College registrants are reminded that providing after-hours (outside of regular office hours) coverage is both a professional and legal imperative. This responsibility is part of the common law duty of care and is outlined in the College’s Care Coverage Outside Regular Office Hours practice standard.
In jurisdictions subject to common law (all provinces and territories except Quebec), the duty of care imposes a legal obligation on registrants within the context of the patient-physician relationship, and includes the duty to make referral or coverage arrangements when they are not available to treat the patient. This is outlined in the CMPA’s Medico-legal handbook for physicians in Canada.
The practice standard is clear in stating that all registrants involved in treating patients are required to ensure ongoing medical care. This means that ongoing medical care is not only the responsibility of family physicians, but also of specialists who are involved in the treatment of patients. The requirement for on-call coverage does not oblige a registrant to provide in-person care to patients. A virtual consult is acceptable.
Registrants must ensure that their patients are aware of the on-call or after-hours coverage that is available to them for urgent matters that arise out of care provided. Recorded voice messages should provide callers with contact information for a registrant who has agreed to provide coverage. Some registrants fulfill this obligation by providing their personal cell phone numbers and cover the practice themselves, while others in groups normally ensure that someone is designated to field phone calls, usually as part of an on-call rotation.
Where group call is not feasible, such as the situation of solo specialists in small communities, registrants must make clear arrangements with other colleagues to ensure that their practice is covered when they are not available. In such cases, a shared care model is required, where the consultant’s involvement is contingent on referring physicians and colleagues providing the after-hours coverage. It is also acceptable to have calls managed initially by a first-tier responder (such as an advanced practice nurse or even a lay answering service), but only as part of an established protocol. Registrants must be immediately available to the first responder.
Registrants may assign on-call coverage to groups of colleagues or to local emergency departments if all parties have agreed to this arrangement in advance. All registrants who are part of the agreement must be willing to accept calls from colleagues’ patients while on duty in the emergency department. It is not appropriate to leave a message for patients telling them to go to an emergency department for after-hours, non-urgent care if this has not been arranged with and agreed to by the physicians and surgeons in the emergency department. Registrants must understand that the patient is the one who determines the urgency of their situation. Urgent care is meant to address same-day issues that are not life-threatening (such as post-procedure complications, adverse reactions to medication, or worsening medical symptoms that were previously deemed worthy of watch and wait advice), while emergent issues are considered life-threatening (such as difficulty breathing, a life or limb injury, or signs of stroke or heart attack).
On-call availability is also required to manage inquiries from pharmacists who may have questions about a prescription that has been issued to a patient or from pathologists and radiologists who may have critical test results that need immediate attention. Patients whose care needs immediate attention should be directed to an emergency department and it is expected that the attending physician will provide a “hand-over” of relevant medical information to the physician in the emergency department.
It is, of course, always acceptable for registrants to direct patients with emergencies requiring immediate attention to call 9-1-1, and to inform patients that they have the option to call the provincial health advice line at 8-1-1 to receive general health advice.
Clear communication is key. Patients, their families, other health professionals in the circle of care, laboratories, imaging facilities, hospitals and others must be informed of coverage arrangements—that is, how to “ensure ongoing medical care.” While the College receives very few complaints from patients unable to contact their physician after hours, laboratory directors, radiologists, hospital-based physicians, home nurses, and pharmacists frequently call with concerns that they cannot reach the treating physician.
In the event of a complaint alleging harm to a patient due to inadequate after-hours coverage, the task of the Inquiry Committee (established by the Health Professions Act to investigate complaints) is to assess registrant compliance with the relevant standard.
Questions related to after-hours care may be directed to communications@cpsbc.ca.
Heidi M. Oetter, MD
Registrar and CEO
Comments on this or any other article published in the College Connector can be submitted to the communications and public affairs department at communications@cpsbc.ca.
