Canadian Medical Protective Association Research Articles

Preventing medical malpractice in mid-20th-century Canada: CMPA and its approach to concerns about varicose vein treatments.

The founding of the Canadian Medical Protective Association (CMPA) in 1901 was pivotal to Canadian medical malpractice law. At first, the CMPA was a small mutual defence organization that pooled membership fees to cover the costs of physicians facing malpractice litigation. In its early days, the

Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery.

Retrospective descriptive study. The aim of this study was to describe closed medicolegal cases involving physicians and spine surgery in Canada from a trend and patient safety perspective. Spine surgery is a source of medicolegal complaints against surgeons partly owing to the potential severity of associated complications. In previous medicolegal studies, researchers applied a medicolegal lens to their analyses without applying a quality improvement or patient safety lens. The study comprised a 15-year medicolegal trend analysis and a 5-year contributing factors analysis of cases (civil legal and regulatory authority matters) from the Canadian Medical Protective Association (CMPA), representing an estimated 95% of physicians in Canada. Included cases were closed by the CMPA between 2004 and 2018 (trends) or 2014 and 2018 (contributing factors). We fit a linear trend line to the annual rates of spine surgery cases per 1000 physician-years of CMPA membership for physicians in a neurosurgery or orthopedic surgery specialty. We then applied an ANOVA type III sum of squares test to determine the statistical significance of the annualized change rate over time. For the contributing factors analysis, we reported descriptive statistics for patient and physician characteristics, patient harm, and peer expert criticisms in each case. Our trend analysis included 340 cases. Case rates decreased significantly at an annualized change rate of -4.7% (P = 0.0017). Our contributing factors analysis included 81 civil legal and 19 regulatory authority cases. Most patients experienced health care-related harm (89/100, 89.0%). Peer experts identified intraoperative injuries (29/89, 32.6%), diagnostic errors (14/89, 15.7%), and wrong site surgeries (16/89, 18.0%) as the top patient safety indicators. The top factor contributing to medicolegal risk was physician clinical decision-making. Although case rates decreased, patient harm was attributable to health care in the majority of recently closed cases. Therefore, crucial opportunities remain to enhance patient safety in spine surgery.Level of Evidence: 4.

College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017

Background:An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA).Methods:We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100 000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians.Results:Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017. While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013–2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient–physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism.Interpretation:Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.

Anesthesiology Airway-related Medicolegal Cases From the Canadian Medical Protection Association

(Can J Anesth. 2021;68:183–195) The practice of anesthesiology has changed dramatically over the years, with new technology and updated strategies to manage and improve patient safety. The continual evaluation of patient outcomes and the development of protocols and guidelines help to further evolve the practice. One area worth reviewing is airway management. Anesthesiologists can learn from critical incidences described in malpractice cases to inform initiatives that drive patient safety. The aim of this paper was to describe closed claims legal cases involving anesthesiologists and airway-related management in Canada.

Physician Burnout in Canada: Challenges and Possible Future Interventions

Background: Physicians are the backbone of the health-care industry, and the state of their well-being significantly influences the productivity, financial conditions and overall performance of the health care system. The objectives of this literature review are to highlight the challenges posed by physician burnout to the Canadian health care system and suggest possible recommendations to reduce this burnout. Methods: Database searches were conducted to study the effects of physician burnout on the health care system. Websites of organizations like the Canadian Medical Association, Canadian Medical Protective Association, Canadian Collaborative Centre for Physician Resources and Medical Council of Canada were searched. Research papers from Canada, the United States, Europe and Hong Kong were assessed to support the existence of burnout among physicians in Canada and globally. Results: Burnout affects the Canadian health care system in terms of estimated cost, patient safety, productivity, performance, COVID-19 pandemic response and future medical workforce supply. It was found that the level of physician burnout is increasing notably among the Canadian workforce, with the COVID-19 pandemic adding more stress to the situation. The costs of burnout rendered to the health care system are continually increasing each year in Canada. Many physicians across the world are considering retiring early, while others are considering quitting the profession altogether, adding to the pressure already imposed on the physicians remaining in the system. Recommendations to reduce burnout among physicians from the literature were studied as part of this review. Conclusion: Physician burnout has several negative impacts on the health care system. This literature review provides a concise overview of the major challenges posed by burnout among Canadian physicians. It will help contribute to plans and strategies to reduce physician burnout in the future.

