UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking") of
DR. NICHOLAS PETER KOUTRAS
("Dr. Koutras") 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;
"ICR Committee" means the Inquiries, Complaints and Reports Committee of the College; "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. Koutras, certificate of registration number 63994, am a member of the College.
(3) I, Dr. Koutras, acknowledge that the College conducted an investigation bearing File Number CAS-372046-R8V0V9 (the "Investigation") into whether I engaged in professional misconduct and/or am incompetent in my general medicine practice and conduct, including in my care and conduct in relation to the COVID-19 pandemic and my prescribing of ivermectin for COVID-19.
(4) I, Dr. Koutras, acknowledge that I signed an interim undertaking in lieu of the ICR Committee making an Order under section 25.4 of the Code on July 21, 2022 (the "2022 Undertaking").
(5) I, Dr. Koutras, acknowledge that this Undertaking replaces the 2022 Undertaking.
(6) I, Dr. Koutras, acknowledge that, in addition to accepting this Undertaking, the College will also deliver a caution in person.
B. UNDERTAKING
(7) I, Dr. Koutras, undertake to abide by the provisions of this Undertaking, effective immediately.
(8) Practice Restrictions
(a) I, Dr. Koutras, undertake to restrict my practice as follows:
(i) I will not provide medical exemptions in relation to vaccines for COVID- 19;
(ii) I will not provide medical exemptions in relation to mask requirements for COVID-19; and
(iii) I will not prescribe ivermectin or hydroxychloroquine in relation to COVID- 19.
(9) Professional Education
(a) I, Dr. Koutras, undertake to participate in and successfully complete all aspects of the detailed IEP, attached hereto as Appendix "A", including all of the following professional education (the "Professional Education"):
(i) Individualized instruction in professionalism satisfactory to the College, with an instructor selected by the College.
(ii) Review, reflection, and discussion of the following resource with the instructor providing the individualized instruction:
1. The College's Practice Guide: Medical Professionalism and College Policies;
(iii) The following learning modules in Evidence-Informed Decision Making in Public Health, National Collaborating Centre for Methods and Tools, McMaster University:
1. Introduction to Evidence-informed Decision Making;
2. Searching for Research Evidence in Public Health;
3. Critical Appraisal of Intervention Studies;
4. Assessing the Applicability and Transferability of Evidence.
(iv) Review, reflection, and a written summary of the following policies and other self-study:
1. The Spread of Misinformation, Dialogue. 2023., College of Physicians and Surgeons of Ontario;
2. Murthy V.H. Confronting Health Misinformation: The U.S. Surgeon General's Advisory on Building a Healthy Information Environment. 2021;
3. Selected sections from McIntosh, K. COVID-19: Epidemiology, virology, and prevention. UpToDate. Retrieved August 8, 2023:
(i) Prevention; and
(ii) Post-Exposure Management.
4. The following section from Cohen, P., Gebo, K. COVID-19: Evaluation of adults with acute illness in the outpatient setting. UpToDate. Retrieved August 8, 2023:
(i) Therapies that we do not recommend.
5. The following section from Burel, CI. Acquired long QT syndrome: Definitions, pathophysiology, and causes. UpToDate. Retrieved August 9, 2023:
(i) Drugs that prolong the QT interval.
6. Medical Records Documentation, CPSO Policy;
7. Consent to Treatment, CPSO Policy;
8. Complementary / Alternative Medicine, CPSO Policy.
(v) Review, and reflection of the following policies and other self-study:
1. Pasquetto I.V., et al. MisinfoRx: A Toolkit for Healthcare Providers;
2. Popp M, et al. Ivermectin for preventing and treating COVID-19.
Cochrane Database of Systematic Reviews; and
3. Singh B, et al. Chloroquine or hydroxychloroquine for prevention and treatment of COVID-19. Cochrane Database of Systematic Reviews. 2021;2:CD013587.
(b) I, Dr. Koutras, undertake to complete the Professional Education within three (3) months, or, if no satisfactory program is available by that time, by the first possible opportunity thereafter.
(c) I, Dr. Koutras, 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.
(d) I, Dr. Koutras, acknowledge that a report or reports may be provided to the College regarding my progress and compliance with the Professional Education.
(e) I, Dr. Koutras, acknowledge that if any of the programs or 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.
(10) Monitoring
(a) I, Dr. Koutras, undertake to inform the College of each and every location at which I practise or have privileges, including, but not limited to, any hospitals, clinics, offices, and any 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. Koutras, 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. Koutras, 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. Koutras, acknowledge that I have executed the OHIP consent form, attached hereto as Appendix "B".
C. ACKNOWLEDGEMENT
(11) I, Dr. Koutras, acknowledge that all appendices attached to or referred to in this Undertaking form part of this Undertaking.
(12) I, Dr. Koutras, 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. Koutras, 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. Koutras, 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. Koutras, 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. Koutras, 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. Koutras, acknowledge that, during the time period that this Undertaking remains in effect, this Undertaking shall be posted on the Public Register.
(b) I, Dr. Koutras, 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. Koutras engaged in professional misconduct and/or is incompetent in his general medicine practice and conduct, including in his care and conduct in relation to the COVID-19 pandemic and his prescribing of Ivermectin for COVID-19. As a result of the investigation:
Dr. Koutras will restrict his practice as follows:
Dr. Koutras will not provide medical exemptions in relation to vaccines for COVID-19;
Dr. Koutras will not provide medical exemptions in relation to mask requirements for COVID-19; and
Dr. Koutras will not prescribe ivermectin or hydroxychloroquine in relation to COVID-19.
Dr. Koutras will engage in professional education, including in respecting CPSO policies, public health guidance, and Ministry of Health directives during a declared pandemic, misinformation and evidence-based decision making, the prevention and treatment of COVID-19 in an outpatient setting, appreciating the risk of QT prolongation and arrhythmia from certain drugs, and documenting consent discussions.
D. CONSENT
(18) I, Dr. Koutras, 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:
(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. Koutras, 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. Koutras, give my irrevocable consent to any persons who facilitate my completion of the Professional Education, and to all Chiefs of Staff, to disclose to the College, and to one another, any of the following:
(a) any information relevant to this Undertaking;
(b) any information relevant for the purposes of monitoring my compliance with this Undertaking;
(c) 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.