On March 12, 2018, the Discipline Committee found that Dr. Ian Kent Shiozaki has committed an act of professional misconduct in that: he has engaged in an act or omission relevant to the practice of medicine that, having regarding to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional; and he failed to maintain the standard of practice of the profession. The Discipline Committee also found that Dr. Shiozaki is incompetent.

Dr. Shiozaki is a general practitioner who, at the relevant time, practiced family medicine in Newboro, Ontario. On October 22, 2015, the College received information from a physician about a mutual elderly patient regarding the dosages of a stimulant prescribed by Dr. Shiozaki.

 

On the basis of this and other information, the College commenced an investigation under section 75(1)(a) of the Health Professions Procedural Code to obtain a broader view of Dr. Shiozaki’s general medicine practice, including his prescribing. In February 2016, the College received information from the Ministry of Health and Long-Term Care’s Narcotics Monitoring System regarding Dr. Shiozaki’s prescribing of controlled drugs, including narcotics, from January 1, 2015 to December 31, 2015 (the “NMS data”).

The College retained a specialist in family medicine to provide an opinion on Dr. Shiozaki’s general medicine practice, including his prescribing. The family medicine specialist reviewed 25 patient charts, the NMS data and interviewed Dr. Shiozaki on two occasions. In his interview with the family medicine specialist, Dr. Shiozaki described himself as having a special interest in pain management and stated that he received pain consultations from other physicians.

The family medicine specialist identified significant concerns in Dr. Shiozaki’s care and treatment of his patients’ chronic non-cancer pain, particularly in the areas of a) prescribing of controlled drugs, including narcotics, and b) injecting of opioids, and associated storage and disposal of injectable opioids. The concerns identified by the specialist included the following:
Prescribing of controlled drugs, including narcotics:
o Large numbers of pills/patches were frequently prescribed at a time.

o Opioids were often titrated rapidly and titrations were frequently done on the basis of a patient’s self-escalation.

o Many opioids were prescribed at unconventional and very off-label dosing intervals.

o Transdermal opioids were frequently directed to be placed in off-label locations, such as on the location of the pain.

o Opioids were often blended; many cases involved blending 3 opioids.

o High doses of opioids were frequently used, even for conditions where opioids were not recommended per the 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.

o Some of the patients on high dose opioid therapy were likely suffering from opioid- induced hyperalgesia.

o Many patients were on long-term benzodiazepine therapy in addition to high dose opioid therapy (± sleep apnea).

o Many patients in the charts reviewed exhibited aberrant drug-related behaviour;

Dr. Shiozaki consistently continued to prescribe and increase dosages of opioids, and failed to refer patients to other pain or addiction resources, in the face of:
o repeated patient requests for early releases and renewals (medications “stolen”, “lost”, “dropped down sink”, “going away”, etc.);

o inconsistent urine drug screens (UDS positive for non-prescribed opioids and/or negative for opioids prescribed by Dr. Shiozaki, indicating potential binging or diversion);

o inadvertent opioid intoxication and overdose;

o alerts from other professionals (pharmacists and other physicians) regarding patients and the medications prescribed Dr. Shiozaki.

o Amphetamines were frequently prescribed for “fibro fog, fatigue, energy…”; these patients were often on high-dose opioid therapy and sometimes also using significant amounts of sleep aids.

Injection of opioids, and associated storage and disposal of injectable opioids:
o Dr. Shiozaki performed many injections/injection techniques for his patients. Opioids were injected, in the office, into knees, the SI joint, piriformis and even trochanteric areas.

o In one patient, Dr. Shiozaki injected an opioid (Demerol) into a patient’s artificial knee joint which is very unusual and exposed the patient to a risk of infection of the prosthesis.

o Patients’ injectable opioids were stored in Dr. Shiozaki’s office in a hollowed out “book”.

This was not locked. Dr. Shiozaki had previously had a safe in his office for storing opioids; that safe was stolen.

o Dr. Shiozaki ‘shared’ patients’ injectable opioids between patients when needed.

o Dr. Shiozaki disposed of some opioids in his office (e.g. down the sink).

