As from April 23, 2024, the following are imposed as terms, conditions and limitations on the certificate of registration held by Dr. Ashwin Rajan Maharaj in accordance with an undertaking and consent given by Dr. Maharaj to the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. ASHWIN RAJAN MAHARAJ
("Dr. Maharaj")
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;
"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;
"Public Register" means the College's register that is available to the public.
(2) I, Dr. Maharaj, certificate of registration number 67100, am a member of the College.
(3) I, Dr. Maharaj, acknowledge that following four public complaints, the College conducted investigations bearing File Numbers CAS-418833-K4G5Z7, CAS-436555-C8G2Y9, CAS-438950-V2D1J1 and CAS-435724-H0B2G8 (the "Investigations") into my care of, and conduct towards, patients in my general surgery practice.
(4) I, Dr. Maharaj, acknowledge that, in addition to accepting this Undertaking, the College will also deliver cautions in person in connection with all four Investigations.
B. UNDERTAKING
(5) I, Dr. Maharaj, undertake to abide by the provisions of this Undertaking, effective immediately.
(6) Practice Restrictions
(a) I, Dr. Maharaj, undertake that I will no longer perform "endoscopic hemorrhoidectomy", or any other procedure or treatment that is not evidence-based or which does not align with the standard of practice of the profession.
(7) Clinical Supervision
(a) I, Dr. Maharaj, 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. Maharaj, undertake to remain free of any conflict of interest with the Clinical Supervisor.
(c) I, Dr. Maharaj, acknowledge that I have reviewed the Clinical Supervisor's undertaking, attached hereto as Appendix "A", 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 "B";
(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) During High Level Supervision, directly observe five (5) patient encounters at every meeting, including three (3) patients being provided laser hemorrhoidectomy and/or Transanal Hemorrhoidal Dearterialization ("LHP/THD patients"). If fewer than three (3) LHP/THD patients are seen in a given week, my Clinical Supervisor shall observe all of my LHP/THD patients. The direct observation of LHP/THD patients shall include all aspects of my patient management, including pre and post-procedure discussions;
(v) After a minimum of four (4) weeks of High Level Supervision, and direct observation of a minimum of twenty (20) patient encounters, including twelve (12) LHP/THD patients, 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");
(vi) 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;
(vii) Review at least fifteen (15) of my patient charts at every meeting;
(viii) Discuss any concerns arising from the direct observation or chart reviews;
(ix) Make recommendations to me for practice improvements and ongoing professional development and inquire into my compliance with the recommendations;
(x) 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;
(xi) 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
(xii) Remain free of any conflict of interest with me.
(d) I, Dr. Maharaj, 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 "B", as well as the areas of concern identified in the reports of the assessors dated July 6, 2023, August 1, 2023, November 25, 2023, December 5, 2023, and February 24, 2024 (CAS-418833-K4G5Z7), November 29, 2023 and December 8, 2023 (CAS-436555-C8G2Y9 and CAS-435724-H0B2G8), and concerns that may arise during the period of Clinical Supervision.
(e) I, Dr. Maharaj, undertake to cooperate fully with the Clinical Supervision of my practice, conducted under the term of this Undertaking and Appendix "A" 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. Maharaj, undertake to ensure that Appendix "A" to this Undertaking is signed and delivered to the College within thirty (30) days of the date I execute this Undertaking.
(g) I, Dr. Maharaj, undertake that if a person who has given an undertaking in Appendix "A" 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. Maharaj, undertake that if I am unable to obtain a Clinical Supervisor on the provisions set out under sections (7)(f) and/or (7)(g) above, I will cease practising medicine until such time as I have obtained a Clinical Supervisor acceptable to the College.
(i) I, Dr. Maharaj, 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. Maharaj, undertake to participate in and successfully complete all aspects of the detailed IEP, attached hereto as Appendix "B", including all of the following professional education (the "Professional Education"):
(i) PROBE: Ethics & Boundaries Program, by receiving a passing evaluation or grade, without any condition or qualification. I, Dr. Maharaj, will agree to abide by any recommendations of the PROBE program;
(ii) Informed Consent eLearning Module, CMPA;
(iii) Review, reflection, and discussion with my Clinical Supervisor of the following policies and other self-study:
1. Bleday, R.; Breen, E. (2023). Home and office treatment of symptomatic hemorrhoids. UpToDate, including all references noted in my IEP;
2. Rivadeneira, D.; Steele, S.R. (2023). Surgical treatment of hemorrhoidal disease. UpToDate;
3. Code of Ethics, CMPA;
4. Delegation of Controlled Acts, College policy, and Advice to the Profession - Delegation of Controlled Acts;
5. Uninsured Services: Billing and Block Fees, College policy;
6. Consent to Treatment, College policy;
7. Good Practices - Physician-Patient: Clinical Decision-Making, CMPA;
8. Good Practices - Physician-Patient: Informed Consent, CMPA;
9. Good Practices - Physician-Patient: Patient-centred communication, CMPA;
10. Good Practices - Physician-Patient: Documentation and record keeping, CMPA;
11. Medical Records Management, College policy;
12. Medical Records Documentation, College policy; and
(iv) any additional professional education recommended by my Clinical Supervisor.
(b) I, Dr. Maharaj, 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. Maharaj, 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. Maharaj, acknowledge that a report or reports may be provided to the College regarding my progress and compliance with the Professional Education.
(e) I, Dr. Maharaj, acknowledge that if any of the programs 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. Maharaj, undertake that, approximately six (6) months after the completion of the Clinical Supervision set out in section (7) above and Appendix "A" 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 may include a chart review of a minimum of fifteen (15) charts, 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. Maharaj, undertake to co-operate fully with the Reassessment, conducted under the term of this Undertaking.
(c) I, Dr. Maharaj, 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. Maharaj, 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. Maharaj, undertake to inform the College of each and every location at which I practice, delegate, or have privileges, including, but not limited to, any hospitals, clinics, offices, and any Out-of-Hospital Premises or Independent Health Facilities with which I am affiliated, in any jurisdiction (collectively my "Practice Location" or "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. Maharaj, 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. Maharaj, 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. Maharaj, acknowledge that I have executed the OHIP consent form, attached hereto as Appendix "C".
C. ACKNOWLEDGEMENT
(11) I, Dr. Maharaj, acknowledge that all appendices attached to or referred to in this Undertaking form part of this Undertaking.
(12) I, Dr. Maharaj, 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. Maharaj, 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. Maharaj, 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. Maharaj, 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. Maharaj, 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. Maharaj, acknowledge that, during the time period that this Undertaking remains in effect, this Undertaking shall be posted on the Public Register.
(b) I, Dr. Maharaj, 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:
College investigations were conducted into Dr. Maharaj's care of, and conduct towards, patients in his general surgery practice. As a result of the investigations:
Dr. Maharaj will practise under the guidance of a Clinical Supervisor acceptable to the College for at least 7 months.
Dr. Maharaj will engage in professional education, including in the assessment and management of patients presenting with anorectal complaints, evidence-based treatment, delegation, informed consent, communication, and medical record-keeping.
Dr. Maharaj's practice will be reassessed by an assessor selected by the College within 6 months of the end of the period of Clinical Supervision and the completion of the professional education.
D. CONSENT
(18) I, Dr. Maharaj, 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. Maharaj, 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. Maharaj, 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 "A" 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.