Accepting new patients

Abstract

Objective

To gauge the public’s opinion of the College of Physicians and Surgeons of Ontario’s (CPSO’s) policy on how primary care physicians should accept new patients.

Design

Deliberative citizens’ council.

Setting

Toronto, Ont.

Participants

Twenty-five public members of the Toronto Health Policy Citizens’ Council.

Methods

A 2-day council session was held, during which the new policy was presented and council members heard from experts with various perspectives on the issues involved. Council members then deliberated and developed recommendations concerning the policy.

Main findings

Council members agreed that a first-come, first-served policy was an appropriate method for family physicians to use when accepting new patients. They thought the policy’s exception, which allows physicians not to accept patients based on a lack of clinical competency in an area, should be clarified in order to avoid it being used as an excuse to inappropriately screen patients. Counsel members also encouraged the CPSO to publicize its policy as widely as possible, so that potential patients undergoing screening in the future will recognize that this goes against the CPSO’s policy and can take appropriate action if they wish.

Conclusion

How family physicians accept new patients into their practices is a sensitive issue. The CPSO policy provides guidance on how new patients should be admitted, which, if it is appropriately enacted, seems reasonable to informed members of the public.

In 2009, the College of Physicians and Surgeons of Ontario (CPSO) introduced a policy on how Ontario family physicians should accept new patients into their practices.¹ The new policy was partly motivated by reports that family physicians were increasingly relying on screening tools and interviews to select patients.² When complaints about some of these practices were referred to the Ontario Human Rights Commission, the CPSO acted by creating the new policy.³ The new CPSO policy states that physicians should follow a first-come, first-served principle and discourages interviewing or screening patients before establishing a patient-physician relationship. The policy does allow for limitations of clinical competence and scope of practice to be permissible grounds for not accepting patients as long as decisions to accept or refuse new patients on this basis are made in good faith. If family physicians do choose to limit their scope of practice, the limits on the type of patients who are being accepted need to be communicated to all patients who are considering establishing a patient-physician relationship. The CPSO policy also allows for patients in greater need of care to be given priority. Patients who believe a physician has violated this policy can now file a complaint, which will be investigated by the college.

The CPSO’s policy appears to go further in restricting the discretion of family physicians to select new patients than the guidelines offered by other provincial colleges.^4–7 It has also been criticized by a number of stakeholders. The Ontario Medical Association (OMA) argues that family physicians themselves are in the best position to manage how their practices accept new patients.⁸ The OMA points to the fact that there are a number of existing codes that already restrict the factors physicians can consider in selecting new patients. For example, the Canadian Charter of Rights and Freedoms, the Ontario Human Rights Code, and the Canadian Medical Association’s Code of Ethics all prohibit selecting new patients on the basis of race, ethnic origin, citizenship, religious affiliation, sex, sexual orientation, age, family status, or disability.^9–11 The OMA also argues that it is unclear how the new policy will affect other health care initiatives aimed at increasing primary care access for specific patient populations (eg, those with complex mental illness¹²) or reducing wait times (part of Ontario’s Wait Time Strategy¹³). The OMA contends that as the new policy was originally written, “physicians who accept Wait Time Strategy (WTS) patients on a priority basis could be at risk of a finding of professional misconduct.”⁸ The CPSO later clarified that the policy does allow physicians to accept patients in accordance with these provincial initiatives.² Concerns have also been expressed that using a first-come, first-served approach will result in new practices being overwhelmed with patients with complex medical and psychiatric conditions, so that younger family physicians might not be able to maintain the proper balance of patients required to run an effective practice.¹⁴ It has even been argued that the new policy will result in some family physicians no longer offering comprehensive care¹⁴ or refusing to accept new patients altogether, “further worsen[ing] the family doctor shortage” in Ontario.¹⁵

Because many Canadians have difficulties in securing regular family physicians, how physicians accept new patients when openings become available in their practices is an important social issue. How physicians accept new patients also raises a number of difficult ethical questions, including what factors physicians should legitimately be allowed to consider in selecting new patients. Although it is of direct concern to patients, there appears to be little consideration given to what the public thinks a reasonable policy should be in this area. The purpose of this project was to gauge the public’s opinion of the new CPSO policy.

METHODS

We devoted a session of the Toronto Health Policy Citizens’ Council (THPCC) to considering the new CSPO policy. The THPCC has been established as part of a wider research project examining public engagement in health policy, and it consists of 25 members of the public (11 men and 14 women) who were randomly selected by an independent third-party to ensure a diverse group in terms of age, sex, and cultural and socioeconomic backgrounds.¹⁶ The council members range in age from their early 20s to their late 60s. The purpose of the council is to have citizens who do not have particular vested interest in health care deliberate and comment on important, value-sensitive health care issues. None of the council members are employed in health-related occupations. Council members are remunerated for participating in council sessions. Research ethics approval for the entire research project was granted by the Research Ethics Board of St Michael’s Hospital in Toronto, Ont.

The council members were asked to deliberate on the following 2 questions:

• Do you think that the CPSO policy “Accepting New Patients” is reasonable?

