On February 13, 2017, the Discipline Committee found that Dr. Thomas Joseph Barnard committed an act of professional misconduct in that he failed to maintain the standard of practice of the profession; and, he has engaged in an act or omission relevant to the practice of medicine that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional.
Dr. Barnard is a family physician practising in Windsor. He operates a family medicine practice called the Barnard Wellness Centre, at which he is the sole primary care physician, and also operates the Fresh Medical Spa, which is located at the same address as his family medicine practice.
Failed to Maintain the Standard of Practice Section 75(1)(a) Investigation into care of a single patient On October 18, 2012, the College received a letter from the Chief Coroner for Ontario, enclosing reports from a Coroner’s investigation of the death of a person who was a regular patient of Dr. Barnard’s between May 2000 and April 2012. The Coroner’s report indicated that the cause of death was a multi-drug toxicity, which included controlled substances that had been prescribed to the patient by Dr. Barnard.
Dr. Barnard failed to maintain the standard of practice of the profession in his care and treatment of the patient.
The College retained a family physician who found that Dr. Barnard demonstrated a lack of skill and did not meet the standard of practice for the following reasons:
- His information gathering was perfunctory;
- His histories were not sufficiently detailed;
- The physical examinations were cursory at best and appeared to be generated from a template. Often they were not relevant to the presenting complaint;
- There was no information about family history in his notes. It was gathered from the consultant reports;
- The patient's surgical history was not recorded except in the consultant's notes;
- He did not routinely ask about allergies;
- His assessments were not based on the history and physical findings; he often reiterated the patient's complaint rather than making a true diagnosis;
- The rationale for his treatment plans was difficult to understand;
- The Cumulative Patient Profile (“CPP”) at the front of the chart was difficult to read;
- The results of the patient's tests were not organized for easy retrieval; and
- He did not keep an up to date list of the medications that were prescribed and every consultant who looked after the patient had an incomplete or inaccurate list of her actual medications.
The family physician also opined that Dr. Barnard: lacked knowledge about the risks of polypharmacy and the risks of treating chronic pain with opioid analgesics; demonstrated a lack of judgment by continuing to prescribe drug combinations with known risks of harm, by continuing to prescribe narcotics when it was obvious that the patient was unable to control her use and the medication was doing more ‘to her’ than ‘for her’, and by continuing to provide the patient with large numbers of narcotics when he knew the patient was unable to prevent theft by her husband.
On November 9, 2014, Dr. Barnard signed an undertaking to the College restricting him from prescribing any Narcotics, Controlled Drugs, Benzodiazepines/Other Targeted Substances and all other Monitored Drugs and Narcotics Preparations, with the exception of Tylenol with codeine #3 in limited amounts.
Section 75(1)(a) Investigation into prescribing practices
The College conducted a broader investigation into Dr. Barnard’s prescribing practices with respect to 25 patients. A family physician retained by the College concluded that Dr. Barnard’s care of 11 patients did not meet the standard of practice and that he demonstrated various degrees of a lack of knowledge, skill or judgment. He opined that in 7 charts the care provided posed a potential risk of exposing patients to harm or injury and, of these 7, the risk of harm was particularly high with respect to 4 patients.
The four cases in which it was concluded that the risk of exposing the patient to harm or injury was particularly high were those in which:
- A patient was receiving frequent morphine injections as well as other narcotics while she was pregnant;
- A patient who had severe migraine headaches was receiving frequent morphine injections as well as nasal butorphanol, the amounts of which were well in excess of recommended guidelines for non-cancer pain;
- A patient was receiving very frequent morphine injections for chronic pelvic pain, much in excess of recommended guidelines; and
- A patient’s chart contained indications from anonymous phone calls that he was selling his medication and a letter from the Children’s Aid Society expressing concern of large amounts of narcotic medication in a household with small children.
Dr. Barnard failed to maintain the standard of practice of the profession in his care of 11 patients.
Section 75(1)(a) Investigation regarding broader patient care
On September 18, 2012, the College received information regarding Dr. Barnard from the Ministry of Health and Long-Term Care (MOHLTC) as a result of a review of his medical records for services completed in 2009. MOHLTC medical advisors identified clinical concerns with respect to Dr. Barnard’s patient care.
