Summary of Allegations: (April 11, 2014) Allegations of Dr. Patel's professional misconduct and incompetence have been referred to the Discipline Committee of the College. It is alleged that Dr. Patel is incompetent and/or failed to maintain the standard of practice of the profession in his care of 27 patients. It is further alleged that Dr. Patel has engaged in disgraceful, dishonourable or unprofessional conduct, including by: inadequate supervision of members of his staff and/or at his place of practice; improper delegation of controlled acts; improperly permitting and/or directing staff members to prescribe to patients; inappropriately having staff care for and treat patients in his absence; inappropriate billing to the Ontario Health Insurance Plan; conduct during a medical appointment with Patient A that included exposing the patient's breast without warning; inappropriately ending the doctorpatient relationship with Patient B; communicating inappropriately with Patient B; and failing to provide an acceptable audit trail for the electronic medical records of Patients A and B upon request by the College investigator and/or to maintain audit trails in accordance with College policy.
(November 19, 2014) It is alleged that Dr. Patel has engaged in disgraceful, dishonourable or unprofessional behaviour by failing to comply with his undertaking to the College dated May 1, 2014, including by continuing to delegate controlled acts and failing to abide by the recommendations of his clinical supervisor.
Decision Summary: On March 9, 2015, the Discipline Committee found that Dr. Patel committed an act of professional misconduct by failing to maintain the standard of practice of the profession in his care of 25 patients and is incompetent, in that, his professional care of these patients displayed a lack of knowledge, skill or judgment that was of such a nature or to such an extent that his practice should be restricted or that he is unfit to continue to practise. The Committee also found that Dr. Patel engaged in disgraceful, dishonourable or unprofessional conduct, namely: inadequate supervision of staff; improper delegation of controlled acts; improperly permitting and/or directing staff to prescribe to patients; inappropriately having staff care for and treat patients in his absence; inappropriate billing to OHIP; and breaching his undertaking to the College. Dr. Patel admitted to the allegations.
In addition, Dr. Patel pleaded no contest to and the Discipline Committee found that Dr. Patel committed an act of professional misconduct, in that he failed to maintain the standard of practice of the profession and that he engaged in disgraceful, dishonourable or unprofessional conduct regarding his care of Patients A and B.
An investigation into Dr. Patel’s practice was initiated after the College received information that Dr. Patel had been allowing staff to perform patient care beyond that which was appropriate for a non-physician staff member to provide. When College investigators attended at Dr. Patel’s clinic in April 2011, staff and patients were present. College investigators were advised that Dr. Patel was on vacation.
Dr. Patel inappropriately billed OHIP during the time period that he was on vacation in April 2011. OHIP billings for the time period of Dr. Patel’s absence indicated that the total amount billed in his name while he was on vacation was $34,079.14. Dr. Patel was not present in the office while any services were performed during this time. Dr. Patel inappropriately billed OHIP during this time period. Dr. Patel also engaged in other inappropriate billing practices: billing for a minor assessment when faxing prescription renewals to or receiving them from pharmacies; billing for a minor assessment when a patient’s family member dropped off or picked up a document, prescription or testing kit; and billing inappropriately with respect to administration of the Rotateq vaccination.
Dr. X, independent expert, identified a number of areas in which Dr. Patel’s practice was unsatisfactory, including that he:
(a) made unsubstantiated diagnoses, including of diabetes.
(b) ordered numerous unnecessary tests that were not appropriate to patients’ circumstances, based on the use of templates and routine. Inappropriate blood tests were also ordered as a matter of routine. Decisions were generally made to order tests before Dr. Patel had seen the patient.
(c) inappropriately treated respiratory infections in both adults and pediatric patients with medications that do not meet the standard of practice, and he failed to consider asthma where it would have been indicated to do so. Patients with respiratory infections were sometimes required unnecessarily to come in daily or almost daily for a period of time for a treatment that was not indicated.
(d) failed to address patients’ presenting concerns on occasion.
(e) failed on one occasion to follow up appropriately on an abnormal electrocardiogram.
(f) inappropriately prescribed the ‘morning sickness’ medication Diclectin to a prenatal patient who did not complain of nausea or vomiting.
(g) failed to ensure that information in the patient chart was informative.
(h) failed to appropriately supervise staff and improperly delegated controlled acts. There was no documentation in the charts of instructions by Dr. Patel to his staff, including with respect to assessments and examinations conducted in his absence, nor were there any medical directives provided. Dr. X identified instances in which the care delivered in this manner showed a lack of appropriate clinical decision-making reflective of the lack of supervision.
(i) failed to obtain informed patient consent to the delegation of controlled acts to staff, or to staff involvement in their care.
After a referral to the Discipline Committee, Dr. Patel entered into an undertaking dated May 1, 2014. Among other things, Dr. Patel undertook that, effective immediately, he would not “delegate to any other person any Controlled Act, as that term is defined in the Regulated Health Professions Act, 1991.” He also undertook to engage a Clinical Supervisor, Dr. Y, who would review his practice. Dr. Patel undertook “to co-operate fully with the supervision of” his practice, and to abide by the recommendations made by his Clinical Supervisor, including but not limited to any recommended practice improvements and ongoing professional development.
