCIATION
Perspective
VOLUME 6 | NO. 5
DECEMBER 2014
F E AT U R E Medico-legal aspects
of providing mental
healthcare to patients
WHAT’S INSIDE
HOSPITAL READMISSIONS
BACK PAIN
Discharge strategies
Diagnosis starting with the assessment
2015-2019 STRATEGIC PLAN
HOSPITAL-ACQUIRED INFECTIONS
CMPA responds to members’ evolving
medico-legal needs
Prevention, control are in everyone’s hands
A IS FOR ALIAS
Getting the right care
to the right patient
contents
DECEMBER/WINTER 2014
CMPA PERSPECTIVE, DECEMBER 2014
VOL. 6 NO. 5, P1405E
03 WHAT’S NEW
© The Canadian Medical Protective Association
2014 — All reproduction rights reserved.
Publications mail agreement number 40069188.
CMPA Perspective magazine is published
quarterly and is available in digital
format at cmpa-acpm.ca. A special edition
is also published annually.
Find out what the CMPA is doing to enhance its services and
help you practise medicine safely.
04 Medico-legal aspects of providing mental healthcare to patients
Providing care to patients experiencing mental health issues?
These risk management strategies are for you.
Ce document est aussi offert en français.
07 Reducing unplanned hospital readmissions
Address all correspondence to:
The Canadian Medical Protective Association
P.O. Box 8225, Station T, Ottawa, ON K1G 3H7
Telephone: 1-800-267-6522, 613-725-2000
(Monday to Friday, 8:30 a.m. to 4:30 p.m. ET)
Facsimile: 1-877-763-1300, 613-725-1300
Email: [email protected]
Website: cmpa-acpm.ca
Learn about discharge strategies to help reduce the risk
of unplanned hospital readmissions, unfavourable patient
outcomes, and medico-legal problems.
10 CMPA releases its 2015-2019 Strategic Plan
Discover how the Association will meet members’ medico-legal
needs in an evolving healthcare landscape.
The information contained in this publication
is for general educational purposes only and is
not intended to provide specific professional
medical or legal advice, or to constitute a
“standard of care” for Canadian healthcare
professionals. Your use of CMPA learning
resources is subject to the foregoing as well as
the complete disclaimer, which can be found
at cmpa-acpm.ca; enter the site and go to
“Terms of use“ at the bottom of the page.
12 Diagnosing back pain:
Keeping an open mind helps minimize risk
Read about the assessment issues that can impede your
diagnosis of back pain.
15 Lowering patients’ risk of hospital-acquired infections
Consider the risk reduction lessons from this review of CMPA
cases involving infections from healthcare.
18 A is for alias — Getting the right care to the right patient
Misidentifying a patient is a risk and can result in harm. Learn
how to lessen your exposure to potential problems.
2 CMPA PERSPECTIVE
December 2014
Explore:
cmpa-acpm.ca
Connect:
@cmpamembers
WHAT’S
NEW
From the CEO
Medical marijuana article updated
The CMPA has revised its online article about
medical marijuana to include the preliminary
guidance provided by the College of Family
Physicians of Canada (CFPC) regarding the
authorization of dried cannabis for chronic
pain or anxiety. The CFPC’s guidance centres
on 15 recommendations to help family
doctors when faced with requests for
medical marijuana.
Annual receipts available
online in January
This January, members will be notified by
email when their annual receipt is ready
to access. Members can then sign into the
members-only area of the CMPA website to
access their receipt.
You can prepare for this change by
providing us with your email address (call
1-800-267-6522). Also, if you haven’t already,
you can sign in to the members-only area
of the website with your member number
and password.
Mark your calendar for
CMPA CME events!
The 2015 calendar of member events is
now available on the CMPA website. Join
us for a safe care symposium or a regional
conference in your area.
CMPA Research Grant Recipients
CMPA research grants totalling almost
$200,000 were awarded to 4 researchers
in 2014.
The CMPA Grant Program provides funding
for research projects aimed at improving
patient safety and the quality of healthcare
for Canadians by enabling physicians to
practise more safely.
For a complete list of recipients,
visit cmpa-acpm.ca.
In November, the CMPA Council approved the Association’s renewed
2015-2019 Strategic Plan. This new Strategic Plan reaffirms our
two-fold commitment to providing high-quality advice, assistance,
and support to our members and to advance meaningful changes
that contribute to a safe and effective healthcare system.
A well-functioning healthcare system supports the availability of
safe medical care for all Canadians, and the provision of medical
liability protection is an essential component of such a system. The
CMPA has a long track record of meeting physicians’ medical liability
protection needs, allowing them to practice with the confidence that
their professional integrity will be protected, and the knowledge that
patients who have experienced proven harm from negligent medical
care will be appropriately compensated.
The CMPA understands the challenges our members face in a
dynamic healthcare environment and that we, like our members,
must adapt to changing times. While the new Strategic Plan builds
on over 110 years of success, it also embodies elements of change.
So, while we will continue to protect physicians’ medical liability
needs, we will offer supportive programs for those members who
need additional assistance reducing their risk. Preventing harm is the
best way to save lives and reduce costs and the CMPA is committed
to contributing to safe care.
We also recognize that, as with other elements of healthcare, the
medical liability system is under financial pressure. We will work with
others to address sustainability challenges so that physicians can
remain confident in their liability protection. This entails concerted
efforts to contain protection costs, including efforts to reduce system
costs that benefit neither injured patients nor their physicians.
I am very proud of this plan. It reaffirms our unwavering
commitment to protecting our members, and to enhancing our
contribution to the Canadian healthcare system. You can view the
full 2015-2019 Strategic Plan on our website at cmpa-acpm.ca.
Hartley Stern, MD, FRCSC, FACS
December 2014
CMPA PERSPECTIVE 3
Medico-legal
aspects of providing
mental healthcare
to patients
Hitch
The prevalence and impact of mental
health conditions are receiving
considerable attention. Family physicians,
psychiatrists, and other healthcare
providers play an important role in
caring for patients with mental health
conditions. As this area of medicine can
often intersect with the law, physicians
should be aware of the steps they can
take to manage the associated risks.
The CMPA experience
THE CMPA REVIEWED its legal and medical
regulatory authority (College) cases that closed
between 2009 and 2013 and found that 1,308
involved a patient with a mental health condition.
