On March 5, 2018, the Discipline Committee found that Dr. Naseeruddin Syed committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession.
Dr. Syed is a general practitioner, with a practice in Peterborough.
Investigation One
On August 2014, Dr. Syed’s former nurse contacted the College expressing concern regarding various aspects of Dr. Syed’s practice, including his prescribing practices. Based on the information requested by the College in April 2015 regarding claims for all monitored drugs made by Dr. Syed’s patients, the College commenced an investigation.
The College retained an expert who reviewed 25 of Dr. Syed’s patient charts, pharmacy records,narcotic monitoring system data and conducted an interview with Dr. Syed. He opined that Dr.Syed's dedication to the practice of medicine and his belief that he is truly acting in the best interests of his patients are not questioned, but he had concerns about Dr. Syed’s knowledge and judgment which may expose his patients to possible harm. He also was of the view that Dr. Syed’s skill was difficult to determine due the extremely poor and woefully sparse documentation on the charts reviewed. He concluded that 24 of 25 charts reviewed failed to meet standards; 6 out of 25 patient charts displayed a lack of knowledge, the majority regarding dosing of psychoactive drugs; 4 out of 25 patient charts displayed a lack of judgment, the majority regarding prescriptions of benzodiazepines, narcotics and antidepressants; and 6 of 25 patient charts reveal exposure of Dr. Syed's patients to harm or injury, specifically relating to his general prescribing practices.
Investigation Two
The College received information from two physicians who practise in a methadone maintenance practice at the Ontario Addiction Treatment Centres (“OATC”) in Peterborough, outlining concerns regarding Dr.Syed’s prescribing of high doses and large amounts of benzodiazepines to several methadone patients.Concerns regarding serious or fatal respiratory depression were relayed. 6 patients were identified and concerns were raised about an admission to the local hospital's Intensive Care Unit in the group of patients due to recent benzodiazepine overdose.
Dr. Syed stated to the College investigator that he was not aware that the 6 patients were being prescribed methadone.
The manager of the pharmacy located at the same address as Dr. Syed’s practice, relayed to the College investigator concerns regarding the early release of medications in patients claiming to have lost their prescriptions and regarding the maximum dosages of benzodiazepines being prescribed. By letter dated July 5, 2015, one of the physicians who contacted the College expressing concerns regarding Dr. Syed’s prescribing provided a further report with respect to his concerns about specific patients.
The College retained an expert who reviewed Dr. Syed’s general medicine practice, including his prescribing practice. After reviewing 10 patient charts, pharmacy records and interviewing Dr. Syed the expert concluded, among other things, that despite the guidelines for documentation afforded by the EMR, in not a single case during this chart review of these 6 patients was the record of treatment properly populated with adequate detail to meet College standards. In fact, there were glaring absences of documentation in the vast majority of charts reviewed, such that not one met record-keeping standards. The latter case is similar to that of the five previous, in that these patients were all prescribed psychoactive drugs, many in excessive quantities, despite all being on methadone and followed by a physician managing their addictions. While Dr. Syed maintained in his interview that he was unaware that these patients were on methadone, he acknowledged that many of the clientele of this walk-in clinic were drug addicts with poor social support.
The expert noted that with this knowledge the physician managing these patients should be extremely diligent in assessing and treating these patients, including careful history taking and thorough physical examination to ensure the safety of the patient. According to the expert, in 6 patients whose charts were reviewed, Dr. Syed has failed to meet the standard of practice of the profession and at times may have exposed his patients to potential harm.
Dr. Syed advised the College that he did not know the patients to whom the two physicians referred were on methadone. However, during the investigation, the College reviewed Dr. Syed’s charts for these patients, which revealed that:
- Dr. Syed had received a fax from the pharmacy indicating that Patient A, who was identified by the two physicians, was on methadone in January, 2015. Despite this, he prescribed benzodiazepines to Patient A in February, 2015.
- Dr. Syed continued to prescribe narcotics and benzodiazepines to Patient B throughout February, March and April, 2015 and prescribed benzodiazepines to Patient C in March 2015 in two cases after being told by both physicians that they were methadone patients.
- Patient D identified by both physicians was seen in the emergency department for overdose of sedatives (specifically having taken many of the 2mg tablets of Clonazepam prescribed by Dr. Syed at once). The patient was admitted to the ICU for overdose of sedatives. Five days later, there was no patient visit in his chart, yet Dr. Syed prescribed Ativan to Patient D. About ten days later, Dr. Syed discussed the recent overdose and admission to hospital with Patient D as well as the recent letter from the physician and again prescribed Ativan to patient D.
