On July 21, 2017, the Discipline Committee found that Dr. Ejaz Ahmed Ghumman committed an act of professional misconduct in that he has failed to maintain the standard of practice of the profession.
Dr. Ghumman is a general surgeon practising at the hospital in a city in Ontario. From 2007, Dr. Ghumman was a Chief of Staff at the hospital, but resigned his position in April 2017, following a referral of this matter to the Discipline Committee of the College.
Dr. Ghumman received his medical degree in Pakistan in 1982 and a specialist qualification in general surgery in Ireland in 1991. In 1999, Dr. Ghumman obtained a certificate of independent practice in Newfoundland and received his specialist qualification in general surgery in Canada in 2004. In 2007, Dr. Ghumman received his certificate of independent practice in Ontario.
Failure to Maintain Standard of Practice of the Profession: Patient X
In June, 2015, Patient X complained to the College regarding Dr. Ghumman’s care in conducting her laparoscopic gallbladder removal surgery and his post-operative care.
Several months prior to the complaint, Dr. Ghumman assessed Patient X for symptomatic gall stones. He explained to Patient X her treatment options, discussed the potential risks and benefits of surgery, and obtained Patient X’s informed consent for a laparoscopic gallbladder removal surgery, which was scheduled for the following month. On the day of the surgery, Dr. Ghumman discussed the surgical plan with Patient X in the day surgery area at the hospital.
During the surgery, the clip applier that Dr. Ghumman applied on Patient X’s cystic artery unexpectedly jammed and could not be pulled off as it could damage an artery. Dr. Ghumman considered converting to an open procedure, but decided to continue laparoscopically and to take steps to divide the cystic artery in order to remove the jammed clip applier.
Following the anesthetist’s suggestion to use Filshie clips, which are applied with a narrower clipper than other clips, Dr. Ghumman proceeded to place a Filshie clip, but was concerned that he might have mistakenly placed it on the common bile duct or the right hepatic artery. Dr. Ghumman directed nurses to make several telephone calls, but could not find a way to remove the Filshie clip without risking torn vessels or tearing the bile duct.
He continued with the procedure and applied another Filshie clip on the cystic artery, which allowed him to divide the cystic artery and remove the jammed clipper.
Dr. Ghumman removed the gallbladder, which tore during removal, placed a drain and completed the surgery. He noted in his Operative Report that if a clip is on a common bile duct, he may have to refer Patient X to a Hepatobiliary Surgeon.
Following the surgery, Dr. Ghumman told Patient X that the surgery went well. He indicated that he encountered a complication when the clipper jammed, which he was then able to remove, but was concerned that he might have placed a clip on her right hepatic artery or common bile duct.
Patient X was discharged home the same day with instructions for monitoring and to return two days later for a CT scan and to remove the drain placed during surgery.
When Patient X returned two days later, she reported feeling unwell, was in pain, and was having trouble eating. Dr. Ghumman discussed the results of Patient X’s CT scan with a radiologist at the hospital, who opined that Patient X’s common bile duct looked normal and indicated that no clip was visualized on the common bile duct. Dr. Ghumman reported to Patient X’s family doctor that he had a small incident during surgery but that he was satisfied, after the CT scan, that the clip was not on the common bile duct. He indicated that he was concerned because he had applied the clip “a little bit blind”, but now felt the clip was on tissues along the gallbladder, which was not a problem. Dr. Ghumman decided not to remove the drain that day and instructed Patient X to return three days later for removal of the drain and follow up tests.
When Patient X returned to Dr. Ghumman for drain removal three days later, she reported feeling itchy, was unable to eat, and her complexion was jaundiced.
The next day, Dr. Ghumman telephoned Patient X and informed her that according to her blood work results her bilirubin was high. Elevated bilirubin levels may cause jaundice and may indicate problems with the liver or bile duct, and may also account for the type of itching experienced by Patient X. Dr. Ghumman advised Patient X to drink plenty of fluids to stay well hydrated and call his office if her condition worsened.
In two days, Patient X contacted Dr. Ghumman and complained of increased itching. He booked an ultrasound appointment and blood work for the next morning. The ultrasound results suggested that the common bile duct was obstructed and blood work indicated that Patient X’s bilirubin had increased over the previous three days. Dr. Ghumman advised Patient X that the clip he was concerned about had actually been placed incorrectly and had likely caused obstruction of the patient’s common bile duct. He organized Patient X’s immediate transportation to London Health Sciences Centre (“London”) for emergency admission and surgery.
Following the surgery, the Hepatobiliary Surgeon noted that there was a clip going across Patient X’s entire bile duct. The surgery was complicated by intra-operative and post-operative bleeding, which required transfusion of eight units of blood. Patient X remained hospitalized in London for approximately one week after the surgery.