The most frequently identified types of medical
practice were psychiatry at 47% and family
practice at 42%. The top presenting
medical conditions were mood
disorders; neuroses; stress-related
and somatoform disorders; and
disorders due to substance use such
as alcohol, opioids, and cocaine.
Jupiterimages
Documentation (31%),
communication with patients (15%),
and patient evaluation (14%) were
the most common clinical issues related
to the care provided. These were followed
by medication issues such as managing patient
pharmacotherapy and physician prescribing
practices, and conduct issues such as the
blurring of the boundaries in the doctor-patient
relationship.
4 CMPA PERSPECTIVE
December 2014
Competent care
Doctors caring for patients with mental health
conditions should have the knowledge and
clinical competence to appropriately deliver
care. The skills include screening for and
detecting mental illness; initiating, monitoring,
or discontinuing treatment, when appropriate;
providing motivational interventions; supporting
self-management, as appropriate; and developing
links with other partners in care.1
Collaborative care
Patients are more likely to consult their family
physician about a mental health concern than
any other healthcare provider. Yet, no single
provider can be expected to have the knowledge
and skills to provide all the care patients may
require. When care is delivered in a collaborative
approach, the roles of all health providers should
be clearly defined, coordinated, complementary,
and responsive to the changing needs of
patients. Patients are a key component in their
care, understanding that the family doctor,
psychiatrist, or other providers will remain
involved. The patient, or the family, will need
to know at all times who the principal contact
should be when a particular problem arises.2
Ideally, psychiatrists and other providers
recognize and build on the care provided by
family physicians. Doctors are encouraged to
communicate with each other and with other
providers in a timely and appropriate manner.
This can mean integrating the mental healthcare
plans of psychiatrists with those of family
physicians or other providers, and ensuring that
all clinical activities are well coordinated for the
benefit of patients.3
When collaborating with other mental
health providers, physicians should consider
the following:4
ӹӹ effective communication, including clear and
timely information between themselves, other
health providers, patients, and families
ӹӹ consultation between and among other
physicians and mental health professionals,
whether in a primary care setting, a
mental health facility, a psychiatrist’s office,
or by telephone
ӹӹ coordinated care plans, including monitoring
and discharge plans, and clinical activities to
avoid duplication and to guide patients to the
appropriate programs or resources
ӹӹ integration of activities such as shared care
planning and decision making, with care being
shared according to the respective skills and
availability of participants
Patient assessment and diagnosis
It is important to carry out an adequate and
effective assessment of patients with mental
health conditions. This may include the need for
collateral information from the patient’s family,
when appropriate. To help make a diagnosis,
physicians may wish to consult appropriate
mental health screening tools, such as those for
depression, anxiety disorders, bipolar disorder,
and suicide risk. As a mental health condition
may rapidly change, appropriate and timely
re-evaluation may be required.
Appropriate prescribing
The use of psychotropic medication is on the
rise, and physicians should remain vigilant.
This is especially important in cases of off-label
prescribing or when prescribing medication
to children, youth, and seniors. At all times, a
consent discussion should be conducted and
documented in the patient’s medical record.
Moreover, physicians and other healthcare
providers should monitor patients who are
on medication.
Patient handovers
Patient handovers are high risk points in patient
care, and require the transfer of adequate
and correct information to support patient
safety and continuity of care. In hospitals, an
important issue to consider when treating
patients with mental health conditions is the
interaction between emergency physicians
and psychiatrists, and between day and night
psychiatrists, particularly in relation to patient
handovers. Physicians should follow the
institution’s protocols for handovers, including
the transfer of care related to consultations, as
well as responsibilities for patient monitoring,
treatment, and discharge decisions. And
handovers should be documented in the
medical record.
Effective and clear communication
between healthcare providers is also
essential to safe patient handovers in
community settings. When multiple
physicians and other healthcare
providers are involved in caring for
patients with mental health conditions,
providers should confirm that the reason for
the transfer of care is clear to all involved (for
example, family physician and psychiatrist).
Doctors and other providers should also verify
that the roles and responsibilities of each care
contributor are clear to the patient and family,
as well as to other members of the team.
Consent, privacy, and
other considerations
Physicians are always required to obtain
consent prior to non-emergent treatment.
Consent must be voluntary, patients must
have the capacity to consent, and they must be
properly informed by their doctors. Patients
who are suffering from mental incapacity may
still retain sufficient mental ability to give valid
consent for medical treatment. Much depends
on whether the patient is able to adequately
appreciate the nature of the condition, the
proposed treatment, its anticipated effect, the
alternatives, and the potential consequences
of treatment refusal. The laws applicable
in most provinces and territories provide a
means to obtain substitute consent when the
patient is incapable of giving valid consent by
reason of immaturity or incapacity. Finally,
the determinant of capacity in a minor has
become the extent to which the young person’s
physical, mental, and emotional development
will allow for a full appreciation of the nature
and consequences of the proposed treatment,
including the refusal of such treatments. In
December 2014
Thomas Northcut
Patients who
are suffering
from mental
incapacity
may still retain
sufficient
mental ability
to give valid
consent
for medical
treatment.
CMPA PERSPECTIVE 5
Québec, youth can provide consent for care if they
have the capacity and are 14 years of age or older.
Doctors should be familiar with the applicable
legislation in their jurisdiction.
On the privacy front, physicians are well-aware
that privacy and confidentiality of patient
information is critical. This is equally
important when considering mental
health information, and particularly
relevant due to the stigma that may
be associated with these conditions.
In terms of the release of mental
health patient information to third
parties, there are occasions when
a physician’s duty to society may
outweigh the obligation of physicianBeau Lark/Fuse
patient confidentiality, thereby justifying
the voluntary disclosure of information about
a patient to the appropriate authority. Facts such
as a clear risk to an identifiable person or group
of persons, the risk of serious bodily harm or
death, and whether the danger is imminent
should be considered in determining whether
information about a patient may be disclosed
without the individual’s consent. Physicians should
be knowledgeable about applicable legislation and
statutes regarding confidentiality and privacy. The
CMPA is available for advice in these matters.
Telepsychiatry
As telemedicine grows, more patients access
mental health services through interactive
videoconferencing, or telepsychiatry. Physicians
participating in telepsychiatry should be aware of the
salient regulatory, administrative, and clinical issues
associated with this form of healthcare delivery.5
These include matters of licensing, credentialing, and
jurisdiction; applicable College guidelines or policies;
and standards for videoconferencing systems.
