Prescriptions of powerful drugs without follow-up, incorrect diagnoses, non-screening for cancer: dozens of worrying problems are raised each year by inspectors who scrutinize the practice of doctors in Quebec.
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In several cases, the breaches put patients at risk, indicate the reports of the professional inspections of the Collège des médecins du Québec (CMQ) of 2021, obtained by The newspaper over there Access to Information Act (see below).
For example, a doctor used a product not recognized by Health Canada, depressed people were not assessed for their suicidal risk, and patients with chronic illnesses did not receive the necessary follow-up.
Many shortcomings in the use of antibiotics and the assessment of geriatric problems were also raised.
Patients at risk
As provided by law for all professional orders in Quebec, the CMQ must carry out inspections each year (hospitals, control questionnaires, individual visits).
“We are firmly convinced that there is no doctor in Quebec who gets up in the morning saying, ‘I’m going to harm my patients,'” said Dr.r Anas Nseir, director of professional inspection at the CMQ.
“We absolutely want to protect the patient, but give the doctor the chance to improve,” he says.
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To be more effective, the inspection department uses a statistical targeting technique that selects the doctors most at risk, out of the 22,566 doctors in the province. Thus, approximately 200 professionals are inspected each year.
“Instead of going fishing in the ocean, where you may find few doctors who need our help […] and perhaps let dangerous doctors practice, we prefer to develop programs, validate them with statisticians, and go see these doctors who are more at risk, underlines the Dr Nseir. And I’m proud to say that we have a very good success rate.
For example, physicians over 70 are nine times more likely to have gaps in their practice, according to CMQ analyses. The other professionals most targeted are those who have been referred by the Syndic of the Order, and those who have been the subject of a report.
Abuse of telemedicine
It should be noted that doctors have been abusing telemedicine since the pandemic (sometimes more than 80% of consultations).
“We still see it, deplores the Dr Nseir. Today, there are no more severe health restrictions. There is no reason for a doctor not to see his patients.
As a general rule, the doctors inspected are notified, have completed a 40-page questionnaire, and know why they are being met. So they can prepare. However, surprise visits are also possible.
“But these are special cases where it is believed that there is almost immediate danger for the patient”, notes the Dr Nseir.
An intimidating and stressful inspection
Although doctors are stressed and sometimes even refractory when they undergo an inspection visit, the exercise is carried out with an educational perspective, assures the College of Physicians of Quebec.
“It’s a very intimidating thing for doctors, it’s not a walk in the park when you get a letter from the College,” says Dr.r Sylvain Dion, vice-president of the Federation of General Practitioners of Quebec (FMOQ).
Pedagogical approach
“We cannot say that it is fun for a professional to be inspected, whether it is a doctor, a lawyer or an accountant, concedes the Dr Anas Nseir, director of professional inspections at the College of Physicians of Quebec (CMQ). Deep down, people don’t like it.”
In the context, the College says it has a constructive approach, with the aim of helping the professional to improve when necessary.
“From the start, we explain to them that we come to watch with them as a peer,” he assures us.
Moreover, the FMOQ says it has noted a beneficial change in tone in inspections over the past four years, which is now much less “traumatic”.
“A few years ago it was very inquisitive. We asked for a more humane process with these doctors. There was a crash. The visits are more constructive”, appreciates the Dr Dio.
Currently, a quarter of physicians in Quebec are over 60 years old. Thus, the targeting of older physicians for inspections must be carried out diligently, believes the FMOQ.
“Fragile balance”
“It can be a delicate balance when you put a lot of pressure on doctors. […] Sometimes, it could encourage some to withdraw.
Moreover, the latter assures us that the FMOQ agrees with the idea of professional inspection.
“It’s a profession where it’s important to provide quality and safe services,” says Dr. Dion.
The Federation of Medical Specialists of Quebec refused the interview request of the Log.
About 200 doctors are subject to an individual inspection each year by the College of Physicians of Quebec, to ensure that their practice respects the rules of the art. However, all sorts of shortcomings are noted in inspection reports, obtained by The newspaper. For reasons of confidentiality, no information allows us to reveal the identity of the doctors. Here are excerpts.
GAPS IN CARE
- Absence of research for major geriatric syndromes in the population at risk
- Absence of gynecological examination when indicated (ovarian torsion, bleeding)
- Examination of the abdomen is often absent, even if the patient consults for abdominal pain
- Incomplete examination in case of breast mass
- rare physical exam
- Non-systematic monitoring of chronic diseases (asthma, type 2 diabetes, blood pressure control)
- Patients with glaucoma complications not referred to specialists
- Prevention issues
- Cancer screening is not done rigorously
- A note mentions that a 5 year old seems to understand words. “At that age, that uncertainty should have triggered more evaluation.”
- Incomplete assessment and management of ADHD
POORLY STORED MEDICINES
- Medicines stored in a bar type refrigerator without temperature control
- Medicines and medical equipment found in the doctor’s office are outdated: silver nitrate, urinary analysis strip, etc.
PRESCRIPTION PROBLEMS
- Use of injectable products not recognized by Health Canada, or prohibited by the World Anti-Doping Agency
- Medical Cannabis Prescription Without Tracking
- Renewal of medication for 24 months without having assessed the patient’s condition to know if the medication is still required
- Use of platelet-rich plasma for unrecognized indications such as erectile dysfunction
- Benzodiazepines: very frequent use, little or no withdrawal and cessation trials. Little review of their use and the clinical condition of the patient.
- “Non-standard” testosterone prescriptions and for unrecognized indications such as pain
- Use of naloxone not indicated at end of life
- In long-term opioid cases, “lack of risk factor assessment for advice, overdose”
MENTAL HEALTH
- No search for dangerousness in the event of paranoid ideation, suicidal verbalization or dark thoughts
- Assessment of mental health issues such as anxiety disorders is superficial. There is usually no mental examination except for suicidal ideation
- Although the doctor generally links the ailments of the patients to psychological problems, there is generally no collaboration with a psychiatrist or a psychologist in the files.
MISUSED TELEMEDICINE
- Diagnosis of acute otitis media without physical examination (telephone consultation)
- No verbal or written patient consent to a teleconsultation
- More than 80% of a doctor’s clinical interventions are carried out by telemedicine (chronic diseases without a physical examination for sometimes more than 2 years, elderly patients, acute problems requiring a physical examination)
BREAKAGE OF CONFIDENTIALITY
- The doctor says he gets information about a patient by seeing her friend who is also his patient. He enters the test result of a patient’s friend in the file of this one in order to compare them
- The technology used by a doctor does not respect confidentiality standards (use of personal email, photos of patients on the personal computer)
- Photos of naked or identifiable minor patients are sent without informed parental consent
- Sending email to the wrong recipient
OTHERS
- Frequent use of the medical consultation as an opportunity to offer an aesthetic service not covered by the public system
- Erroneous belief of the doctor in connection with nutrition: in order to justify the non-use of nutritionists, the doctor speaks of an old study which would have shown that the addition of fiber in bread was nothing other than the addition of sawdust Of wood
- Many doctors had writing that was difficult to decode, even indecipherable
WHO DOES THE INSPECTIONS?
- Nine full-time medical inspectors
- They must have at least 10 years of practice (often more than 15 years)
- They come from different medical specialties
- Each inspection lasts 1-2 days
TARGETING INSPECTED DOCTORS
- Referred by the trustee 41%
- Physicians over 70 24%
- Reports 21%
- Physicians over 60 5%
- Other 9%
Conclusion of inspections
- Adequate practice 53%
- Imposed internship or tutoring 29%
- Limited practice or voluntary retirement 12%
- Dispute 6%
Source: CMQ