The family medicine specialist opined that Dr. Shiozaki failed to meet the standard of practice of the profession and that he demonstrated a lack of knowledge, skill and/or judgment in his prescribing of controlled drugs, including narcotics, and, in some cases, his injecting of opioids and associated storage and disposal of injectable opioids, in all 25 patient charts reviewed.

In addition to the concerns identified about Dr. Shiozaki’s treatment of pain, the family medicine specialist identified other concerns about Dr. Shiozaki’s general medicine practice in 11 of the 25 charts reviewed, including a failure to offer or document age-specific preventive screening and a failure to adequately treat and monitor certain conditions.

Report of College’s Pain Medicine Expert Given the information obtained in the investigation about Dr. Shiozaki’s performing injections in his office, the College retained a pain medicine expert to provide an opinion about whether certain injections performed by Dr. Shiozaki were of a nature that they could only be performed in a licensed Out-of-Hospital Premises.

The pain medicine expert reviewed 5 patient charts, and attended at Dr. Shiozaki’s office on December 2, 2016, where he toured the clinic, reviewed equipment and interviewed Dr. Shiozaki as to the variety of injections that he performed. Dr. Shiozaki advised the pain medicine expert that he had not performed nerve block injections since the Out-Of-Hospital Premises program was implemented.

In his report, the pain medicine expert took issue with one of the injection procedures conducted by Dr. Shiozaki and concluded that “Dr. Shiozaki is performing nerve blocks in the form of SI joint injections […] This is a Level 1 nerve block procedure under the OHP guidelines.” Level 1 nerve block procedures may only be performed in authorized Out-Of-Hospital Premises.

Dr. Shiozaki’s office was not an authorized Out-Of-Hospital Premises. Dr. Shiozaki applied to the College in 2010 to have his office authorized as an Out-Of-Hospital Premises because he was performing nerve blocks. He elected not to proceed with the application after learning what was required to obtain authorization to operate an Out-Of-Hospital Premises and advised a College investigator at that time that he was no longer performing nerve blocks.

The pain medicine expert identified concerns with Dr. Shiozaki’s clinic’s preparedness for medical emergencies given that Dr. Shiozaki was performing Level 1 nerve block procedures, and opined that, in the 5 charts that he reviewed, Dr. Shiozaki’s procedural notes fell below the standard of practice of the profession and that Dr. Shiozaki demonstrated a lack of knowledge on the safe storage of opioids, specifically injectable Demerol.

Interim Undertaking
By letter dated February 1, 2017, Dr. Shiozaki responded to the reports of the family medicine specialist and the pain medicine expert retained by the College. In that letter, he stated that he had not been aware that SI joint injections were nerve blocks pursuant to the OHP Guidelines and that he had ceased to perform them. He proposed to enter into an Undertaking to cease prescribing Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and Monitored Drugs, and to cease injecting opioids. He also provided a list of injections that he proposed to continue to perform.

In support of his proposal, Dr. Shiozaki provided the College with the report an anesthesiologist and pain medicine specialist, who reviewed the same charts as the family medicine specialist and the pain medicine expert. The anesthesiologist and pain medicine specialist’s report noted that she “did concur with some of the concerns expressed by the [family medicine specialist and pain medicine expert retained by the College].” She also opined that she had “no concerns” with Dr. Shiozaki’s proposal to continue to perform certain types of injections not requiring OHP facilities and that, in her view, he is “competent and capable” to perform them.

Dr. Shiozaki also provided the College with a report dated March 17, 2017 of a family medicine and emergency medicine specialist, who reviewed the 11 patient charts in which the family medicine specialist retained by the College identified other concerns about Dr. Shiozaki’s general medicine practice. The family /emergency medicine specialist noted in his report that Dr. Shiozaki has a challenging patient population and, as an isolated rural family physician in a small community, he has limited ancillary resources to assist him with the management of his patients.

On April 3, 2017, following the referral of the allegations in this matter to the Discipline Committee, Dr. Shiozaki voluntarily entered into an Undertaking in lieu of an Order pursuant to s. 37 of the Code (the “Section 37 Undertaking”). The Section 37 Undertaking provides that Dr. Shiozaki shall not prescribe Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and Monitored Drugs. In addition, Dr. Shiozaki undertook to cease to provide injections except as expressly provided.