Physicians should follow any established protocols
or procedures specific to each of the telepsychiatry
services offered. When orienting a patient to
telepsychiatry, consent for this mode of care delivery
should be obtained and documented in the medical
record. In addition, doctors should be attentive
to their communication styles and interactions
when using this form of healthcare delivery.
Issues of patient assessment, diagnosis, and care
planning remain just as important with interactive
videoconferencing as in face-to-face encounters.
6 CMPA PERSPECTIVE
December 2014
Risk management tips
The CMPA suggests all physicians
caring for patients with mental health
conditions consider the following risk
management tips:
ӹӹ Consider whether the patient should be
assessed before treatment decisions are
made or before medication is prescribed.
ӹӹ Obtain a thorough medical history that
includes risk factors (e.g. medications,
suicide risk assessment), family history,
and collateral information (e.g. medical
records, speaking with family) to obtain a
comprehensive assessment of the patient.
A deficient evaluation can contribute
to potential underestimation of the risk
for self-harm or harm to others, and the
inappropriate prescription or tapering
of medications.
ӹӹ Obtain informed consent for all nonemergent treatment, including when
using electronic communication channels
to deliver care, such as telepsychiatry.
ӹӹ Document comprehensively, clearly, and
at the time of patient contact. When
appropriate, documentation should
include a clear diagnosis and treatment
plan. Medication records should contain
justification for any changes made to the
patient’s medication regime.
ӹӹ Communicate to the patient, and family
when appropriate, any treatment changes
or potential side effects and adverse
reaction to prescription medications.
ӹӹ Communicate openly, sensitively,
respectfully, and professionally with the
patient and family. n
1. College of Family Physicians of Canada, Canadian Psychiatric Association, “The
evolution of collaborative mental health care in Canada: A shared vision for the
future,” Canadian Journal of Psychiatry (2011) Vol. 56 No. 5
2. Canadian Psychiatric Association, College of Family Physicians of Canada, “Shared
mental health care in Canada: Current status, commentary and recommendations,”
December 2000. Accessed on June 10, 2014 from:
http://www.cfpc.ca/uploadedFiles/Directories/_PDFs/sharedmentalcare.pdf
3. College of Family Physicians of Canada, Canadian Psychiatric Association, “The
evolution of collaborative mental health care in Canada: A shared vision for the
future,” Canadian Journal of Psychiatry (2011) Vol. 56 No. 5
4.Ibid
5. Shore, Jay H., “Telepsychiatry: Videoconferencing in the delivery of psychiatric
care,” American Journal of Psychiatry (2013) Vol. 170 No. 3. Accessed on July 25,
2014 from: http://ajp.psychiatryonline.org/article.aspx?articleID=1655117
Reducing
unplanned
hospital
readmissions
Readmissions continue to be a focus
of quality improvement initiatives
in Canada and internationally
because they place such a strain on
healthcare systems. But preventable
readmissions also have serious
implications for patients, physicians,
and healthcare providers caring for
them. According to the Canadian
Institute for Health Information,
nearly 8.5% of patients in Canada
are readmitted to an acute care
hospital within a month of
their initial discharge.1
TongRo Images
T
HE CMPA IDENTIFIED 75 medico-legal
cases that closed between 2009 and 2013
involving inadequate discharge planning —
of which the vast majority led to an unplanned
readmission. In these cases, discharge planning
included assessing the patient to determine
whether they were fit for discharge, making
appropriate arrangements for continuing medical
care, and providing the patient with clear written
or verbal follow-up instructions including
information on when and who to contact, and
where best to seek medical attention.
Nearly two-thirds of readmissions occurred
after a surgical intervention, while the rest were
after hospitalization for a medical, obstetric, or
psychiatric condition.
Post-surgical readmissions
Most readmissions in surgical care followed
same-day or overnight-stay gastro-intestinal,
gynecologic, orthopaedic, and urologic surgeries.
The majority of patients were readmitted
within a week of discharge, most often the next
day. These patients usually required additional
surgery or intensive care. A small number of
patients died from their complications.
Most readmissions
in surgical care
followed same-day
or overnight-stay
gastro-intestinal,
gynecologic,
orthopaedic, and
urologic surgeries.
Readmissions were largely due to surgical
complications being recognized late. When
peer experts reviewed the care, they identified
premature discharge as a common theme,
and various risk factors, including difficult
surgery, unstable vital signs, ongoing pain, or
co-morbidities that would have necessitated
a longer period of observation. Premature
discharge was often attributed to physicians
not re-assessing the patient before discharge or
nursing not communicating their concerns about
a patient’s condition. In a few cases, physicians
failed to review post-operative investigations that
they had ordered.
In a considerable number of cases, ineffective
discharge planning, including inadequate
follow-up and suboptimal transitions of care,
was the main driver for readmission. Underlying
all of these cases was poor communication
— between physicians; between nurses and
physicians; and between physicians and patients.
Miscommunication between physicians and
patients most often involved the discharge
discussion and included not advising patients of
the symptoms and signs that would alert them to
seek medical attention, and when and where to
access that care.
December 2014
CMPA PERSPECTIVE 7
Non-surgical readmissions
Most of the patients in non-surgical cases
were readmitted within 10 days of discharge.
Patients were sometimes found to have been
discharged before their medical condition
had been completely addressed, or were
readmitted because the underlying condition
had continued or progressed, which most
often included infections and cancers.
Expert review
identified
two main
problem areas
in these cases:
follow-up of
investigations
and discharge
planning.
8 CMPA PERSPECTIVE
Expert review identified two main
problem areas in these cases: follow-up
of investigations and discharge planning.
Overlooked test results were often significant
and should have been acted on. In some
cases where medical trainees were involved
in the discharge, the experts were critical of
attending physicians who did not personally
review the medical record or assess the
patient. When examining discharge
planning, the experts were critical of poor
coordination of home care, particularly
for patients with multiple health issues or
who were not considered safe or ready for
discharge.
Two cases illustrate these findings. The
first demonstrates the consequences of a
premature patient discharge following day
surgery and highlights the importance
of effective communication between a
nurse and a physician about a change in
a patient’s condition. The second shows
the repercussions of inadequate discharge
planning and coordination of care.
CASE 1: PREMATURE DISCHARGE,
LACK OF COMMUNICATION
During a laparoscopic right salpingooophorectomy on a 35-year-old woman, a
gynecologist encounters difficulty and removes
a large ovarian cyst by posterior colpotomy.
After the surgery, the patient requires oxygen
to maintain appropriate oxygen saturation.