Complaint of Patient E
In March 2015, the College received a complaint from Patient E expressing concerns that Dr. Syed failed to provide appropriate care when ordering medications for him during a walk-in visit. Specifically, Dr. Syed prescribed a medication that patient E was allergic to, prescribed high doses of benzodiazepines, knowing that Patient E is on methadone and has a general lack of knowledge concerning mental health patients and is over-prescribing to them.
The College retained an expert who reviewed the standard of care provided by Dr. Syed to Patient E. The expert opined, in part, that not one of the patient’s eight visits in 2015 contained the required elements to meet the standards of record keeping of the College: the histories were incomplete, the physical exams often undocumented and the diagnoses usually only represented by OHIP billing codes. The plans for management were prescriptions only with rare advice as to how to specifically manage the patient's presenting complaints. Dr. Syed demonstrated lack of knowledge concerning the management of drug-seeking, habituated methadone patients. Dr. Syed demonstrated lack of skill in advising tapering of benzodiazepines without specific instructions. Dr. Syed demonstrated lack of judgment by allowing himself to be manipulated into repeat prescriptions of such a class of drugs and his prescriptions of narcotics, including Nucynta, in this patient. The pharmacist brought to light Dr. Syed's lack of knowledge of a potentially serious drug interaction between Nuycynta and Cymbalta. Dr. Syed demonstrated a lack of judgment by stopping the antidepressant instead of the narcotic in this instance. The clinical practice of Dr. Syed with - regard to Patient E had the potential in several instances to expose his patient to harm.
Complaint of Patient F
In May 2016, the College received a complaint from Patient F expressing concerns that Dr. Syed failed to provide appropriate assessment, diagnosis and treatment when she attended the walk-in clinic with gynaecological concerns about a growth. Dr. Syed did not conduct a physical examination of the patient and proceeded to prescribe her medication without adequate explanation. The patient consulted a pharmacist,who expressed some disagreement with the prescription. As a result, the patient did not fill the complete prescription.
The College retained an expert who reviewed the standard of care provided by Dr. Syed to Patient F. The expert concluded, in part, that the care provided by Dr. Syed did not meet the standard of the profession. The expert noted that the patient's concern was of the lesion on her labia, and it is standard practice to examine this lesion. According to the expert, sometimes a physician may defer exam, but this would be based on agreement with the patient, which was not the case in this instance. Regarding the concern about the prescription provided, the expert noted that for a typical yeast infection, a patient may potentially be prescribed Diflucan 150mg for one day and/or a topical treatment (such as the Terazol 7), while Dr. Syed prescribed Diflucan for seven days along with a repeat. According to the expert, this is a definite concern, as it is not the standard treatment for a common yeast infection (as Dr. Syed implied it was in his letter). The expert further noted that Patient F’s short visit demonstrated concerns regarding the knowledge, skill and judgment provided by Dr. Syed. According to the expert, there is reason to believe that Dr. Syed's clinical practice may expose patients to harm or injury, as examination of patients is vital to the correct diagnosis and that the prescription provided in the case of Patient F appears to be excessive and may cause harm to the patient. However, the expert noted that this is one short encounter, and may not be indicative of Dr. Syed's overall practice style.
The Interim Order of the the Inquiries, Complaints and Reports Committee (ICRC)
On February 14, 2017, the ICRC directed the Registrar to impose terms, conditions and limitations on Dr.Syed’s certificate of registration, which remain in effect until April 15, 2018.
Disposition
On March 5, 2018, the Discipline Committee ordered that:
- Dr. Syed attend before the panel to be reprimanded.
- the Registrar suspend Dr. Syed’s certificate of registration for two (2) months, to commence at 12:01 a.m. on April 15, 2018.
- the Registrar impose the following terms, conditions and limitations on Dr. Syed’s certificate of registration upon his return to practice at the conclusion of his suspension:
- Prescribing Log
- Dr. Syed, shall keep a Log of all prescriptions for Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs (as set out in Schedule “A”), in the form attached as set out in Schedule “B”, which will include at least the following information (the “Prescribing Log”):
- the date of the appointment;
- the name of the patient and chart/file number;
- the name of the medication prescribed, dose, direction, number of tablets to be dispensed and frequency;
- the clinical indication;
- whether the prescription is for a new medication and/or different dose or frequency than - currently prescribed to the patient (Y/N);
- Dr. Syed’s signature;
- the date of the Clinical Supervisor’s review (if applicable, as set out below); and
- the Clinical Supervisor’s signature (if applicable, as set out below).
