On April 14, 2015, the Discipline Committee found that Dr. Swaran Kaur Syan committed an act of professional misconduct in that she failed to maintain the standard of practice of the profession in respect of her care and treatment of 20 patients. Dr. Syan admitted to the allegation.
The allegations arose from an investigation into Dr. Syan’s clinical care and two patient complaints. With respect to the investigation into Dr. Syan’s clinical care, in 2011 the College requested further information in response an affirmative answer on Dr. Syan’s Registration Renewal. Dr. Syan advised that a patient of her family practice had a myocardial infarction while enrolled in a clinical research study for hypertension medication. Dr. Syan was a sub-investigator for the study and had referred the patient for the clinical research study. The College considered this information and commenced an investigation in order to obtain a broader view of Dr. Syan’s practice including her enrollment of patients in clinical research studies.
Dr. X, a specialist in family medicine, was retained by the College to provide an opinion on Dr. Syan’s care. Dr. X reviewed a total of 25 charts and noted a number of areas where Dr. Syan’s general family practice and her enrollment of patients in clinical research studies was unsatisfactory including:
With regard to record-keeping, for example: Dr. Syan’s handwritten progress notes were difficult to read and sometimes illegible; it was difficult to identify patients’ subjective concerns, patient history, physical findings, diagnoses, treatment plans, and what medications were being refilled; the patients’ Cumulative Patient Profiles were not up-to-date or accurate; there was no accurate list of current medications for patients, including duration and dosages, and a review of lab, specialist and hospital reports revealed a number of diagnoses not documented on Dr. Syan’s charts.
With regard to overall care, for example: there was a failure to monitor the side-effects of medications and to consider the effects of poly-pharmacy; there was a failure to routinely conduct age-appropriate preventive screening; and narcotics and benzodiazepines were prescribed with no clear diagnosis.
With regard to the enrollment of patients in clinical research studies, for example: patients were enrolled in research studies for which they did not clearly meet the study criteria, specialists were not aware of patients’ enrolment in research studies in which they would be receiving medications, it was not possible to determine from a patient’s family practice chart whether the patient was enrolled in a clinical research trial, when enrollment in the trial had taken place, what medications the patient was on in the course of the trial, and when or whether the patient’s participation in the trial had ended.
Dr. X specified that the deficiencies in Dr. Syan’s practice did not arise because Dr. Syan’s patient charts were handwritten rather than electronic, but were rather indicative of a general failure to meet the standard of practice of the profession of a family physician in the care and treatment of her patients
With respect to patient complaints, Patient A saw Dr. Syan’s from June to November 2012. Patient A’s daughter complained that Dr. Syan failed to adequately investigate or treat her
mother’s ongoing health concerns. Dr. X opined that Dr. Syan provided care that, at times, fell below the standard expected and charting that was consistently brief, lacking in essential components, did not document medications, and was, overall, sub-standard.
Patient B was seen by Dr. Syan at a walk-in clinic when he sought care for his elbow after a fall. Patient B’s wife complained that Dr. Syan failed to order an x-ray. Dr. Syan diagnosed an olecranon bursitis and aspirated 20cc of blood. Patient B attended upon another physician and was subsequently found to have an elbow fracture for which he required surgery. Dr. X opined that Dr. Syan’s care of Patient B fell below the standard of practice of the profession. Dr. X noted that the first diagnosis to be considered and ruled out given this patient’s history and findings would be a fracture and an x-ray would be a standard investigation to determine this.
On November 11, 2014, the Inquiries, Complaints and Reports Committee (ICRC) directed the Registrar to impose terms, conditions and limitations on the certificate of registration of Dr. Syan on an interim basis, prior to the hearing of this matter. In accordance with the terms of the Section 37 Order, Dr. Syan has seen approximately ten patients a week, with supervision. Recent reports received from Dr. Syan’s supervisors indicate that she has displayed an appropriate level of medical knowledge and clinical judgment in her care and treatment of patients, that her record-keeping is improving and she has followed their recommendations.
The relevant facts from Dr. Syan’s history with the College include the following: In July 2008, Dr. Syan completed the Medical Record-Keeping Course. In February 2011, Dr. Syan was cautioned by the ICRC to maintain adequate and legible records and they directed that she complete the Medical Record-Keeping course for a second time and be re-assessed. In September 2012, Dr. Syan completed the Medical Record-Keeping course for a second time. Dr. Syan is currently completing a preceptorship in record-keeping in her non-surgical cosmetic medicine practice and will be reassessed in this area of her practice upon completion of the preceptorship, which is scheduled to be completed in July 2015.
The Discipline Committee ordered and directed that:
- The Registrar suspend Dr. Syan’s certificate of registration for a period of two (2) months, commencing from April 14, 2015 at 11:59 p.m.
