On January 18, 2018, the Discipline Committee found that Dr. Emad Samir Luka Guirguis committed an act of professional misconduct, in that he has engaged in an act or omission relevant to the practice of medicine that having regard to all the circumstances would reasonably be regarded by members as disgraceful, dishonourable, or unprofessional.
Dr. Guirguis is a family physician practising in Mississauga and in Oakville. He received his certificate of registration authorizing independent practice from the College of Physicians and Surgeons of Ontario (the “College’) in May 2007. At all relevant times, Dr. Guirguis practised in a group family medicine practice.
Incapacity Investigation
In May 2014, the College received information from a pharmacist and from a physician that Dr. Guirguis had been forging prescriptions for Percocet for himself using the College registration number and signature of a colleague with whom he shared an office.
The College made preliminary inquiries into Dr. Guirguis’ capacity to practice medicine, which later became a full incapacity investigation. In response to receiving notice of the College’s intent to conduct an incapacity investigation, Dr. Guirguis provided information to the College regarding his self-prescribing and admitted that he had written prescriptions to himself under another physician’s name, explaining that he takes Percocet in order to treat a men’s health related issue.
Percocet is brand name of a narcotic medication. The generic name for the opiate pain reliever in Percocet is oxycodone hydrochloride. Oxycodone is a narcotic medication.
A College retained independent specialist (the Assessor), who assessed Dr. Guirguis’ capacity to practise, did not conclude that Dr. Guirguis suffers from any disorder related to substance use or substance abuse, noting that there were no reports of Dr. Guirguis presenting under the influence of opioids while at work and no complaints from patients, colleagues or coworkers. The Assessor reported that Dr. Guirguis openly described his history, motivation and pattern of self-prescribing Percocet in 2013 and 2014, by writing prescriptions for himself under one colleague’s name.
Section 75(1)(a) Investigation Regarding Prescribing
Self-prescribing
The College conducted investigation into Dr. Guirguis’ conduct, including his self-prescribing. The information requested and obtained by the College from the Ontario Ministry of Health and Long Term Care’s Narcotics Monitoring System (“NMS”) regarding all prescriptions for monitored drugs issued to Dr. Guirguis between April, 2012 and February, 2015 showed a total of 27 prescriptions from two prescribers. One prescriber was the physician who was previously known to the College from the initial report. The second prescriber was another physician with whom Dr. Guirguis shared an office. Both of these physicians worked with Dr. Guirguis at the Clinic during this period and all three names appear at the top of the Clinic’s printed prescription pads. Through its investigation the College learned that in addition to Percocet, the 27 prescriptions forged by Dr. Guirguis included additional medications, such as Benzodiazepines, statins and nonsteroidal anti-inflammatories.
Prescribing to Family
The College also requested and obtained data regarding NMS prescriptions written by Dr. Guirguis for all patients between May, 2012 and May, 2016, which indicated that on several occasions during this period Dr. Guirguis wrote prescriptions for controlled/monitored drugs for at least 3 members of his family. Dr. Guirguis billed the Ontario Health Insurance Program for his treatment of these 3 family members; however, he does not have any medical records reflecting his prescriptions of controlled drugs or any other treatment of these family members.
Dr. Guirguis’ conduct is not consistent with his professional obligations, including those set out in the College’s policies regarding physicians’ treatment of self or family members or others close to them.
Disposition
On August 24, 2018 the Discipline Committee ordered and directed that:
- The Registrar suspend Dr. Guirguis' certificate of registration for a period of six (6) months, effective immediately.
- The Registrar impose the following terms, conditions and limitations on Dr. Guirguis' certificate of registration upon his return to practice at the conclusion of his suspension:
Restrictions
- Dr. Guirguis shall keep a log, for a period of one year from the date of this Order, of all prescriptions for any of the following (the “Prescription Log for Controlled Drugs”):
- Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
- Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Dugs and Substances Act, S.C., 1996, c. 19);
- Controlled Drugs (from Part (i) of the Food and Drug Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);
- Benzodiazepines and Other Targeted Substances (from the Benzodiazepines and Other Targeted Substances Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19); and
- All other Monitored Drugs (as defined under the Narcotics Safety and Awarenes Act, 2010, S.O. 2010, c. 22).
- The Prescription Log for Controlled Drugs shall be in a form acceptable to the College, but shall include the following:
- 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. Guirguis’ signature; and
- Dr. Guirguis 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.
