CMPA: Practically Speaking

Contingency planning for the unplanned absence from practice

Episode Summary

Retirement, parental leave, illness, moving to a new practice – what considerations should be made when taking an unplanned leave of absence? This episode looks at the importance of planning for the unforeseen, and ensuring patients’ continuity of care is at the forefront of those arrangements.

Episode Notes

Related CMPA Perspective article:

Closing or leaving a practice: Tips for primary care physicians

https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2020/closing-or-leaving-a-practice-tips-for-primary-care-physicians

Episode Transcription

Announcer: You're listening to CPMA, Practically Speaking.

Dr. Steven Bellemare: Hello everyone. Steven Bellemare here.

Dr. Yolanda Madarnas: And Yolanda Madarnas. Welcome to today's podcast, which builds on the article about leaving or closing a practice. The principles we touch on today are really going to go well beyond retirement and are applicable to short-term and longer-term absences from a practice, like parental leave or illness, moving to a new practice, or the foreseen departure that's left until the last minute to coordinate.

Steven: In fact, all of these scenarios highlight the need for physicians to maintain continuity of care, and they're applicable to family medicine, as well as specialty medicine, community, or hospital settings, so all of us really.

We need to get into the habit of planning for the unforeseen to happen.  Let's not bury our heads in the sand here.

Yolanda: This takes us to three take-away messages today. Continuity of patient care is the underlying premise,

Steven: It's a good first one.  As a second one, I'd say that having a written agreement when joining a group or clinic can be a lifesaver.

Yolanda: Thirdly, collaborate with colleagues proactively about a plan.

Steven: Let's start with continuity, Yolanda.

Yolanda: Contingency plans for leaving a practice are best made early, at the time you enter into the practice.

Steven: For issues such as who will provide coverage for you when you're off, for instance.

Yolanda: Specifically, who's going to see your patients?  Who is going to follow-up on test results when you're not there?

Steven: As well as who will be the custodian of the medical records, and who will continue to have access to these once you leave?

Yolanda: But collaboration and having a contract or agreement are actually two different things.

Steven: Right.

Yolanda: But both do have a role, don't they?

Steven: Ideally, all of these situations that we just mentioned are spelled out in a written agreement.  I'm sure you've spoken to people on the phone about these situations.

Yolanda: Yeah.  The reality though is that more often they're not - there is no such agreement, certainly not one in writing.  It's an informal gentleman's agreement, not even with a handshake these days, and without an agreement, physicians needing to leave a practice experience way more stress and headaches than needed.

Steven: Right, Yolanda.  You know, I don't want us to be too preachy here, right, but good planning is really worth the investment, isn't it?

Yolanda: Absolutely.  You can look at it as a way of contributing to your self-care.

Steven: That's right.  Planning ahead of time will actually make the issue of leaving practice so much easier for you.

Yolanda: Let me give you an example here of a typical call might be from a physician who is expecting and had planned her maternity leave effective on a particular date, but due to medical complications during the pregnancy, now has to leave several months earlier than planned.  Having an agreement in place to fall back on was invaluable when she was no longer in the mental headspace to deal with handing over her practice.

Steven: Alright now.  Hold on here. I know your listeners are thinking, wow, I did not know CMPA could help me with my contracts.

Yolanda: No.

Steven: No, we don't, but your provincial, territorial medical associations might be able to provide you some advice on how to construct such a contract, such an agreement.

Yolanda: Even in the absence of a written agreement, the key is to collaborate with your group leadership and your colleagues, and having a formalized shared plan or mindset regarding the follow-up of test results and ongoing patient care.

Steven: That might be done through securing a locum or a colleague to cover an unexpected leave from your practice, but if that's unsuccessful, and that's not infrequent, right?  There are a number of things that we need to consider.

Yolanda: Let's get back to the basics.  It's about taking steps to ensure continuity of care for your patients.

Steven: That could be, for example, summarizing the case of more complex patients using your accumulative patient profile.

Yolanda: I know your colleagues will really appreciate this, and your patients are likely to benefit as well.

Steven: You know that keeping an accumulative patient profile is actually a requirement in most provinces in the country, so that actually gives you a reason to do it and to keep it up to date, right? 

What about the doc who practices in a solo practice?

Yolanda: That is a challenge, and although it is a less common scenario, it is still a reality out there for many of our colleagues.  At the very least, I'd suggest that we consider developing an alliance with another solo physician, for instance, and agree ahead of time to help each other out in a pickle.

Steven: I think we can't overemphasize that a bit, agree ahead of time, because when you're very stuck at the last moment, and you need someone, that’s of course when you're having - you're going to have the difficulties finding someone to help.

Yolanda: That's the default unfortunately where many patients wind up going to either a walk-in clinic or the emergency department.

Steven: Which isn't ideal, but, you know, can help meet the needs of some patients who really need access.  Access to and transfer of your medical records then needs to be considered for sure.

