On February 1, 2018, the Discipline Committee found that Dr. Christopher Stephen Doyle 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 of the circumstances, would reasonably be regarded by members as unprofessional. The Committee also found that Dr. Doyle is incompetent.
Dr. Doyle is a psychiatrist who received his Independent Practice Certificate with the College of Physicians and Surgeons of Ontario (“College”) in 2001. During the relevant period, Dr. Doyle worked at the Hospital and maintained a private practice in Mississauga.
Patient A
Patient A was referred to Dr. Doyle by her family physician, Dr. X, in August of 2013. Together with his referring letter, Dr. X provided Dr. Doyle with medical records for Patient A, containing reference to Patient A’s previous sexual boundary issues with a mental health professional while under the professional’s care, and reference to Patient A having developed an infatuation with a prior treating psychiatrist.
Dr. Doyle was Patient A’s psychiatrist between October 2013 and July 2014, during which time he focused on Patient A’s medications. By December of 2013, Dr. Doyle’s diagnosed Patient A as “a borderline woman with increased anger and increased depression”.
During the time she was Dr. Doyle’s patient, Patient A perceived that Dr. Doyle’s demeanour towards her changed, in that he became increasingly casual during her appointments, including sitting back with his feet up on the coffee table and using profanities in front of Patient A. Patient A told Dr. Doyle that she was depressed and not motivated to exercise anymore. She had previously reported to Dr. Doyle that she enjoyed cycling and running. Dr. Doyle told Patient A about his own interest in cycling and showed her an app on his cell phone that he used to track cycling progress and that showed his progress against other cyclists in the online community. He told Patient A that she could use the app as well to track her exercise progress and keep motivated.
Patient A explained in her complaint and in her interview with the College that as a result of Dr. Doyle’s casual demeanor and the information that he shared with her during the sessions, Patient A began to feel that Dr. Doyle wanted to foster a friendship or relationship with her. In July 2014, Patient A told Dr. Doyle about her feelings for him. Dr. Doyle indicated that he was flattered but that her feelings were not appropriate for the physician-patient relationship. Patient A perceived that Dr. Doyle to be extremely uncomfortable by her disclosure. He stopped the session and asked Patient A to see his secretary to make a subsequent appointment, while in the past, Dr. Doyle had scheduled all subsequent sessions himself on his cell phone at the end of Patient A’s appointments. Patient A booked a follow-up appointment for August 2014 with Dr. Doyle through the secretary and left the session feeling confused, ashamed and humiliated.
The following day Patient A sent Dr. Doyle an email apologizing and seeking clarity as to what had transpired in her appointment. Dr. Doyle responded explaining that he could no longer see Patient A and while her feelings are understandable, they are not appropriate for their relationship. He explained that this is called “eroticized transference” and that due to his previous issues, it is not something that he can safely manage at this time. He wrote that he appreciates her honesty, but that it prevents them from working together therapeutically.
Patient A described the emotional impact of Dr. Doyle’s response to her disclosure and the termination of her care as “devastating.” She went to see her family physician in July 2014, reporting suicidal thoughts and self-blame as a result of this interaction with Dr. Doyle. She went to the hospital with a suicide plan several days later and was voluntarily admitted to Hospital for several days.
Further to the email exchange, which Patient A perceived as notice of termination, Patient A had no contact with Dr. Doyle. She did not attend the subsequent appointment that she had booked with Dr. Doyle. Patient A submitted a complaint to the College in July 2014, describing mixed feelings: she wrote that Dr. Doyle “does seem to care about what he does and is extremely competent with the medications”.
Dr. Doyle states that he waited for Patient A during her scheduled appointment in August 2014, at which point he planned to properly terminate the patient-physician relationship. Dr. Doyle did not take any action in respect to the transfer of care for Patient A, he did not send a termination letter to Patient A and did not communicate with the referring physician about the end of the therapeutic relationship. He did not make arrangements for the prescription of Patient A’s medications, nor did he assist in finding another psychiatrist for Patient A.
The Expert Report
An expert retained by the College to review this matter opined that:
- Dr. Doyle failed to meet the standard of practice of the profession in this case and that his medical record-keeping was inadequate to serve as a record to ‘tell the patient’s story’ and to support diagnostic decision-making and treatment planning. The expert opined that if Dr. Doyle behaved as described by Patient A, this would be a failure to uphold the professionalism, and boundaries essential to the physician-patient relationship. The expert further opined that Dr. Doyle failed to meet the standard of practice of the profession in the manner he terminated the doctor-patient relationship.