Medico-legal Closed Case Trends in Canadian Plastic Surgery: A Retrospective Descriptive Study.

Background:To enhance patient safety and prevent medico-legal complaints, we need to understand current trends and impacts. We aimed to characterize Canadian plastic surgery medico-legal patterns in many dimensions.Method:This retrospective descriptive analysis of Canadian Medical Protective Association data between January 1, 2013 and December 31, 2017 included closed regulatory body complaints and civil-legal actions involving plastic surgeons. We excluded class action legal cases and hospital complaints. We collected data on patient allegations, procedure types, healthcare-related patient harms, and peer expert criticisms. The primary outcome of interest was physician medico-legal outcome.Results:We found 414 cases that met the inclusion criteria: 253 (61.1%) cases involved cosmetic procedures and 161 (38.9%) noncosmetic procedures. The annual incidence among plastic surgeon members of regulatory body complaints and civil-legal actions was 12.1% and 6.7%, for a combined incidence of 18.8%. The most common allegations were deficient clinical assessment, inadequate informed consent, delayed or misdiagnosis, and inadequate monitoring. Leading contributing factors were physician–patient communication breakdown, deficient clinical judgments, and inadequate documentation. The top procedural complications included cosmetic deformity, poor scarring, upper extremity stiffness or deficit, major structural injury, and mental health disorder. Less than half of cases (198/414, 47.8%) had unfavorable medico-legal outcomes for the surgeon. Patients were compensated in 86/198 (43.4%) of civil-legal cases.Conclusions:Plastic surgeons experience more medico-legal complaints for cosmetic versus noncosmetic procedures. To minimize medico-legal risks, plastic surgeons should focus on strong physician–patient communication, patient education/consent, thorough clinical assessment, minimizing potentially preventable complications, and maintaining relevant documentation.

Canada's System of Liability Coverage in the Event of Medical Harm: Is It Time for No-Fault Reform?

Many Canadians believe that physicians have malpractice insurance via the Canadian Medical Protective Association (CMPA). However, the CMPA is not an insurance company; it is a defence fund for physicians and has no obligation to compensate all claimants. CMPA expenses have increased nearly tenfold in 30 years and although public budgets support the majority of CMPA fees, less than 0.3% of injured patients receive compensation. A reform of the system is vital. Several developed countries have adopted a “no-fault” system to provide more equity and transparency and to ensure that the majority of funds go directly to injured patients rather than toward the payment of legal and administrative fees.

Soft Tissue Filler Therapy and Informed Consent: A Canadian Review.

Soft Tissue Filler (STF) Therapy for cosmetic facial rejuvenation is associated with known complications. The manifestation of these known complications can lead to patients commencing civil litigation actions or making complaints to provincial regulatory authorities and alleging that the practitioner failed to obtain the patient’s informed consent to the therapy. Data provided by the Canadian Medical Protective Association (CMPA) on medical-legal cases arising from the provision of STF therapy between 2005 and 2019 are presented. Select reported case law decisions from Canadian courts and regulatory bodies addressing the concept of informed consent are reviewed. Insights about the risk factors pertaining to the process of obtaining informed consent for STF therapy are presented to increase an understanding of the elements of communication and documentation needed to ensure patients are aware of the consequences of this treatment.