She is admitted overnight, but the nurse does
not notify the most responsible physician.
Throughout the night, the patient develops a
fever and continues to require supplemental
oxygen. Early the next morning, the patient
complains of severe abdominal pain and is
unable to void. Another gynecologic resident on
the team does not assess the patient but verbally
prescribes a parasympathomimetic to stimulate
urination. Throughout the morning, the patient
is febrile, hypotensive, and tachycardic. She
eventually voids and is discharged later that
morning without being reassessed by the team.
Three days later, the patient presents to the
emergency department in early stages of septic
shock. Her white blood count is elevated, and
an abdominal CT scan shows findings consistent
with bowel perforation. She undergoes a
Hartmann procedure with colostomy for a rectal
tear. Her post-operative course is complicated
by hemorrhage, abdominal and pelvic abscesses,
prolonged ventilation, and pulmonary embolism.
A legal action ensues. The main experts’
criticism is that the patient should not have
been discharged, as earlier diagnosis of the
Ingram Publishing
December 2014
CASE 2: INADEQUATE DISCHARGE
PLANNING AND CARE COORDINATION
A family physician (FP) prescribes antivirals and
antibiotics for a hospitalized elderly woman
with facial herpes zoster and associated
cellulitis. The patient has multiple co-morbidities
including diabetes mellitus, atrial fibrillation, and
severe chronic obstructive pulmonary disease
requiring oxygen supplementation. The patient’s
condition improves three weeks later, and the FP
discontinues the antivirals. The FP meets with her
family to plan her discharge for the Sunday. The
patient is transferred home, but home oxygen
is not set up, medications are not sent with
her, and home care services are not arranged.
The patient’s condition declines, and she is
readmitted a few days later.
A regulatory authority (College) complaint
follows. The investigative committee reminds the
family physician to make plans for discharging
patients as far in advance as possible.
Ryam McVay
rectal tear would likely have been made and
led to a less complicated post-operative course.
Defence experts were also critical of the nurses
for not advising the gynecologist of the patient’s
abnormal vital signs in the hours following
surgery, and of the resident for prescribing
without formally assessing the patient. This failed
communication resulted in missed opportunities
to reassess the patient. Without expert support,
a settlement is paid to the patient, shared by the
CMPA and the hospital.
Strategies to reduce readmissions
Many readmissions identified in the analysis of CMPA
cases may have been avoided had different actions
been taken before the patient’s discharge. The
following strategies are based on expert opinions in the
cases analyzed:
ӹӹ Review pertinent clinical documentation, test results,
and consultation reports before discharging patients.
ӹӹ Consider reassessing patients, as required, before
discharging them.
ӹӹ Use multidisciplinary teams to assess patients’ home
care requirements, when appropriate.
ӹӹ If another physician assumes care after discharge,
provide pertinent information in a timely manner,
such as patients’ clinical condition and treatment plan.
ӹӹ Reconcile patients’ medications before discharge.
ӹӹ Consider using a structured communication
tool, including a discharge summary, for sharing
information during transitions of care.
ӹӹ Provide clear written and verbal discharge instructions
to your patients or their caregivers, including
symptoms and signs that should alert them to seek
further medical attention and where to find that care.
ӹӹ Ensure follow-up care is arranged and advise your
patients who will be providing this care.
ADDITIONAL READING
AT cmpa-acpm.ca
“CMPA Good Practices Guide “
“Discharging patients following day surgery”
“How effective management of test results
improves patient safety”
“The most responsible physician: A key link in
the coordination of care”
“The post-operative period —
Patient discharge and follow-up”
ӹӹ Verify that the roles and responsibilities of each
physician are clear to patients and to the other
physicians and healthcare providers. In Québec,
discharge instructions to patients must include the
contact information for the team that provided
the care.2
ӹӹ Document your discharge instructions in the
medical record. n
1. Canadian Institute for Health Information, “All-Cause Readmission to Acute Care and Return to the
Emergency Department” Ottawa, Ont.: CIHI, 2012
2. Collège des médecins du Québec, Procédures et interventions en milieu extrahospitalier, Guide d’exercice
du Collège des médecins du Québec, August 2011, Accessed November 2014 from :
http://www.cmq.org/fr/Public/Profil/Commun/AProposOrdre/Publications/%7E/media/Files/Guides/
Guide-Procedures-Interventions-ExtraHosp-2011.ashx?11229
December 2014
CMPA PERSPECTIVE 9
BUILDING ON A STRONG FOUNDATION —
CMPA releases its 2015–2019
Strategic Plan
The CMPA Council recently approved the Association’s renewed 2015-2019
Strategic Plan. The plan builds on the Association’s strong foundation of success
to ensure it can meet the evolving medical liability protection needs of members
in an increasingly complex and cost-constrained healthcare environment.
W
ITH THIS PLAN, the Association
reaffirms its commitment to provide
high-quality advice, assistance,
and support to members facing medico-legal
difficulties. This core commitment has enabled
physicians to confidently care for their patients
for more than a century knowing the CMPA
will protect their medical liability interests.
ӹӹ
While several countries have experienced the
breakdown of their medical liability system,
Canada has benefited from the CMPA’s
effective medical liability model that supports
the delivery of safe care while ensuring that
physicians are protected and patients who
have experienced harm are appropriately
compensated. The provision of cost-effective
protection in Canada has never been more
important. With this in mind, the 2015-2019
Strategic Plan focuses on three strategic
outcomes: assisting physicians, contributing to
safe medical care, and supporting an effective
and sustainable medical liability system.
A strong focus on physician assistance,
safe medical care, and the medical liability
system
10 CMPA PERSPECTIVE
Assisting physicians
At the heart of the plan is CMPA’s continuing
commitment to assist physicians facing medicolegal issues by providing timely and accurate
advice and, if required, legal assistance. As
always, in the event a patient has been harmed
by negligent medical care, the CMPA provides
appropriate compensation on the physician’s
behalf. The CMPA will also continue to assist in
reducing medical liability risk and promoting safe
care by educating physicians about appropriate
prevention strategies and responses to harm.
These core activities have protected members’
professional integrity, allowing them to practise
with confidence since 1901.