Yolanda: This is definitely a problem in solo practice, and to a lesser extent in a group practice where there's someone there even if you're not who could grant access to the patient or a provider.

Steven: Having a plan for communication about your absence and about how to access healthcare is going to be a big part of this.

Yolanda: Let's get back to the CPP summary.  I think that your office might be able to provide a copy of this to your patients during your absence, so that they can take it with them wherever they seek care, remembering the patient is often a vehicle that we can leverage to assist in their own care.

Steven: For that to happen, Yolanda, a very simple step that people may not have thought of is the importance of letting your office staff know that an accumulative patient profile exists on charts for people to access if you were to not be available.  That's especially important for patients who are being actively investigated or treated.

Yolanda: To reiterate, it is important to try to engage our patients in their own care, so they understand not only the need for follow-up but the appropriate access points in the healthcare system during our absence.

Steven: This is not something that you'll be able to do if you're suddenly ill.  Your staff needs to understand the importance of this aspect so they can do it for you on their own without your direction.

Yolanda: This intends to rely on administrative staff in the office who remain during your absence. That's part of planning for continuity of our administrative staff, and it is important. They really can be the glue that helps keep this all together during an absence.

Steven: You know to this effect, Yolanda, some physicians actually have office overhead insurance that might actually be able to help with this kind of contingency planning.  It's part of your financial planning, isn't it?

Yolanda: It is indeed, and it would be money well spent, I think.

Steven: Okay, so that kind of covers the unanticipated temporary absence from a clinic or from an office, but, Yolanda, what if we're not planning to come back, as in, that's it.  I'm closing my practice.  What do we do then?

Yolanda: One place to start is to consider the records and the custodianship of those records.  It's generally not an issue when the clinic or the facility is the custodian of the records, as they shoulder those responsibilities and not the physician. The bigger issue is when the physician is the custodian of the records.

Principles that apply here is that the patient can have a copy of the record but not the original.  The physician remains the custodian of that original and must do so for the required period of time according to the regulatory authority.

Steven: Right, so those do vary across provinces, and we would recommend that you consult your college guidelines or give us a call at the CMPA so that we can tell you how long to keep these records.  They typically can't just stay in your basement.

Yolanda: These retention periods vary from five to ten years in most jurisdictions.  Our recommendation is that you keep them for the minimum requirement dictated by the college, and for minors, there are also requirements to keep them for a set period of time, often ten years past the age of majority.  In fact, it's probably wise to keep records indefinitely, considering that there's no limitation period, for example, in college complaints, and it is extremely challenging to defend a physician who's involved in a college complaint when there is no medical record to speak to the care.

Steven: There are some cases that we do see from time to time where patients can make complaints to the college 15, 20 years after the fact, especially when they're concerned about the nature of the relationship that they had with their physician.  When there's no medical records anymore, it makes it a much more complicated issue to explain what went on.

Yolanda: It becomes a he said, she said when there's no record to speak to what took place.

Steven: Is there more to consider do you think, Yolanda, around permanently leaving an office, or for a very long period of time?

Yolanda: Looking after ourselves is important, and it is okay to take a break.  There might be requirements to notify your regulatory authority or college in the case of a prolonged absence, but really these are very specific scenarios, and they are too complex to be simplified in a podcast.  Our suggestion would be, please call us, because there are many, many issues to consider before taking specific action.

Steven: Right, and by all means, this podcast doesn't cover all the aspects of closing a practice, but it's a place to start.

It's time to wrap up already, Yolanda.  How about a communication tip for our listeners?

Yolanda: Let's remember that the patient is potentially a valuable partner in this transition.  Giving them a copy of their record, or their CPP will help their new provider deliver more informed care.

Steven, how about a documentation tip to finish up?

Steven: Well, I think that it's really valuable to have a written policy for your office, to ensure your staff remembers to deal with all these issues that we talked about.  Things like informing patients, informing colleagues, and the referral base, and informing your local hospitals, and the pharmacies of your absence.  Keeping a log of who's been informed and how. These things can be done with signs in your office, by sending emails, leaving voicemail messages, or posting on your websites.  Even letters sent to specific groups that may be more at risk, but the bottom line is these things have to be considered ahead of time.

Yolanda: Well, that's all for today.  We hope you've enjoyed this podcast.

Steven: I hope you forgive me for sounding preachy, but it does come from the heart.

Yolanda: It really does.  Just a quick reminder as well that we would love to hear from you, our listeners, if you have any questions, comments, or program ideas, we would love to hear from you.

Steven: Email us at podcasts@CMPA.org.

Yolanda: I'm Yolanda Madarnas.

Steven: I'm Steven Bellemare.

Yolanda: Remember, when you change the way you look at things.

Steven: The things you look at, change.

Yolanda: Goodbye.

Steven: Bye-bye.

Announcer: These learning materials are for general educational purposes only and are not intended to provide professional medical or legal advice, nor to constitute a standard of care for Canadian healthcare providers.