The right to privacy of patient medical images in Iranian (Islamic) and Western law

The use of images taken by the physician during the treatment and care of the patient can endanger the patient's privacy and image rights and lead to the disclosure of the patient's identity. The right to privacy of the patient's image therapy in the legal field is included in the category of the right to personality and in the realm of Islamic law is in the category of the sin against mankind. On the other hand, these images provide a unique opportunity for physicians in education and research. Given that based on the rights of persons to their image, no one can take a photo or video without the consent of a person, today, some domestic legal systems provided the correct Conditions to use patient images to protect patients' rights and prevent possible disputes between physician and patient. Non-disclosure of patient identity, informed consent, and safe maintenance are the three main conditions in using patient images. According to the necessity of finding the right to privacy of patient medical images, the present study aims to achieve the principles and criteria of protection of this right For legislation in Iran, Through descriptive-analytical method, Reviewing and analyzing the results of scientific theories and legal attitudes of international centers such as the International Committee of Medical Journal Editors and the Canadian Medical Protective Association has considered and Western countries such as Australia, England, and Canada.

ICRE Abstracts: Quality Improvement

ICRE Abstracts: Quality Improvement

Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

BackgroundEvidence-based campaigns are available to support appropriate diagnostic testing in cardiology, but medico-legal concerns can impede implementation. MethodsWe conducted a retrospective descriptive analysis of medico-legal cases (civil legal, regulatory authority, hospital matters) involving cardiologists in Canada. For eligibility, cases must have closed at the Canadian Medical Protective Association between January 1, 2009 and December 31, 2018. We defined test underuse and overuse using criticisms in the medico-legal record from peer experts, regulatory authorities, or hospitals. We used a contributing factors framework and descriptive statistics for analysis. ResultsFrom 2009 to 2018, the Canadian Medical Protective Association closed 60,598 cases with 368 (0.6%) involving a cardiologist. Within those cases, there was no criticism of cardiac diagnostic test overuse and 15 cases (4.1%) with criticism of underuse (tests not ordered, not expedited, delayed). In 12 of 15 cases of underuse (80.0%), the patient experienced severe harm or death. Of 8 civil legal cases, 6 were decided in favour of the plaintiff (75.0%) and 2 were dismissed by consent before proceeding to trial (25.0%). Decisions on regulatory authority matters did not favour the cardiologist (7 of 7 cases). In all cases of underuse, there was need for focused testing to investigate new or worsening symptoms. The most common contributing factors included clinical decision-making, situational awareness, and communication with teams and patients. ConclusionsMedico-legal cases involving cardiologists and the overuse or underuse of cardiac diagnostic tests were extremely rare in Canada, despite the potential for harm. The criticisms of cardiac diagnostic test underuse related to issues with diagnosing symptomatic patients.

Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association

PurposeWe analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern.MethodsWe included all airway-related civil legal cases involving specialist anesthesiologists that closed from 2007 to 2016. The following variables were abstracted by CMPA medical analysts: clinical context, peer expert opinions of contributing factors, and patient and legal outcomes.ResultsWe found 46 of the 406 (11%) closed cases involving anesthesiologists to be airway-related. Twenty-six cases (57%) involved elective surgery and 31 patients (67%) were categorized as American Society of Anesthesiologists physical status III. Twenty-five cases (54%) occurred outside the operating room (e.g., postanesthesia care unit, intensive care unit, or other satellite locations). In 19 (42%) cases, there was at least one predictor of a difficult airway. Peer experts identified judgement failures in 30 cases (65%), most commonly inadequate airway evaluation. In 30 cases (65%), the patient died or had a permanent brain injury. The medicolegal outcome favoured the patient in 27 (59%) cases, with a median [interquartile range] payment of 422,845 [257,637-935,673] CAD.ConclusionsSevere patient harm is common when airway management is the focus of a CMPA medicolegal complaint involving anesthesiologists. Patients were otherwise typically low risk cases presenting for elective surgery. Failure to assess or to change management based on the airway exam or encountered difficulty were the most common errors. Our findings support the continued need for adoption, adherence, and practice of guidelines for anticipated and unanticipated difficult airway management for every patient encounter.

