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Doctors, dentists, pharmacists: The mistakes you can’t know about
Published on Friday January 11, 2013

DALE BRAZAO/TORONTO STAR
Toronto colonoscopy doctor Harry Himal was cautioned regarding the length of time he planned to wait to perform a follow-up colonoscopy for a patient who later died of complications from colon cancer. When contacted by the Star, Himal declined to comment.

More than 2,000 secret cautions were issued to Ontario’s health-care professionals — doctors, nurses, dentists and others — for mistakes or improper behaviour in the past five years.

The cautions, mostly prompted by patient complaints, were handed down by the colleges that regulate the province’s front-line health workers and are kept permanently on their records.

But patients have no way of finding out from the colleges if their health-care providers have been cautioned.

That’s because a provincial law that governs the province’s health professions does not require cautions to be made public.

Colleges can deal with verified complaints through public disciplinary actions and, as the Star found, by issuing secret cautions.

Colleges argue they are not permitted to publicly disclose details about cautions under the law.

In rare cases, the details of cautions become public when they are appealed to a provincial review board, but the outcomes of these appeals — posted online — do not contain the names of practitioners. The Star had to make a special request in writing to obtain names in cases where patient care suffered.

In one case, Toronto doctor Harry Himal, who performs colonoscopies, was cautioned concerning the “follow-up of abnormal test results and delay in diagnosis and management of colon cancer with liver metastases.”

His patient, Bert Gabriel, died of complications from the disease. Gabriel’s widow, Rosemarie Rohrbach-Gabriel, filed an appeal arguing a caution was not enough.

“Somewhere there is a flaw in this whole system,” Rohrbach-Gabriel told the Star. “Just a caution, when the public doesn’t know about it, it’s not good enough.”

The College of Physician and Surgeons said it was concerned with the length of time Himal planned to wait to perform a follow-up colonoscopy when he found inflammation in Gabriel’s lower bowel.

When contacted at home by the Star by phone and in person, Himal declined to comment and referred all questions to his lawyer, Jeffrey Freedlander. He, too, declined to comment.

The Star’s investigation found that the province’s 21 health regulatory colleges issued 2,205 cautions — either written or oral — to health-care workers between 2007 and 2011. There are approximately 267,000 regulated health-care professionals in Ontario, including psychologists, massage therapists, optometrists, midwives and physiotherapists.

Among the other previously secret cases uncovered by the Star:

Toronto doctor Faith Patricia Feinberg was cautioned regarding her management of a patient’s vaginal bleeding, “including her failure to follow up on abnormal test results and to document appropriate and thorough discussions with the patient regarding management of her concerning symptoms/findings.”

The patient saw Feinberg, a general practitioner, on several occasions in 2004 and 2005 complaining of vaginal bleeding. An ultrasound revealed a mild thickening of the lining of the uterus, while a urologist recommended the patient see a gynecologist if the bleeding continued. The patient continued to experience vaginal bleeding into late 2005 but was not referred to a gynecologist until early 2007 following severe pelvic and hip pain and more bleeding. A biopsy revealed the patient had advanced endometrial cancer.

Despite surgery and chemotherapy, the patient died in November 2007 at the age of 77 from effects of the disease.

Following a complaint by the patient’s daughter, the College of Physicians and Surgeons of Ontario investigated and issued an oral caution to Feinberg. In its decision, the college’s complaints committee said it found “troubling deficiencies” with Feinberg’s care and said the doctor should have considered cancer a possibility.

Feinberg declined to comment when contacted by the Star.

In her response to the committee, however, Feinberg said she made appropriate referrals and advised the patient to see a gynecologist on four occasions but that the patient would not agree to do so until February 2007.

The committee noted that Feinberg did not document any gynecological referrals in the patient’s record, but added notes about referrals in an addendum to the patient’s record after the cancer diagnosis.

Ottawa-area chiropractor David Covey was cautioned and advised to “refrain from engaging in fear mongering which is designed to induce fear and apprehension” after he sent a letter in 2009 to a female patient telling her that a “reversed curve” in her spine “decreases your lifespan by at least 10 years” and that “if you do nothing, or don’t know to do anything in ignorance, that you will pay with a lower quality of life and a shorter life.”

Covey told the Star he believed it was his professional obligation to do “everything in my power” to make sure the patient was aware of his diagnosis for successful treatment to take place.

“The college saw it one way, I saw it another way,” he said. “I feel really bad for the lady. She didn’t understand. I didn’t have a chance to sit down with her and explain what we do and why we do it. I felt it was very serious for this lady.”

