December 12, 2018

Quick Takes

Episode 2: What all physicians need to know about the new Ontario Ministry of Transportation reporting requirement

[Musical intro]

David Gratzer: Welcome to Quick Takes. My name is Dr. David Gratzer and I am a staff psychiatrist here at CAMH. As you know in July the Ministry of Transportation in Ontario changed reporting requirements. Joining us today to discuss Dr. Brittany Poynter who's Medical Head of our Emergency Services and Associate Chief and Travis Barron who's a resident and medical doctor here at CAMH. Why don't we start by talking about a few cases and how we might approach these cases in our emergency departments or on our inpatient wards or in our outpatient clinics. Does that sound fair?

Brittany Poynter: It sounds good.

 

Travis Barron: Sounds great.

David Gratzer: All right. So, let's look at case one. Young man comes to our emergency department. He has fairly significant psychotic symptoms over the months leading up to that presentation: auditory hallucinations, very concerned about CSIS, very concerned about Donald Trump. And there's no history of substance. What are some things that you guys might think about in terms of whether or not to report? Brittany?

Brittany Poynter: Well, I mean based on the case and the new guidelines I think this is very clearly reportable. He's has acute psychosis. He has abnormalities of perception. He has an untreated illness and it's been going on for quite some time. To me this is a very clear case that would be reportable.

David Gratzer: And the reason for that is, unlike in the past requirements, now there's more of a focus on psychosis.

Brittany Poynter: There's a real focus on psychosis and in fact I polled some of our colleagues who work in schizophrenia and they agree that, for some people's practices, the new requirements would include reporting almost anybody in their practice. For many people with schizophrenia their illnesses are chronic. They have recurring symptoms. Even at best, they suffer with some symptoms of psychosis. And so one would always be mandated to report them.

David Gratzer: Because of that change in the language around transient versus non-transient?

Brittany Poynter: That's right.

David Gratzer: Travis, do you want to weigh in?

Travis Barron: Yes, certainly, and I think Dr. Poynter put her finger on it. This is, based on the clinical scenario given, likely to reoccur. Meaning that it is not distinctly transient and is mandatory to be reported. If this was an acute onset of psychosis, and there was the absence of substance use, one could argue it would be a brief psychotic disorder. And, depending on the clinical picture, you could make the argument it is unlikely to reoccur and would not need to report. But in this instance, I do believe this is concerning for a primary psychotic illness such as schizophrenia based on the [scenario].

David Gratzer: So, to pivot for a bit, if this were a patient who'd come to emergency department with many years of illness, several past hospitalizations, any hesitation on your part to report?

 

Travis Barron: So I think the question is there is less around psychosis and more around what constitutes "acute." When we look at the language in the legislation, insofar as what constitutes acute, we really need to rely on the CCMTA driving documents which are actually built into the legislation. They describe anything acute as change in perception – anything other than baseline, if individuals lack insight into their symptoms – all of those things are signs that there may be an acute psychosis going on.

David Gratzer: So there you would think perhaps a little bit more?

Brittany Poynter: I think if somebody's illness is chronic, and they have recurring hospitalizations, to me that indicates a level of instability and possibly questionable compliance, or adherence to treatment, or treatment that just isn't working, that there's a refractory illness. And I would tend to report in those cases as well.

David Gratzer: The way the requirements are written you would report whether or not your patient had endorsed actually having a driver's license?

Brittany Poynter: That's how it's written.

David Gratzer: So psychosis is handled differently. If we had this conversation a year ago you may have hesitated a little bit more before reporting. Is that fair?

 

Travis Barron: Certainly. The legislation has always been clear insofar as whether or not someone owns a driver's license. You have always needed to report in those instances. That is not new with the new legislation. I think what was happening in the past is physicians were assessing the whole clinical picture – what is the likelihood of this individual getting in a car causing an accident – that sort of thing. And now physicians are really being asked to look at purely the diagnosis, the presence or absence of a diagnosis, and not ask to assess driving risk for example.