An effective medical liability system must be
sustainable in the short and longer term. The
CMPA will enhance its management of medical
liability cases by seeking earlier case resolution
and employing the most appropriate approach
to achieve a fair and timely result. For members
whose medical liability experience is more
extensive than their colleagues, the Association
will work to provide access to services to help
them meet their professional obligations. In
keeping with the core value of mutuality,
members are expected to be responsive to
the Association’s efforts to assist them, and to
practise in a manner consistent with the values of
the medical profession.
Contributing to safe medical care
Effective risk and harm reduction requires a
strong commitment from physicians and other
healthcare providers. Knowing their medical
liability interests are protected, physicians can be
confident in making this important commitment.
December 2014
OUR MISSION: To protect physicians’ professional integrity and promote
safe medical care in Canada
The Association recognizes physicians
practise within a system of care and system
level improvements are essential in ensuring
Canadians have access to safe and effective
care. The CMPA will continue to actively
collaborate with other organizations to
identify high-risk medical practices and to
develop and champion harm prevention
strategies. This includes a focused approach
on clinical issues and practices where the risk
of harm is relatively high.
Supporting the medical liability system
An effective and sustainable medical liability
system not only ensures physicians are
available to provide care; it is an essential
element of a well-functioning healthcare
environment. The CMPA is committed to
working with others to address sustainability
challenges, including championing sensible
reforms that reduce overall system costs.
For example, the Association will actively
advocate for civil justice, regulatory, and
administrative reforms that enhance the
financial sustainability of the medical liability
system while protecting the interests of
all parties involved. We will also support
policy initiatives that contribute to resolving
medical liability issues in a fair and timely
manner, including measures that eliminate
unnecessary costs and streamline processes.
ӹӹ
Physicians practise within a system of care and
system level enhancements are essential in ensuring
Canadians have access to safe and effective care.
The CMPA is also committed to
strengthening its operational and
governance practices to achieve optimal
results, including providing members
with improved fee predictability. We
will continue to engender member and
stakeholder trust by reporting performance
and financial results in a transparent and
responsible manner.
Positioning the CMPA for success
The achievement of this plan depends
on the CMPA’s continued ability to
respond to the evolving needs of its
over 90,000 members.
ӹӹ
The CMPA has a strong five-year plan.
Through its ongoing focus on assisting
physicians, contributing to safe medical
care, and supporting the medical liability
system, the CMPA is well positioned to
continue to fulfill its mission: To protect
physicians’ professional integrity and
promote safe medical care in Canada. n
While retaining
our core services,
we must adapt
to ensure we can
deliver sustainable
medical liability
protection well
into the future.
Marcio Siloa
Interested in CMPA Council positions for 2015?
The 2015 Report of the Nominating Committee
will be available on the CMPA’s website as
of February 25th, 2015. Its release will mark
the start of the nominations process from the
CMPA membership.
In addition to the slate of candidates proposed
by the Nominating Committee, all CMPA
members in an area and division with an
open position in 2015 have the opportunity
to seek election to the CMPA Council. An
eligible member nomination will result in the
requirement for an election.
Members interested in being nominated
as candidates for election to Council are
invited to review the Candidate information
guide. Additional information can be found
at cmpa-acpm.ca, or by contacting the
Association at 1-800-267-6522 or emailing
[email protected].
December 2014
CMPA PERSPECTIVE 11
Diagnosing back pain:
Keeping an open mind
helps minimize risk
Back pain is often a diagnostic dilemma that goes
unresolved. While it is one of the most common
reasons Canadians seek care1,2 studies have found
that most of the time no physiologic cause for
the pain is established.3 This is because many
conditions that cause back pain are self-limited
and improve without treatment. On rare occasions,
however, serious conditions present with back pain
as a primary symptom. Failing to properly assess
patients with back pain and effectively rule out
these diagnoses can lead to serious outcomes.
T
Sebastian Kaulitzki
Ordering imaging for patients with
uncomplicated back pain is typically
not effective and may cause harm.4
That is why campaigns aimed
at reducing unnecessary testing
and treatment, such as Choosing
Wisely (choosingwiselycanada.org),
recommend against imaging for new
cases of back pain in most patients
who are not experiencing “red
flag” symptoms or signs.5 Canadian
and international clinical practice
guidelines describe evidencebased conservative approaches to
managing back pain.
12 CMPA PERSPECTIVE
December 2014
HE CMPA ANALYZED MEDICO-LEGAL CASES, closed
between 2008 and 2013, that involved a patient with a
primary complaint of back pain and documented peer
expert criticism of the diagnostic assessment. The most common
missed diagnosis was cauda equina syndrome — neurological
impairment that results from compression of the nerve roots
in the spinal canal below the termination of the spinal cord.
This condition, which has many potential causes, including disc
herniation, spinal stenosis, and lesions, requires urgent surgery
to prevent lasting damage.
Other missed back conditions included vertebral fracture and
other spinal pathologies. Non-spinal conditions that presented
with back pain included renal disease; malignancies such as
lymphoma and bone metastases; cardiovascular events (most
often dissecting abdominal aortic aneurysm [AAA]); and
infections, such as epidural abscess, discitis, or osteomyelitis.
Frequently, experts attributed the missed diagnosis to the
physician’s failure to appreciate the significance of the patient’s
presentation. This included missing red flags, such as fever,
weight loss, neurological symptoms, or certain characteristics of
the pain. There were also situations of physicians not following
up on abnormal laboratory findings, such as an elevated white
cell count or erythrocyte sedimentation rate. In some cases,
physicians were criticized for not re-evaluating patients who
returned with pain that persisted, progressed, or did not respond
to treatment as expected.
CASE 1: FAILING TO RECOGNIZE RED FLAGS LEADS TO CAUDA EQUINA SYNDROME
An orthopaedic surgeon refers his patient,
a 28-year-old woman with long-standing
sciatica, to a neurosurgeon, after MRI shows a
worsening of her lumbar disc protrusion (right
L5–S1) and spinal stenosis. The appointment is
made for a few months later, but the patient
visits the emergency department (ED) the
following week with severe right leg pain with
weakness and urinary urgency.
The ED physician performs a neurological exam
and finds only an absent right deep tendon
knee reflex and some diminished muscle
strength of the right extensor hallucis longus.
She diagnoses acute multi-level radiculopathy
with motor impairment. She admits the
patient to hospital under the care of her family
physician (FP), who is notified by telephone of
her condition.
