January 31, 2003

Code of Conduct for Physicans – From the College of Physicans and Surgeons

** I have highlighted segments that have great significance to me.**

General Responsibilities:

1. Consider first the well-being of the patient.

2. Treat all patients with respect; do not exploit them for personal advantage.

3. Provide for appropriate care for your patient, including physical comfort and spiritual and psychosocial support, even when cure is no longer possible.

4. Practise the art and science of medicine competently and without impairment.

5. Engage in lifelong learning to maintain and improve your professional knowledge, skills and attitudes.

6. Recognize your limitations and the competence of others and when indicated, recommend that additional opinions and services be sought.

7. In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status. This does not abrogate the physician’s right to refuse to accept a patient for legitimate reasons nor to confine practice to a specific condition or recognized field of clinical interest.

8. Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants.

9. Provide whatever appropriate assistance you can to any person with an urgent need for medical care.

10. 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 adequate notice that you intend to terminate the relationship.

11. Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available; there should be no fee for such treatment.

Communication, Decision Making and Consent:

12. Provide your patients with the information alternatives, and advice* they need to make informed decisions about their medical care, and answer their questions to the best of your ability.

13. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.

14. Ensure that information is available or has been provided to patients so that they know how to obtain care in your absence.

* new wording added by CPSM

15. Recommend only those diagnostic and therapeutic procedures that you consider to be beneficial to your patient or to others. If a procedure is recommended for the benefit of others, as for example in matters of public health, inform your patient of this fact and proceed only with explicit informed consent or where required by law.

16. Respect the right of a competent patient to accept or reject any medical care recommended.

17. Ascertain wherever possible and recognize your patient’s wishes about the initiation, continuation or cessation of life-sustaining treatment.

18. Respect the intentions of an incompetent patient as they were expressed (e.g. through an advance directive or proxy designation) before the patient became incompetent.

19. Treatments that offer no benefit and serve only to prolong the dying process should not be employed. When appropriate, an effort should be made to explain non-provision of futile treatments with patients and families.

20. When the intentions of an incompetent patient are unknown and when no appropriate proxy is available, render such treatment as you believe to be in accordance with the patient’s values or, if these are unknown, the patient’s best interests.

21. Respect your patient’s reasonable request for a second opinion from a physician of the patient’s choice.

22. Recognize the need to balance the developing competency of children and the role of families in medical decision-making.

23. Be considerate of the patient’s family and significant others and cooperate with them in the patient’s interest.

Confidentiality:

24. Respect the patient’s right to confidentiality except when this right conflicts with your responsibility to the law, or when the maintenance of confidentiality would result in a significant risk of substantial harm to others or to the patient if the patient is incompetent; in such cases, take all reasonable steps to inform the patient that confidentiality will be breached.

25. When acting on behalf of a third party, take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to the third party.

26. Upon a patient’s request, provide the patient or a third party with a copy of his or her medical record, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others.

26.1 Duty to Warn when a patient threatens to cause serious harm to another person or persons and it is likely that the threat will be carried out, the physician must inform the appropriate authority or otherwise ensure that the threatened party is informed.

The Referral Process:

27. Definitions:
Primary care is the provision of health care services in response to a patient presenting with a need for any aspect of health care.

Continuing care is the provision of a plan of management for a patient which is developed in response to the individual’s specific health care needs and which changes as these needs vary over time. Except where concurrent therapy exists, there will be only one continuing care physician attending the patient.

The primary continuing care provider is the specific physician designated as being responsible for the patient’s continuing management (personal physician). In most situations this physician will be a family physician, although in some circumstances the role will be assumed by a specialist such as a paediatrician, gynaecologist, or internist. Except in emergencies, the personal physician or co-therapist shall be the referrer.

Non-physician providers may be the primary health care provider where no alternative exists or for a discrete area of health care. The term “discrete” means that the care is organ or body part specific and within the defined field of competence of a certified health care practitioner to provide primary continuing care.

27.1 Transfer of care occurs:

(a) when the role of the physician responsible for the ongoing management of the patient is terminated; when a new physician has accepted responsibility for continuing management of that patient.

There is an ethical obligation for the former to provide information necessary to the patient’s ongoing management.

(b) Another physician may be requested to assume responsibility for a specific program of treatment. At the conclusion of such treatment, a summary of the treatment provided will be given to the referrer if relevant.

27.2 Co-therapy is the provision of care by a second individual concurrent to the personal physician. A second physician may be involved in the care of a patient only with the knowledge and agreement of the personal physician.

27.2.1 A physician may continue treatment within the context of consultation.

27.2.2 A non-physician provider may administer an ongoing plan of management for the patient where the focus of the management is organ or disease specific and within the competency of the certified health care provider. Non-physician concurrent therapists should be known to the personal physician and report to that individual any findings or complications which may have significance relative to the patient’s overall well-being.

27.3 Consultation:
27.3.1 The consultant is any physician from whom a referrer seeks an opinion. The consultant may also be requested to assume treatment. The consultant need not be a specialist.

As referrer, you are the physician responsible for the care of the patient or may be a non-physician responsible for a discrete component of the patient’s health care who has specific need of a physician with specific training/expertise with regard to: (i) request for opinion and/or (ii) request to treat.

As referrer, you must provide the physician to whom the patient has been referred with all information which may help in the patient’s treatment and additional information the latter deems useful.

27.3.2 Request for Opinion
In a request for opinion, the referrer is limiting the consultant to the collection of data necessary to the rendering of an opinion to the referrer.

27.3.2.1 As the referrer, you must clearly state relevant information concerning the patient’s history and clinical findings, together with the question which is to be addressed.

27.3.2.2 As a consultant, you are acting in the capacity of advisor to the referrer and shall promptly provide the results of the consultation and the appropriate recommendations to the referrer, in writing.