Prior Discipline Committee Findings
On May 31, 2014, the Discipline Committee found that Dr. Shiozaki had committed an act of professional misconduct in that he had engaged in an act or omission relevant to the practice of medicine that, having regard to all of the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional. In particular, Dr. Shiozaki admitted that he had engaged in numerous boundary violations with a patient, including kissing her on the lips and breasts, putting his hand in her pants, and lying on top of her.

The Discipline Committee ordered that Dr. Shiozaki’s certificate of registration be suspended for six months, three months of which would be suspended provided that Dr. Shiozaki completed a Boundaries course.

Other Relevant College History
In May 2008, in response to a complaint from a patient of Dr. Shiozaki’s regarding Dr. Shiozaki’s recommendation of an investment opportunity, the Inquiries, Complaints and Reports Committee of the College (the “ICRC”) directed Dr. Shiozaki to attend to be cautioned in person about his conduct and the perception of a conflict of interest in the circumstances.

In April 2012, in response to information from two physicians detailing concerns about Dr. Shiozaki’s prescribing of opioids, the ICRC conducted an investigation. The ICRC counselled Dr. Shiozaki to use supportive resources such as the 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and to consider other non-medicinal modalities for the treatment of chronic pain.

Cooperation in the matter at hand

Dr. Shiozaki cooperated with the College at all times in its investigation of the matter at hand.

Disposition
The Discipline Committee ordered and directed that:
- the Registrar suspend Dr. Shiozaki’s certificate of registration for a period of six (6) months, commencing on March 12, 2018 at 11:59 p.m.
- the Registrar impose the following terms, conditions and limitations on Dr. Shiozaki’s certificate of registration:

Restrictions on prescribing and injections
Dr. Shiozaki shall not issue new prescriptions or renew existing prescriptions for or administer any of the following substances:
o Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);

o Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);

o Controlled Drugs (from Part G of the Food and Drug Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);

o Benzoiazepines 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); and (A summary of the above-named drugs [from Appendix I to the Compendium of Pharmaceuticals and Specialties] is attached hereto as Schedule “A”; and the current regulatory lists are attached hereto as Schedule “B”);

o All other Monitored Drugs (as defined under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22 as noted in Schedule “C”); and as amended from time to time.

Dr. Shiozaki shall not perform any injections except as expressly provided below.

- Dr. Shiozaki may perform the following injections with the following substances:
- Permitted injections:
1. Pre-skin biopsy and other freezing injections such as sutures;

2. Intramuscular Botox injection therapy for treatment of chronic migraine;

3. Trigger point injections;

4. Ligament injections;

5. Tendon sheath injections;

6. Bursa injections (excluding the sacroiliac bursa);

7. Flu shot, tetanus shot, and other general primary care immunization injections.

Permitted substances to be injected:
1. Xylocaine (Lidocaine);

2. Durolane/Synvisc (Hyaluronan);

3. Marcaine (Bupivacaine);

4. Botox (Botulism toxin);

5. Kenalog (Triamcinolone);

6. Saline; and

7. Substances related to the injections permitted in sub-paragraph i. 7.

Dr. Shiozaki shall post a sign in all waiting rooms, examination rooms and consulting rooms, in all of his practice locations, in a clearly visible and secure location, in the form set out at Schedule “D”. For further clarity, this sign shall state as follows:

IMPORTANT NOTICE
Dr. Shiozaki will not prescribe or administer any of the following:
- Narcotic Drugs
- Narcotic Preparations
- Controlled Drugs
- Benzodiazepines and Other Targeted Substances
- All other Monitored Drugs
- Dr. Shiozaki will not perform any injections except as expressly provided by the Order of the Discipline Committee of the College of Physicians and Surgeons of Ontario dated March 12, 2018.

Further information may be found on the College of Physicians and Surgeons of Ontario
website at www.cpso.on.ca

- Dr. Shiozaki shall post a certified translation(s) in any language(s) in which he provide services, of the sign described in paragraph 6(iv) above in all waiting rooms, examination rooms and consulting rooms, in all of his Practice Locations, in a clearly visible and secure location.

