BONUS! In our Double Take bonus episode, CAMH legal counsel, Kendra Naidoo, talks to Dr. Gratzer about the more technical aspects of these changes for substance, psychosis, and suicidal thoughts.
If you have another 8 minutes to spare, and you want to know what the legal department at CAMH has to say about mandatory report, then download our Double Take episode. In it, Dr. Gratzer speaks with CAMH legal counsel, Kendra Naidoo.
In this bonus episode:
View this episode's transcript here Or Download it as a PDF
December 12, 2018
Double Take - Episode 2
Episode 2 Bonus Content: In this clip Dr. Gratzer talks to Kendra Naidoo, Legal Counsel at CAMH, about more technical aspects of these changes for substance, psychosis, and suicidal thoughts.
[Musical intro]
David Gratzer: I'm Dr. David Gratzer and welcome to Quick Takes. On this podcast we're looking at Ministry of Transportation changes and how that influences clinician’s decisions. I'm joined by Kendra Naidoo Legal Counsel here at CAMH. Welcome Kendra.
Kendra Naidoo:Thank you.
David Gratzer: Kendra, what is the change?
Kendra Naidoo: So previously physicians were required to report if a patient was suffering from a condition that made it dangerous to drive. In other words, there was a judgment associated with whether the condition was associated with the risk of driving. Now, the mandatory report has been split into two frameworks. There is a mandatory report if one of six enumerated conditions exists. That report is triggered by the existence of the condition and is not withstanding whether the person is likely to be driving, has a driver's license, or whether there's any danger associated with driving. The second branch of the report is now a permissive report. So even if one of the six conditions doesn't exist, the physician is now permitted to make a report if they believe the person's condition makes it dangerous to drive. The other major change is that the reporting conditions have been expanded to include nurse practitioners and occupational therapists. Nurse practitioners have both the mandatory and the permissive report and occupational therapists now have a permissive ability to report.
David Gratzer: So let's talk about mandatory reporting because I think that'll be the most concerning to our doctors. Big shift in what the ministry is thinking about. Practically speaking, where do you think more reporting is likely to occur?
Kendra Naidoo: Well certainly in the context of those six conditions, two of them. One is psychiatric illness, which requires a report if the person is suffering from acute psychosis currently, currently suffering from severe abnormalities of perception, or currently has a suicidal plan involving a vehicle or an intent to harm others with a vehicle. Because that is no longer necessarily associated with a risk of driving, and it's the mere presence of current acute psychosis that triggers the report, we expect that in psychiatric care settings that will result in an increase in reporting.
David Gratzer: So we're handling psychosis differently. What advice would you give to our clinician colleagues about psychosis then and things to think about?
Kendra Naidoo: Certainly the definition of what constitutes "acute" psychosis continues to be an open question. But we'll have to be thinking about when that threshold is met, as well as importantly, how to discuss this now with patients who may not have been reported earlier but if they're in an acute stage of their illness a report will have to be made, and that can be damaging to the therapeutic relationship. Potentially very impactful on the patient and thinking about how to address that with them.
David Gratzer: So in terms of the six conditions: psychosis we're thinking about differently now. Tell me about suicidal thoughts.
Kendra Naidoo: So now if there's a suicidal plan involving a vehicle, that triggers a mandatory report. That likely is not a significant change. I would have thought that under the previous reporting mechanism if somebody had a suicidal plan involving a vehicle that may have already triggered the previous report, so likely not as significant a change there, but it is important to be aware that if that suicidal plan does involve a vehicle that instantly triggers the mandatory report.
David Gratzer: So two changes you've just outlined: one not so huge, but psychosis is very different.
Kendra Naidoo: It is very different. It used to be, particularly in inpatient settings, if someone came in with an acute illness the question of whether to report could be deferred until prior to discharge because by then the person's condition may have settled and their psychosis may not have been as acute. While they're an inpatient there is typically no risk associated with driving. Because that nexus with risk has been removed from the analysis, upon presentation to the emergency department or an inpatient setting, the physician would be required to make that report even if there was going to be a prolonged inpatient stay.
David Gratzer: Big change.
Kendra Naidoo: Big change. And another secondary change that is equally impactful is that it used to be when a report was made the ministry would investigate and retain discretion but not necessarily revoke the person's license. Now under the new regime, as soon as a report is made, there's an automatic suspension of the person's driver's license and they would have to apply to the ministry to have that license reinstated.
David Gratzer: So a fundamental change in when doctors report. Fundamental change in how the ministry interprets and acts on those reports. Substance is also considered differently now.
Kendra Naidoo: It is. So, substance use disorder is one of the six enumerated conditions. That's defined as an uncontrolled substance use disorder and the person is non-compliant with treatment recommendations. So, both of those conditions have to be met.
David Gratzer: But there's a vagueness about treatment.
Kendra Naidoo: Absolutely. There's a vagueness about what constitutes an uncontrolled substance use disorder. Does that require full or partial remission? Or does it merely require that the person is controlling their use? And they have to be non-compliant with treatment recommendations. But what constitutes a treatment recommendation? And what constitutes non-compliance – is partial compliance sufficient, for example? Those are still open questions.
David Gratzer: It sounds like when one speaks about changes around psychosis and suicidal thoughts that's much clearer under these changes, but when one speaks about substance it's much more open to interpretation.
Kendra Naidoo: It is open to interpretation. Yes.
David Gratzer: What advice would you give to doctors wrestling with these issues?
Kendra Naidoo: Clinical consultation is always helpful. If physicians aren't certain whether something rises to the level, for example, of an acute psychosis. Is this an uncontrolled substance use disorder? Those are areas where consultation with their clinical colleagues may be very helpful. Certainly, in the context of substance use disorder. There is an opportunity there for dialogue with the patient. If when addressing treatment recommendations informing the patient that if they're noncompliant or if their use is uncontrolled a report may have to be made. That may be a vehicle to discussing how to encourage the client to be compliant with their treatment recommendations whatever those are, and a tool to help provide an incentive for patients to comply.
[Rapid fire]
David Gratzer: Let's shift gears for a moment and do a rapid-fire minute on these changes. One minute on the clock? Here we go. Kendra is this a big change?
Kendra Naidoo: It's a very significant change.
David Gratzer: Are we going to see more reporting?
Kendra Naidoo: Absolutely.
David Gratzer: What concerns you about these changes?
Kendra Naidoo: The therapeutic relationship between the physician and the patient, because of the increased reporting, as well as the significant impact on our patients where they may otherwise not have been reported.
David Gratzer: The 'grey' is on substance?
Kendra Naidoo: The grey is on substance as well as what constitutes an acute psychosis.
David Gratzer: And different clinicians could have different interpretations.
Kendra Naidoo: And we have seen that in practice already.
David Gratzer: And you're receiving many questions about this already?
Kendra Naidoo: On at least weekly, if not more, basis.
David Gratzer: Wow. It was not like this before?
Kendra Naidoo: No, not at all.
David Gratzer: Do you think the ministry might revisit or revise?
Kendra Naidoo: I hope so. Certainly, advocacy efforts are underway, and we hope that those will be successful but they do take a long time.
David Gratzer: If you were to talk to the deputy minister tomorrow what would you say?
Kendra Naidoo: I would ask them to reconsider the impact this has on physician practice, on patients, as well as on whether people will continue to seek out care if their driver's license may be revoked.
David Gratzer: At the buzzer, one last question. Are you losing sleep over this?
Kendra Naidoo: I am. I think we all are.
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Until next time.