Toronto dentist Gary Glassman was cautioned after he failed to review a patient’s complete medical history when prescribing an antibiotic that triggered a life-threatening anaphylactic reaction in the patient.

In September 2009, the patient contacted Glassman to schedule a root canal the following month. The patient and a staff member at Glassman’s office exchanged emails to arrange the appointment and determine the appropriate prophylactic antibiotic before the treatment.

When the patient indicated to the staff member that she was allergic to penicillin, Glassman prescribed Clindamycin instead without referring to the patient’s chart, which was located off-site. But the chart indicated that the patient was also allergic to Clindamycin. The patient began taking the medication shortly before the appointment and developed a severe reaction, resulting in hospitalization.

The patient complained to the Royal College of Dental Surgeons of Ontario, which issued Glassman an oral caution and stressed that “in the absence of a previously completed medical history, the member is obligated to obtain a new medical history prior to prescribing medication.”

When contacted by the Star, Glassman referred questions to his lawyer, Symon Zucker, who criticized the college’s investigation into the complaint for failing to consult any other dentists or doctors about prescription practices.

“Doctors routinely prescribe over the phone,” Zucker said. “There’s got to be some accountability on the part of the person who’s calling and saying I want treatment.”

Zucker stressed that Glassman followed general protocol.

“Most of the time, the cautions are justified. In this case, it wasn’t. That’s why it’s unfortunate that Gary’s been caught up in it.”

London pharmacist Paul Yip was issued a caution in 2010 stressing the “importance of ensuring that the correct type and quantity of medication is dispensed to the right patient with the correct instructions.”

The caution stemmed from a complaint made by a customer who alleged that she filled a prescription for six tablets of Amerge, a migraine medication, but upon opening the package at home discovered the blister pack contained only two tablets.

She claimed that when she phoned the pharmacy to correct the error, Yip questioned whether she was sure she had picked up the medication at that exact location, and was told there was no record of her name in the pharmacy system, that the packaging did in fact contain six tablets and the package she described did not exist. The pharmacy eventually agreed to provide the additional tablets.

The Ontario College of Pharmacists complaints committee cautioned Yip that “a vital part of the dispensing process is checking that the right medication and quantity is being dispensed. Any failure to follow careful and thorough checking procedures is a significant departure from the standards of practice of the profession.”

Yip told the Star he couldn’t comment specifically on the case.

“The most important thing I do is care for the well-being of my patients,” Yip said. “In health care, any type of discrepancy is serious and in my practice everyday I do what’s best for the care of my patients.”

Alliston-area medical radiation technologist Luis Fernandez was cautioned regarding “the standards of practice as they relate to professional boundaries, sexual abuse prevention, and the importance of communicating with a patient before touching the patient.” The patient alleged that during a 2009 appointment Fernandez “rubbed his pelvis against her back and did not move away when she asked him to move away.”

The patient also complained that Fernandez “positioned her head by pulling back on her neck and causing her pain.”

Fernandez, who is now retired but occasionally fills in for staff absences at various medical imaging centres in the Alliston area, said he treated the patient “perfectly normal” but declined to discuss the case in further detail.

“I don’t really feel like starting again with any of this,” he said. “It really put me quite down.”

Presented with some of the Star’s findings, Health Minister Deb Matthews said she would look into the issue of cautions and talk to the colleges.

“I need to respect that these are self-regulating professions, but I do think the world is changing in terms of expectations around transparency,” Matthews told the Star. “I think we all expect more information and I think it’s important that colleges keep up with the expectations.”

Under Ontario’s Regulated Health Professions Act, colleges are not required to make cautions public or publish the complaints that spark the warnings. Colleges publish the number of cautions issued every year, but keep details and names of the professionals involved secret.

The College of Physicians and Surgeons issued the most cautions to its members with 1,211, followed by the Royal College of Dental Surgeons with 251, and the Ontario College of Pharmacists with 202.

Complaints are reviewed by a panel of at least three members of a college’s complaints committee, at least one of whom must be a member of the public appointed by the province.

If a college upholds a complaint, it can issue a caution, or, if there are allegations of incompetence or professional misconduct, such as sexual abuse, it can refer the complaint for a public discipline hearing.

Colleges consider cautions advisory or remedial in nature. Cautions are, however, kept permanently on members’ records and can be referred to by the colleges if subsequent complaints are made.

The only time cautions become public is in rare cases when they are appealed to the Health Professions Appeal and Review Board, a provincial panel that reviews decisions by the colleges. Complaints are usually appealed by either the patient, patients’ loved ones or the health worker themselves.

