Who Can Request a Diagnostic Test / Procedure?

1. Who Can Request a Diagnostic Test / Procedure? Dr. D.H. Blackman Senior Deputy Registrar College of Physicians & Surgeons of B.C. May 12, 2008

2. The Challenge The Challenge: Balancing patient access and choice with quality, safety and continuity of care—in the patient’s best interest.

3. Background In practice, the College of Physicians & Surgeons of British Columbia expects members to: • Practise with competence, based on scientific knowledge and methods generally acceptable to the profession • Avoid practising with, or taking responsibility for, other healthcare providers who practise using methods of diagnosis or treatment not compatible with generally accepted scientific medical knowledge

4. Background The surge in public interest in complementary and alternative therapies is acknowledged. These therapies differ from conventional medical practice because they are “unproven.” Assertions, speculation and testimonials are not clinical data, and do not substitute for scientific evidence.

5. Background We are increasingly being urged or mandated to work collaboratively with other health professionals with the potential to provide better care more efficiently and cost effectively. The Government’s declared vision is that patient choice and access to care must be expanded, with the resultant potential for expanded scopes of practice.

6. What is a “test”? Is it not a professional consultation with a colleague?

7. What is a “test”? • The Pathologist is examining the patient’s biological sample to give the referring physician an opinion on the potential diagnosis of that patient. • The Diagnostic Radiologist is examining the patient using some form of technology, and reporting his or her clinical opinion based on the history and physical findings provided on the requisition and their findings using the appropriate imaging technique.

8. Responsibilities Once consulted, you are clinically involved with that patient, and incur fiduciary and ethical responsibilities in that relationship. You have assumed a degree of responsibility for the diagnosis and care of that patient.

9. Responsibilities Given those obligations and responsibilities, what assurance do you have that the opinion you provide will be acted upon appropriately? That it, that a critical result will be addressed, especially if the appropriate Rx lies outside the scope of practice of the healthcare professional ordering the “test” (i.e. seeking the consultation)?

10. Payment Issues • Currently, the MSP only covers care that is “medically required”—a term that is somewhat ill defined, but currently excludes naturopathy, chiropractic, physiotherapy and others, even though those practitioners are regulated health professionals. • While payment is not the primary focus of whether a particular practitioner can initiate the consultation, it is a consideration.

11. Regulation Regulation under the Health Professions Act • Currently, the regulations relating to Nurse Practitioners, Midwives and Podiatrists include referring for such consultations in their scope of practice, whereas such is not the case for others. • However, this is likely to change given the Government’s announced plans in Bill 25 currently before the Legislature.

12. Guidance Notwithstanding those potential changes, how should one proceed? • Understand your relationship and obligations once a patient attends you upon referral, irrespective of who referred the patient to you. 2. Understand the scope of practice of the referring practitioner, and determine how you are going to ensure that a critical finding will be addressed appropriately—otherwise, “Tag, You’re It.”

13. Guidance • Ensure that those with whom you are interacting clinically have appropriate and adequate liability protection. • Review the CMPA perspective on collaborative care, published and circulated with their Information Letter in September 2007. 5. Ensure that the patient understands and accepts any financial obligation that might arise from your clinical interaction with them before you provide the service.

14. Guidance • Communication is essential. Ideally, the patient’s primary care physician should be copied on all reports, with the patient’s expressed consent. However, even that poses potential problems and liability for that physician, who might have been unaware that the patient had a problem and had consulted another practitioner, but now “knows.”

15. Thank You Questions?