In October, 2015, the College retained an expert, a general surgeon, to provide opinion regarding Dr. Gumman’s care of Patient X. The expert opined that although the technical complication involving the clip applier during surgery was beyond Dr. Ghumman’s control, his actions in response to the problem were below the standard of practice of the profession. He noted the following concerns:
- Dr. Ghumman failed to convert to an open procedure in order to first define the anatomy with careful dissection around the jammed clipper;
- Despite his concern of having injured an important structure, Dr. Ghumman failed to obtain the advice of a hepatobiliary surgeon or another general surgeon, either during or immediately following the surgery. Although there was only one other surgeon in a hospital in a small community where he works, he could have sought assistance through a service that provides urgent and emergent support for hospital-based physicians;
- Dr. Ghumman’s operative note shows that he was aware of the need to obtain the critical view, but he placed the Filshie clip applier in the area of undissected tissue;
- The fact that there was a retained portion of a surgical bag after the surgical procedure demonstrates a lack of care and poor technique.
Failure to Maintain the Standard of Practice of the Profession – Other Patients
Subsequently, the College commenced an investigation under s.75 (1)(a) of the Health Professions Procedural Code into Dr. Ghumman’s surgical practice. The College-retained expert and the expert retained by Dr. Ghumman reviewed Dr. Ghumman’s twenty-five patient charts. Both experts opined that Dr. Ghumman failed to maintain the standard of practice of the profession in the following areas:
- Prolonged and unnecessary use of prophylactic antibiotics post-operatively with respect to some patients. While there was no evidence of actual harm, overuse of antibiotics presents a risk of potential harm to patients, particularly in the hospital setting where there is a risk that antibiotic resistance will make treatment of infections more difficult. This issue was described as minor by both experts;
- Overuse of surgical drains in some patients, in the absence of evidence of an abscess requiring drainage or the development of post-operative collection of clear fluid. There was no evidence of actual harm or potential risk of harm to patients. This issue was described as minor by both experts;
- Deficient record-keeping pertaining to incomplete documentation of the patients’ consent to a colonoscopy. There was no evidence of actual harm to any patient.
On July 21, 2017, the Committee ordered and directed on the matter of penalty and costs that:
- The Registrar impose the following terms, conditions and limitations on Dr. Ghumman’s Certificate of Registration:
Chief of Staff Role
a) Dr. Ghumman shall not re-apply for the Chief of Staff position at any hospital until successful completion of the re-assessment described below.
Clinical Supervision
(a) Dr. Ghumman shall retain a College-approved Clinical Supervisor who will sign an undertaking in the form attached as Schedule “A” to the Order;
(b) For a period of twelve (12) months commencing on the date that the Clinical
Supervisor is approved by the College, Dr. Ghumman may practise only under the
supervision of the Clinical Supervisor;
(c) Clinical Supervision of Dr. Ghumman’s practice shall contain the following
elements:
Moderate-Level Supervision
a) For an initial period of approximately four (4) weeks, the Clinical Supervisor will engage in a period of moderate-level supervision, during which time the Clinical Supervisor will at minimum:
(i) Review materials provided by the College and have an initial in-person
meeting with Dr. Ghumman to discuss practice improvement
recommendations;
(ii) Thereafter, discuss with Dr. Ghumman once a week by telephone or secure
electronic video conference to pre-clear all general surgery cases done in the
operating room under a general anaesthetic;
(iii) For on-call cases where Dr. Ghumman is not able to speak to his Clinical
Supervisor prior to surgery, the Clinical Supervisor will review such cases as
soon as possible after the surgery and in any event within approximately 24
hours post-surgery by telephone or secure electronic video conference;
(iv) Provide reports to the College once every two (2) weeks, or more frequently if the Clinical supervisor has concerns about Dr. Ghumman’s standard of practice or conduct;
(v) Discuss with Dr. Ghumman any concerns the Clinical Supervisor may have arising from his meetings with Dr. Ghumman and case reviews;
(vi) Make recommendations for practice improvements and ongoing professional
development, and inquire into Dr. Ghumman’s compliance with any
recommendations;
(vii) Keep a log of all patient charts reviewed along with patient identifiers.
