On September 25, 2018, the Discipline Committee found that Dr. Alexander Michael Alexander committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession, and in that he has engaged in conduct or 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. Alexander is a general practitioner, who received his certificate of registration authorizing independent practice in June 1988. Throughout the relevant time, Dr. Alexander practised in Toronto.
Practice Assessment and Undertaking
In 2013, Dr. Alexander underwent an assessment of his practice by a College-appointed assessor, who identified concerns with Dr. Alexander’s practice, including his approach to chronic disease management, his conduct of physical examinations, his infection control techniques, his prescribing, his record-keeping, and his communication with consultants. As a result of the assessment, Dr. Alexander entered into an undertaking with the College on January 10, 2014, wherein he agreed, among other things, to engage a supervisor acceptable to the College, to participate in and successfully complete an educational plan and any additional professional education recommended by his supervisor, and to undergo a practice reassessment within six months after the completion of the clinical supervision. Dr. Alexander completed the clinical supervision as required by his undertaking.
Failure to Maintain the Standard of Practice of the Profession
The College retained an expert to perform the reassessment of Dr. Alexander’s practice required by his 2014 undertaking. The expert’s review focused on care provided from April 2015 onwards,and involved review of fifteen patient charts and observation of professional encounters with six other patients. The expert reported on January 19, 2017 that Dr. Alexander failed to maintain the standard of practice of the profession and observed that Dr. Alexander:
- Took limited patient histories;
- Performed physical examinations that were not tailored to the patient’s presenting problems and/or were performed incorrectly;
- Did not consistently document physical examinations;
- Performed assessments that were lacking;
- Developed treatment plans that were lacking or absent;
- Failed to take appropriate steps to manage infection control; and
- Provided only monthly prescriptions to patients on chronic medication, requiring them to return frequently and unnecessarily to the office.
The following was noted with respect to Dr. Alexander’s care of two patients (patients A and B):
- Patient A: while Dr. Alexander did not fail to maintain the standard of practice of the profession by failing to acknowledge a fracture shown by an x-ray (as the patient was being followed by an orthopedist and Dr. Alexander did not order the x-ray), or by referring the patient to a dermatologist for a diagnosis of vitiligo, he otherwise failed to maintain the standard of practice of the profession regarding patient A.
- Patient B: while Dr. Alexander did not fail to meet the standard of the profession by failing to order an x-ray and ultrasound of the shoulder, he otherwise failed to maintain the standard of practice of the profession regarding patient B.
Disgraceful, Dishonourable or Unprofessional Conduct
In the course of communicating with the College regarding the cases reviewed by the College’s expert, Dr. Alexander, through his counsel, forwarded to the College a copy of a patient agreement for opioid therapy pertaining to Patient C. Dr. Alexander’s counsel advised that this agreement was signed in 2009. However, the agreement had a copyright date of 2011 on it from the pharmaceutical company and referred to the 2010 Canadian Guideline (“Guideline”) for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.
The College obtained three complete patient charts in respect of patients C, D, and E, all of whom were patients whose care was reviewed by the College’s expert. Each patient’s chart contained a signed agreement for opioid therapy. Despite the fact that all three agreements contained a 2011 copyright date and references to the Guideline, the agreement for opioid therapy for each of the three patients was dated before 2011, as follows: Patient D’s agreement was dated November 21, 2009; Patient E’s agreement was dated February 27, 2008, and Patient C’s agreement was dated April 11, 1996.
Dr. Alexander backdated each of the three patient agreements for opioid therapy, which constituted disgraceful, dishonourable or unprofessional conduct. It was misleading that Dr.Alexander provided Patient C’s agreement to the College asserting that it had been signed in 2009, while it was dated 1996 and signed at some time during or after 2011. Dr. Alexander advised College investigator that he could not identify when any of the agreements were signed,but that it would have been in or after 2011 and many years after they were dated. Dr. Alexander further stated that he backdated the agreements to reflect approximately when he would have first started prescribing narcotics to the patient, and their initial dosage. He said that this is not his current practice, but represents something that he did in the past.
Dr. Alexander’s Discipline History
Dr. Alexander has been the subject of two prior findings by the Discipline Committee of the College:
- In June 1991, the Discipline Committee found that Dr. Alexander engaged in disgraceful, dishonourable or unprofessional conduct by failing to report an incident of abuse to the Children’s Aid Society. Dr. Alexander was reprimanded.
