1 The Standard of Care of Residents and Clerks: Caging the Rare Birds of the Medical Profession

By: Liam H. M. O’Reilly BA University of Victoria MA University of Victoria JD Schulich School of Law, Dalhousie University

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INTRODUCTION

2 In Canadian jurisprudence, residents’ and clerks’ standard of care (SOC) is not settled law. Clarke J. quoted below, in Considine v City Camp Hospital 1 , aptly illustrates the difficulty in setting residents’, and by analogy clerks’, SOC: On issues of liability the resident is somewhat like a rare bird. He is chosen by the Faculty of Medicine of Dalhousie University. He is assigned to various hospitals during his residency. At each he falls under the rules of the hospital required for routine matters. He is a medical doctor licensed by the provincial board. He is paid a salary by the province. He does not submit accounts to Medical Services Insurance. The hospital where he happens to be at a given time has no real powers of control or discipline. He works under the direction of a senior doctor or team of doctors. His senior doctor varies from patient to patient. While he may be hard to locate when it comes to fixing liability for medical wrongdoing, the resident is certainly not a ghost by the patient's bed or while participating in a surgical procedure in an operating room. 2 The purpose of this paper is to explore the various interpretations of residents’ and clerks’ SOC, and propose a solution. Canadian case law has established a diffuse SOC, which can be articulated as a spectrum: residents may be held to the SOC of a resident, a no-student doctor (a doctor with a full license no longer seeking accreditation through a university program), a specializing resident, or a non-student doctor specialist. Residents’ and clerks’ SOC should be based on a broad categorization approach and a rational well-informed patient expectations test. This SOC approach rejects the establishment of the SOC based on smaller categorizations: such as year of education, experience, or specialty or non-specialty. Reinforcing and structuring the SOC of resident and clerks will ensure quality medical care, medical education, and ensure patient compensation for adverse events. OUTLINE This paper is divided into five distinct parts. Part 1: “Regulation and Education of Residents and Clerks”; will review the education, legislation, and policies of residents and clerks. The province of Nova Scotia (NS) will be used for exemplifying the educational processes, legislation, and professional regulation that apply to residents and clerks. Part 2: “Residents’ and Doctors’ The Standard of Care Authorities”; will briefly review the main authorities on doctors and residents SOC. Reference in the

1 Considine v Camp Hospital, [1982] NSJ No. 341, 133 DLR (3d) 11 [Considine]. 2 Considine v Camp Hospital, [1982] NSJ No. 341, at para 68,133 DLR (3d) 11 [Considine].

3 spectrum cases will be made to which authorities were invoked to define the SOC in each instance. This is to aid the reader in understanding how judges came to similar or opposing understandings of the SOC. However, some cases draw on the same exact authorities but come to divergent conclusions. Part 3: “The Spectrum of Residents’ Standard of Care”; will analyze the case law, articulating the SOC spectrum for residents. This will exemplify the full spectrum of the SOC on which residents are placed. Further, the SOC of clerks will be extrapolated from the spectrum and secondary sources. Part 4: “American Residents’ Standard of Care and Proposed Solutions”; will explore the residents’ and clerks’ SOC in the United States (US). In addition, three US SOC propositions will be explored and critiqued. This will aid in avoiding shortcomings in the development of a Canadian SOC. Part 5: “Setting a Canadian Standard of Care for Residents and Clerks”; will focus on the articulation of a Canadian SOC that protects patients, and opposes the view of distinct educational and experiential SOCs for residents and clerks. This may possibly affect the autonomy and financial concerns of residents and clerks. However, it will ensure compensation for negligently injured patients and push residents and clerks to be more prudent.

PART 1: REGULATION AND EDUCATION OF RESIDENTS AND CLERKS A review of a resident’s and clerk’s education and regulation is necessary to set terminology, illuminate the relationship between residents and clerks and their superiors, and explain the education and autonomy of residents and clerks at different points in their education. This will illustrate the differing autonomy and licensing of residents and clerks compared to that of non-student doctors. Some scholars have suggested the educational and regulatory differences between residents and non-student doctors can justify a lower resident SOC. 3 Further, a short 3 This will be discussed in Part 4.