The medico‐legal helpline: A content analysis of postgraduate medical trainee advice calls

Available literature exploring medical liability and postgraduate medical education consistently posits that postgraduate trainees worry about their exposure to medico-legal liability. This assumption has formed the basis for research and curriculum development. The aim of this study was to describe the encounters that lead physicians-in-training to seek external medico-legal guidance. We sought to provide empirical evidence on trends and themes related to medico-legal advice requests from physicians-in-training. Our primary dataset consisted of records of calls from physicians-in-training to the medico-legal helpline of the Canadian Medical Protective Association (CMPA), a national mutual defence organisation providing medico-legal advice and liability protection for over 95% of Canada's physicians. We conducted a trend analysis of the frequency of calls for advice over 10years from physician-in-training compared with non-trainee physicians. Furthermore, we performed a content analysis of calls made over the most recent 2years (2016-2017) to elucidate the concerns that led to trainees seeking medico-legal advice. The 10-year trend analysis revealed that the annual growth in the number of physician-in-training advice calls (8.8%) exceeded other CMPA physician groups and was in excess of trainee population growth over the same period. The content analysis identified four core themes: managing confidential information, complex care situations, academic matters and patient safety incidents. Our findings indicate that trainees are asking questions about their medico-legal liability with increasing frequency. This study contributes new evidence on the issues that lead to trainees seeking help. We believe that understanding trainees' medico-legal advice requests will support medical educators to tailor quality improvement education to learners' needs.

&lt;p&gt;Peri-Operative Patient Safety – An Interactive Workshop for Section 3 CPD Credits Developed in Collaboration with the CMPA&lt;/p&gt;

BackgroundThe Royal College of Physicians and Surgeons of Canada requires physicians to collect credit in continuing professional development courses including Section 3 credits which require feedback and self-assessment. This study aims to examine the effectiveness of offering Section 3 credits in a conference setting using an interactive workshop on peri-operative patient safety developed in collaboration with the Canadian Medical Protective Association (CMPA). Both the knowledge gained and the attitudes towards the conference were analysed.MethodsThis was a pre/post-test study design. An interactive case studies workshop was implemented on medicolegal issues for patient care, before, during, and after surgery at the Canadian Society of Otolaryngology Head and Neck Surgery annual meeting. The workshop used small group and large interactive group educational strategies to gauge knowledge of both pre and post cases. Participants completed a questionnaire at the end of the workshop comparing their attitudes before and after the workshop.ResultsThere were 22 participants in the workshop. A little over half knew the requirements for Section 3 CPD credits (58%) but only 36% knew how to obtain them. The data demonstrated with 95% confidence intervals, statistically significant improvement in how participants felt about their ability to identify at-risk behaviours in surgical practice (2.10 to 2.90, 3-point Likert, p<0.001), to analyze the impact of at-risk behaviour on patient care (1.95 to 2.65, p<0.001), and to develop strategies to address at-risk behaviours in surgical practice and improve patient care (1.95 to 2.80, p<0.001). One hundred percent of participants felt similar workshops should be included in future annual meetings, and 94% felt that future meetings should include more opportunities to obtain Section 3 credits.ConclusionThis study demonstrates the effectiveness of an interactive workshop in a conference setting to fulfill the need for Section 3 continuing professional development credits.

MP40: What are the factors contributing to medico-legal risk of procedural interventions performed by physicians practicing emergency medicine?