The College retained a family physician to provide an opinion regarding the standard of care provided by Dr. Barnard to 37 patients. The family physician concluded that the standard of care was not met in any of the cases reviewed and that Dr. Barnard displayed a lack of knowledge and judgement in each case. She also opined that Dr. Barnard’s clinical practice and conduct exposed all but one of the patients whose care was reviewed to a risk of harm. The conclusions were based, in part, on the following concerns:
- Dr. Barnard’s administration of human chorionic gonadotropin (“HCG,” known colloquially as “human growth hormone”) for weight loss in the management of obesity despite it being discredited and rejected by the medical community;
- Numerous, significant examples of disjointed and episodic care with poor recordkeeping and judgment that impairs the provision of an adequate diagnosis and case management;
- Certain use of “off label” prescribing and potentially harmful prescribing (including prescribing HCG as described above; potentially harmful prescribing of narcotics for non-cancer pain; prescribing benzodiazepines with narcotics; Methotrexate and Plaquenil without indication; prescribing hormone replacement therapy without appropriate documentation and assessment; prescribing high doses of vitamin D; prescribing iron and high doses of vitamin B without indication);
- Failure to meet the standard in his documentation of consent for “off label” or potentially harmful prescribing, and other failures of documentation;
- Lack of documentation of appropriate follow-up on test results;
- Failing to document history, physical examination, diagnosis, and informed consent when prescribing complementary and alternative medicines, and prescribing some such medicines which he knew had no medical evidence for use, such as HCG; and
- The use of excessive laboratory testing in the absence of clear documentation of medical need.
In December 2015, the College requested updated patient records from Dr. Barnard for 10 patients whose care had been reviewed. It was found that Dr. Barnard’s care did not meet the standard of practice in any of the charts reviewed and that his care continued to display a lack of knowledge, skill and judgment.
Dr. Barnard failed to maintain the standard of practice of the profession in his care of 37 patients as described above.
Investigation Regarding Patient A
Patient A became Dr. Barnard’s patient in the Barnard Wellness Centre in May 2012. Patient A had a history of testosterone levels having been documented as low by other physicians as recently as 2011, but it was very high based on the initial bloodwork ordered by Dr. Barnard in May 2012.
Dr. Barnard treated Patient A, including continually prescribing testosterone injections from July 2012 until April 2013, when Dr. Barnard severed the doctor-patient relationship.
The College retained a family physician with a focus in men’s health, including testosterone deficiency, to review Dr. Barnard’s care in regard to Patient A, who found that Dr. Barnard did not meet the standard of practice of the profession in that he:
- Displayed poor documentation and recordkeeping of his thought process and/or discussions with Patient A;
- Failed to adequately counsel Patient A in the hazards of continued steroid use;
- failed to try to have Patient A adhere to a more traditional protocol for testosterone replacement, with lower initial dosing and further titration based on serum testosterone levels and/or symptom management, and escalated the dosage of testosterone without monitoring hematocrit; and
- Demonstrated poor judgment in embarking on an unorthodox treatment plan of high dosing with little monitoring that, while for the most part it worked along with the desires and with the consent of the patient, was not in the best long term interests of the patient.
Dr. Barnard failed to maintain the standard of practice of the profession in his care of Patient A.
Investigation Regarding Patients B and C
Patient B became Dr. Barnard’s patient in March 2012 and Patient C became Dr. Barnard’s patient in February. Dr. Barnard terminated both patients from his practice.
Dr. Barnard treated Patient B for chronic pain. He prescribed Lyrica, Cymbalta, Botox injections, vitamin injections and testosterone injections beginning in May 2012. Dr. Barnard did not record Patient B’s serum testosterone levels before prescribing testosterone injections.
