DRAFT: TO BE PRESENTED AT THE OPENING OF THE 2024/25 PARLIAMENTARY SESSION


The Honourable Sylvia Jones MPP

Minister of Health and Long Term Care

College Park 5th Floor

777 Bay St

Toronto, ON

M7A 2J3

 

9 September 2024

 

Dear Minister

 

PROPOSED AMENDMENTS TO REGULATED HEALTH PROFESSIONS ACT 1991

 

I wish to suggest some amendments and improvements to the Regulated Health Professions Act 1991, as amended in 2009 and 2017.  I understand that there is no relevant Bill before Parliament at present, so I would be grateful if this letter could be held in general correspondence until the Standing Committee on Social Policy considers a relevant Bill and seeks public input on it.  If possible I would also like to give evidence in person or send a representative, so I should be grateful if you would notify me when the Committee is preparing to consider amendments to this Act.

 

I am a Canadian citizen and currently a full time family physician in Britain.  I practised as a family physician in Ontario between 2007-2016, these amendments are based on my experience during that time, and they mainly relate to the regulatory activities of the College of Physicians and Surgeons of Ontario (CPSO), although if the amendments are made law, they would also apply to all of the self-governing health professions listed in the Act[1].

 

These amendments should be non-contentious.  They are mainly intended to level the playing field between the College and its members, increase transparency, and impose requirements on the College similar to the requirements which the College imposes on its members.


I suggest that a change in the law is necessary because the CPSO has a track record of long delays in implementing reforms, even when those reforms are clearly and urgently needed.  For example, enabling legislation was introduced into the Regulated Health Professions Act in 2009 to provide for alternative dispute resolution with respect to a complaint.  This could have been used to reduce investigation times, but was not implemented by the CPSO until 2018, to a self-congratulatory post on X (formerly Twitter) which stated:


“The CPSO is excited to announce a new element to our complaints process: Alternative Dispute Resolution (ADR). This is designed to help patients resolve concerns with their doctor without the need for a lengthy investigation.” (Twitter, 10 December 2018).


This should have been implemented nine years earlier.  The CPSO only implemented this change reluctantly and as a result of external pressure from the Ministry of Health and the 2016 Goudge Report.  For further details please see below. 


 

SUMMARY OF PROPOSED AMENDMENTS

 

 A. Removal of “never reapply” undertakings from the Act

 B. Improved procedures for timely disposal of complaints

 C. Access by members to their personal college files

 D. Improved record keeping by colleges

 E. Improved procedures for dealing with malicious complaints

 F. Improved access to college data

 

 

A. REMOVAL OF “NEVER REAPPLY” UNDERTAKINGS FROM THE ACT

 

Background and rationale for the proposed amendment

 

Since 1994, the CPSO has issued numerous “never reapply” undertakings, in which the physician typically undertakes never to apply or reapply for a licence in Ontario or in any other jurisdiction.  330 of these undertakings have been signed by physicians from 1994 to the present date.  These were identified by an analysis of the CPSO’s online database, a secondary database of these undertakings was created[2], and a chart compiled from the secondary database[3].   An unknown but probably larger number of these undertakings have been offered to physicians who have refused to sign them.  The CPSO has refused to confirm the number of these undertakings which have been offered or the number which have been signed[4].

 

A recent example of a “never reapply” undertaking is attached[5].  Having signed it, the physician then resigns from the college and the undertaking is displayed on the college website.  The effect of the undertaking is similar to that of revoking a physician’s licence, which is normally done only for the most serious cases, for example sexual misconduct.

 

These undertakings are probably legally unenforceable on the ground that they are an unreasonable restraint of trade, although I do not know of any case in which one has been put to the test in a court of law.  The principle may be illustrated by this hypothetical example:

 

A skilled computer programmer leaves his employment with Microsoft.  As part of his leaving package he signs an undertaking never to apply to work for Google.  In breach of his undertaking, he applies for and is given a job with Google.  Microsoft sues.  The court refuses to uphold the undertaking because it is is an unreasonable restraint of trade.  The court holds that it is in the public interest for skilled computer programmers to be allowed to use their skills, and either rewrites the undertaking with severe limitations, for example replacing “never” with “one year”, or strikes down the undertaking altogether.