Dr. Y reviewed patient charts from Dr. Patel’s practice and observed patient encounters in his office as required by the Undertaking. In the course of her duties, Dr. Y found that Dr. Patel continued to delegate controlled acts in breach of his Undertaking.
Dr. Patel failed to abide by practice recommendations made by Dr. Y, in breach of his undertaking, namely:
(a) to cease having staff enter billing codes for visits that were in progress and to begin entering billing codes only upon completion of a patient encounter.
(b) to cease billing for visits at which the patient was not present, including missed appointments and where the patient or family member was dropping off or picking up forms, specialist information, or specimens for testing.
(c) to augment subjective histories documented by staff with his own additional questions.
(d) to obtain informed consent from patients prior to staff documenting patients’ subjective histories.
(e) to take steps to ensure that his EMR system clearly indicated which details were entered by which individual.
(f) to take steps to ensure his staff did not make clinical decisions.
(g) to cease ordering unnecessary diagnostic tests.
(h) to cease routinely prescribing Biaxin and Alupent for cough symptoms.
In addition, Dr. Patel failed to abide by patient-specific treatment recommendations made by Dr. Y, in that he did not discontinue a drug, Diabeta, which is associated with hypoglycemia to a patient who had experienced a hypoglycemic episode, continued to prescribe narcotics to a patient without adequate documentation, and continued to prescribe Ventolin to a patient without the suggested addition of another inhaler such as Advair to provide better symptom relief.
With respect to Patient A, she attended at Dr. Patel’s office because she was experiencing foot problems and looking for a family physician. A female staff member, whom Patient A believed was a nurse but who was not a nurse, documented Patient A’s history in detail, as well as her blood pressure, weight, and height. Patient A expressed to both the staff member and to Dr. Patel that she was being followed by Hospital 1 for a health issue related to her breasts, and did not require a breast examination. During the examination, Dr. Patel made comments that made Patient A feel uncomfortable, did not examine her feet, and conducted a breast examination without her consent.
Dr. X indicated that Dr. Patel’s care did not meet the standard of practice of the profession. The history and other information in the chart obtained was contradictory. Patient A was subjected to unnecessary investigations, and did not have her concerns regarding her presenting complaint addressed. She had a breast examination to which she had not consented. There were errors in judgment in not seeking to obtain information from Hospital 1 or ordering appropriate tests, and there was a lack of adequate supervision of the staff member who saw Patient A before Dr. Patel. Dr. Patel’s care displayed a lack of knowledge and judgment.
With respect to Patient B, he attended at the office of Dr. Patel complaining of chest pain. He was initially seen by a staff member, who recorded his history and vital signs, and performed an electrocardiogram. Dr. Patel informed Patient B that his electrocardiogram was normal, and that he could not treat him. Dr. Patel advised him that he could go to a hospital emergency department if he wished.
The next day, Patient B was admitted to hospital, where he underwent triple bypass surgery. Patient B was discharged from hospital with instructions to follow up with his family physician.
After Patient B voiced concerns regarding post-operative care, he was discharged from Dr. Patel’s practice by letter, five days after his discharge from hospital.
Dr. X opined that based on Patient B’s account of his patient encounter, Dr. Patel did not meet the standard of practice of the profession and lacked knowledge and judgment in his treatment of Patient B. It would have been appropriate for Dr. Patel to either call the emergency department or send information either separately or with the patient. Patient B’s discharge from Dr. Patel’s practice also exposed him to harm, as he was not given any time to find a new primary care provider, and the discharge instructions from the hospital had indicated the need to see his primary care provider within the week.
With respect to both Patients A and B, Dr. Patel failed to provide an audit trail for their electronic medical records that accorded with College policy upon request by the College investigator.
In making its decision, the Discipline Committee rejected the submissions that were made by counsel for Dr. Patel in favour of a suspension and detailed program of re-education. The Committee disagreed with the opinion of an expert witness called by Dr. Patel on the structure and implementation of the proposed remediation, instead finding that Dr. Patel was not remediable. The Committee took into account the fact that it had disciplined Dr. Patel on two previous occasions, finding that the cumulative impact of the breadth and pervasiveness of Dr. Patel’s clinical misconduct, and its extent, together with his failure to respond to the recommendations of his supervisor, provided evidence of ungovernability and constituted professional misconduct that deserved the most serious sanction. Dr. Patel’s delegation practices and billing offences were a serious breach of the public trust. The safety of the public, maintenance of public confidence in the profession and its ability to govern itself, and the maintenance of the integrity of the profession, called for imposition of a penalty of revocation in this case.
On May 20, 2015, the Discipline Committee ordered and directed that:
- the Registrar revoke Dr. Patel's certificate of registration, effective immediately.
- Dr. Patel to appear before the Committee to be reprimanded, and that the fact of the reprimand be recorded on the register.
- the parties make written submissions with respect to costs payable to the College, to be exchanged and filed with the Hearings Office of the College within 21 days of the date of this order.
Terms and conditions imposed on certificate by: Member