27.3.2.3 Except in an emergency or 27.3.3, you may become the attending physician of a patient only upon the patient’s request or authorization.

27.3.3 Request for Opinion and to Treat
The referrer is asking the consultant not only for an opinion but also for treatment to be provided to the patient for the problem specified.

27.3.3.1 You shall address the issue raised by the referrer through history, examination, and investigation.

27.3.3.2 Collect whatever information is relevant to continuing management and advise the referring physician whether you are prepared to continue with treatment. If you agree to continue with treatment, it shall be confined to the specific problem presented. You will obtain additional consultations only when they are clearly indicated to assist or enable comprehensive management of the problem for which the patient was referred.

27.3.3.3 Should you find any unrelated problems, you will bring them to the attention of the referrer for action except where immediate action is clinically indicated or delay will cause the patient economic or physical or mental hardship. In the event of an exception, you will promptly inform the referrer of the circumstances.

27.3.3.4In the event of previously unrecognized need for mandatory reporting, you may complete the reporting or shall ensure that it is done by the referrer.

27.3.4 The consultant who accepts the role of a treating physician is acting as a concurrent therapist with the personal physician. In such a role the consultant should make reasonable effort to ensure that the family physician is kept informed regarding the patient’s progress and in the selection of additional consultants who may be required.

27.4 When you assume the care of a patient during the absence of the attending physician you must, on the availability of the latter, supply any information useful to continue treatment.

27.5 When providing patient services, ensure that you are clearly identified to the patient.

27.6 In an emergency, assist a colleague when the latter so requests.

27.7 Consider the patient’s preference in selection of a consultant.

27.8 Acknowledge a patient’s right to attend another health care provider.

Fees:

28. In determining professional or other fees to patients, consider both the nature of the service provided and the ability of the patient to pay.

29. Provide the patient with any explanation necessary for understanding the account.

30. Advise the patient in advance to the provision of services and/or any relevant billings:

30.1 that a service may be uninsured;

30.2 the specific terms and conditions relevant to payment;

30.3 any penalties for non-attendance or non-payment;

30.4 if payment will be required in advance of a requested, elective, uninsured service. In no other circumstances require payment in advance.

Responsibilities to Society:

31. When expressing medical opinions for public consumption you:

31.1 will first communicate to colleagues, through recognized scientific channels, the results of any medical research, in order that those colleagues may establish an opinion of its merits before they are presented to the public.

31.2 when informing the public about services, shall:

31.2.1 provide information which is factual, exact and verifiable;

31.2.2 not use superlative or comparative adjectives or descriptions regarding the quality of the services, products or personnel referred to in the advertising;

31.2.3 not use testimonials advocating for the personnel referred to in the advertisement;

31.2.4 not use unsuitable, false, misleading or deceptive information;

31.2.5 not promote one’s services in a pressing and/or repetitive manner. This is soliciting and is inappropriate.

32. Recognize that community, society and the environment are important factors in the health of individual patients.

33. Accept a share of the profession’s responsibility to society in matters relating to public health, health education, environmental protection, legislation affecting the health or well-being of the community, and the need for testimony at judicial proceedings.

34. Recognize the responsibility of physicians to promote fair access to health care resources.

35. Use health care resources prudently.

36. Refuse to participate in or support practices that violate basic human rights.

37. Recognize a responsibility to give the generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate.

Responsibilities to the College:

38. When practising shall use only the professional name registered with the College and shall display such name prominently in office signage and exclusively in registries, advertising and telephone directories. An alternative name may be used only with the written approval of the College.

39. When reproducing the graphic symbol of the College for advertising purposes, must ensure that the reproduction is accurate and that the approval of the College is given for any use other than business cards/announcements.

40. Shall reply promptly in writing to any request from the College.

Responsibilities to the Profession:

41. Recognize that the self-regulation of the profession is a privilege and that each physician has a continuing responsibility to merit this privilege.

42. Teach and be taught.

43. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues.

44. Be willing to participate in peer review of other physicians and to undergo review by your peers.

45. Enter into associations only if you can maintain your professional integrity.

46. Avoid promoting, as a member of the medical profession, any service (except your own) or product for personal gain.

47. Do not keep secret from colleagues the diagnostic or therapeutic agents and procedures that you employ.

48. Collaborate with other physicians and health professionals in the care of patients and the functioning and improvement of health services.

Responsibilities to Oneself:

49. Seek help from colleagues and appropriately qualified professionals for personal problems that adversely affect your service to patients, society or the profession.

Clinical Research:

50. Ensure that any research in which you participate is evaluated both scientifically and ethically, is approved by a responsible committee and is sufficiently planned and supervised that research subjects are unlikely to suffer disproportionate harm.

51. Inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of your participation.

52. Before proceeding with the study, obtain the informed consent of the subject, or proxy, and advise prospective subjects that they have the right to decline or withdraw from the study at any time, without prejudice to their ongoing care.

Financial:

53. Do not enter any agreement where a reward, direct or indirect, is associated with the volume of your work, your referrals, your orders, or your fees.

54. Accept a gift of a substantial nature from a patient only after the patient has received independent financial and/or legal advice.

55. Avoid any inappropriate personal benefit in ordering drugs, appliances or diagnostic procedures from any facility in which you have a financial interest.

56. Refrain from accepting any unwarranted material benefit in the practise of your profession.

57. Refrain from obtaining an unwarranted material benefit for a patient.

58. Refrain from paying any form of rebate to a patient which is not generally available to the public and do not offer any material inducement other than competitive pricing.

59. For other clinical situations where appliances are indicated, the physician should provide a prescription so that the patient may obtain these appliances from the supplier of choice.

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