- Dr. Doyle’s deficits in clinical record keeping are very significant and may arise from lack of knowledge on the standard of care requirements, or poor judgement. The expert noted that Dr. Doyle’s notes reflected an awareness of the patients’ vulnerabilities, though this was not incorporated into his treatment plan. According to the expert, the boundary crossings, failures in professionalism and in recognition/management of the dynamics in the therapeutic encounter could reflect a lack of skill, knowledge, judgement or a combination of the forgoing. The expert further noted that Dr. Doyle’s failure to maintain the standard of practice in the manner of patient termination could have resulted from Dr. Doyle’s lack of knowledge, lack of skill in managing the situation, or lack of judgement.
- If Patient A’s clinical record is representative of Dr. Doyle’s practice of medical record-keeping, his self-described ‘informal style’ with patients, and boundary crossings, it is likely that patients would be exposed to harm, which is estimated to be higher than what would be expected from care provided by a practitioner who maintained the standard of care in these areas.
Upon review of the information that on one occasion, in the context of discussing Patient A’s depression, Dr. Doyle told Patient A about his other patient (whose name he did not disclose) who suffered from severe depression and did not care for himself such that his teeth had fallen out, the expert opined that although unintended, this practice is ill advised and could lead to confidentiality breaches, given the possibility that Patient A could have later seen an edentulous man in the waiting area, and reasonably believe that she could then put a face to the story she heard directly from Dr. Doyle. The expert noted that Dr. Doyle has twice written to the College indicating that he should not have spoken about the other patient to Patient A. In the expert’s opinion this was not a violation of the standard of care.
Section 75(1)(a) Investigation
Following the complaint of Patient A, the College conducted an investigation into Dr. Doyle's private practice. The expert retained by the College reviewed Dr. Doyle’s 24 patient charts, transcribed clinical notes, and interviewed Dr. Doyle. The expert opined that Dr. Doyle failed to meet the standard of practice of the profession in 16 of the 24 patient charts reviewed. The expert further opined that Dr. Doyle's care displayed a lack of knowledge in 1 of the 24 patient charts reviewed and that Dr. Doyle's care displayed a lack of skill and/or judgement and exposed or is likely to expose his patients to harm or injury in 19 of the 24 patient charts reviewed.
The issues identified by the expert included, but were not limited to, the following:
- Inadequate documentation/record-keeping;
- Lack of diagnostic clarity/consistency;
- Inadequate risk assessments and/or interventions for self-harm and aggressive ideation;
- Lack of attention to substance use history and/or inadequate assessment of alcohol/substance use;
- Use of non-professional and/or non-objective language in clinical notes
- Inadequate psychotropic medication intervention and/or sub-therapeutic medication dosing;
- Failure to make mandatory report to MOT and/or CAS;
- Inadequate follow-up/frequency of monitoring/appointments;
- Inappropriate prescribing of stimulant medication;
- Inappropriate prescribing of a narcotic;
- Inappropriate prescribing of medical marijuana in patient with primary psychotic illness;
- Ongoing prescribing of a medication (stimulants, benzodiazepines) that patient is known to be abusing;
- Inadequate medication monitoring (efficacy, side effects, interactions, blood work);
- Failure to maintain appropriate/professional boundaries;
- Inappropriate polypharmacy and/or combinations of benzodiazepines, atypical antipsychotics and/or sedative hypnotics; and
- Inappropriate prescribing of medications for non-psychiatric conditions and without notifying the patient's primary care provider.
Upon interviewing Dr. Doyle, the expert made positive findings, which include, but are not limited to the following:
- Dr. Doyle was able to describe the essential elements required in the psychiatric history, mental status examination, for a consultation report leading to a differential diagnosis and treatment plan;
- Dr. Doyle was able to accurately describe differential diagnoses for different clinical presentations and the necessary historical detail required to discriminate between these differentials to provide a working diagnosis;
- Dr. Doyle was able to describe the relevant diagnostic criteria in the DSM-IV framework he used for the common diagnoses he made;
-Dr. Doyle was generally able to discuss appropriate dosing for psychiatric medications, and the concerns with polypharmacy, particularly with combination sedative hypnotics and combination atypical antipsychotics;
- Dr. Doyle was mostly able to describe standard of care baseline investigations and recommended monitoring for the use of atypical antipsychotics and divalproex and lithium;
-Dr. Doyle was able to describe the requirements for mandatory reporting regarding driving and reporting child safety concerns;
- Dr. Doyle was able to describe the potential negative impact of cannabis on many psychiatric illnesses and the lack of empirical evidence of benefit;
- Dr. Doyle was able to describe appropriate strategies and interventions for patients abusing medications he prescribes;
- Dr. Doyle was able to discuss the potential hazards to a patient regarding provision of prescription medications for non-psychiatric conditions that he does not monitor, and the particular risks of doing so with opiates;
- Dr. Doyle was able to describe appropriate interventions for ill patients who have prolonged absences from the practice, or when there is information about a crisis, clinical deterioration, emergency room visits etc.; and
- Dr. Doyle was able to identify as inappropriate, the use of non-professional language in the patient records.
