On September 25, 2018, the Discipline Committee found that Dr. James Scott Bradley Martin committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession. The Committee also found that Dr. Martin is incompetent.
Dr. Martin is an obstetrician-gynecologist who received his certificate of registration authorizing independent practice in June 1977. Throughout the relevant time, Dr. Martin practised in London, Ontario.
Patient A
The College commenced investigation after being contacted in 2016 by staff in the Ministry of Health and Long-Term Care with inquiries regarding Dr. Martin's prior approval application for an adolescent female-to-male transgender patient (Patient A) seeking sex reassignment surgery (a mastectomy). At the time the investigation began, Dr. Martin described his practice as focused on transgender care and hormone replacement therapy. He indicated that he saw approximately thirty patients a week, spending fifteen hours a week in direct patient contact.
The College retained an expert, a pediatrician and adolescent medicine specialist, to review Dr. Martin's care of Patient A. The expert’s report was received on July 11, 2017. The expert found, among other things, that:
- Dr. Martin did not meet the standard of practice of the profession regarding care for adolescents with gender dysphoria in his care of Patient A;
- Dr. Martin prescribed cross-sex hormones to Patient A, an adolescent, at their first visit. Gross-sex hormones have many side effects, including infertility, and more time is necessary to process this information so that adolescents can make an informed decision. Dr. Martin lacked judgment in this regard;
- Dr. Martin lacked judgment regarding determination of mental health needs and supports. The mental health portions of the patient chart were limited, and he did not specifically address common mental health diagnoses that co-occur with gender dysphoria in adolescents, such as depression and anxiety. There was no mental health assessment before initiating cross-sex hormones;
- Dr. Martin's conduct could expose patients to harm or injury, based on his prescribing cross-sex hormones to a young patient at the first visit with minimal mental health history- taking and the lack of assurance that the patient has sought and is accessing appropriate mental health resources and supports.
The expert provided an addendum to his report, in which he advised that his opinion had not been affected after reviewing a response submitted by Dr. Martin. Dr. Martin failed to maintain the standard of practice of the profession and was incompetent in his care of Patient A.
Patient B
In 2016, a relative complained to the College about Dr. Martin's treatment of Patient B, an adolescent male-to-female transgender patient. The complainant voiced concerns that Dr. Martin had prescribed hormone replacement therapy and was prepared to approve sex reassignment surgery without a mental health assessment.
College expert reviewed the patient's care and provided a report on July 11, 2017. Among other things, the expert found that:
- Dr. Martin did not meet the standard of practice of the profession regarding care for adolescents with gender dysphoria in his care of Patient B;
- Dr. Martin prescribed cross-sex hormones to Patient B, an adolescent, at their first visit. Cross-sex hormones have many side effects, including infertility. More time is necessary to process the information regarding side effects so that adolescents can make an informed decision. Dr. Martin lacked judgment in this regard. The short length of the first consultation (described by Dr. Martin as thirty minutes), at which cross-sex hormones were prescribed, was also concerning, given the time required for an informed consent discussion to take place;
- Dr. Martin lacked judgment regarding determination of mental health needs and supports. The mental health portions of the patient chart were limited and the notes were similar from visit to visit. Dr. Martin did not specifically address common mental health diagnoses that co-occur with gender dysphoria in adolescents, such as depression and anxiety. There was no mental health assessment before initiating cross-sex hormones;
- Dr. Martin's conduct exposed patients to harm or injury, based primarily on Dr. Martin's initiation of cross-sex hormones at the first visit, as well as Dr. Martin's lack of understanding regarding the need to assess an adolescent patient's mental health.
Dr. Martin failed to maintain the standard of practice of the profession and was incompetent in his care of Patient B.
Dr. Martin’s Discipline History
On June 9, 2014, the Discipline Committee found that Dr. Martin failed to maintain the standard of practice of the profession in his fertility practice and directed the Registrar, among other things, to suspend his certificate of registration for a period of two months and restrict his practice to reproductive endocrinology and the interpretation of fertility-related ultrasound images. Dr. Martin admitted that he provided an excessive number of intrauterine insemination (“IUI”) treatment cycles in some cases, delaying patients from moving on to more effective treatment options. He also, among other things, failed to document important discussions regarding patients’ treatment options that he claimed took place, including about patients choosing to continue with IUI rather than try other interventions.
Dr. Martin’s Inquiries, Complaints and Reports Committee (the “ICRC”) History
On April 11, 2014, in response to a complaint from a patient, the ICRC cautioned Dr. Martin regarding improper OHIP billing and advised him regarding the adequacy of his record-keeping and documentation with patients who exceed six IUI procedures.
On August 15, 2014, in response to a complaint from a couple regarding infertility treatment as well as communications with Dr. Martin and his staff, the ICRC cautioned Dr. Martin to ensure that he responded promptly to communications from the College about complaints, and advised him regarding documentation, to ensure that he fully documents patient interactions.
On June 10, 2016, the ICRC considered investigations into three complaints from families of transgender patients. As a result, the ICRC required Dr. Martin to attend in person for cautions. The complaints also grounded a broader investigation into Dr. Martin’s hormone and transgender practice. The ICRC required Dr. Martin to complete a specified continuing education or remediation program (“SCERP”) regarding transgender care, including moderate clinical supervision and a reassessment.
Clinical Supervision
As required by the SCERP ordered by the ICRC in June 2016, Dr. Martin retained a clinical supervisor for transgender care. The Clinical Supervisor provided reports and identified areas for improvement with respect to Dr. Martin’s failure to adequately canvas and document mental health issues and history, and his practice of initiating hormone therapy during initial visits, sometimes before appropriate examinations (such as baseline blood testing) had been completed and acted upon. During the course of the clinical supervision, the Clinical Supervisor documented that Dr. Martin made improvements to these aspects of his practice. At the conclusion of the clinical supervision, the Clinical Supervisor stated that he had no major concerns, but continued to identify areas for improvement.
Dr. Martin’s Status Pending the Discipline Hearing
On August 22, 2017, the ICRC made an interim order, which required, among other things, that Dr. Martin refrain from providing transgender care to any new patients under the age of eighteen, and that he practise under clinical supervision in providing transgender care to existing patients under the age of eighteen. Dr. Martin subsequently advised the College that he had chosen not to obtain a clinical supervisor. Accordingly, as of September 23, 2017, under the terms of the order Dr. Martin was required to cease providing transgender care to patients under the age of eighteen.
As of August 16, 2018, Dr. Martin permitted his certificate of registration to expire.
Dr. Martin’s Undertaking
Dr. Martin has entered into an undertaking, by which, among other things, he has undertaken to resign his certificate of registration and not to apply or re-apply for registration as a physician to practise medicine in Ontario or any other jurisdiction.
Disposition
On September 25, 2018, the Discipline Committee ordered and directed that:
- Dr. Martin appear before the panel to be reprimanded.
- Dr. Martin pay to the College its costs of this proceeding in the amount of $6,000.00 within sixty (60) days from the date of this Order.
Terms and conditions imposed on certificate by: Discipline Committee