- The Registrar place the following terms, conditions and limitations on Dr. Syan's certificate of registration:
(a) For an indefinite period of time, Dr. Syan shall not be involved in clinical research studies in any manner, including but not limited to the enrollment of patients in clinical research studies. While Dr. Syan is subject to this restriction, the following statement shall appear on the public register: Dr. Syan shall not be involved in clinical research studies in any manner, including but not limited to the enrollment of patients in clinical research studies;
(b) For an indefinite period of time, Dr. Syan shall practice only in a group setting and/or as a member of a group of physicians with cross-coverage. While Dr. Syan is subject to this restriction, the following statement shall appear on the public register: Dr. Syan shall practice only in a group setting and/or as a member of a group of physicians with cross-coverage;
(c) Dr. Syan shall, before June 14, 2015, deliver an undertaking in the form attached [to the Order] as Schedule “A” signed by a College-approved clinical supervisor, (the “Clinical Supervisor”), whose role shall be guided by the Individualized Education Plan (the “IEP”) attached [to the Order] at Schedule “B”. Commencing on the day that Dr. Syan resumes practice following her suspension, Dr. Syan may practice family medicine and/or walk-in medicine only with the supervision of the Clinical Supervisor. Dr. Syan shall be subject to this term, condition and limitation for a period of no less than twelve (12) months, and shall be released therefrom only upon receipt of satisfactory report(s) from her Clinical Supervisor and approval, in its sole discretion, by the College;
(d) If Dr. Syan fails to retain a Clinical Supervisor as required above or if, prior to the completion of the required period of supervision above, Dr. Syan’s Clinical Supervisor is unable or unwilling to continue in that role, Dr. Syan shall within twenty (20) days deliver a new undertaking in the form attached [to the Order] as Schedule “A” signed by a new College-approved clinical supervisor, failing which she shall cease to practice family medicine and walk-in medicine until such time as she has retained a Clinical Supervisor and the fact that she has ceased to practice family medicine and walk-in medicine shall be a term, condition and limitation on her Certificate of Registration until that time;
(e) After Dr. Syan has delivered an executed Undertaking from a Clinical Supervisor to the College as described above in paragraph 4(c), Dr. Syan shall see patients in her family medicine and/or walk-in medicine practice only in accordance with the Remediation Program described at subparagraphs 4(e)(i)-(viii) (the “Remediation Program”), until the Remediation Program has been completed:
i. Throughout the Remediation Program, Dr. Syan shall maintain an up-to-date log (the “Patient Log”) listing every patient seen by her in her family medicine and/or walk-in medicine practice, including the patient’s name, date of birth, OHIP number, date of appointment or visit, and reason for visit. Dr. Syan shall maintain the original Patient Log and shall send a copy to the College at the end of every calendar month;
ii. In Phase One of the Remediation Program, Dr. Syan shall see no more than a combined total of thirty (30) patients per week in her family medicine and/or walk-in medicine practice. Dr. Syan shall submit these patients’ charts and the Patient Log to the Clinical Supervisor for review and shall meet with the Clinical Supervisor at least once every seven (7) days to discuss the Clinical Supervisor’s review of her patients’ charts and any concerns arising therefrom, including with particular reference to the educational needs identified in the IEP attached [to the Order] at Schedule “B”. While Dr. Syan is subject to this restriction, the following statement shall appear on the public register: Dr. Syan shall see no more than a combined total of thirty (30) patients per week in her family medicine and/or walk-in medicine practice;
iii. Also in Phase One of the Remediation Program, Dr. Syan shall develop a continuing professional development plan (the “CPD Plan”), in conjunction with her Clinical Supervisor, addressing the educational needs identified in the IEP attached [to the Order] at Schedule “B”, to be submitted to the College for approval. The CPD Plan must include personal learning objectives and a plan to meet those objectives. The plan must meet the requirements for continuing professional development set by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada;
iv. Upon approval by the College of the CPD Plan and if reports from the Clinical Supervisor indicate that it is appropriate to do so and if approved by the College, after a minimum of one (1) month in Phase One of the Remediation Program, Dr. Syan may move to Phase Two of the Remediation Program, during which she shall see no more than a combined total of sixty (60) patients per week in her family medicine and/or walk-in medicine practice. Dr. Syan shall submit 50% of these patients’ charts, as selected by the Clinical Supervisor, and the Patient Log to the Clinical Supervisor for review and shall meet with the Clinical Supervisor at least once every seven (7) days to discuss the Clinical Supervisor’s review of her patients’ charts and any concerns arising therefrom, including with particular reference to the educational needs identified in the IEP attached [to the Order] at Schedule “B”. While Dr. Syan is subject to this restriction, the following statement shall appear on the public register: Dr. Syan shall see no more than a combined total of sixty (60) patients per week in her family medicine and/or walk-in medicine practice;