The FP refers the patient to an anesthesiologist
for pain management with epidural steroid
injections. When the anesthesiologist
examines the patient before administering the
injection, he notes loss of sensation in her right
lateral lower leg with weakness and diminished
knee reflex. He administers the injection, and
the patient is discharged the next day. At a
follow-up appointment with her FP a few days
later, the patient reports an episode of urinary
incontinence. The physician advises her to go
immediately to the nearest tertiary hospital ED
to be assessed by a neurosurgeon. The patient
undergoes an emergency laminectomy and
decompression for cauda equina syndrome;
however, she is left with permanent neurological
deficits including bladder and bowel dysfunction.
The patient files a legal action against all
physicians involved in her care. Experts are critical
that the FP did not urgently refer the patient to
a neurosurgeon when she was first admitted
through the ED, and that the anesthesiologist
did not appreciate the severity of the patient’s
symptoms when he examined her.
Many cases involved incidents of physicians
not fully considering elements of patients’
history or co-morbidities that might put
them at risk for a serious outcome. In a few
cases vascular causes of back pain, such as
a dissecting AAA, were not included in the
moodboard
differential diagnosis for patients with obvious
risk factors. Conversely, other cases involved
physicians who mistakenly attributed a
patient’s symptoms to a past or pre-existing
condition, thereby failing to consider other
differential diagnoses.
CASE 2: ANCHORING DELAYS MALIGNANCY DIAGNOSIS
A 14-year-old boy visits the ED complaining of
back spasms and continuing back pain since
participating in a mountain bike race one week
earlier. He has already visited a chiropractor and
physiotherapist, and he is taking an NSAID and
muscle relaxant prescribed by his FP, all with
no improvement.
On examination, the ED physician notes
dorsolumbar spasms, no tenderness, and no
masses. When asked, the patient denies having
bladder or bowel problems. The physician
diagnoses severe muscle spasms and orders
an analgesic and muscle relaxant. When he
assesses the patient 30 minutes after receiving
the medications, his pain is gone, and he is
discharged with instructions to follow up with his
FP in the morning.
The next day the patient has difficulty walking
and visits another physician, who promptly
refers him to the children’s hospital after
a neurological exam finds pronounced leg
weakness. The patient is ultimately diagnosed
with anaplastic large cell lymphoma at T8–T10
and undergoes treatment.
A legal action is filed against the ED
physician. Experts are critical that he did not
perform a complete neurological assessment
or ask the patient about symptoms of
numbness or weakness.
Mario Teijeiro
December 2014
CMPA PERSPECTIVE 13
Inappropriate prescribing of narcotics for pain control
was commonly associated with diagnostic issues. In
some of these cases, the use of narcotics was central
when the drugs contributed to addiction or related to
serious patient outcomes. In others, their use obscured
the progression of neurological symptoms making
diagnosis more difficult.
Cognitive biases such as attribution error (a form
of stereotyping: explaining a patient’s condition on
the basis of their disposition or character rather
than seeking a valid medical explanation) may have
contributed to the inadequate assessment of a patient’s
back pain, particularly in cases where physicians were
found to be too quick to fix on a particular diagnosis,
or conclude that a patient was malingering. In a few
cases epidural abscesses were missed in patients with a
history of drug addiction, despite their representing a
high-risk group for this complication.
ADDITIONAL READING AT
cmpa-acpm.ca
“Cauda equina syndrome: A case for timely
recognition and treatment”
“Spinal epidural abscess: a rare, insidious
and potentially catastrophic infection”
CMPA Good Practices Guide —
section on “Cognitive biases”
14 CMPA PERSPECTIVE
Managing medico-legal risk
When assessing patients with complaints
of back pain, consider the following risk
management actions which are based on the
experts’ opinions in the cases analyzed:
ӹӹ Be aware of the current evidence-based
conservative approaches to managing the
care of patients with back pain, which
include guidance on the use of medication
for pain management.
ӹӹ Take a complete and appropriate physical
examination, and evaluate for red flags
associated with back pain that might indicate
the need for urgent diagnostic imaging or
referral to a specialist.
ӹӹ Keep an open mind when patients explain
the source of their symptoms.
ӹӹ Pause and reflect on the differential
diagnosis, being careful to consider
possibilities that may be threatening to
life or limb.
ӹӹ Reflect on whether cognitive biases are
influencing your diagnosis.
ӹӹ Advise your patients of the symptoms and
signs that should alert them to seek further
medical attention.
ӹӹ When patients return with the same
or worsening symptoms, re-evaluate
your diagnostic assumption and
repeat the physical examination, with
neurological exam.
ӹӹ Ensure your documentation reflects
a thorough assessment, history
taking, differential diagnosis, and
discharge instructions. n
1. Cassidy, J.D., Carroll, L.J., Côté, P., “The Saskatchewan health and back
pain survey. The prevalence of low back pain and related disability in
Saskatchewan adults,” Spine (1998) Vol. 23 No. 17, p.1860
2. Deyo, R.A., Mirza, S.K., Martin, B.I., “Back pain prevalence and visit rates:
estimates from U.S. national surveys, 2002.” Spine (2006) Vol. 31 No. 23, p.2724
3. Deyo, R.A., Rainville, J., Kent, D.L., “What can the history and physical
examination tell us about low back pain?” Journal of the American Medical
Association (1992) Vol. 268 No. 6, p.760
4. Srinivas, S.V., Deyo, R.A., Berger, Z.D., “Application of “less is more” to low back
pain.” Archives of Internal Medicine (2012) Vol. 172 No. 13, p.1016
5. Choosing Wisely Canada. Imaging tests for lower back pain: When you need
them—and when you don’t. Accessed July 7, 2014 from:
http://www.choosingwiselycanada.org/materials/imaging-tests-for-lowerback-pain-when-you-need-them-and-when-you-dont/
December 2014
Staphylococcus aureus
DTKUTOO
Lowering patients’ risk of
hospital-acquired infections
Hospital-acquired infections can make
patients sicker, lengthen hospital stays,
and even result in significant disability
or death. Prevention is an important
quality of care measure. Although
healthcare facilities are responsible for
enforcing infection control practices,
it is the responsibility of all healthcare
providers, including physicians, to
follow the practices.
I
N A REVIEW of recent CMPA medico-legal
cases (closed between 2008 and 2013) with
a suspected or proven healthcare-associated
infection in patients, the physicians most
often involved were orthopaedic surgeons,
general surgeons, and family physicians. The
most common types of micro-organisms
were Staphylococcus aureus — including
methicillin-resistant (MRSA), Escherichia coli
and Clostridium difficile (C. diff). The sources of
infection included care that involved implanted
devices, indwelling urinary and vascular
catheters, and surgical wounds.