- Dr. Syed is to keep a copy of all prescriptions he writes for Narcotic Drugs, Narcotic
- Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs, in the corresponding patient chart.
- Clinical Supervision re: Narcotic Practice
- Dr. Syed is to practise under the guidance of a clinical supervisor acceptable to the College (the “Clinical Supervisor”), for a minimum of nine (9) months on the terms set out below (the “Clinical Supervision”).
- The Clinical Supervisor shall sign an undertaking in the form attached hereto as Schedule “C”.
- Dr. Syed shall cooperate fully with the Clinical Supervision and abide by all recommendations of his Clinical Supervisor with respect to practice improvements and education.
- Dr. Syed shall consent to the disclosure by the 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 to monitor Dr. Syed’s compliance with this Order. This shall include, without limitation, providing the Clinical Supervisor with any reports of any assessments of Dr. Syed’s practice in the College’s possession.
- If the Clinical Supervisor who has given an undertaking in Schedule “C” to this Order is unable or unwilling to continue to fulfill its terms, Dr. Syed shall, within seven (7) 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.
- Dr. Syed shall not prescribe any narcotics or controlled substances unless and until the Clinical Supervision is in place.
- If Dr. Syed is unable to obtain a Clinical Supervisor on the terms set out in sections 4.B, he will cease prescribing Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs until such time as he has obtained a Clinical Supervisor acceptable to the College.
- If Dr. Syed is required to cease prescribing Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs as a result of section 4.B(vii) above this will constitute a term, condition or limitation on his certificate of registration and that term, condition or limitation will be included on the Public Register.
Phase 1 of Clinical Supervision (“Phase 1”)
- Dr. Syed is to engage in Phase 1 of Clinical Supervision for a minimum of two (2) months on the terms set out below.
- During Phase 1, Dr. Syed is to meet with the Clinical Supervisor once a week to discuss the Clinical Supervisor’s review of a minimum of twenty (20 charts for patients to whom Dr. Syed has prescribed:
- Narcotic Drugs, or
- Narcotic Preparations; or
- Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs where the patient is also prescribed a Narcotic Drug and/or Narcotic Preparation.
- If there are not twenty (20) charts for patients to whom Dr. Syed has prescribed the above substances, the Clinical Supervisor shall review the charts of all patients listed in the prescribing log since his prior review.
- During Phase 1, the Clinical Supervisor must sign and date the Prescribing Log to confirm the charts that the Clinical Supervisor has reviewed and discussed with Dr. Syed.
- During Phase 1, the Clinical Supervisor will provide a report to the College at least once a week.
- After a minimum of two (2) months of Phase 1, if the Clinical Supervisor is satisfied that Dr. Syed has the necessary knowledge, skills and judgment to practice in a less highly supervised environment, the Clinical Supervisor may recommend to the College that supervision be reduced.
Phase 2 of Clinical Supervision (“Phase 2”)
- Upon the recommendation of the Clinical Supervisor and approval by the College, Dr. Syed shall engage in Phase 2 of Clinical Supervision for a minimum of three months on the terms set out below.
- During Phase 2, Dr. Syed is to meet with the Clinical Supervisor at least once every two (2) weeks to discuss the Clinical Supervisor’s review of a minimum of fifteen (15) charts for patients to whom Dr. Syed has initiated a new prescription for:
- Narcotic Drugs, or
- Narcotic Preparations; or
- Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs where the patient is also prescribed a Narcotic Drug and/or Narcotic Preparation.
- If there are not fifteen (15) charts for patients to whom Dr. Syed has initiated a new prescription for the above substances, the Clinical Supervisor shall review the charts of all patients listed in
the prescribing log since his prior review.
- During Phase 2, the Clinical Supervisor must sign and date the Prescribing Log to confirm the charts that the Clinical Supervisor has reviewed and discussed with Dr. Syed.
- During Phase 2, the Clinical Supervisor will provide a report to the College at least once every two (2) weeks.
- After a minimum of three (3) months of Phase 2, if the Clinical Supervisor is satisfied that Dr. Syed has the necessary knowledge, skills and judgment to practice in a less highly supervised environment, the Clinical Supervisor may recommend to the College that supervision be reduced.