David Gratzer: Ok. So, a big change around psychosis. Let's talk about another case. A person comes to emergency department – we're coming to the holidays and perhaps this story's too familiar with us. Alcohol use problems over the years significantly worse. There's job related stress. There's personal related stress. Here's a person who, like many of our patients, has struggled with his substance use and has sought sobriety, and, at points, has done very well, in other points, hasn't really followed up with AA and sister organizations, and he's just done badly. He presents after a two day binge. What are your thoughts about reportability, Brittany?

Brittany Poynter: To me this case isn't as cut and dry as the last case. I think we have to decide what does engagement and treatment mean. And I think that's a pretty subjective term especially when it comes to people with substance use disorders. So 50 percent engagement in follow up appointments, actually among the entire population, might actually be pretty good. For me that's a big question - what does engagement mean? And, for some people, for some providers, it might even be a willingness to attend appointments. Right? That might be considered engagement. That might be enough. I think in this scenario, he has made strides, he's cut down on his drinking, he's very clear on his pattern of drinking, and I would want to speak to the wife to get her sense of whether there's been any risky behaviours. I wouldn't necessarily automatically report.

David Gratzer: Travis?

 

Travis Barron: Well, I agree with Dr. Poynter. There are some questions, particularly around engagement and treatment, and what that constitutes. What is more clear in this scenario is that this does constitute a uncontrolled substance use disorder. According to the CCMTA documents which are built into the legislation, for a substance use disorder to be considered controlled, you need to reach remission and/or twelve months of abstinence – which is clear to not be the case for this gentleman. That being said, if you do decide that this gentleman is relatively engaged in treatment, you still are in a position to make a discretionary report. And we must always be cognizant that the absence of a mandatory duty to report does not mean the absence of a duty to report. So, in that instance, if you ultimately do decide he is participating in treatment, I think speaking to the wife is very, very important. So that you can get a sense for any high- risk driving behaviours, any reason or thought that why you may need to issue a permissive or discretionary report in this instance.

David Gratzer: With substance then, to speak a little bit more succinctly, engagement is something different than we thought of before. But with a case like this what we're also wondering about too is the collateral and what more information we have. There's a little bit of a 'grey' I think in the wording than on the wording over psychosis. Brittany, I know you've spoken to some of our colleagues – and how have they weighed in?

Brittany Poynter: I think there's a real difference in terms of opinions and what constitutes engagement. In the emergency department may be far more likely to report. In fact, I think we always have been far more likely to report, than our colleagues who work with these individuals in our addiction programs. And for some of them, as I said earlier, a willingness to attend appointments would constitute engagement in treatment. So, they may be reporting less frequently now than they were previously.

David Gratzer: So to take a step back, if we talk about the changes around psychosis that seems a lot more clear. Again, there's that 'grey zone' and one can wonder about certain cases. When we talk about substance here, it seems a lot more grey and a lot more open to interpretation. And again, the catch phrase is engagement. Is that fair?

Brittany Poynter: Yeah.

David Gratzer: Both of you agree?

Brittany Poynter: Yeah.

David Gratzer: Fair enough. Let's talk about one last case. We've talked about somebody with substance, and we've talked about engage ability in care. What happens if we take a 27-year-old woman who shows up to the emergency department with opioid use disorder and has never been diagnosed before, though she recognizes she's had this problem for a while and has never engaged in care, but, boy, she's interested in care and detox.

Brittany Poynter: These cases, although they illustrate sort of the challenges, in the emergency department I would gather so many more details. I would gather so much more information to base my decision on. It's really hard for me to comment in this scenario. What I would do I mean I would be wanting to know about. Her driving history, whether she has a car, whether she has a license. I know that's not part of the legislation, but I would still want to know those things. I would want to know. You know has she made attempts to engage in any treatment in the past. How much is she using? How often is she using? Has she had any unintentional overdoses? I would want to speak to somebody from her family or friends – somebody who could corroborate her story and the information she's providing. So, I would only make the decision whether to report or not once I had all of that other information at hand.

David Gratzer: It's complicated.

Brittany Poynter: It's complicated. And I think that in these sort of scenarios, these have huge implications – to revoke somebody's license. And so, we're obligated to do a deep dive into somebody's history and determine, you know this may be a life changing decision that we're making, and so we owe it to them to get as much information as possible.

David Gratzer: Well said. Travis?

