As from March 26, 2025, the following is imposed as a term, condition and limitation on the certificate of registration held by Dr. Melinda Anne Musgrave in accordance with an undertaking and consent given by Dr. Musgrave to the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
(“Undertaking”)
of
DR. MELINDA ANNE MUSGRAVE
(“Dr. Musgrave”)
to
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
(the “College”)
A. PREAMBLE
(1) In this Undertaking:
“Code” means the Health Professions Procedural Code, which is Schedule 2 to the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as amended;
“Discipline Tribunal” means the Ontario Physicians and Surgeons Discipline Tribunal of the College;
“ICRC” means the Inquiries, Complaints and Reports Committee of the College;
“IEP” means Individualized Education Plan;
“OHIP” means the Ontario Health Insurance Plan;
“Ontario Physicians and Surgeons Discipline Tribunal” means the Discipline Committee established under the Code;
“Practice Location” or “Practice Locations” means each and every location at which Dr. Musgrave practices, delegates, or has privileges, including, but not limited to, any hospitals, clinics, offices, and any Out-of-Hospital Premises and Independent Health Facilities with which she is affiliated, in any jurisdiction;
“Public Register” means the College’s register that is available to the public.
(2) I, Dr. Musgrave, certificate of registration number 72329, am a member of the College.
(3) I, Dr. Musgrave, acknowledge that the College conducted an investigation bearing File Number CAS-438678-F9T0K8 (the “Investigation”) into whether I engaged in professional misconduct and/or am incompetent in my plastic surgery practice.
B. UNDERTAKING
(4) I, Dr. Musgrave, undertake to abide by the provisions of this Undertaking, effective immediately.
(5) Practice Restrictions
(a) I, Dr. Musgrave, undertake that I will not engage in any of the following:
(i) Sternal wound management;
(ii) Surgical excision and management of melanoma, subject to the exception in section (5)(b), unless performed within a multi-disciplinary oncology care model and in collaboration with a surgical oncologist or general surgeon; and
(iii) Free tissue transfer surgical procedures, except when acting in the role of a surgical assistant as defined in section (5)(c).
(b) I, Dr. Musgrave, acknowledge that the restriction in section (5)(a)(ii), does not apply to excisions of melanoma lesions that are less than 0.8 millimetres in thickness and do not include high-risk features. This exception applies only to melanoma in situ and clinical or pathological stage 1A.
(c) I, Dr. Musgrave, undertake that when acting in the role of a surgical assistant for free tissue transfer surgical procedures, as set out in section (5)(a)(iii), my scope of practice will be limited in the following ways:
(i) I shall only practice medicine as a surgical assistant of a surgeon:
1. certified by the Royal College of Physicians and Surgeons or recognized as a surgical specialist by the College; and
2. who holds privileges at Health Sciences North, or other Practice Location as may be approved by the College,
(collectively, a “Qualified Surgeon”); and
(ii) for further clarity, but without limiting the generality of section (5)(c)(i) above:
1. I will not provide any pre-operative or post-operative care whatsoever; and
2. a Qualified Surgeon must always be physically in attendance when I am acting in the role of a surgical assistant.
(d) I, Dr. Musgrave, undertake that when acting in the role of a surgical assistant for free tissue transfer surgical procedures, as set out in section (5)(a)(iii), I will not engage in any practice of medicine that is not expressly and specifically listed in section (5)(c) above.
(6) Posting a Sign
(a) I, Dr. Musgrave, undertake that I shall post a sign in all waiting rooms, examination rooms and consulting rooms, in all my Practice Locations, in a clearly visible and secure location, at all times whether or not I am physically present at the Practice Location, in the form set out at Appendix “A.” If providing care in a virtual setting, I shall display the sign to the patient at the outset of the patient encounter. If the patient encounter is by telephone, I shall read the sign to the patient at the outset of the patient encounter. For further clarity, this sign shall state as follows:
“Dr. Musgrave must not engage in any of the following:
(i) Sternal wound management.
(ii) Surgical excision and management of melanoma, unless performed within a multi-disciplinary oncology care model and in collaboration with a surgical oncologist or general surgeon.
This restriction does not apply to melanoma lesions that are less than 0.8 millimetres in thickness and do not include high-risk features.
(iii) Free tissue transfer surgical procedures, except when acting in the role of a surgical assistant.
Further information may be found on the College of Physicians and Surgeons of Ontario website at www.cpso.on.ca.”