• If yes, how would you make it better? If not, what fundamental changes should be made?

The THPCC uses a deliberative process, in which the council members interact with experts and with each other, to arrive at a set of recommendations. There is no attempt to force consensus—genuine areas of disagreement after deliberation are reported as such. The advantage of this type of process is that it allows citizens to become educated about a topic, to deliberate on it for a period of time, and to come to an informed and considered position.¹⁷ Deliberative methods are becoming a more established way of engaging members of the public in health policy questions. The National Institute for Health and Clinical Excellence in the United Kingdom has had a standing citizens’ council for a number of years.^18,19 The Government of Ontario has recently established a citizens’ council to advise on policies relating to drugs.²⁰

The council meeting began with the citizens receiving copies of the CPSO, followed by presentations from 3 experts on the topic, each expert offering a different perspective on the issues involved. First, a family physician described the current patient selection process in his practice. He explained how the CPSO policy would affect his practice and the practices of his colleagues. He pointed out that it was often not physicians but their office staff members who had more control over who entered the practice. He believed that his ability to control the makeup of his practice was what had allowed him to practice for such a long time. He stated that the new policy was going to increase the stress on family doctors, decrease the attractiveness of working as a doctor in Ontario, and ultimately decrease access for patients.

A representative from the CPSO presented the rationale for establishing the new policy: screening is unfair to patients; it marginalizes the people most in need of care or those who have the greatest difficulty accessing care; and it is unfair to other doctors who feel compelled to accept unwanted patients.²¹ He also discussed how the practice of screening patients was becoming more common for new medical graduates.

Finally, a representative from the Ontario College of Family Physicians discussed some of the limitations her organization saw with the CPSO policy. She explained the following concerns: the policy would cause some family physicians to stop accepting new patients; there were not any good data showing there was even a problem with patients being inappropriately screened; and new doctors are particularly careful about ensuring they have the skills and experience to treat the people they see, which could be put at risk if they do not have discretion over whom they treat. The 3 presenters then answered questions from the council members. An invitation was sent to the OMA to send a representative to present to the citizens’ council, but the organization did not participate.

The council members were then randomly divided into 3 small groups to discuss the questions presented to them. Each group was moderated by a member of the research team, whose role was to encourage every member’s voice to be heard and to answer any factual questions that arose over the course of the deliberations, while abstaining from injecting personal opinions about the topic. At the end of the second day, the entire council met to hear the results of the deliberations of the 3 small groups and to further discuss the topic as a whole group. At the end of this discussion, the council members developed their recommendations concerning the 2 questions they were asked. Detailed notes on the entire council meeting were taken by the research team and were used to formulate a draft report. The presentations and all group discussions were recorded and transcribed to allow for further analysis. The draft report was sent to all council members for review. During the next council meeting, the council members, as a group, approved the revised final report as being an accurate reflection of their findings.²² The entire process is outlined in Table 1.

Table 1.

Citizens’ council process

SESSION	ACTIVITY
Day 1 (4.5 h)	Introduction to the topic
	Presentations from experts (eg, explanation of issues; overview of the policy; arguments for and against the new policy)
	Question-and-answer between experts and council members
	Small group discussion (3 groups)
Day 2 (5.5 h)	Small group discussion (continued)
	Full group discussion
	Recommendations drafted
Follow-up	Draft report sent to citizens
	Council approves the final report

RESULTS

Is a policy needed?

The citizens’ discussion covered a range of issues. It was initially recognized by the citizens that there would be no need for a policy about accepting patients if there were not a shortage of family physicians in Ontario. The citizens thus recommended that ensuring that all Ontarians have access to family physicians should remain a priority of the Ontario Ministry of Health and Long-Term Care. Some citizens questioned the need for any policy on accepting new patients, as most discriminatory screening is already restricted by the Ontario Human Rights Code. One citizen said, “This [policy] just seems like motherhood.” On the other hand, other citizens (or their relatives and friends) had experienced what they thought was inappropriate screening and argued that the CPSO policy would reinforce to Ontario physicians that most screening of new patients is inappropriate.

The citizens had a good deal of sympathy for the situation faced by family physicians and recognized that the new policy might place added burdens on some physicians. Some of the citizens said that they would likely feel uncomfortable if they had no discretion over which people they accepted as clients in their businesses, and acknowledged that some types of patients are likely difficult to treat and counsel. There was a good deal of discussion about the rights of physicians to limit their practices, but the citizens ultimately believed that patients’ rights to access health care trumped physicians’ discretion to tailor their practices, and that a clear policy was needed regarding how primary care physicians accepted new patients.

What principle should the policy embody?

Given that access to care was believed to be a fundamental right and that a policy about accepting new patients was needed, the citizens agreed that first-come, first-served was an appropriate principle to use when accepting patients into a practice. While it is possible that family physicians could use initial surveys or interviews that are in accordance with the existing human rights codes (eg, for the purposes of informing patients about a particular focus of the practice), there was concern that these methods might be used to inappropriately screen patients. The citizens believed that the first-come, first-served approach was likely the most effective way to remove suspicions that inappropriate screening has occurred. The citizens also commented that violations of the first-come, first-served approach were easier to investigate, if there was suspicion that a physician was violating the policy.