According to his public profile on the College of Physicians and Surgeons website, Harry Himal, the Toronto colonoscopy doctor, has a clean record.

There is nothing to indicate that he was cautioned by the college in relation to his treatment of Bert Gabriel, a 65-year-old patient who saw Himal in late July 2008 for a colonoscopy.

According to the provincial appeal and review board, Gabriel saw Himal following a CT scan that found a thickening of Gabriel’s bowel wall, as well as a colon condition called diverticulitis and a 4.8-centimetre spot on his liver, among other things.

During Gabriel’s colonoscopy, Himal found what he described as a “funny lesion” suggestive of what the provincial appeal and review board called an “inflammatory mass.” This caused a narrowing of the colon and prevented the scope from moving further, and the full procedure couldn’t be completed.

Himal told the college he conducted “biopsies” but the result of only one biopsy was ever reported. The result suggested no cancer, but rather “inflammatory changes.” Himal suggested a full colonoscopy in October.

Gabriel continued to experience pain and diarrhea and in late August, he returned to see Himal, who scheduled an ultrasound and a chest X-ray. The results indicated a 6.5-centimetre lesion on his liver suggestive of a tumour.

In early October, before a full colonoscopy could be completed by Himal, Gabriel was admitted to Toronto’s Sunnybrook hospital with an acute bowel obstruction, which turned out to be a cancerous tumour. Doctors removed the tumour, but it was too late.

Gabriel was diagnosed with Stage 4 colon cancer with lymphatic involvement and liver metastases. Despite several months of aggressive chemotherapy, radiation and surgery on his liver, Gabriel died of complications from the disease in May 2009.

His widow, Rosemarie Rohrbach-Gabriel, complained to the College of Physicians and Surgeons, believing that Himal should have further investigated her husband’s symptoms more quickly when the initial colonoscopy couldn’t be completed.

Following her complaint, the college decided to caution Himal. In its ruling, the college’s complaints committee said it was concerned with the length of time Himal planned to wait after Gabriel’s first colonoscopy before scheduling another one, especially in light of the CT scan that showed a liver lesion.

“This led to an unnecessary delay in the diagnosis of Mr. Gabriel’s cancer,” the committee said in its ruling.

The committee’s second significant concern was that a single biopsy of the lesion Himal discovered in Gabriel’s colon was “insufficient.”

“Multiple biopsies are usually required for a large mass like this to sample it adequately. There is no information before the committee to explain why, if Dr. Himal took multiple biopsies, results for only one are reported,” the committee stated.

“Dr. Himal’s management was suboptimal in his failure, as a surgeon, to appreciate that the inflammatory mass could be colon cancer. Dr. Himal could have, and should have, acted sooner and more definitively in ordering appropriate investigations and referring Mr. Gabriel as necessary.”

Rohrbach-Gabriel appealed the college’s decision to the provincial appeal and review board, arguing that an oral caution against Himal was not an appropriate remedy. But the provincial board agreed with the college, saying an oral caution was reasonable.

At the provincial appeal and review board hearing, Himal’s lawyer, Jeffrey Freedlander, argued that an oral caution was considered serious for a member of a regulated health profession and that the warning would serve to improve the quality of patient care.

Kathryn Clarke, a spokeswoman for the College of Physicians and Surgeons, said the college was prohibited under legislation to comment on the case.

Linda Gough, president of the Federation of Health Regulatory Colleges of Ontario, says all of the colleges she deals with are “committed to ensuring that the quality of practice is maintained for the public.”

“We’re all in the quality business dealing with very complex issues, but the purposes of the colleges are always the public interest,” Gough said.

She stressed that cautions are intended to be remedial and do not indicate findings of professional misconduct.

When asked if she thought it would be in a patient’s interest to learn if their health-care provider had been cautioned, she said there has to be a “balancing of transparency with the reasonable privacy rights of members.”

Markham medical malpractice lawyer Amani Oakley says cautions should be made public so that patients can make informed choices. She says patients looking up their health-care providers on the college websites are often led to believe the professionals have exemplary records when that may not be the case — a situation she calls “disturbing.”

“If a complaint is upheld, it should be made public, it should be accessible,” Oakley said. “There is absolutely nothing that says that they cannot release details to the public. In fact, that’s the role of the college. The role of the college is a watchdog for the public.”

http://www.thestar.com/news/canada/arti … know-about

Statistics: Posted by yoda — Fri Jan 11, 2013 11:02 am