(b) I Dr. Musgrave, undertake to post a certified translation in any language in which I provide services, of the sign described in section (6)(a) in all waiting rooms of all my Practice Locations, in a clearly visible and secure location, in the form set out at Appendix “A”.
(c) I, Dr. Musgrave, undertake to provide the certified translation described in section (6)(b), to the College within thirty (30) days of executing this Undertaking.
(d) I, Dr. Musgrave, undertake that if I elect, after the execution of this Undertaking, to provide services in any other language, I will notify the College prior to providing any such services.
(e) I, Dr. Musgrave, undertake to provide to the College the certified translation described in section (6)(b) prior to beginning to provide services in any language described in section (6)(d).
(7) Clinical Supervision
(a) I, Dr. Musgrave, undertake to practise under the guidance of a clinical supervisor or clinical supervisors acceptable to the College (the “Clinical Supervisor” or “Clinical Supervisors”), for at least seven (7) months (“Clinical Supervision”). Clinical Supervision shall cease only upon approval from the College.
(b) I, Dr. Musgrave, undertake to remain free of any conflict of interest with the Clinical Supervisor.
(c) I, Dr. Musgrave, acknowledge that I have reviewed the Clinical Supervisor’s undertaking, attached hereto as Appendix “B”, and understand what is required of the Clinical Supervisor. The Clinical Supervisor will, at minimum:
(i) Facilitate the education program set out in the IEP, attached hereto as Appendix “C”;
(ii) Review the materials provided by the College and have an orientation session with me, including to discuss the objectives for the Clinical Supervision;
(iii) Meet with me at my Practice Location, or another location approved by the College, once every week for a minimum of four (4) weeks (“High Level Supervision”);
(iv) After a minimum of four (4) weeks of High Level Supervision, if my Clinical Supervisor recommends and the College approves a reduction in the level of supervision, my Clinical Supervisor will meet with me at my Practice Location, or another location approved by the College, once every two (2) weeks for a minimum of three (3) months (“Moderate Level Supervision”);
(v) After a minimum of three (3) months of Moderate Level Supervision, if my Clinical Supervisor recommends and the College approves a reduction in the level of supervision, my Clinical Supervisor will meet with me at my Practice Location, or another location approved by the College, once every month for a further three (3) months (“Low Level Supervision”), and until the College approves the end of Clinical Supervision;
(vi) Review at least fifteen (15) of my patient charts at every meeting, including at least three (3) charts involving patients seen for the management of cutaneous malignancies including melanoma. Supervision shall not end until a minimum of one hundred and ninety-five (195) total patient charts have been reviewed, which shall include a minimum of thirty-nine (39) charts involving patients seen for the management of cutaneous malignancies including melanoma;
(vii) Discuss any concerns arising from the chart reviews;
(viii) Make recommendations to me for practice improvements and ongoing professional development and inquire into my compliance with the recommendations;
(ix) Perform any other duties, such as reviewing other documents or conducting interviews with staff or colleagues, that the Clinical Supervisor deems necessary to my Clinical Supervision;
(x) Submit written reports to the College at least once every week for four (4) weeks during High Level Supervision, or until the College approves a reduction in the level of supervision to Moderate Level Supervision, once every month for three (3) months during Moderate Level Supervision, or until the College approves a reduction in the level of supervision to Low Level Supervision, and then once at the end of supervision, or more frequently if the Clinical Supervisor has concerns about my standard of practice; and
(xi) Remain free of any conflict of interest with me.
(d) I, Dr. Musgrave, acknowledge that the charts reviewed shall be selected by the Clinical Supervisor based on the educational needs identified in the IEP, attached hereto as Appendix “C”, and concerns that may arise during the period of Clinical Supervision.
(e) I, Dr. Musgrave, undertake to cooperate fully with the Clinical Supervision of my practice, conducted under the term of this Undertaking and Appendix “B” to this Undertaking, and to abide by the recommendations of my Clinical Supervisor, including but not limited to, any recommended practice improvements and ongoing professional development.
(f) I, Dr. Musgrave, undertake to ensure that Appendix “B” to this Undertaking is signed and delivered to the College within thirty (30) days of the date I execute this Undertaking.
(g) I, Dr. Musgrave, undertake that if a person who has given an undertaking in Appendix “B” to this Undertaking is unable or unwilling to continue to fulfill its provisions, I 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.
(h) I, Dr. Musgrave, undertake that if I am unable to obtain a Clinical Supervisor on the provisions set out under sections (7)(f) and/or (g) above, I will cease practising medicine until such time as I have obtained a Clinical Supervisor acceptable to the College.