4 history on the changing education of residents will clarify any discrepancies between new and old case law. Undergraduate Education: The Clerk The University of Dalhousie’s (Dalhousie) undergraduate “MD Program” is four years, and is broken into three categories: Med 1 (first year); Med 2 (second year); and Clerkship (third and fourth year). Med 1 and 2 includes lectures, lab work, case problems, and patient contact experience. 4 Clerks directly apply a variety of medical skills in both clinic and hospital settings. 5 Dalhousie covers the liability of medical undergraduates. 6 Upon completion of the “MD Program”, students receive their MD degree and are eligible to apply for their required residency. Post-Graduate Education: The Resident Medical Residency is a two to six year post-graduate medical program. 7 During residency, the Canadian Medical Protective Association (CMPA), a medical “defence association”, defends students’ liability. 8 A resident is labelled, similar to the “MD Program”, by year: Post-Graduate Year 1 (PGY1), Post-Graduate Year 2 (PGY2), and etc. Residency at Dalhousie’s Faculty of Medicine offers 24-sub specialty training programs, specialty programs, family medicine, and electives at the affiliated teaching hospitals. 9 During the mandatory two- 4 University of Dalhousie, Faculty of Medicine, Med 1 (Pre-Clerkship), online: Faculty of Medicine <http://www.medicine.dal.ca/departments/core-units/undergraduate/program/med-1.html>. 5 University of Dalhousie, Faculty of Medicine, Med 3 (Clerkship), online: Faculty of Medicine < http://www.medicine.dal.ca/departments/core-units/undergraduate/program/med-3.html>.; University of Dalhousie, Faculty of Medicine, Med 4 (Clerkship), online: Faculty of Medicine < http://www.medicine.dal.ca/departments/core-units/undergraduate/program/med-4.html> 6 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, s. 4(b), online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 7 Jean Gray & John Ruedy, “Undergraduate and Postgraduate Medical Education in Canada” (1998) Can Med Assoc J 158 at 1048. 8 Dalhousie, Faculty of Medicine, Calendar Residency Safety Policy, online: Faculty of Medicine < http://postgraduate.medicine.dal.ca/ResidentSafteyPolicy.html> ; The Canadian Medical Protective Association, About The CMPA, online: CMPA < https://oplfrpd5.cmpa-acpm.ca/about;jsessionid=FC1226DBE05C73063A33E69B6808EC53> 9 University of Dalhousie, Faculty of Medicine, Residency Training, online: Faculty of Medicine < http://www.medicine.dal.ca/programs/residency.html l>.

5 year residency, doctors will train in internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry and emergency medicine. 10 Upon completion of this two-year residency, residents are accredited doctors in family medicine. 11 Residents can choose to extend or resume their residency in order to specialize. Licensing and Regulation of Clerks and Residents The Nova Scotia Medical Act (Act), established The College of Physicians and Surgeons of Nova Scotia (CPSNS), which regulates and sets the standards for medical practitioners and the practice of medicine throughout the province. 12 This is achieved through a licensing regime, the “Medical Register”. 13 Only licensed practitioners are able to “practice medicine” and use titles such as “medical doctor”, “doctor”, “surgeon”, or etc. 14 The regime regulates physicians via: fees, scope of practice of specific physicians, imposition of terms on licensees, investigation of complaints, license renewals, license suspensions, license revocation, and imposition of compensation. 15 The CPSNS administers a disciplinary body for ethical and professional complaints warranting investigation. 16 The CPSNS’s code of ethics, standard medical practices, and regulations are recognized under the Act. Further, Violation of the Act is an offence. 17 Therefore, a resident’s or clerk’s violation of standard practices may result in disciplinary action. For medical students, the Act established a “Medical Education Register”. 18 This sets out the regulations, qualifications, and student’s permitted interactions with patients. 19 Additionally, 10 Jean Gray & John Ruedy, “Undergraduate and Postgraduate Medical Education in Canada” (1998) Can Med Assoc J 158 at 1049. 11 Jean Gray & John Ruedy, “Undergraduate and Postgraduate Medical Education in Canada” (1998) Can Med Assoc J 158 at 1048. 12 Medical Act, RS NS 1995-96, c 10 s 4(3). 13 Medical Act, RS NS 1995-96, c 10 s 6(3), 19(1). 14 Medical Act, RS NS 1995-96, c 10 s 2(w), 3, 40(1). 15 Medical Act, RS NS 1995-96, c 10 s. 21(1), 32(1), 38(1), 48, 52, 66(2)(e), 54(5), s 67. 16 Medical Act, RS NS 1995-96, c 10 s 2(w), 3, 40(1). s 48. 17 Medical Act, RS NS 1995-96, c 10 s 2(w), 3, 40(1). s 6(2), 6(2)(k), 6(2)(s), 6(3), 38(1). 18 Medical Act, RS NS 1995-96, c 10 s 27(1). 19 Medical Act, RS NS 1995-96, c 10 s 27(1), 27(2).

6 if students are from an approved school (undergraduate medical students (ie. Med1-Clerkship ) or holders of a medical degree and are engaged in pre-registration physician training or post­graduate training, they are eligible for registration. 20 Students who enroll in the undergraduate “MD Program”, or are starting their residency, are required to register via the “Medical Education Register”. 21 Therefore, medical students have a unique medical license compared to that of non-student doctors. CPSNS Student Policies The CPSNS policies for undergraduates and post-graduates inform the responsibilities of both the students and their supervisors. Specifically, “the CPSNS policies reflect the position of the College of Physicians and Surgeons of Nova Scotia. Physicians licensed with the College are expected to be familiar with and to comply with College policies”. 22 The policies are not legally binding, although they are the expected ethical and professional conduct. 23 However, Canadian jurisprudence has held that policies and guidelines can determine or aid in the determination of the SOC. 24 Undergraduate and Resident Policies Broadly speaking, the difference between undergraduate and resident is the decreased supervision of residents and increased autonomy compared to undergraduate students.