The College retained a family physician to review the care provided by Dr. Barnard to Patients B and C, who opined that the care provided to both patients fell below the standard of the 4 profession based on a lack of skill, knowledge and judgement and that Dr. Barnard’s care exposed them to harm. Specifically, Dr. Barnard:
- Demonstrated a lack of skill in the quality and quantity of his information gathering, in his record keeping and in his performance of proper physical assessments;
- Demonstrated a lack of knowledge when he increased Patient C’s dose of thyroxine and added Cytomel without evidence of thyroid deficiency;
- Demonstrated a lack of knowledge when he prescribed Flagyl to Patient C without indication;
-Demonstrated a lack of knowledge in failing to identify the significance of Patient C’s rising erythrocyte sedimentation rate (“ESR”) (which with other symptoms was suggestive of an autoimmune disorder); and
- Demonstrated poor judgment in failing to comply with College guidelines for record keeping, prescribing drugs and the use of alternative therapies.
The College retained a second family physician with some knowledge of and interest in complementary and alternative medicine, to provide an opinion regarding Dr. Barnard’s care of Patients B and C, having regard to the College’s Complementary/Alternative Medicine Policy. With regard to Patient B, the family physician opined that Dr. Barnard’s use of testosterone and vitamin injections was unconventional and not supported by any scientific evidence of which he was aware. Dr. Barnard had failed to clearly indicate the diagnosis although he treated chronic pain syndrome with an associated neuropathy. Dr. Barnard did not document valid informed consent for his unconventional therapeutic interventions.
With respect to Patient C:
- Dr. Barnard’s care of Patient C’s inflammatory disorders falls within the realm of complementary medicine;
- Dr. Barnard failed to provide an appropriate clinical assessment with regard to Patient C. He recorded no clear working diagnosis or treatment plan;
- Dr. Barnard failed to document a conventional diagnosis;
- He did not record any evidence of informed consent having been obtained for the unconventional therapeutic interventions;
- He failed to address the patient’s elevated ESR; and
- Despite the poor assessment and review of Patient C, his care did not demonstrate a lack of knowledge or skills. However, Dr. Barnard showed poor judgment by failing to document more appropriate patient counselling regarding the unconventional therapies being utilized.
Dr. Barnard failed to maintain the standard of practice of the profession in his care of Patients B and C.
Investigations Regarding Patients D, E and F
Patients D, E and F, who were a mother and her two children, became Dr. Barnard’s patients in the Fall/Winter of 2010/2011, and continued as his patients until November 2013.
The College retained a family physician to review the standard of care provided by Dr. Barnard to Patients D, E and F, who concluded that Dr. Barnard did not meet the standard of practice of the profession in relation to Patients D, E and F and that he demonstrated a lack of knowledge and skill. Examples of Dr. Barnard’s lack of knowledge and skill include:
- a lack of knowledge of appropriate testing and investigations for specific symptoms. Among other things, Dr. Barnard repeatedly ordered a broad spectrum of tests on Patients D, E and F without indication, including broad annual testing for Patient D, and ordered specific tests that were not inappropriate based on the patient’s age or lack of suitability as a screening tool;
- a lack of knowledge in treating asthma in children with respect to Patients E and F, where those patients received oral medications without any clear indication for their use and without corresponding use of inhaled medications;
- a lack of knowledge in the use of antibiotics, including prescribing incorrect doses and prescribing in cases where antibiotics are not indicated;
- a lack of knowledge in prescribing with respect to dosage of Topamax;
- a lack of knowledge of the treatment of anxiety for Patient D, and giving inappropriate treatment for the same; and
- a lack of skill in the documentation of visits, including incomplete or absent charting of history, physical examinations and assessments that seemed to be in an identical template for nearly every visit, missing vital signs, and a lack of any differential diagnosis and treatment plan in any of the entries.
Dr. Barnard failed to maintain the standard of practice of the profession in his care of Patients D, E. and F.
Disgraceful, Dishonourable and Unprofessional Conduct
Patient B became Dr. Barnard’s patient in 2012 and his wife, Patient C, became Dr. Barnard’s patient in 2013. During a double appointment in 2013, attended by both Patient B and C, Dr. Barnard became upset when asked to complete a Functional Abilities Form for Patient B. He told Patient B to “come back when you have your head screwed on right”. Patient B and C left the office. A few days later, they received a letter from Dr. Barnard sent by courier terminating both patients from his practice. The letter and termination were unexpected. Prior to the termination, Dr. Barnard had requested a consultation with a specialist for Patient C. Shortly after the last appointment, and before receiving the termination letter, Patient C received a call from Dr. Barnard’s office indicating the date and time for the specialist consultation. On the scheduled date in July, Patient B and Patient C attended at the specialist’s office for the consultation.