The expert’s concerns identified in the interview include, but are not limited to:
- Although Dr. Doyle acknowledged the risks of and poor evidence for use or combination of antipsychotics, this was commonly observed in his use of these medications, more than would be expected in a similar practice of a general adult psychiatrist.
- Although Dr. Doyle described appropriate lithium monitoring, this was generally not observed in his records. Dr. Doyle generally would not monitor kidney function or serum calcium levels, which increases the risk of patient morbidity and is not supported by guidelines.
- Although Dr. Doyle was able to appropriately describe standard of care strategies for abusing medication he prescribed, he acknowledged that he did not do so enough. This was a significant concern in the care provided in some of the records reviewed.
Youtube Videos
The expert reviewed a series of YouTube videos posted by Dr. Doyle on his YouTube channel named “DrChristopherDoyle” between 2012 and 2014. The expert reported the following concerns about the videos:
- Lack of judgement, professionalism and boundaries with a tone of promotion in a video, in which Dr. Doyle is talking about his use of “the juice of the purple” that gave him stamina to compete in a bike race against professional cyclists.
- Lack of judgement, professionalism and boundaries in a video, in which Dr. Doyle is pictured after spinning class, shirtless, discussing the benefits of exercise to himself physically and mentally and once again promoting the “purple” drink.
- Lack of judgement, professionalism and boundaries in a video in which Dr. Doyle is depicted in an educational session, in which he states marijuana is “excellent” as a PTSD treatment. According to the expert, marijuana is not the standard of care for PTSD and has the potential to harm some patients.
- Breach of standard for physician advertising, lack of judgement and professionalism and abuse of a fiduciary relationship with respect to a videotaped patient testimonial in the office by a female patient. Dr. Doyle is seen in the background, as the patient enthusiastically describes her experience of working with him, that he “taps into my creative side and empowers me…. Go Dr. Doyle!”
- Nine of the twenty-nine videos reviewed are therapeutic in nature. With respect to these nine videos, the expert opined that each falls below the standard of care.
- Thirteen of the twenty nine videos are educational in nature. With respect to thirteen videos, the expert opined that ten videos fall below the standard of care and three videos meet the standard of care.
- Seven of the twenty nine videos are philosophical in nature and show Dr. Doyle’s reflections on various topics. According to the expert, six of the seven videos show a lack of judgement.
Overall, the expert opined that:
- Twenty three of the twenty nine videos demonstrate a lack of judgment; and
- discussions contained in fifteen of the twenty nine videos expose or are likely to expose patients to risk of harm.
The expert noted that some effort was made by Dr. Doyle to obtain consent from the patients to discuss their clinical material on YouTube, or to post material from their sessions online on YouTube. However, according to the expert, the consents are inadequate such that they were not specific to the purpose for which they were used.
Interim Suspension
On April 10, 2017, the Inquiries, Complaints and Reports Committee (the ICRC) referred specified allegations of professional misconduct to the Discipline Committee. On May 9, 2017, the ICRC issued an interim order suspending Dr. Doyle’s certificate of registration.
Unprofessional Communication
In January 2017, a medical adjudicator from the Canada Student Loans Program called Dr. Doyle, in order to verify the authenticity of a medical report that she was reviewing for an individual who was a patient of Dr. Doyle. The adjudicator described that after dialing Dr. Doyle’s phone number, Dr. Doyle answered with profanity and spoke rudely, stating “If you need your prescriptions filled, go to the [profanity] pharmacy.” Assuming that she had dialed incorrectly, the adjudicator dialed again. Dr. Doyle answered with more profanity, stating “Stop [profanity] calling me”. When the adjudicator introduced herself and stated the purpose of the call, Dr. Doyle identified himself and apologized, indicating that he thought he was talking to a patient who was calling him non-stop. The adjudicator then reported her experience with Dr. Doyle to the College and described the profanities used as “f-bombs”.
Disposition
On August 7, 2018, the Discipline Committee ordered and directed that:
- The Registrar revoke Dr. Doyle’s certificate of registration, effective immediately;
- Dr. Doyle appear before the Committee to be reprimanded with 90 days of the date this order becomes final;
- Dr. Doyle pay costs to the College in the amount of $16,500 within 90 days of the date this order becomes final.
On September 6, 2018, Dr. Doyle appealed the Discipline Committee’s decision on penalty and costs to the Divisional Court of the Superior Court of Justice. Pursuant to s.71 of the Health Professions Procedural Code, the Discipline Committee’s penalty decision remained in effect despite the appeal.
On June 23, 2019, the Divisional Court dismissed Dr. Doyle’s appeal of the penalty decision.