20 Medical Act, RS NS 1995-96, c 10 s 27(1), 27(3). 21 College of Physicians and Surgeons Registration Regulations, NS Reg 141/96, s 18, 20. 22 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 1, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 >; College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 1, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 23 Personal communication between Liam O’Reilly and Gus Grant (Registrar and Chief Executive Officer of College of Physicians of Nova Scotia) (22 October 2014). 24 Mooney v British Columbia (Attorney General), 2004 BCCA 402, 2004 CarswellBC 1707.; Hamstra v British Columbia Rugby Union, 1989 CarswellBc 619, [1989] BCWLD 2211.

7 Additionally, specializing residents, generally, have more autonomy than that of residents completing their two-year required residency, especially in non-specialization tasks. Regardless, both undergraduates and residents must identify themselves as students and acquire express consent to perform treatment from patients. A. Undergraduate Policies Supervisors of undergraduates (Med1-Clerk) students are doctors, including residents, who have the responsibility of guiding, observing, and assessing undergraduate medical students. 25 Each patient has a Most Responsible Physician (MRP) who has “final accountability for the medical care of the patient, whether or not a student is involved in the clinical encounter”. 26 The MRP/supervisor ensures the patient, their families, and other health care workers are informed of the clerk’s station as a medical student. 27 The MRP/supervisor assess the capacity, competence, and required supervision of undergraduates. The level of involvement of undergraduates in medical treatment is measured by individual competence and educational assessments. 28 The MRP/supervisor must approve all medical tasks performed by undergraduates beforehand and counter-sign them afterwards. 29 25 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 3, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 26 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 2, 3, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 27 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 3, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 28 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 6, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 29 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 4, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 >

8 Breach by undergraduates, of either professional or ethical conduct is reported to the Dalhousie Faculty of Medicine. 30 In all situations informed consent must be obtained. 31 In rare situations, an undergraduate may have to conduct a “significant component, or all, of a medical procedure,” however, if the MRP/supervisor is absent, the undergraduate must, “where possible”, obtain written or oral consent. 32 B. Post-Graduate Policies Residents can only practice medicine within the confines of their training program. Residents, like clerks, are subject to a MRP/supervisor regime. 33 Further, residents are only to participate in treatment of patients to his/her competence level. The resident must ensure the patient, or substituted decision maker, knows their: “name, role, stage in the postgraduate program, and degree of involvement in patient’s care”. 34 The resident must ensure the patient, or alternate decision maker, is informed of the name and role of the MRP. The resident must communicate the following with the MRP/supervisor: patient assessment, significant change in patient’s condition, consideration of significant treatment changes, patient discharge, concerns of the patient or substitute decision makers, significant risks to the patient in emergency situations,

30 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 6, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 31 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 6, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 32 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Undergraduate Medical Education, March 2014, p. 7, online: College of Physicians & Surgeons of Nova Scotia http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=141&PortalId=0&TabId=18 0 > 33 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 3, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 34 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 4, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 >

9 and clinical findings. 35 The resident must acquire informed consent for treatment or change of treatment. When a resident, without supervision performs a procedure either partially or completely, the patient must be aware of this fact and give express consent (written or oral). 36 The MRP/supervisor must ensure that the patient or substitute decision maker, and the medical staff are aware of the resident’s status as a student. Further, the MRP must inform the patient that he/she is the MRP of their treatment, and “ultimately accountable for the patient’s care”. 37 The MRP/supervisor must oversee the resident to determine if the resident has the “competence (knowledge, skill and judgment) to participate in, and not compromise, the patient’s care”. 38 Residents’ responsibilities evolve with their competency; however, they are never completely independent of supervision. 39 The MRP/supervisor must ensure patient treatment is performed at the same level, or above, as if the resident was not involved. 40 Evolution of Residents Education and Terminology The educational framework and terminology of resident and clerks above is the current framework in NS. However, Canadian medical education and titles for residents has not always

35 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 4, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 36 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 5, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 37 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 4, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 38 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 3, 4, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 39 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 5, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 > 40 College of Physicians & Surgeons of Nova Scotia, Policy Regarding Professional Responsibilities in Postgraduate Medical Education, March 2014, p. 5, online: <http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=142&PortalId=0&TabId=1 80 >