Clinical competency

The CPSO’s policy states that “clinical competence and scope of practice are permissible grounds for limiting patient entry into a practice.”¹ The council members were concerned that this opt-out clause could be used as an excuse for inappropriate screening. They raised the example of a family physician who might say that he or she was not competent to provide care to a patient with HIV or an elderly patient with severe heart failure simply to avoid serving certain types of complex patients. While recognizing that advances in medical knowledge and the aging population place demands on family physicians to keep current, the council members believed that family physicians practising in Ontario should be able to competently care for almost all types of patients, with help from other colleagues and specialists as needed. Therefore, they thought that clinical competency should rarely be used as a reason for selecting patients. The citizens recommended that the CPSO policy should be more explicit about what is covered by this opt-out clause, so that it cannot be used to undermine the intent of the overall policy.

The policy in effect

Council members recognized that good judgment was important when practising and enforcing the CPSO policy. For example, the council members believed that it was appropriate for a family physician to preferentially accept a patient with clearly greater medical needs or to accept dependants of current patients before accepting other patients. Council members thought that while a policy was needed in this area, most family physicians in Ontario already accept patients on an appropriate basis, and that in enacting this new policy the CPSO needs to ensure that it does not overburden practices that are already appropriately accepting new patients. The citizens were concerned that Ontarians are not as aware of the CPSO’s policy as they should be. They encouraged the CPSO to publicize this policy as widely as possible, so that potential patients undergoing screening in the future will recognize that this goes against the CPSO’s policy and can take appropriate action if they wish. They also thought the policy and its underlying principles should be taught in medical schools and as part of residency curricula, as it is often new physicians who have the bulk of openings for new patients.

DISCUSSION

Because it funds and is the ultimate user of the health care system, the public should clearly have a role in the policy-making process around most health care issues. Public engagement in policy making can lead to better understanding and increase the trust the public has in the health care system. Moreover, in the context of complex, value-laden policy decisions, public engagement can enhance the quality of decisions by bringing to the deliberations the full range of relevant value considerations. A deliberative citizens’ council has been shown to be an effective means of getting informed public input on complicated health policy issues.²³

After 2 days of deliberation, the council members’ position was supportive of the general principle underlying the CPSO’s new policy. It is noteworthy that some council members related stories about how they believed that they or their families had been inappropriately denied access to care. These first-hand cases had a clear role in convincing the council about the need for a firm policy in this area. Council members hoped that the CPSO policy would both reduce the number of cases in which inappropriate screening occurred and decrease the likelihood that patients who were not accepted into a practice would perceive that they were inappropriately barred from that practice. Council members were sympathetic to some of the issues raised by critics of the new policy. All stakeholder groups agreed that the most egregious grounds for screening patients (eg, on the basis of race, cultural background, or sexual orientation) should be and are already prohibited. While agreeing that a first-come, first-served approach is appropriate, the council members also recognized that the CPSO needed to be reasonable in its actual application of the policy.

Conclusion

To the best of our knowledge, the citizens’ council described here represents the first time the Canadian public has been engaged about how physicians should accept new patients. We recognize that our public engagement exercise only involved one group of citizens. Further public engagement is needed to confirm the public’s opinion about how physicians accept new patients, particularly in other provinces where colleges have proposed different policies or which currently lack clear guidance in this area. We do think that the public’s perspective on this issue is important and needs to be represented in formulating appropriate policies. We also hope that our successful example of engaging the public on this issue will encourage further public engagement about policies related to physician practices that have a direct effect on patients.

EDITOR’S KEY POINTS

• Because many Canadians have difficulties in securing regular family physicians, how primary care physicians accept new patients when openings become available in their practices is an important social issue.

• A citizens’ council that examined the College of Physicians and Surgeons of Ontario’s (CPSO’s) policy on accepting patients agreed that a first-come, first-served approach was appropriate for family physicians to use when accepting new patients.

• Counsel members encouraged the CPSO to publicize its policy as widely as possible, so that potential patients who believe they underwent inappropriate screening know what the standards are and can appeal to the CPSO if they wish.

POINTS DE REPÈRE DU RÉDACTEUR

• Comme plusieurs canadiens ont de la difficulté à se trouver un médecin de famille régulier, la façon dont les médecins de première ligne acceptent de nouveaux patients lorsqu’une place se libère dans leur clinique est une question socialement importante.

• Après avoir pris connaissance des politiques du Collège des médecins et chirurgiens d’Ontario (CMCO) au sujet de la prise en charge de patients, un conseil de citoyens a convenu qu’une approche « premier arrivé premier servi » était celle que le médecin de famille doit utiliser pour accepter de nouveaux patients.

• Les membres du conseil ont incité le CMCO à publiciser sa politique le plus largement possible, afin que les patients qui estimeraient ne pas avoir été correctement sélectionnés connaissent les règles existantes et puissent en appeler au CMCO s’ils le désirent.