 

Travis Barron: You know when it comes to first presentation of a substance use disorder, I think this is one of the instances where the new legislation actually gives physicians tools to help individuals with their long-term recovery. So, when it comes to the law there are clear obligations with mandatory reporting and it doesn't ask you to consider one's driving history. That being said, this is a first-time presentation of a substance use disorder. There is not yet treatment to adhere to, which means you are not in a position to make a mandatory report to begin with. Again, I'll highlight here that the absence of a obligation to make a mandatory report does not constitute the absence of an obligation to report. You must assess whether or not you should issue a permissive or discretionary report at this time. And in those instances, I think there is a huge benefit. To what Dr. Poynter was saying in terms of diving into someone's history, determining any high-risk driving behaviours – are they truly interested in treatment? Is this actually the first time that they've accessed services and looking for help for this? What I myself have been doing, as well as a number of my colleagues in the emergency department, really use this as a as an opportunity to tell individuals that treatment for their substance use disorder is essential and if they don't follow up with treatment recommendations which are made in the emergency department, in the future when they access the health care system, they are going to be reported to the Ministry of Transportation on a mandatory basis.

Brittany Poynter: I think that's always a good idea. Read somebody the riot act and tell them the risks if they continue with their current behaviour.

David Gratzer: Right. And to think about risk not just in terms of the substance but in terms of impact on life like driver's license.

Brittany Poynter: Of course.

David Gratzer: Let's shift gears for a moment and do a rapid-fire minute where we'll talk about some of these things in perhaps a serious, but not overly serious, manner. Can we have one minute on the clock?

David Gratzer: Brittany, is this a big deal?

Brittany Poynter: Yes.

David Gratzer: Has this changed your practice?

Brittany Poynter: Yes.

David Gratzer: How?

Brittany Poynter: I'm reporting more people.

David Gratzer: How many more people do you think?

Brittany Poynter: Good question. I don't know... 25 percent more? 50 percent more? And I'm seeing more people being reported.

David Gratzer: Right – and it's around psychosis? It's around addiction?

Brittany Poynter: That's right. It's around those two issues.

David Gratzer: And those are the issues that that cause you the most stress in terms of interpreting the changes?

Brittany Poynter: For sure.

David Gratzer: What what are you worried about?

Brittany Poynter: I'm worried about inconsistency: in our department, between emergency departments, and among services at CAMH, and how we as a health care providers interpret the legislation.

David Gratzer: What advice would you give to our colleagues?

Brittany Poynter: We need to come together as a team. We have to really go through the new legislation with a fine-tooth comb, as Travis has done, and develop I think some further guidelines to help us.

David Gratzer: And at the buzzer one quick question: is the Ministry of Transportation Deputy Minister off your Christmas card mailing list?

Brittany Poynter: This year.

David Gratzer: Okay, Travis, she did pretty well.

 

Travis Barron: OK.

David Gratzer: Are you stoked?

 

Travis Barron: Yes.

David Gratzer: One minute. Travis, are you reporting more?

 

Travis Barron: I made three Ministry of Transportation reports in all of PGY1. I've made forty five reports in PGY2.

David Gratzer: Are you over reporting, Travis?

 

Travis Barron: I don't think I am over reporting. I do think I am following the legislation to the most literal interpretation of the text.

David Gratzer: And that's fair and you've obviously done a deep dive. But some of our colleagues agree to disagree. What are the cases where you think that they disagree with you the most?

 

Travis Barron: I think when it comes to acute psychosis in particular there's often been a bit of a back and forth in terms of whether or not to report someone as it relates to their likelihood of driving in the future.

David Gratzer: Is this legislation... is this requirement change fair?

 

Travis Barron: I don't think it is, actually. I think the Ministry of Transportation in the old system did very little on their part to actually assess individuals, when it comes to their ability to drive, and with the new legislation they assess individuals even less. And they're asking physicians to make a determination on ability to drive based on the presence or absence of a diagnosis.

David Gratzer: And at the buzzer: Travis do you think this will contribute to stigma?

 

Travis Barron: Without a doubt.

David Gratzer: Thank you guys. And that's Quick Takes podcast on Ministry of Transportation requirements.

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Until next time.