(i) I, Dr. Musgrave, acknowledge that if I am required to cease practise as a result of section (7)(h) above this will constitute a term, condition or limitation on my certificate of registration and that term, condition or limitation will be included on the Public Register.
(8) Professional Education
(a) I, Dr. Musgrave, undertake to participate in and successfully complete all aspects of the detailed IEP, attached hereto as Appendix “C”, including all of the following professional education (the “Professional Education”):
(i) Effective Team Interactions, Canadian Medical Protective Association, including the following prerequisites:
1. Effective communication: The key to creating reciprocal partnerships, Canadian Medical Protective Association;
2. Improving patient safety: Enhancing situational awareness for healthcare professionals, Canadian Medical Protective Association;
3. Safe to speak: Fostering a culture of psychological safety in healthcare teams eLearning Module, Canadian Medical Protective Association;
(ii) Medical Record-Keeping Workshop, University of Toronto;
(iii) Review, reflection, and discussion with my Clinical Supervisor of the following policies and other self-study:
1. Enhanced Recovery After Surgery (ERAS) peri-operative care guidelines relevant to current surgical practice including the Breast ERAS Guideline;
2. Altman AD, Helpman L, McGee J, et al. Enhanced recovery after surgery: implementing a new standard of surgical care. CMAJ. 2019;191(17):E469-E475;
3. Essentials of Medical Professionalism, College policy;
4. Professional Behaviour, College policy;
5. Transitions in Care, College policy;
6. Medical Records Documentation, College policy;
(iv) any additional professional education recommended by my Clinical Supervisor.
(b) I, Dr. Musgrave, undertake to provide proof to the College of my successful completion of the Professional Education, including proof of registration and attendance and participant assessment reports, within one (1) month of completing it. I acknowledge that the College will determine, in its sole discretion, whether I have successfully completed the Professional Education.
(c) I, Dr. Musgrave, undertake to complete this requirement within three (3) months, or, if no satisfactory program is available by that time, by the first possible opportunity thereafter.
(d) I, Dr. Musgrave, acknowledge that a report or reports may be provided to the College regarding my progress and compliance with the Professional Education.
(e) I, Dr. Musgrave, acknowledge that if any of the programs and/or self-study resources listed above become unavailable, substitution requests will be reviewed by the College and the College will determine in its sole discretion whether substitution is appropriate.
(9) Reassessment of Practice
(a) I, Dr. Musgrave, undertake that, approximately six (6) months after the completion of the Clinical Supervision set out in section (7) above and Appendix “B” to this Undertaking, and the completion of the Professional Education set out in section (8) above, I will submit to a reassessment of my practice (“the Reassessment”) by an assessor or assessors selected by the College (the “Assessor” or “Assessors”). I acknowledge that the Reassessment will include a chart review of a minimum of fifteen (15) charts, and may include direct observation of my care, interviews with me, colleagues and co-workers, feedback from patients, and any other tools deemed necessary by the College.
(b) I, Dr. Musgrave, undertake to co-operate fully with the Reassessment, conducted under the term of this Undertaking.
(c) I, Dr. Musgrave, acknowledge that my Clinical Supervisor may receive and review the findings of the Assessor, and may discuss with the Assessor any issues or concerns arising from the Reassessment.
(d) I, Dr. Musgrave, acknowledge that the results of the Reassessment will be provided to me and reported to the College and the Reassessment may form the basis of further action by the College.
(10) Monitoring
(a) I, Dr. Musgrave, undertake to inform the College of each and every one of my Practice Locations within five (5) days of executing this Undertaking. Going forward, I further undertake to inform the College of any and all new Practice Locations within five (5) days of commencing practice at that location.
(b) I, Dr. Musgrave, undertake that I will submit to, and not interfere with, unannounced inspections of my Practice Locations and patient records by a College representative for the purposes of monitoring my compliance with the provisions of this Undertaking.
(c) I, Dr. Musgrave, give my irrevocable consent to the College to make appropriate enquiries of OHIP and/or any person who or institution that may have relevant information, in order for the College to monitor my compliance with the provisions of this Undertaking.
(d) I, Dr. Musgrave, acknowledge that I have executed the OHIP consent form, attached hereto as Appendix “D”.
C. ACKNOWLEDGEMENT
(11) I, Dr. Musgrave, acknowledge that all appendices attached to or referred to in this Undertaking form part of this Undertaking.