Phase 3 of Clinical Supervision (“Phase 3”)
- Upon the recommendation of the Clinical Supervisor and approval by the College, Dr. Syed, shall engage in Phase 3 of Clinical Supervision for a minimum of four (4) months on the terms set out below.
- During Phase 3, Dr. Syed shall mee with the Clinical Supervisor at least once a month to discuss the Clinical Supervisor’s review of a minimum of fifteen (15) charts for patients to whom Dr.Syed has initiated a new prescription for:
- Narcotic Drugs, or
- Narcotic Preparations; or
- Controlled Drugs, Benzodiazepines and Other Targeted Substances and All other Monitored Drugs where the patient is also prescribed a Narcotic Drug and/or Narcotic Preparation.
- If there are not fifteen (15) charts for patients to whom Dr. Syed has initiated a new prescription for the above substances, the Clinical Supervisor shall review the charts of all patients listed in the prescribing log since his prior review.
- During Phase 3, the Clinical Supervisor must sign and date the Prescribing Log to confirm the charts that the Clinical Supervisor has reviewed and discussed with Dr. Syed.
- During Phase 3, the Clinical Supervisor(s) will provide a report to the College at least once every month.
- After a minimum of four (4) months of Phase 3, if the Clinical Supervisor is satisfied that Dr.- Syed has the necessary knowledge, skills and judgment to practice without supervision, the Clinical Supervisor may recommend to the College that the Clinical Supervision cease.
- Clinical Supervision re: Non-Narcotic Practice
- By June 15, 2018, Dr. Syed shall obtain a clinical supervisor acceptable to the College, who will supervise Dr. Syed’s general practice upon completion of his suspension for a period of nine (9) months, and who will sign an undertaking in the form attached hereto as Schedule “D” (the “General Practice Clinical Supervisor”).
- Dr. Syed shall cooperate fully with the Clinical Supervision and abide by all recommendations of his General Practice Clinical Supervisor with respect to practice improvements and education.
- Dr. Syed shall consent to the disclosure by the General Practice Clinical Supervisor to the College, and by the College to his General Practice Clinical Supervisor, of all information the General Practice Clinical Supervisor or the College deems necessary or desirable in order to fulfill the General Practice Clinical Supervisor’s undertaking and to monitor Dr. Syed’s compliance with this Order. This shall include, without limitation, providing the General Practice Clinical Supervisor with any reports of any assessments of Dr. Syed’s practice in the College’s possession.
- If the General Practice Clinical Supervisor who has given an undertaking in Schedule “D” to this Order is unable or unwilling to continue to fulfill its terms, Dr. Syed 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.
- If Dr. Syed is unable to obtain a General Practice Clinical Supervisor in accordance with paragraphs 4(C)(i) or 4(C)(iv) of this Order, he shall cease practising medicine until such time as he has done so, and the fact that he has will constitute a term, condition or limitation on his certificate of registration until that time.
- Reassessment of Practice
- Approximately three (3) months after each aspect of the Clinical Supervision set out above has ceased, Dr. Syed will submit to a comprehensive reassessment of his entire practice by an assessor or assessors selected by the College (the “Assessor(s)”). The Reassessment may include a chart review, direct observation of Dr. Syed’s care, interviews with colleagues and co-workers, feedback from patients and any other tools deemed necessary by the College. Dr. Syed shall abide by all recommendations made by the Assessor(s), and the results of the Reassessment will be reported to the College and may form the basis of further action by the College.
- Compliance
- Dr. Syed shall co-operate with unannounced inspections of his office practice and patient charts for the purpose of monitoring and enforcing his compliance with the terms of this Order.
- Dr. Syed shall inform the College of any and all new practice locations including, but not limited to, hospital(s), clinic(s) and office(s), in any jurisdiction five (5) days in advance of commencing practice at that location.
- Dr. Syed shall give his irrevocable consent to the College to make appropriate enquiries of the Ontario Health Insurance Plan (“OHIP”), the Drug Program Services Branch, the Narcotics Monitoring System (“NMS”) implemented under the Narcotics Safety and Awareness Act, 2010 and/or any person or institution who may have relevant information, in order for the College to monitor my compliance with the provisions of this Order.
- Dr. Syed shall be responsible for any and all costs associated with implementing the terms of this Order.
- Dr. Syed pay costs to the College in the amount of $10,180.00 within 30 days of the date of this Order becomes final
Terms and conditions imposed on certificate by: Inquiries, Complaints and Reports Committee