 

Similar principles apply to “never reapply” undertakings by physicians.  It is in the public interest that competent and ethical physicians should be allowed to use their skills, in Ontario or anywhere else.  The CPSO may argue that a particular physician is incompetent or unethical, but the burden of proof for this would be on the CPSO, and they would need to prove this with evidence about the physician’s behaviour, not by evidence of the fact that he has signed an undertaking.

 

The principles governing what constitutes unreasonable restraint of trade are explained in an online article by a Canadian lawyer[6].

 

One would expect that “never reapply” undertakings would only be used for the most serious breaches of competence or ethical standards.  However, in most cases the reason for issuing the undertaking is unclear.  I have divided the 330 undertakings identified from the CPSO’s online database into four categories:

 

-    Sexual, where there was an allegation of sexual misconduct, either proven or unproven, and involving either a patient or co-worker.

-    Explicable, where there appeared to be some other reason why the undertaking was appropriate, for example, gross incompetence, gross breach of ethical standards, serious criminal conviction, psychiatric incapacity, failure to cooperate with a college investigation or repeated failure to remediate.

-    Inexplicable, where no details were given other than “incompetence”, “professional misconduct”, “failure to uphold the standards of the profession” or similar, or where it appeared to be an inappropriately harsh penalty (see examples below).  Undertakings were allocated to the “inexplicable” category when no reasonable cause could be found after searching the CPSO database, news media and social media.

-  Covid-19 related.  This is a new category which appeared for the first time in 2022. Since the start of the Covid-19 pandemic, the CPSO has required physicians not to "disseminate false and misleading information" about Covid-19, which may include the physicians' personal opinions about mask wearing, vaccine safety and the effectiveness of certain Covid treatments. Several physicians have been disciplined for allegedly failing to comply with these guidelines, including five to date who have signed "never reapply" undertakings.


I am uneasy about this most recent, Covid-19 related category.  The CPSO's position is that physicians who disseminate false and misleading information are putting patients' lives at risk and the public should not be exposed to those physicians or their ideas.  However, some physicians have strong and genuinely held concerns about the effectiveness and safety of vaccines and other Covid-19 measures and feel that they should be allowed to express those concerns. , We should bear two additional things in mind: firstly, the public is accustomed to hearing opposing viewpoints, for example from lawyers and politicians, and are generally able to make their own minds up after hearing both sides of an argument; and secondly, the history of medicine contains numerous examples of orthodox teaching which was proved wrong, and mavericks who were proved right.


This is a complex issue and I am not in a position to judge whose views are right and whose are wrong.  For this reason I have not categorised Covid-19 related "never reapply" undertakings as either "explicable" or "inexplicable", but instead I have created a separate category for them.

 

Recent examples of “never reapply” undertakings in the “inexplicable” category include:

 

Dr Judith Hamilton CPSO no. 25264

Signed a “never reapply” undertaking on 23 February 2023, apparently in connection with inappropriate prescribing of opioids[7].

 

Dr John Hsuen CPSO no. 27746

Signed a “never reapply” undertaking on 18 December 2021, apparently because “concerns have been identified with my medical record-keeping”[8].

 

Neither of these physicians appears to have any previous discipline history with the CPSO, nor does there appear to have been any attempt by the CPSO to help them remediate.  Was there really no way in which these physicians could have been assisted to either retain their licenses, or to retire honorably?

 

By far the largest category of “never reapply” undertaking is “Inexplicable”.  One suspects that the CPSO has adopted the “never reapply” undertaking as a convenient way of disposing of complaints without the inconvenience of investigating the complaint or justifying its decision.

 

There is little educational or deterrent value in publishing “inexplicable never reapply” undertakings on the CPSO’s website.  If members are not told what behaviour is being sanctioned, they do not know what behaviour to avoid.