However, when they arrived they were told that although Patient C had been booked for an appointment, it had been cancelled. Dr. Barnard did not advise Patient C at any time that he had cancelled her consultation with the specialist.
Dr. Barnard engaged in disgraceful, dishonourable and unprofessional conduct in the manner in which he terminated Patients B and C from his practice, in cancelling Patient C’s specialist consultation and in failing to notify her of the cancellation.
Dr. Barnard entered into an undertaking to the College on January 20, 2017, by which he has agreed, among other things, that, effective March 17, 2017, he shall no longer practice family medicine and shall no longer bill the Ontario Health Insurance Plan. Dr. Barnard may only provide certain aesthetic and cosmetic services and may provide nutritional counselling. Dr. Barnard shall post a clearly visible sign in the waiting rooms of all his Practice Locations, which states as follows: "Dr. Barnard must not practise family medicine or provide any OHIP-insured service.”
Disposition
On February 13, 2017, the Discipline Committee ordered and directed that:
- The Registrar suspend Dr. Barnard’s certificate of registration for a period of four (4) months commencing on March 17, 2017 at 12:01 a.m.
- The Registrar impose the following terms, conditions and limitations on Dr. Barnard’s certificate of registration:
a. Dr. Barnard shall not prescribe or recommend human chorionic gonadotropin (“HCG”) for the purpose of weight loss to any individual;
b. Dr. Barnard shall have clinical interactions with no more than a total of forty-eight (48) patients per day, at a rate of no more than six (6) patients per hour within each hour;
c. Dr. Barnard shall execute the Prescribing Resignation Letter to Health Canada, which is attached hereto as Schedule “A” (the “Resignation Letter”) to the Order, and shall consent to the College sending the Resignation Letter to Health Canada onhis behalf;
d. Dr. Barnard shall not issue new prescriptions or renew existing prescriptions for any of the following substances:
i. Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
ii. Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
iii. Controlled Drugs (from Part G of the Food and Drug Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);
iv. Benzodiazepines and Other Targeted Substances (from the Benzodiazepines and Other Targeted Substances Regulations made under the Controlled Drugs and Substances Act., S.C., 1996, c. 19);
(A summary of the above-named drugs [from Appendix I to the Compendium of 7 Pharmaceuticals and Specialties] is attached hereto as Schedule “B” to the Order; and the current regulatory lists are attached hereto as Schedule “C” to the Order)
v. All other Monitored Drugs (as defined under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22 as noted in Schedule “D” to the Order); and as amended from time to time.
e. Dr. Barnard shall, by July 17, 2017, retain a clinical supervisor or supervisors (the “Clinical Supervisor”) acceptable to the College, who will sign an undertaking in the form attached hereto as Schedule “E” to the Order. For a period of four (4) months thereafter, Dr. Barnard may practise only under the supervision of the Clinical Supervisor. Clinical supervision of Dr. Barnard’s practice shall contain the following elements:
i. Dr. Barnard shall facilitate review by the Clinical Supervisor of twenty (20) patient charts per month or, should Dr. Barnard treat fewer than twenty (20) patients in any month, the charts of all patients with whom he had clinical interactions in that month, and shall permit the Clinical Supervisor to directly observe him in practice for one half-day per month, with the Clinical Supervisor providing a report every two (2) months to the College.
ii. Dr. Barnard shall meet with the Clinical Supervisor at least once per month or more frequently if requested by the Clinical Supervisor, to: discuss the results of the Clinical Supervisor’s review of patient charts and direct observation of Dr. Barnard’s practice; discuss Dr. Barnard’s care, treatment plans, and follow-up; identify any issues or concerns regarding Dr. Barnard ’s care, treatment plans, or follow-up, discuss and receive recommendations for improvement and professional development.