10 been static. Prior to 1993, medical schools required clerks, after graduation, to complete only a single year of residency (commonly referred to as a rotating internship) training in a hospital(s). 41 After this one-year residency, residents could specialize, which would extend or resumes their residency. 42 In 1993, a two-year mandatory residency was implemented in Canadian medical schools. 43 Consequently, a pre-1993 resident, completing their required residency, would be analogous to a post-1993 first year resident (PGY1). 44 Post-1993 residents who complete the two-year residency are accredited family doctors (which may include sub-focuses within this field), often referred to as generalists. 45 Any doctor who has completed the two-year residency (including those who are specializing) are also referred to as physicians. 46 Due to the educational changes noted above, the case law below uses a variety of terms to describe residents and doctors. Residents in older case law have been labelled: “intern,” “interne,” “junior doctor,” or “resident” depending on their education (required residency or residency specialization). 47 Yet, modern case law, generally, refers to residents as “residents” and clerks as “interns”. 48 Still, some current case law has started to utilize the official titles of 41 Jean Gray & John Ruedy, “Undergraduate and Postgraduate Medical Education in Canada” (1998) Can Med Assoc J 158 at 1049. 42 Aldana v March, [1999] BCJ no. 21 at para 12, 44CCLT (23) 164, [Aldana]. 43 The Royal College of Physicians and Surgeons of Canada & The College of Family Physicians of Canada, Directions For Residency Education 2009: A Final Report of the Core Competency Project, 2009, p. 3 online: <https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CCYQFjAB&url=http%3A%2F%2Fwww.ro yalcollege.ca%2Fcommon%2Fdocuments%2Feducational_initiatives%2Fccp_final_report_2009.pdf&ei=QgpdVIX0MY-BygT9soCoAw&usg=AFQjCNF6GrJ9sGQs7jnRUTWTfksADucytQ&sig2=WLubQZD9PPN82mzaJJ3e3A> 44 Chantel Cabaj, “Entering the Abyss: The Resident’s Standard of Care” (2001) 19 Health LJ 4 at para 14. 45 A generalist is defined as “a general physician or family physician; a physician trained to take of the majority of nonsurgical diseases, sometime including obstetrics”, see: Williams & Williams, Illustrated Stedman’s Medical Dictionary, 24 th ed (Baltimore: Williams & Wilkins 1982) at 590.; Jean Gray & John Ruedy, “Undergraduate and Postgraduate Medical Education in Canada” (1998) Can Med Assoc J 158 at 1048.; The Royal College of Physicians and Surgeons of Canada & The College of Family Physicians of Canada, Directions For Residency Education 2009: A Final Report of the Core Competency Project, 2009, p. 30 online: <https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CCYQFjAB&url=http%3A%2F%2Fwww.ro yalcollege.ca%2Fcommon%2Fdocuments%2Feducational_initiatives%2Fccp_final_report_2009.pdf&ei=QgpdVIX0MY-BygT9soCoAw&usg=AFQjCNF6GrJ9sGQs7jnRUTWTfksADucytQ&sig2=WLubQZD9PPN82mzaJJ3e3A> 46 A physician is defined as “a practitioner of medicine; a doctor; a person who has knowledge, and who is licensed by the proper authorities, to examine and care for the sick”, see: Williams & Williams, Illustrated Stedman’s Medical Dictionary, 24 th ed (Baltimore: Williams & Wilkins 1982) at 1083. 47 Aldana at para 13; Vancouver General Hospital v Fraser Estate, [1952] SCJ No. 13 at para 1, [1952] SCR 36, [Fraser].

11 residents and clerks (ie. PGY1, PGY2, etc.). Despite this ambiguous use of terminology, no negligent cases of undergraduate clerks have been reported. 49 Therefore, the negligent student doctor focused upon, below, will either be a pre-1993 or post-1993 resident in the process of completing either their required residency or their specialization residency. The terms in the case law below, when necessary, will be simplified. Residents’ and Clerks’ Education, Regulation, and Policies Part 1, above, illustrates how medical undergraduates and post-graduates are regulated and educated. Specifically, this framework provides context for understanding student’s educational competence, relationships with MRPs/supervisors, and autonomy. Notably, undergraduate and graduate student’s education greatly affects their competency and thus autonomy. As students become further educated their responsibility and scope of practice increases. However, regardless of educational level, MRPs and supervisors regulate and assess students’ competency. Therefore, the MRP/supervisor via this relationship may find herself/himself negligent for the actions of a resident or clerk. Consequently, understanding the role of medical students is subject to education as well as the relationship between them and the MRP/supervisor. This context, of the status and responsibilities of medical students, is crucial to fully understand the case law explored below.

PART 2: RESIDENTS’ AND DOCTORS’ STANDARD OF CARE AUTHORITIES This section will review the main authorities that set the SOC for residents, doctors, and specialist. Each case will be analyzed and foreshadow particular ambiguities either explicitly or