- In April 2012, the Discipline Committee found that Dr. Alexander failed to maintain the standard of practice of the profession in his care of twenty-eight patients. The Discipline Committee ordered that Dr. Alexander submit to an assessment of his practice and abide by the assessor’s recommendations. It also ordered a reprimand and costs.
The 2013 assessment of Dr. Alexander’s practice was conducted pursuant to the Discipline Committee’s 2012 order.
Dr. Alexander’s Complaints Committee and Inquiries, Complaints and Reports Committee (the “ICRC”) History
In August 1995, the Complaints Committee required Dr. Alexander to attend in person for a caution regarding: the importance of proper wound management, including thorough cleansing, especially in animal bites where there is a high potential for infection; improper dosage of prescribed medication; the need for clear follow-up instructions; and, his basic knowledge of rabies management. The decision arose from a complaint about Dr. Alexander’s care of a four-year old boy who had been bitten by a dog.
In January 1999, the Complaints Committee cautioned Dr. Alexander to consider the utility of a cardiogram when investigating undiagnosed abdominal and arm pain.
In April 2010, the ICRC required Dr. Alexander to attend in person for a caution regarding his premature destruction of patient records before the time period after which it is allowed by law.
In December 2014, the ICRC required Dr. Alexander to attend in person for a caution regarding filling out Special Diet Forms (and other medical forms) without properly investigating the patient’s eligibility for the benefit.
Interim Undertaking and Subsequent Clinical Supervision
On May 24, 2017, Dr. Alexander entered into an interim undertaking, which was accepted by the ICRC in lieu of making an interim order. The undertaking has been in place pending the Discipline Committee’s decision regarding the allegations against him. Among other things, it has required that Dr. Alexander practise under the guidance of a clinical supervisor, who must meet with him weekly to review ten to fifteen patient charts and must also observe no fewer than ten of his patient encounters for no less than one-half day per month.
As a result of his interim undertaking, Dr. Alexander has been practising under the clinical supervision. The Clinical Supervisor has made numerous recommendations for practice improvement to Dr. Alexander and has noted that Dr. Alexander has made improvements in many of the areas in issue. The Clinical Supervisor continues to make recommendations in some of these areas.
Dr. Alexander’s Subsequent Education
Since the allegations of professional misconduct were referred to the Discipline Committee in 2017, Dr. Alexander has completed The University of Toronto Medical Record Keeping course,the 48th Annual Winter Refresher Course for Family Medicine at the University of Wisconsin, and the Endocrinology in Primary Care course offered by Medical Education Resources Inc.
Disposition
On September 25, 2018, the Discipline Committee ordered and directed that:
- the Registrar suspend Dr. Alexander’s certificate of registration for a period of six (6) months, commencing at 12:01 a.m. on November 1, 2018.
- the Registrar to place the following terms, conditions and limitations on Dr. Alexander’s certificate of registration:
Public Protection Prior to Suspension and Remediation
- Until the commencement of the period of suspension of his certificate of registration set out above, Dr. Alexander shall continue to be bound by the terms of the undertaking into which he entered on May 24, 2017;
Professional Education and Clinical Supervision
- Dr. Alexander shall participate in and successfully complete all aspects of the Individualized Education Plan (“IEP”) attached to this Order as Schedule “A,” including all of the following professional education:
- Within six (6) months of the date of this Order, Dr. Alexander shall complete individualized instruction in medical ethics satisfactory to the College, with an instructor approved by the College. The instructor shall provide a summative report to the College including his or her conclusion about whether the instruction was completed successfully by Dr. Alexander;
- The period of Clinical Supervision described below; and
- Any additional professional education recommended by his Clinical Supervisor (defined below).
- For a period of twelve (12) months commencing on the date that he resumes practice following the suspension of his certificate of registration described above, Dr.Alexander may practise only under the guidance of a clinical supervisor or clinical supervisors (the “Clinical Supervisor”) acceptable to the College, who has executed an undertaking in the form attached to the Order as Schedule “B.” Dr. Alexander shall successfully complete his IEP under the guidance of his Clinical Supervisor. Dr. Alexander shall cooperate fully with the Clinical Supervision of his practice, which shall contain the following elements:
- Dr. Alexander shall meet with his Clinical Supervisor at his Practice Location, or another location approved by the College, once every week for at least three (3) months. Thereafter, if recommended by the Clinical Supervisor and approved by the College, they may meet every two (2) weeks.