iii. Dr. Barnard shall fully cooperate with, and shall abide by any recommendations of, his Clinical Supervisor, including but not limited to any recommended practice improvements and ongoing professional
development.
iv. If a Clinical Supervisor who has given an undertaking in the form attached at Schedule “E” to this Order is unwilling or unable to continue to fulfill its terms, Dr. Barnard shall, within twenty (20) days of receiving notice of same, obtain an executed undertaking in the same form from a similarly qualified person who is acceptable to the College and ensure that it is delivered to the College within that time.
v. If Dr. Barnard is unable to obtain a Clinical Supervisor in accordance with paragraph 5(v) or paragraph 5(v)(d) of this Order, he shall cease practising medicine immediately until such time as he has done so, and the fact that he has ceased practising medicine will constitute a term, condition or limitation on his certificate of registration until that time.
f. Approximately six (6) months after the completion of Clinical Supervision, Dr. Barnard shall undergo a reassessment of his practice by a College-appointed assessor (the “Assessor”). The assessment may include a review of Dr. Barnard’s patient charts, direct observation, interviews with staff and/or patients, one or more interviews with Dr. Barnard, and/or a formalized evaluation. The results of the assessment shall be reported to the College after which Dr. Barnard shall abide by any recommendations made by the Assessor by which the College has requested Dr. Barnard to abide.
g. Dr. Barnard shall consent to such sharing of information among the Assessor, the Clinical Supervisor, and the College as any of them deem necessary or desirable in order to fulfill their respective obligations and in order to monitor Dr. Barnard’s compliance with this Order and with any terms, conditions or limitations on his certificate of registration.
h. Dr. Barnard shall consent to the College providing any Chief(s) of Staff or a colleague with similar responsibilities, such as a medical director, at any location where he practises (“Chief(s) of Staff”) with any information the College has that led to this Order and/or any information arising from the monitoring of his compliance with this Order.
i. Dr. Barnard shall inform the College of each and every location where he practices, in any jurisdiction (his “Practice Location(s)”) within five (5) days of this Order and shall inform the College of any and all new Practice Locations within five (5) days of commencing practice at that location.
j. Dr. Barnard shall maintain an up-to-date daily log of every patient with whom he has a clinical interaction, which shall include the patient’s name, the date, and the hour within which the clinical interaction occurred (“Patient Log”). Dr. Barnard shall maintain the original Patient Log and shall send a copy to the College at the end of every calendar month.
k. Dr. Barnard shall cooperate with unannounced inspections of his Practice Location(s) and patient charts by a College representative(s) for the purpose of monitoring and enforcing his compliance with the terms of this Order.
l. Dr. Barnard shall post a sign in the waiting room(s) of all his Practice Locations, in a clearly visible and secure location, in the form set out at Schedule “F” to the Order, and a certified translation of the same in any language in which he provides services, with Dr. Barnard providing such certified translation to the College within thirty (30) days of this Order or, should he later begin providing services in another language, prior to doing so. For further clarity, this sign shall state as follows:
IMPORTANT NOTICE
Dr. Barnard must not prescribe:
- Narcotic Drugs
- Narcotic Preparations
- Controlled Drugs
- Benzodiazepines or Other Targeted Substances
- All Other Monitored Drugs.
Further information may be found on the College of Physicians and Surgeons of Ontario website at www.cpso.on.ca m. Dr. Barnard shall consent to the College making enquiries of the Ontario Health Insurance Plan (“OHIP”), the Drug Program Services Branch, the Narcotics Monitoring System implemented under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22, as amended (“NMS”), and/or any person who or institution that may have relevant information, in order for the College to monitor and enforce his compliance with the terms of this Order and any terms, conditions or limitations on Dr. Barnard’s certificate of registration.
n. Dr. Barnard shall be responsible for any and all costs associated with implementing the terms of this Order.
- Dr. Barnard attend before the panel to be reprimanded.
- Dr. Barnard pay to the College costs in the amount of $5,000.00, within thirty (30) days of the date of this Order.
Terms and conditions imposed on certificate by: Member