(12) I, Dr. Musgrave, acknowledge and undertake that I shall be solely responsible for payment of all fees, costs, charges, expenses, etc. arising from the implementation of any of the provisions of this Undertaking.
(13) I, Dr. Musgrave, acknowledge that I have read and understand the provisions of this Undertaking and that I have obtained independent legal counsel in reviewing and executing this Undertaking, or have waived my right to do so.
(14) I, Dr. Musgrave, acknowledge that the College will provide this Undertaking to any Chief of Staff, or a colleague with similar responsibilities, at any Practice Location (“Chief of Staff” or “Chiefs of Staff”).
(15) I, Dr. Musgrave, acknowledge that a breach by me of any provision of this Undertaking may constitute an act of professional misconduct and/or incompetence, and may result in a referral of specified allegations to the Discipline Tribunal of the College.
(16) I, Dr. Musgrave, acknowledge that this Undertaking constitutes terms, conditions, and limitations on my certificate of registration for the purposes of section 23 of the Code.
(17) Public Register
(a) I, Dr. Musgrave, acknowledge that, during the time period that this Undertaking remains in effect, this Undertaking shall be posted on the Public Register.
(b) I, Dr. Musgrave, acknowledge that, in addition to this Undertaking being posted in accordance with section (17)(a) above, the following summary shall be posted on the Public Register during the time period that this Undertaking remains in effect:
A College investigation was conducted into whether Dr. Musgrave engaged in professional misconduct and/or is incompetent in her plastic surgery practice. As a result of the investigation:
Dr. Musgrave must not engage in any of the following:
i. Sternal wound management.
ii. Surgical excision and management of melanoma, unless performed within a multi-disciplinary oncology care model and in collaboration with a surgical oncologist or general surgeon. This restriction does not apply to excisions for melanoma lesions that are less than 0.8 millimetres in thickness and do not include high-risk features.
iii. Free tissue transfer surgical procedures, except when acting in the role of a surgical assistant.
Dr. Musgrave shall post a clearly visible sign in the waiting rooms, examination rooms and consulting rooms of all Practice Locations, which states as follows:
“Dr. Musgrave must not engage in any of the following:
i. Sternal wound management.
ii. Surgical excision and management of melanoma, unless performed within a multi-disciplinary oncology care model and in collaboration with a surgical oncologist or general surgeon.
This restriction does not apply to excisions for melanoma lesions that are less than 0.8 millimetres in thickness and do not include high-risk features.
iii. Free tissue transfer surgical procedures, except when acting in the role of a surgical assistant.
Further information may be found on the College of Physicians and Surgeons of Ontario website at www.cpso.on.ca.”
Dr. Musgrave will practise under the guidance of a Clinical Supervisor acceptable to the College for seven months.
Dr. Musgrave will engage in professional education in complex case management, post-operative care and rehabilitation, effective communication with physician colleagues, office management, and medical recordkeeping.
Dr. Musgrave’s practice will be reassessed by an assessor selected by the College within six months of the end of the period of Clinical Supervision and the completion of the professional education.
D. CONSENT
(18) I, Dr. Musgrave, give my irrevocable consent to the College to provide the following information to any person who requires this information for the purposes of facilitating my completion of the Professional Education and to all Clinical Supervisors, and/or Assessors:
(a) any information the College has that led to the circumstances of my entering into this Undertaking;
(b) any information arising from any investigation into, or assessment of, my practice; and
(c) any information arising from the monitoring of my compliance with this Undertaking.
(19) I, Dr. Musgrave, give my irrevocable consent to the College to provide all Chiefs of Staff with any information the College has that led to the circumstances of my entering into this Undertaking and/or any information arising from the monitoring of my compliance with this Undertaking.
(20) I, Dr. Musgrave, give my irrevocable consent to any persons who facilitate my completion of the Professional Education, and to all Clinical Supervisors, Chiefs of Staff and Assessors, to disclose to the College, and to one another, any of the following:
(a) any information relevant to this Undertaking;
(b) any information relevant to the provisions of the Clinical Supervisor’s undertaking set out at Appendix “B” to this Undertaking;
(c) any information relevant to the Reassessment;
(d) any information relevant for the purposes of monitoring my compliance with this Undertaking; and/or
(e) any information which comes to their attention in the course of providing the Professional Education and which they reasonably believe indicates a potential risk of harm to my patients.
Terms and conditions imposed on certificate by: Member