- Dr. Shiozaki shall provide the certified translation(s) described in paragraph 6(v) above, to the College within thirty (30) days of this Order.

- Should Dr. Shiozaki elect to provide services in any other language(s), he must notify the College prior to providing any such services.

- Dr. Shiozaki shall provide to the College the certified translation(s) described in paragraph 6(vi) prior to beginning to provide services in the language(s) described in paragraph 6(vii).

Injection observation day in hospital-based pain clinic
- Within three (3) months of resuming practice after the period of suspension of his certificate of registration, Dr. Shiozaki shall spend a day observing injections performed by a physician mentor who is an anesthesiologist and who specializes in pain management (the “Physician Mentor”). The observation shall take place in a hospital-based pain clinic and shall focus on the types on injections that Dr. Shiozaki is permitted to perform.

Supervision and re-assessment of general medicine practice, including injections
- Prior to resuming practice after the period of suspension of his certificate of registration, Dr. Shiozaki shall retain a College-approved clinical supervisor to supervise his general medicine practice including his injections for pain management, who will sign an undertaking in the form attached hereto as Schedule “E” (the “Clinical Supervisor”). For a period of six (6) months, Dr. Shiozaki may practice only under the supervision of the Clinical Supervisor and will abide by all recommendations of his Clinical Supervisor with respect to his practice, including but not limited to practice improvements, practice management, and continuing education. The period of Clinical Supervision will commence on the expiry of the period of suspension, or on the date that the Clinical Supervisor is approved, if one is not approved during the period of suspension;

- If, prior to completion of Clinical Supervision, the Clinical Supervisor is unable or unwilling to continue in that role for any reason, Dr. Shiozaki shall retain a new College- approved Clinical Supervisor who will sign an undertaking in the form attached hereto as Schedule “E”. If Dr. Shiozaki fails to retain a Clinical Supervisor on the terms set out above within thirty (30) days of receiving notification that his former Clinical Supervisor is unable or unwilling to continue in that role, he shall cease practicing medicine until such time as he has obtained a Clinical Supervisor acceptable to the College. If Dr. Shiozaki is required to cease practice as a result of this paragraph, this will constitute a term, condition and limitation on his certificate of registration and such term, condition and limitation shall be included on the public register;

- Upon completion of the six (6) month period of Clinical Supervision, as described above, within approximately six (6) months, Dr. Shiozaki shall undergo a re-assessment of his general medicine practice including but not limited to his injections for pain management by a College-appointed Assessor (the “Re-Assessment”). The Re-Assessment may include a review of a selection of Dr. Shiozaki’s office charts, direct observation of Dr. Shiozaki’s injections for pain management and/or other aspects of his practice, an interview with Dr. Shiozaki and/or any other tools deemed necessary by the College.

The Assessor shall report the results of the Re-Assessment to the College;

- Dr. Shiozaki shall inform the College of each and every location where he practices, in any jurisdiction (his “Practice Location(s)”) within fifteen (15) days of this Order and shall inform the College of any and all new Practice Locations within fifteen (15) days of commencing practice at that location;

 

- Dr. Shiozaki shall consent to the sharing of information between the Physician Mentor, the Clinical Supervisor, the Assessor and the College as any of them deem necessary or desirable in order to fulfill their respective obligations;

- Dr. Shiozaki shall consent to the College making enquiries of the Ontario Health Insurance Program, the Narcotics Monitoring System and/or any person or institution that may have relevant information, in order for the College to monitor his compliance with this Order and shall promptly sign such consents as may be necessary for the College to obtain information from these persons or institutions;

- Dr. Shiozaki shall co-operate with unannounced inspections of his office practice and patient charts by the College for the purpose of monitoring and enforcing his compliance with the terms of this Order; and

- Dr. Shiozaki shall be responsible for any and all costs associated with implementing the terms of this Order.

- Dr. Shiozaki attend before the panel to be reprimanded.

- Dr. Shiozaki pay costs to the College in the amount of $5,500.00 within 30 days of the date of this Order.