- Dr. Guirguis shall not issue any new prescriptions or renew existing prescriptions for any member of his family or others close to him for any medication. Dr. Guirguis shall abide by the College's Policy on "Physician Treatment of Self, Family Members, or Others Close to Them", and any future versions of this Policy, a copy of which is attached to this Order as Schedule “A”.
Education
- At his own expense, Dr. Guirguis shall participate in and successfully complete, within six (6) months of the date of this Order, individualized instruction in medical ethics satisfactory to the College, with an instructor approved by the College. The instruction is to include an in-depth review of the College policy on “Physician Treatment of Self, Family Members or Others Close to Them” and its underlying rationale.The instructor shall provide a summative report to the College including his or her conclusion about whether the instruction was completed successfully by Dr. Guirguis.
Drug Screening
- For a period of two years following his return to practice, Dr. Guirguis shall participate in a random urine drug screening process which will include attending a facility that will facilitate random, witnessed urine drug testing at a rate of twelve (12) times per year.
- Dr. Guirguis shall engage a regulated health professional approved by the College to act as a monitor for the purpose of facilitating the random urine drug screening process ("Monitor"). The Monitor shall have available to him or her all relevant information in the College's possession.
- The Monitor shall execute an undertaking in the form attached to this Order as Schedule “B”, which includes a duty to report to the College regarding any positive test result, any missed tests and any concern that Dr. Guirguis may not be in compliance with the terms of this Order.
- Notification regarding the dates for tests will take place according to the discretion of the Monitor. Dr. Guirguis will be required to proceed to a facility approved by the Monitor before closing time on the same day of notification to provide a specimen. He will provide a specimen in the fashion required by the Monitor and will consent to the provision of the specimen under a proper chain of-custody protocol. Failure to adhere to this procedure will be considered a missed test.
- Dr. Guirguis shall submit to urine screening at any time upon the request of the Monitor and/or the College. Any missed tests that have not been excused by the Monitor will be considered a breach of this Order.
- Dr. Guirguis shall not ingest any Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines/Other Targeted Substances and all other Monitored Drugs as set out in the following legislation except within the conditions as noted in section (x) (the “Controlled Drugs”).
- Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
- Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Dugs and Substances Act, S.C., 1996, c. 19);
- Controlled Drugs (from Part (i) of the Food and Drug Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);
- Benzodiazepines and Other Targeted Substances (from the Benzodiazepines and Other Targeted Substances Regulations made under the Controlled
Drugs and Substances Act, S.C., 1996, c. 19); and
- All other Monitored Drugs (as defined under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22).
- Dr. Guirguis shall not consume any Controlled Drugs unless legitimately prescribed for him by a practitioner who has knowledge of the Discipline Committee's Decision and Reasons for Decision and with the prior approval of the Monitor. If Dr. Guirguis consumes one or more Controlled Drugs, the Monitor shall notify the College, in writing, at the earliest opportunity.
Compliance
- Dr. Guirguis shall inform the College of each and every location where he practises, in any jurisdiction ("Practice Locations") 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.
- Dr. Guirguis shall cooperate with unannounced inspections of his practice, Prescription Log and patient charts by a College representatives for the purpose of monitoring and enforcing his compliance with the terms of this Order.
- Dr. Guirguis shall consent to the College providing any Chiefs of Staff or a colleague with similar responsibilities, such as a medical director, at any location where he practises ("Chief(s) of Staff") with any information the College hasthat led to this Order and/or any information arising from the monitoring of his compliance with this Order.
- Dr. Guirguis shall provide his irrevocable consent to the College to make enquiries of the Ontario Health Insurance Plan ("OHIP"), the Drug Program Services Branch, the Narcotics Monitoring System implemented under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22, as amended ("NMS"), and/or any person who or institution that may have relevant information, in order for the College to monitor and enforce his compliance with the terms of this Order and any terms, conditions or limitations on Dr. Guirguis' certificate of registration.
- Dr. Guirguis shall be responsible for any and all costs, including all laboratory services, associated with implementing the terms of this Order.
-Dr. Guirguis attend before the panel to be reprimanded, within 90 days of the date this Order becomes final.
- Dr. Guirguis shall pay to the College costs in the amount of $5,500.00, within thirty (30) days of the date of this Order.
Terms and conditions imposed on certificate by: Member