 

These undertakings are private agreements between the CPSO and its members.  If the CPSO wishes to issue one of these undertakings, the member agrees to sign it, and they both agree that it should be displayed on the college website, there is nothing to stop them from doing so.  However, for all of the above reasons I suggest that it is inappropriate for them to be included in the Act, as this gives them an aura of legitimacy which they do not merit.

 

Section of Act sought to be amended

Schedule 2, Health Professions Procedural Code, Section 23(2).13

 

Current wording of Act

13.   Where, during or as a result of a proceeding under section 25, a member has resigned and agreed never to practise again in Ontario, a notation of the resignation and agreement.

 

Requested action by Health Minister

 

Please delete this subsection.

 


 

B. IMPROVED PROCEDURES FOR TIMELY DISPOSAL OF COMPLAINTS

 

Background and rationale for the proposed amendment

 

The 1991 Act in its original form sought to achieve a balance between the rights of the college, the member and the complainant with regard to time limits and timely disposal of complaints.  Originally, a time limit of 120 days was set, and in the event that the college failed to comply with this time limit, a procedure was set out which could be invoked by either the member or the complainant to ensure that the complaint was disposed of in a timely manner.

When the Act was reviewed in 2009, a large number of amendments were made, including amendments to this section.  The effect of these amendments was to increase the basic time limit from 120 to 150 days, to allow the CPSO to apply for multiple extensions to that time limit, and to water down the procedure for dealing with delays to the extent that it became effectively non-existent and there was no longer any effective mechanism for enforcing compliance by the college.  The effect of this was catastrophic.  Freed of any obligation to comply with the time limits, the CPSO simply ignored them, the number of complaints in the system increased, and the disposal times lengthened in some cases into years.  The cost of complaints escalated until the CPSO was using more public funds to process its complaints than all the other Canadian medical colleges combined[9].  The situation was only rectified after a 2016 report, commissioned by the Ontario Ministry of Health and Long Term Care, confirmed that “More time and money is spent on a disposition in Ontario than in other jurisdictions, with little apparent benefit to the public in terms of better or safer physician services”, “too many complaints and investigations are in the system too long”, and “the 150 day deadline is not met on many occasions”[10].

 

It appears that the 2009 amendments to Section 28 may not have received adequate scrutiny by the Standing Committee on Social Policy at the time they were introduced.  Examination of the transcript of the Committee debates on 8 May 2007 shows that there was no discussion about the changes to the time limits or the process for enforcing them[11].  There appears to have been a great deal of lobbying by the CPSO both before and during the Committee proceedings, suggesting an element of “regulatory capture”; indeed, the CPSO were so keen to ensure that their views were heard that they sent a four-person delegation, including a lawyer, to make oral representations to the Standing Committee on 3 March 2009[12]. 

 

For all of the above reasons, I suggest that the 2009 amendments relating to the time limits and timely disposal should probably not have been passed, or at least, should not have been passed without proper scrutiny, and I would invite the current Standing Committee to reinstate the original wording of this section.  There may be differing views on what the exact wording of Section 28 should be, but two principles should be beyond doubt and should be universally agreed; firstly, if there is a time limit specified in the Act there should be some means of enforcing it; and secondly, if the CPSO wishes to extend that time limit, the burden of proof should be on the CPSO to show good cause.

 

There appears to be little oversight of the CPSO’s activities.  There are various organisations which could, in theory, exercise some oversight and restraint: these include the Canadian Medical Protective Association (CMPA), the Health Professions Appeal and Review Board (HPARB), the Ontario Medical Association (OMA) and the Ministry of Health and Long Term Care (MOHLTC).  However, in practice there appears to be little oversight or input from these organisations and the CPSO is left largely to police itself.  The CPSO is protective of its status as a self-regulating organization, but if self-regulation results in catastrophic outcomes like this, it should be reviewed.