Low-Level Supervision Phase 1
a) After the first four (4) weeks of Dr. Ghumman’s Moderate-Level Clinical
Supervision, upon receipt of a written recommendation from the Clinical Supervisor that Dr. Ghumman is ready to practise under Low-Level Clinical Supervision, and subject to approval by the College, Clinical Supervision shall continue for a further period of eight (8) weeks during which time the Clinical Supervisor will at minimum:
(A) Meet with Dr. Ghumman once every two (2) weeks in person to discuss surgical cases and review a minimum of fifteen (15) patient charts, to be selected in the sole discretion of the Clinical Supervisor, and discuss any issues or concerns arising therefrom with Dr. Ghumman. If the Clinical Supervisor is of the view that fewer than fifteen (15) charts may be reviewed in this period, the Clinical Supervisor shall provide a written recommendation to the College and, subject to approval by the College, may review no fewer than ten (10) patient charts per visit for the remaining portion of this period of clinical supervision;
(B) Provide reports to the College once per month, or more frequently if the Clinical supervisor has concerns about Dr. Ghumman’s standard of practice or conduct;
(C) Discuss with Dr. Ghumman any concerns the Clinical Supervisor may have arising from his meetings with Dr. Ghumman and chart reviews;
(D) Make recommendations for practice improvements and ongoing professional development, and inquire into Dr. Ghumman’s compliance with any recommendations;
(E) Keep a log of all patient charts reviewed along with patient identifiers.
Low-Level Supervision Phase 2
a) After the first eight (8) weeks of Low-Level Clinical Supervision, upon receipt of a written recommendation from the Clinical Supervisor and subject to approval by the College, Clinical Supervision shall continue at Low-Level for the balance of the twelve (12) months of Clinical Supervision, during which time the Clinical Supervisor will at minimum:
(i) Meet with Dr. Ghumman once a month in person to discuss surgical cases and review a minimum of ten (10) patient charts, to be selected in the sole discretion of the Clinical Supervisor, and discuss any issues or concerns arising therefrom with Dr. Ghumman;
(ii) Provide reports to the College once every two months or more frequently if the Clinical supervisor has concerns about Dr. Ghumman’s standard of practice or conduct;
(iii) Discuss with Dr. Ghumman any concerns the Clinical Supervisor may have arising from his meetings with Dr. Ghumman and chart reviews;
(iv) Make recommendations for practice improvements and ongoing professional development, and inquire into Dr. Ghumman’s compliance with any recommendations;
(v)Keep a log of all patient charts reviewed along with patient identifiers.
Individualized Education Plan (“IEP”)
a) The Clinical Supervisor shall facilitate completion of the education program, set out in an IEP to be provided to the Clinical Supervisor by the College, and shall report to the College in his/her reports as to Dr. Ghumman’s progress in completing the IEP.
Other Elements of Clinical Supervision
a) Throughout the period of Clinical Supervision, Dr. Ghumman shall abide by the recommendations of the Clinical Supervisor and shall complete the IEP in co- operation with the Clinical Supervisor;
b) If a clinical supervisor who has given an undertaking as set out in Schedule “A” to this Order is unable or unwilling to continue to fulfill its terms, Dr. Ghumman shall, within twenty (20) days of receiving notice of same, obtain an executed undertaking in the same form from a person who is acceptable to the College and ensure that it is delivered to the College within that time;
c) If Dr. Ghumman is unable to obtain a clinical supervisor in accordance with this Order, he shall cease to practice until such time as he has done so;
d) Dr. Ghumman 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. Ghumman’s compliance with this Order.
Re-Assessment
a) Approximately six (6) months after the completion of the period of supervision set out above Dr. Ghumman shall undergo a re-assessment of his practice, at his own expense, by a College-appointed assessor (the “Assessor(s)”). The re-assessment shall include the elements outlined in the IEP, to be provided by the College. The Assessor(s) shall report the results of the re-assessment to the College;
b) Dr. Ghumman shall consent to the disclosure to the Assessor(s) of the reports of the Clinical Supervisor arising from the supervision, and shall consent to the sharing of all information between the Clinical Supervisor, the Assessor(s) and the College, as the College deems necessary or desirable in order to fulfill their respective obligations.
Monitoring
a) Dr. Ghumman shall inform the College of each and every location where he practices, in any jurisdiction (his “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.
b) Dr. Ghumman shall cooperate with unannounced inspections of his practice and patient charts by one or more College representative(s) for the purpose of monitoring and enforcing his compliance with the terms of this Order.
c) Dr. Ghuman shall consent to the College’s making appropriate enquiries of the Ontario Health Insurance Plan and/or any person or institution that may have relevant information, in order for the College to monitor and enforce his compliance with the terms of this Order.
d) Dr. Ghumman shall be responsible for any and all costs associated with
implementing the terms of this Order.
- Dr. Ghumman appear before the panel to be reprimanded.
- Dr. Ghumman to pay costs to the College for a one day hearing in the amount of $5,500.00 within 30 days of the date of this Order.
Terms and conditions imposed on certificate by: Discipline Committee