Introduction: Physicians who practice emergency medicine (EM) often perform procedural interventions, which can occasionally result in unintended patient harm. Our study's objective was to identify and describe the interventions and contributing factors associated with medico-legal (ML) cases involving emergency physicians performing procedural interventions. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, ML organization which represented over 99,000 physicians at the time of this study. We extracted five years (2014-2018) of CMPA data describing closed ML cases involving procedural interventions (e.g. suturing, reducing a dislocated joint) and excluding interventions related to pharmacotherapy (e.g. injection of local anesthetic), diagnosis (electrocardiograms) and physical assessments (e.g. ear exams), performed by physicians practicing EM. We then applied an internal contributing factor framework to identify themes. We analysed the data using descriptive statistics. Results: We identified 145 cases describing 145 patients who had 205 procedures performed in the course of their EM care. The three most common interventions were orthopedic injury management (47/145, 32.4%), wound management (43/145, 29.7%), and Advanced Cardiac Life Support (24/145, 16.6%). Out of 145 patients, 93.8% (136/145) experienced a patient safety event, and 55.9% (76/136) suffered an avoidable harmful incident. One quarter of patients suffered mild harm (34/76, 25.0%), 18.4% of patients died, 14.5% suffered severe harm, and 13.2% moderate harm. Peer experts were critical of 86/145 cases (59.3%) where the following provider contributing factors were found: a lack of situational awareness (20/68, 29.4%), and deficient physician clinical decision-making (54/68, 79.7%). Clinical decision-making issues included a lack of thoroughness of assessment (33/54, 61.1%), failure to perform tests or interventions (21/54, 38.9%), and a delay or failure to seek help from another physician (17/54, 31.2%). Peer experts were also critical of 48.8% of cases containing team factors (42/86) due to deficient medical record keeping (26/42, 61.9%), and communication breakdown with patients or other team members (25/42, 59.5%). Conclusion: Both provider and team factors contributed to ML cases involving EM physicians performing procedural interventions. Addressing these factors may improve patient safety and reduce ML risk for physicians.

P030: Assessment of lab results on emergency department patients that leave without seeing a physician

Background: Most emergency departments (ED) utilize medical directives to initiate lab investigations for patients prior to physician assessment. This practice facilitates expedited patient care in the ED, resulting in safer and efficient care. However, some patients choose to leave the ED prior to seeing a physician due to prolonged waiting. Previously, at our hospital there was no defined process for identifying and following up on abnormal test results on patients that leave without being seen (LWBS), resulting in lab results often not being reviewed by a nurse or physician. Aim Statement: By April 2020, we aim to have 90% of ED LWBS patients with abnormal results identified and followed up. Measures &amp; Design: A series of consultations and information gathering occurred that included an environmental scan of other EDs and discussions with emergency nurses, emergency physicians, Risk Management, Legal Department, College of Nurses of Ontario and Canadian Medical Protective Association. A process map was developed collaboratively to standardize the process to identify and follow up on abnormal investigations of LWBS patients and a new hospital policy was developed to officially outline this process. The following are the family of measures: Outcome measure – % LWBS patients with abnormal tests that had follow-up documented in chart Process measure – Number LWBS patients with investigations initiated by medical directive, Number LWBS patients, % LWBS patients Balancing measure – Satisfaction of nurses with new process for LWBS patients Evaluation/Results: At baseline, 29% of LWBS patients with abnormal lab results had follow up documented in the chart. After implementation of the new standardized process and policy, the follow up rate of LWBS patients with abnormal results in August, September and October 2019 was 47%, 28% and 29% respectively. Discussion/Impact: These results indicate that standardization and new policy implementation is insufficient to change practice, even one that aims to provide safer patient care. Nevertheless, these interventions are important first steps to improving the safety for ED LWBS patients. We plan to implement an audit and feedback approach to encourage nursing staff to routinely check lab results on LWBS patients.

LO66: Strengthening team communication may decrease medico-legal risk for physicians in the emergency department

Introduction: In a busy emergency department (ED), effective communication is integral to the provision of safe medical care. Physicians working in the ED interact with multiple team members including patients, allied healthcare professionals and other physicians, who all need to understand their verbal and written instructions. Our study's objective was to identify and describe communication problems occurring in the ED setting, and how these problems contributed to patient safety events and increased medico-legal risk for physicians. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, medico-legal organization which represented over 97,000 physicians at the time of this study. We conducted a retrospective descriptive analysis where we extracted five years (2013-2017) of CMPA data describing closed medico-legal cases occurring in the ED involving physicians (any specialty) who experienced complaints due to communication issues. We then applied an internal contributing factor framework to identify data themes. Data were summarized using descriptive statistics. Results: We identified 517 eligible cases involving 521 patients (some cases involved &gt;1 patient). We found that 99.8% (520/521) of patients experienced some form of healthcare-related harm in the ED. Specifically, there was poor communication between: the physician and patient or patient's family (202/517, 39.1%); two or more physicians (79/517, 15.3%), and physicians and other healthcare providers (55/517, 10.6%). Inadequate documentation was observed in more than half of the cases (324/517, 62.7%) and poor team communication affected physicians’ decision making process (326/517, 63%) in areas such as deficient assessments, inadequate investigations, failure or delay to attend to the patient, and disposition decisions. Conclusion: Team communication issues are prevalent among physician medico-legal cases occurring in the ED. Efforts to strengthen communication skills may enhance patient safety and reduce medico-legal risk.

Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases.

Few empirical studies have validated the relation between medicolegal risk and hospital patient safety performance. We sought to determine whether there was a relation between in-hospital patient safety events and medicolegal cases involving Canadian physicians. In this ecological study, we used Poisson regression to compare data from the Canadian Institute for Health Information's Discharge Abstract Database and the database of the Canadian Medical Protective Association (CMPA) of medicolegal cases over 10 years (2005/06 to 2014/15). We identified incidents and cases based on 15 Agency for Healthcare Research and Quality patient safety indicators within the Canadian Institute for Health Information and CMPA data sets. We performed subgroup analyses for obstetrical and surgical cases. We found a statistically significant positive association between volume changes in patient safety indicator events (n = 339 741) and medicolegal cases (n = 15 180) (parameter estimate 1.15, 95% confidence interval [CI] 0.4 to 1.9). This association suggests that, on average, a 10% decrease in events would correspond to a decrease of 11% in medicolegal cases. The degree of positive association varied by practice type, with obstetrics (97 982 patient safety indicator events, 865 cases) showing a 25% decrease in medicolegal cases for every 10% decrease in events (parameter estimate 2.9, 95% CI 0.5 to 5.3) and surgery (168 886 patient safety indicator events, 4568 cases) showing a decrease of 9% for every 10% decrease in events (parameter estimate 0.9, 95% CI 0.2 to 1.7). The statistically significant positive association between patient safety indicator events and medicolegal cases quantifies a relation between patient safety and physician medicolegal risk in Canadian hospitals. This suggests new, practical uses for both medicolegal and patient safety indicator data in system-level quality-improvement efforts.

To err is human: A case-based review of cognitive bias and its role in clinical decision making

To err is human: A case-based review of cognitive bias and its role in clinical decision making

Uninsured Maternity Patients in Calgary: Local Trends and Survey of Health Care Workers.

Uninsured maternity patients comprise a small but complex group of patients and include marginalized Canadians, undocumented immigrants, visitors, and non-Canadians seeking health care and/or citizenship for their newborn. This is the first Canadian study to quantify these patients and to review health care providers' perspectives and practices of care. Data for all deliveries in Calgary, Alberta over a 4-year period (2013-2016) were analyzed. All Calgary anaesthesiologists, family physicians, midwives, neonatologists, obstetricians, and pediatricians were surveyed about their care of these patients, ethical perspectives, and knowledge of liability protection when providing such care. This study found a trend of uninsured deliveries in Calgary (from 0.5% in 2013 to 0.8% in 2016; P < 0.0001) that is accounted for by non-Canadian patients. Midwives and physicians agree on provision of emergency care but not preventive care. Across medical specialties, fewer caregivers felt obliged to care for non-Canadian patients seeking citizenship for their newborn. Among physicians, 61% were aware of the Canadian Medical Protective Association's guidelines on liability coverage for non-Canadian patients, and only 28% consistently protected themselves legally. There is large variation regarding whether physicians bill for services when the patient is uninsured. In Calgary, the study observed an increase in numbers of uninsured maternity patients. Differing ethical perspectives on the care of these patients may lead to conflict within health care teams because of differences on ethical perspectives of care among team members. Health care providers require education to understand the implications and challenges of obstetrical care of non-Canadians.