 

 

Section of Act sought to be amended

Schedule 2, Health Professions Procedural Code, section 28(1)to(5)

 

Current wording of Act

Timely disposal

28 (1)    A panel shall dispose of a complaint within 150 days after the filing of the complaint.  2007, c.  10, Sched.  M, s.  30.

Not affected by ADR

(2)    A referral to an alternative dispute resolution process under section 25.1 does not affect the time requirements under this section.  2007, c.  10, Sched.  M, s.  30.

If complaint not disposed of

(3)    If a panel has not disposed of a complaint within 150 days after the complaint was filed, the Registrar shall provide the complainant with written notice of that fact and an expected date of disposition which shall be no more than 60 days from the date of the written notice.  2007, c.  10, Sched.  M, s.  30.

If further delay

(4)    If a panel has not disposed of the complaint by the expected date of disposition described in subsection (3), the Registrar shall,

    (a) provide the member and complainant with written notice and reasons for the delay and the new expected date of disposition which shall be no more than 30 days from the date of the revised notice or from the expected date of disposition described in subsection (3), whichever is sooner; and

    (b) provide the Board with written notice of and reasons for the delay as were provided to the member and complainant.  2007, c.  10, Sched.  M, s.  30.

Powers of the Board

(5)    The Board, on application of the member or the complainant, shall consider the written reasons for the delay and shall do any one of the following:

    1. Direct the Inquiries, Complaints and Reports Committee to continue the investigation.

    2. Make recommendations the Board considers appropriate to the Inquiries, Complaints and Reports Committee.

    3. Investigate the complaint and make an order under subsection (9) within 120 days of the decision to investigate the complaint.  2007, c.  10, Sched.  M, s.  30.

 

Proposed amended wording of Act (revert to the original wording)

 

Timely disposal

28.-   (1) A panel shall dispose of a complaint within 120 days after the filing of the complaint.

 

Not affected by ADR

(2)  A referral to an alternative dispute resolution process under section 25.1 does not affect the time requirements under this section.  2007, c. 10, Sched. M, s. 30.

 

If complaint not disposed of

(3) If a complaint regarding the conduct or actions of a member has not been disposed of by a panel within 120 days after the filing of the complaint, the Board, on application of the member or the complainant, may require the Inquiries, Complaints and Reports Committee to ensure the complaint is disposed of.

 

If further delay

(4) If the complaint is not disposed of within sixty days after the Board’s requirement, the Board shall investigate the complaint and make an order under subsection (6) within 120 days after the Board’s requirement.

 

Powers of the Board

(5) In investigating a complaint, the Board has all the powers of a panel of the Inquiries, Complaints and Reports Committee and of the Registrar with respect to the investigation of the matter and, in particular, the Board may appoint an investigator under clause 75(c).

 

(6) After an investigation, the Board may do any one or more of the following:

 

1.Refer the matter to the Inquiries, Complaints and Reports Committee.

2.Make recommendations the Board considers appropriate to the Inquiries, Complaints and Reports Committee.

3.Require the Inquiries, Complaints and Reports Committee or a panel to do anything the Inquiries, Complaints and Reports Committee or a panel may do under the Regulated Health Professions Act and this Code except to request the Registrar to conduct an investigation.

 


 

C. ACCESS BY MEMBERS TO THEIR PERSONAL COLLEGE FILES

 

Background and rationale for the proposed amendment

 

Colleges are entitled to inspect and copy a member’s medical records under section 75 and 76 of the Health Professions Procedural Code, patients are entitled to access their own personal health records under section 52 of the Personal Health Information Protection Act, 2004, and individuals generally are entitled to access personal information held about them by commercial organisations under the Personal Information Protection and Electronic Documents Act 2000.  This proposed amendment provides a reciprocal right of access by a member to his or her personal College records.  This is consistent with the CPSO’s commitment to transparency.

 

The CPSO does not fall under the definition of a “commercial organisation” and it is therefore not bound by the right of access requirements of the Personal Information Protection and Electronic Documents Act 2000.  The CPSO currently refuses requests by members to access personal information held about them[13].