In two-thirds of the cases, the physician was
felt to have met the requisite standard of care,
but in some of the cases, peer experts noted
that infection prevention and control is a
responsibility of both the hospital and individual
care providers.
The issues related to physicians’ involvement
included the assessment, management, and
follow-up phases of the diagnostic process.
n
Assessment
The most common problem in the cases was
a deficient assessment, particularly when
the patient showed symptoms and signs of
infection. The physician often failed to order
the necessary diagnostic tests (e.g. cultures) or
imaging (e.g. ultrasound, CT scan). In a few
cases, the physician did not consider the patient’s
increased risk of developing an infection because
of co-morbid conditions (e.g. advanced age,
diabetes, and immunosuppression), extended
hospital stay, previous antibiotic therapy, or the
presence of a C. diff hospital outbreak.
December 2014
CMPA PERSPECTIVE 15
n
Jupiterimages
16 CMPA PERSPECTIVE
CASE EXAMPLE
RULING OUT INFECTION
A 39-year old man undergoes an uneventful
arthroscopic meniscectomy and debridement
of the right knee. One week later, he presents
to the emergency department (ED) complaining
of increasing pain, swelling of the knee, and
decreased mobility. The patient is afebrile with
localized erythema and tenderness around one of
the portal sites with some purulent drainage. The
ED physician diagnoses infection and refers the
patient back to his orthopaedic surgeon who does
not feel there is an obvious infection and decides
to observe the patient and re-assess him at the
next scheduled appointment. The documentation
of this visit is scant.
A few days later, the patient attends another
ED and is referred to a general surgeon who
drains and debrides an abscess near the portal
site but does not think it communicates with the
knee joint. At follow-up a week later the general
surgeon suspects a deep infection and refers
the patient back to his orthopaedic surgeon.
Suspicious of septic arthritis, the orthopaedic
surgeon debrides and irrigates the patient’s knee.
Cultures are positive for Staphylococcus aureus
requiring six weeks of parenteral antibiotics.
The patient subsequently undergoes a total
knee replacement.
The patient initiates a legal action alleging the
orthopaedic surgeon delayed investigating and
treating the infection, which led to an earlier-thanplanned joint replacement surgery. Experts are of
the opinion that when the patient presented one
week after surgery, the orthopaedic surgeon should
have ordered bloodwork, aspirated the knee, and
assessed the need for antibiotics. Experts also
comment that the lack of documentation failed to
demonstrate that appropriate steps were taken to
rule out infection.
Without expert support, a settlement is paid
to the patient by the CMPA on behalf of the
orthopaedic surgeon.
December 2014
Management and follow-up
In many cases of suspected infection,
necessary cultures were not obtained, antibiotic
administration was not initiated or delayed, or
the choice of antibiotic was not appropriate. In
a few cases, experts felt the patient should have
been referred to an infectious disease specialist.
CASE EXAMPLE
PRESCRIBING THE
INAPPROPRIATE ANTIBIOTIC
Two days after undergoing a cystoscopy,
a patient arrives in an ED with fever, chills,
abdominal discomfort, dysuria, and urinary
frequency. The patient is seen by the on-call
urologist and diagnosed with post-cystoscopy
urosepsis. IV antibiotics are prescribed and the
patient is referred back to his treating urologist.
The next day, the treating urologist does a
limited assessment of the patient noting that
the patient had no fever and no pain, diagnoses
a lower urinary tract infection, and discharges
him with a prescription for nitrofurantoin.
The patient calls the urologist’s office the next
day because he is still feeling unwell, and
an appointment is given for three days later.
The patient attends another hospital and is
admitted with urosepsis. His urine cultures grow
Pseudomonas aeruginosa, and he is treated with
an aminoglycoside and a carbapenem.
The patient complains to the College and alleges
the urologist prematurely discharged him. The
College expresses concern about the physician’s
choice of antibiotic, incomplete assessment prior
to discharge, and lack of definite follow-up.
Mamahoohooba
System issues
System problems were related to hospitals’
inadequate processes in managing C. diff
outbreaks and hospitals not adequately
informing its personnel, as illustrated in the
following case.
Stockbyte
CASE EXAMPLE
COMMUNICATING A
HOSPITAL OUTBREAK
A 46-year-old woman, who is obese, diabetic,
and a smoker, is referred to a general surgeon
for recurrent diverticulitis. The patient refuses
surgery and is treated with multiple courses of
antibiotics. A year later, the patient consents
to surgery, and the surgeon extensively
documents a consent discussion. The patient
undergoes a laparoscopic sigmoidectomy. Four
days later, she develops an acute C. difficile
infection and requires ICU admission. It is
thought that the patient is colonized with
C. diff because of repeated use of antibiotics
prior to surgery. The patient’s condition
deteriorates, and she is diagnosed with
pseudomembranous colitis requiring a subtotal
colectomy with ileostomy.
A legal action ensues and the patient alleges
the consent discussion did not include
information regarding C. diff infection, and
the surgeon failed to adequately prevent and
manage the infection. During the course of
the action, the hospital acknowledges that
there was a C. diff outbreak at the time of the
patient’s first surgery. An expert surgeon is
supportive of the surgeon’s care and consent
discussion, but notes some communication
challenges and lapses in documentation. He
adds that the hospital had given no instructions
to avoid surgeries due to a C. diff outbreak.
The legal action is dismissed against the
surgeon, and a settlement is paid to the patient
by the hospital.
Risk management considerations
Based on the expert opinions in the cases reviewed, you should consider the following
risk reduction strategies in your practice:
ӹӹ Consider if patients’ comorbidities increase their risk of acquiring an in-hospital
infection, and if so, be alert to any symptoms and signs of infection.
ӹӹ Adhere to recommended hand hygiene practices.
ӹӹ If appropriate, obtain relevant cultures when an infection is present or
suspected before initiating antibiotic therapy. When available, review sensitivity
and resistance results.
ӹӹ Consider assessing patients when notified of a change in their condition by the
patient, the nursing staff, office employees, or when seen by other healthcare
providers following discharge.
ӹӹ Consult an infectious disease specialist when treatment is ineffective or in a
complicated infectious process.
ӹӹ Ensure effective communication with patients and families, advising on signs and
symptoms that may indicate a complication is setting in, and how and when to seek
further medical care.
