Dialogue Volume 14 Issue 2 2018 | Page 64

DISCIPLINE SUMMARIES
and controlled substance prescribing , and do not meet the standard of care of the profession for a family physician as follows :
• Dr . Fenton ’ s recorded histories are often nonexistent and lack detail to understand the patient ’ s story . His documented physical examinations are either lacking entirely or insufficient for the complex chronic pain condition this patient reports . No investigations are done with respect to Patient A ’ s physical pain or anxiety conditions . Impressions and management plans are not outlined regularly . Not all prescriptions given are recorded in the EMR . Rationale for the prescription of medications ( choice of drug , dose or quantity ), including many controlled substances , is not found in the medical record . CPP was not completed until after the patient was discharged from the practice ;
• Dr . Fenton ’ s prescribing of controlled substances including narcotics , benzodiazepines and stimulants is excessive and without documented justification ;
• Prescription information from the NMS database and Dr . Fenton ’ s chart calculate over 1000 morphine equivalents daily – well in excess of “ watchful dose ” limits . There is a lack of evidence of application of recognized controlled substance prescribing guidelines . There is no adequate discussion of side effects , risks and alternative analgesic options . There are no clear treatment goals documented . There is no documented indication for either stimulant or sedative medication , or discussion about the use [ of ] both categories of medication being prescribed concurrently . There is no supporting documentation of underlying diagnoses to support the use of these medications . There is no supporting evidence of favourable clinical outcomes as a result of these treatments .
• Dr . Fenton appropriately advised Patient A that because of repeated breaches of their opiate treatment agreement , he would no longer continue to prescribe controlled substances for Patient A . This would be partially considered to be within the standard of care for termination of a physicianpatient relationship as per College policy , however the policy also indicates a copy of this letter should be sent by registered mail to the patient and a copy be in the patient record . There is no documentation in the chart or in the patient complaint that the patient received such a letter . In addition , in considering termination of the patient-physician relationship , there is no evidence that arrangement for any consultations with a pain clinic or alternate provider were made which would also be within the standard of care in family medicine . More importantly , there is no evidence of strategies to taper doses of her various medications or dispensing smaller quantities at one time , ( which would have potentially mitigated some of the risk of her having been taking such high doses of narcotics and sedatives ) prior to her dismissal .
It was found that Dr . Fenton is incompetent and failed to maintain the standard of practice in his care and treatment of Patient A , as described above , including his failure to follow the College ’ s Ending the Physician-Patient Relationship policy .
Patient B In January 2015 , the College received a complaint from Patient B who had been a patient of Dr . Fenton ’ s from approximately July 2008 until November 2014 . Patient B ’ s medical history includes hypertension , hypercholesterolemia , diabetes and chronic pain . The College expert opined that Dr . Fenton ’ s care of Patient B did not meet the standard of care including in his record keeping , his chronic disease management and his follow-up on abnormal test results and suggestions of consultants . Specifically , the expert noted the following deficiencies :
• There is evidence that medications are prescribed but not recorded within the EMR . A large gap exists in that there is no evidence of chronic disease management between the periods June 2013 to May 2014 . There is evidence that abnormal test results and suggestions made by a consultant ( in this case , the ER doctor ) are not followed up ;
• Dr . Fenton ’ s treatment of [ Patient B ’ s ] hypertension is not clear from the documentation found in the
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DIALOGUE ISSUE 2 , 2018