 

There is no reason in principle why the College cannot be required to produce the records which it holds about a member.  Other medical regulatory bodies manage it, such as the United Kingdom General Medical Council, where a physician's complete regulatory file is disclosed upon request[14].

 

Inspection of personal files by members would introduce greater transparency and accountability into the CPSO’s decision making processes, for example, by clarifying the reasoning behind the decision to offer a “never reapply” undertaking (discussed above) and identifying the individuals responsible for making these decisions.

 

Section of Act sought to be amended

Schedule 2, Health Professions Procedural Code, Section 23

 

Proposed new wording to be inserted

 

The wording of this proposed amendment closely follows the wording of section 16 of the Health Professions Procedural Code (Disclosure of application file).

 

Disclosure of member’s file

23(15)(1) The Registrar shall give a member, at his or her request, within 14 days, all the information and a copy of each document the College has which relates to that member.

Exception

(2) The Registrar may refuse to give a member anything that may, in the Registrar’s opinion, jeopardize the safety of any person. 

Process for dealing with request

(3) The Registrar shall establish a process for the purposes of dealing with a member’s request under subsection (1).

Fee for access

(4) The Registrar may require a member to pay a fee for making information and documents available to the member if the Registrar first gives the member an estimate of the fee.

Amount of fee

(5) The amount of the fee shall not exceed the amount of reasonable cost recovery.

Waiver of fee

(6) The Registrar may waive the payment of all or any part of the fee that a member is required to pay under subsection (4) if, in the Registrar’s opinion, it is fair and equitable to do so.

(7) For the purposes of this section, “member” includes a person whose certificate of registration has been revoked or has expired or who has resigned as a member.

 


 

D. IMPROVED RECORD KEEPING BY COLLEGES

 

Background and rationale for the proposed amendment

 

It may seem extraordinary to ask for an amendment to the Act requiring a College to keep records in a proper manner.  One would expect that a responsible College would do this as a matter of course without being asked.  The CPSO certainly expects its members to create, store and retrieve patient records in a proper manner; for example, section 95(1)(o) of the Code states that the Council may make regulations "requiring members to keep prescribed records in respect of their practice" and under the CPSO policy "Medical Records Management" it further states: "Physicians must ensure medical records in their custody or control are stored in a safe and secure environment" and "Physicians must ensure medical records are readily available and producible when access is required". 

 

However, there is currently nothing in the Act which imposes a similar duty upon the CPSO to maintain, store and produce records.  In the interests of transparency and accountability, the CPSO should be required to produce its records for inspection upon reasonable request.

 

A particular area of concern is the “never reapply” undertakings which have been discussed above.  I suspect that the quality of the CPSO’s records in this regard may be poor, and that decisions to issue these undertakings are frequently made on the grounds of administrative convenience rather than merit.  However, without inspecting the records it is impossible to know.

 

In the past the CPSO has claimed that its records in “off site storage” are difficult to retrieve and has used this as an excuse not to produce them.  However, it refuses to give any further details about where or what the “off site storage” is or who is looking after the records[15].

 

If members responded in this way to requests by the CPSO to produce their patient records, this would be deemed unacceptable and would result in disciplinary action.  The same behaviour by the CPSO should be equally unacceptable.

 

Section of Act sought to be amended

Schedule 2, Health Professions Procedural Code, Section 3

 

Proposed new wording to be inserted

 

Record keeping

3.2. In furtherance of the objects of the College specified in section 3(1), it is the duty of the College to keep adequate records relating to its members.  The College shall therefore:

(1) appoint one of its employees as a Records Officer with responsibility for keeping,  maintaining and disclosing the records referred to in this subsection;

(2) make an adequate record of every encounter with a member or his legal representative, every discussion pertaining to a member, and every decision taken in respect of a member;

(3) store the records in a manner which allows for retrieval when necessary;

(4) store the records in an adequate location which allows for retrieval when necessary;

(5) disclose the location where records are stored upon reasonable request;

(6) allow inspection of the records storage facility by the Minister upon reasonable request;

(7) disclose records pertaining to a member, to that member upon reasonable request.