- At every meeting, Dr. Alexander and his Clinical Supervisor shall review ten to fifteen (10-15) of his patient charts, which shall be selected by the Clinical Supervisor independently of Dr. Alexander’s participation, on the basis of areas of concern identified in the assessor’s report(s) received on January 19, 2017, the Discipline Committee’s decision and reasons for decision in this matter, as well as any concerns that may arise during the period of Clinical Supervision or that have arisen during the prior period of Clinical Supervision under Dr. Alexander’s interim undertaking entered into on May 24, 2017;
- Once a month, the Clinical Supervisor shall observe no fewer than ten (10) of Dr. Alexander’s patient encounters, for no less than one-half (1/2) a day;
- The Clinical Supervisor shall discuss with Dr. Alexander any concerns arising from the observation of patient encounters and review of patient records, as well as provide recommendations to him, if any;
- The Clinical Supervisor may perform any other duties, such as reviewing other documents or conducting interviews with staff, colleagues, or patients, that the Clinical Supervisor deems necessary to the Clinical Supervision;
- The Clinical Supervisor shall submit written reports to the College at least once every month, or more frequently if the Clinical Supervisor has concerns about Dr. Alexander’s standard of practice; and
- Dr. Alexander shall abide by the recommendations of his Clinical Supervisor, including but not limited to any recommended practice improvements and ongoing professional development;
- If a Clinical Supervisor is unable or unwilling to continue to fulfill the terms of the Clinical Supervisor’s undertaking as set out in Appendix “A” to the Order, Dr. Alexander shall, within twenty (20) days of receiving notice of the same, deliver to the College an executed undertaking in the same form from a person who is acceptable to the College;
- If Dr. Alexander is unable to obtain a Clinical Supervisor in accordance with this Order, he shall cease to practise medicine until such time as he has done so, and the fact that he has ceased to practise medicine will be a term, condition, and limitation on his certificate of registration;
- Dr. Alexander shall consent to the disclosure by his Clinical Supervisor to the College, and by the College to his Clinical Supervisor, of all information the Clinical Supervisor or the College deems necessary or desirable in order to fulfill the Clinical Supervisor’s undertaking and Dr. Alexander’s compliance with this Order, as well as the monitoring thereof;
Practice Reassessment
- Approximately six (6) months after completion of the period of Clinical Supervision set out above, Dr. Alexander shall undergo a reassessment of his practice by a College-appointed assessor or assessors (the “Assessor”). The reassessment shall include direct observation by the Assessor of Dr. Alexander’s patient encounters. The Assessor shall report the results of the reassessment to the College;
- Dr. Alexander shall consent to the disclosure to the Assessor of the reports of the Clinical Supervisor, and shall consent to the sharing of all information between the Clinical Supervisor, the Assessor, and the College, as the College deems necessary or desirable;
Practice Restrictions
- Dr. Alexander shall practise only in a practice setting that has been approved by the College;
- Dr. Alexander shall engage in professional encounters with no more than eight (8) patients every two (2) hours.
- Dr. Alexander shall engage in professional encounters with patients for no more than seven (7) hours per day;
- Dr. Alexander may engage in professional encounters with patients five (5) days per week, and one (1) additional day every second week;
Monitoring of Compliance
- Dr. Alexander shall cooperate with unannounced inspections of his practice and shall consent to monitoring by a College representative(s) of claims that he submits to the Ontario Health Insurance Plan (“OHIP”), for the purpose of monitoring and enforcing his compliance with the terms of this Order;
- Dr. Alexander shall keep a log of all patient encounters, in the form set out at Schedule - “C” to the order, which will include at least the following information:
- the date of the patient encounter, including the day of the week;
- the name of the patient with the chart/file number, if any;
- the start time of the patient encounter;
- the end time of the patient encounter; and
- Dr. Alexander’s initials.
- Dr. Alexander shall submit the original log of patient encounters to the College on a monthly basis, and shall maintain his own copy of the log of patient encounters at all times, making it available to the College upon request;
Other
- Dr. Alexander shall be responsible for any and all costs associated with implementing this Order.
- Dr. Alexander appear before the panel to be reprimanded.
- Dr. Alexander pay the College its costs of this proceeding in the amount of $6,000 within thirty (30) days of the date of this Order.
Terms and conditions imposed on certificate by: Member