ӹӹ Have a clear understanding of how your institution defines and contains an outbreak
of a communicable disease and how that information is communicated to patients,
staff, and the community. n
jJPC-PROD
n
December 2014
CMPA PERSPECTIVE 17
A
is for alias —
Getting the
right care to the
right patient
dr911
Patient misidentification is common and
can occur in areas such as medication
administration, blood product
transfusions, diagnostic testing, and
patient procedures. Harm to patients
and near misses are among the
possible results.
A review of the CMPA’s experience
with issues of misidentification found
54 cases during the seven year period
from 2007-2013. The majority were
legal actions. Specialties at highest
risk were radiology, family practice,
and pathology. The common themes
in these cases include patients with
the same or similar names and results
from the same tests performed
at different times.
18 CMPA PERSPECTIVE
CASE EXAMPLES
RIGHT PATIENT, RIGHT TEST, WRONG DATE
CASE 1: A previously healthy, 52-year-old female is admitted
to hospital for the treatment of newly diagnosed acute
myelogenous leukemia, which was confirmed by a bone
marrow biopsy. Induction chemotherapy is initiated. Despite
appropriate antibiotics and antifungal treatment, the patient
subsequently develops pancytopenia and persistent pyrexia.
Two weeks later, a repeat bone marrow is performed to
assess the need for further treatment. The following day
the attending hematologist visits the pathology department
to review the findings. By mistake, he is directed to the
pathologist who had interpreted the first biopsy two weeks
previous. The hematologist requests an interpretation of
the marrow biopsy but does not specify the date of the
investigation. Recognizing the patient’s name, the pathologist
replies that the biopsy had shown acute leukemia. On this
basis, a second course of chemotherapy is ordered. However
the second marrow biopsy shows no evidence of leukemia.
Several weeks later the error is discovered and the
hematologist discloses what has happened to the patient and
her family, and offers an apology. Unfortunately, the patient
develops pancytopenia and dies of an intracranial hemorrhage
six weeks after admission.
The matter is deemed indefensible and a settlement is paid
to the patient’s family by the Association on behalf of the
attending hematologist.
December 2014
CASE 2: Early in the evening on the third day of
a long weekend, a 42-year-old male presents to a
walk in clinic with signs and symptoms suggestive of
appendicitis. His only significant medical history is a
cholecystectomy one year previously at a community
hospital. The clinic physician contacts the on-call
radiologist at the same community hospital and a
CT scan is performed and filed in the PACS system
(Picture Archive and Communication Systems). The
radiologist, who had been on call all weekend,
reviews the images and notes gallstones but no
signs of appendicitis. The patient is discharged.
Two days later the patient returns with generalized
peritonitis. A ruptured appendix is identified at
surgery. When the radiologist is asked to review
the initial CT scan, he quickly realizes there is clear
evidence of appendicitis as well as a previous
cholecystectomy, neither of which was mentioned in
his report.
Puzzled as to the origin of the oversight, the
radiologist analyses all of the patient’s previous
studies. An abdominal CT scan had been performed
two years previously prior to the cholecystectomy.
The radiologist concludes he had viewed and
reported on this previous study rather than the
current one.
In the subsequent legal action, the matter is
deemed indefensible and a settlement is paid to
the patient by the Association on behalf of the
member physician.
for example, it is not uncommon to have multiple
family members being treated simultaneously after
motor vehicle crashes. If there are patients with
identical last names in a treatment area, if possible,
avoid having them in the same room. It may be
advisable to have some ‘flagging’ system in place that
will put either electronic or physical alerts on census
sheets, addressographs, and patient records. Some
organizations are exploring bar coding as a strategy.2
Allow patients to take part in their own risk
management and further lessen the risk of a mix-up.
If patients have a common name, speak with them
and their family about the possibility of confusion
with another patient and the need for staff to double
check their identity. This will prompt most patients
to question whether they are receiving the correct
investigation and treatment. Be aware, however,
that patients with visual, auditory, or cognitive
impairments may not be capable of taking on this
role and pose special challenges.
When performing tests, it is often necessary to
confirm the identity of the patient as well as the
date and time the test was performed. When
interpreting results, check that the date and time of
the investigation are the ones relevant to the care.
While electronic data management systems provide
a wealth of information, mix-ups can still occur.
Disclosure of harm to patients is required. Members
with questions should not hesitate to call the CMPA
for additional information and advice. n
Considerations for managing risks
It is important that physicians and healthcare
workers are alert to the possibility of mix-ups and
are vigilant in matching the correct patients with
the correct care. At a superficial level, verifying a
patient’s identity appears to be a simple process.
However, as these cases illustrate, additional
measures may be needed to ensure that the right
treatment is being administered to the right patient
at the right time. Based on these cases, there are a
number of strategies for keeping a patient safer.
Physicians should verify the patient’s name and, if
necessary, birthdate and unique numerical identifier
before ordering an investigation or treatment, or
viewing test results. In many instances in a clinicbased practice with outpatients, this information
will not be included in an identity wrist band and
must be sought elsewhere.
ADDITIONAL READING AT
cmpa-acpm.ca
“Communicating with your patient about
harm: Disclosure of adverse events”
“Surgical safety checklists: A team approach
to patient safety”
1. Shojania, K. Agency for Healthcare Research and Quality Web M+M Rounds,
February 2003. Accessed October 2014 from: www.webmm.ahrq.gov
2. WHO Collaborting Centre for Patient Safety Solutions, “Patient Identification:
Patient Safety Solutions,” Volume 1, Solution 2, May 2007
In a busy hospital environment, the likelihood of
having two patients with the same last name is
approximately 30%.1 In an emergency department,
December 2014
CMPA PERSPECTIVE 19
the Canadian Medical Protective Association
Working for you
When you call the CMPA, your
first point of contact is with
our award-winning call centre.
Our knowledgeable Member
Services Representatives and
Membership Administrators
are dedicated to listening to
your needs and providing
you with exceptional
quality service.
Your contact with the
CMPA begins here with
personalized one-on-one
service to meet all your
medico-legal needs.
CMPA
Membership and
Contact Centre
Services
Whether
you have
a medico-legal
concern, a
membership
request, or a general
inquiry, your call will be
handled in a professional,
timely, and confidential
manner.
If you
require
medico-legal
advice or assistance,
we can connect you
with one of our CMPA
Medical Officers.
Contact us by phone or through our secure web mail
(accessible through the member sign in section of our website).
20 CMPA PERSPECTIVE
December 2014
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