 

E. IMPROVED PROCEDURES FOR DEALING WITH MALICIOUS COMPLAINTS

 

Background and rationale for the proposed amendment

 

Most complaints against physicians are made in good faith.  Unfortunately, a small number of complaints are made maliciously and/or with the intent to put pressure on, or take revenge on, the physician.  In the case of a malicious complaint, there is an imbalance of power between the physician and the complainant, in the complainant's favour.  A complaint puts the physician’s medical licence, reputation and livelihood at risk.  The complainant, on the other hand, takes no risk at all.  The Act as currently worded ensures that even if a complaint is made in bad faith, the worst that can happen to the complainant is that no action is taken with respect to the complaint.

 

Opioid seeking patients have long been aware of this, and some of them use the threat of a CPSO complaint to put pressure on physicians in order to obtain opioid prescriptions.  This amendment seeks to redress the balance, and provide an option for the panel to refer the matter to the Crown Attorney’s office if they feel that such a referral is justified.  It does not compel the panel to do so; they are still free to take no action if they think this is the most appropriate disposal.  However, it would send a message to the more aggressive opioid seekers that making threats and frivolous complaints may have adverse consequences for themselves as well as the physician.

 

An example is attached of a typical threat made by an opioid seeking patient[16] [17] [18].

 

Section of Act sought to be amended

Schedule 2, Health Professions Procedural Code, Section 26(5)

 

Current wording of Act

 

(5)    If the panel is satisfied, after considering the written submissions of the complainant and the member, that a complaint was frivolous, vexatious, made in bad faith, moot or otherwise an abuse of process, the panel shall not take action with respect to the complaint.  2007, c.  10, Sched.  M, s.  30.

 

Proposed amended wording of Act

 

(5)    If the panel is satisfied, after considering the written submissions of the complainant and the member, that a complaint was frivolous, vexatious, made in bad faith, moot or otherwise an abuse of process, the panel may:

(i)  take no action; or

(ii)  if it appears that a criminal offence has been committed, refer the matter to the Crown Attorney’s Office.

 

F. IMPROVED ACCESS TO COLLEGE DATA


Buried deep in a sub-menu on the CPSO website, under "Contact us", there is a sub-section entitled "Request College Data".  In the FAQs for this section, the CPSO states that it will only release a standardized data set with the following information: CPSO #, Telephone Number, Graduation Year, Name, Fax Number, Hospital Privileges, Gender, Primary Practice Address, Specialty, Municipality, Secondary Practice Addresses, Language of Practice, Postal Code, Medical School, Registration Status, Registration Class, Registration Status, Effective From.

It will not release any other information.  However, this information set is already available in the Doctor Search section of the CPSO website and is basically a sub-set of the data which the college is required to publish under section 23 of the Health Professions Procedural Code.  So what this means in practice is that the CPSO will not release any information about the workings of the college, other than what it has already published on its website.  This is very frustrating if you are trying to obtain information about, for example, how often "never reapply" undertakings are used, because all enquiries are met with a stonewall refusal.

The CPSO has a commitment to "transparency", but this is about as far removed from transparent as it is possible to get.


Section of Act sought to be amended

Schedule 2, Health Professions Procedural Code, Section 3 (Objects of College)


Proposed amended wording of Act

3 (1) The College has the following objects: ...

11. The provision of information about the workings of the College in response to inquiries, such information not to be unreasonably withheld. 

12. Any other objects relating to human health care that the Council considers desirable.  1991, c. 18, Sched. 2, s. 3 (1); 2007, c. 10, Sched. M, s. 18; 2009, c. 26, s. 24 (11). 


The CPSO was invited to comment on these proposals but has declined to do so.

 

Thank you for your consideration of these proposals.  Please let me know if you or the Standing Committee have any questions.

 

Yours sincerely