v. If reports from the Clinical Supervisor indicate that it is appropriate to do so and if approved by the College, after a minimum of two (2) months in Phase Two of the Remediation Program, Dr. Syan may move to Phase Three of the Remediation Program, during which she shall see no more than a combined total of ninety (90) patients per week in her family medicine and/or walk-in medicine practice. Dr. Syan shall submit 25% of these patients’ charts, as selected by the Clinical Supervisor, and the Patient Log to the Clinical Supervisor for review and shall meet with the Clinical Supervisor at least once every fourteen (14) days to discuss the Clinical Supervisor’s review of her patients’ charts and any concerns arising therefrom, including with particular reference to the educational needs identified in the IEP attached [to the Order] at Schedule “B”. While Dr. Syan is subject to this restriction, the following statement shall appear on the public register: Dr. Syan shall see no more than a combined total of ninety (90) patients per week in her family medicine and/or walk-in medicine practice;
vi. If reports from the Clinical Supervisor indicate that it is appropriate to do so and if approved by the College, after a minimum of three (3) months in Phase Three of the Remediation Program, Dr. Syan may move to Phase Four of the Remediation Program, during which she shall see no more than a combined total of one hundred and twenty (120) patients per week in her family medicine and/or walk- in medicine practice. Dr. Syan shall submit 25% of these patients’ charts, as selected by the Clinical Supervisor, and the Patient Log to the Clinical Supervisor for review and shall meet with the Clinical Supervisor at least once every thirty (30) days to discuss the Clinical Supervisor’s review of her patients’ charts and any concerns arising therefrom, including with particular reference to the educational needs identified in the IEP attached [to the Order] at Schedule “B”. While Dr. Syan is subject to this restriction, the following statement shall appear on the public register: Dr. Syan shall see no more than a combined total of one
hundred and twenty (120) patients per week in her family medicine and/or walk- in medicine practice;
vii. If reports from the Clinical Supervisor indicate that it is appropriate to do so and if approved by the College, after a minimum of six (6) months in Phase Four of the Remediation Program, Dr. Syan may complete the Remediation Program;
viii. Throughout the Remediation Program, Dr. Syan shall cooperate with her Clinical Supervisor and shall abide by all recommendations of her Clinical Supervisor including but not limited to recommendations about her care, recordkeeping, practice improvements, practice management, and continuing education.
(f) Dr. Syan shall consent to the disclosure by her Clinical Supervisor to the College and by the College to her 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. Syan’s compliance with the Order.
(g) Approximately six (6) months after completing the Remediation Program, Dr. Syan shall undergo a reassessment of her family medicine and walk-in medicine practice by a College-appointed Assessor (the “First Reassessment”). The assessment may include a review of Dr. Syan’s patient charts, direct observations, and interviews with staff and/or patients and any other tools deemed necessary by the College. Dr. Syan shall abide by all recommendations made by the Assessor, and the Assessor shall report the results of the assessment to the College.
(h) Approximately twelve (12) months following the completion of the First Reassessment, Dr. Syan shall undergo a second reassessment of her family medicine and walk-in medicine practice by a College-appointed Assessor (the “Second Reassessment”). The assessment may include a review of Dr. Syan’s patient charts, direct observations, and interviews with staff and/or patients and any other tools deemed necessary by the College. Dr. Syan shall abide by all recommendations made by the Assessor, and the Assessor shall report the results of the assessment to the College.
(i) The First Reassessment and the Second Reassessment shall take the place of the reassessment directed by the Inquiries, Complaints and Reports Committee of the College in February 2011.
(j) Dr. Syan shall consent to sharing of information among the Assessor(s), the Clinical Supervisor, and the College as any of them deem necessary or desirable in order to fulfill their respective obligations.
(k) Dr. Syan shall inform the College of each and every location where she practices family medicine and walk-in medicine, in any jurisdiction (her “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, until the results of the reassessments of her practice have been reported to the College.
(l) Dr. Syan shall cooperate with unannounced inspections of her practice and patient charts by a College representative(s) for the purpose of monitoring and enforcing her compliance with the terms of this Order.
(m) Dr. Syan shall consent to the College making appropriate enquiries of the Ontario Health Insurance Program, the Narcotics Monitoring System and/or any person who or institution that may have relevant information, in order for the College to monitor her 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.
(n) Dr. Syan shall be responsible for any and all reasonable costs associated with implementing the terms of this Order.
- Dr. Syan appear before the panel to be reprimanded.
- Dr. Syan pay costs to the College in the amount of $4,460, within thirty (30) days of the date of this Order.
Terms and conditions imposed on certificate by: Member
