Committee: Discipline
Decision Date: 19 Jun 2019
Summary:
On June 19th, 2019, the Discipline Committee found that Dr. Goldstein 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, and that he failed to maintain the standard of practice of the profession.
Background
Dr. Goldstein is an 80-year-old psychiatrist practicing in Toronto, Ontario, who received his certificate of registration authorizing independent practice in 1968.
On the basis of information received from the Health Services Branch of the Ontario Ministry of Health and Long-Term Care (the “Ministry”) identifying concerns with Dr. Goldstein’s recordkeeping and billing practices, as well as other information, the College commenced an investigation under section 75(1)(a) of the Health Professions Procedural Code to obtain a broader view of Dr. Goldstein’s psychiatry practice.
Investigation of Dr. Goldstein’s Practice
The College retained Dr. Ahmed Boachie (“Dr. Boachie”), a psychiatrist and Assistant Professor in the Department of Psychiatry at the University of Toronto, to opine on Dr. Goldstein’s psychiatry practice including his documentation and billing practices. Dr. Boachie reviewed 24 patient charts, the associated OHIP billing for 21 patients, and certain other information.
Dr. Boachie opined that Dr. Goldstein’s documentation practices fell below the standard of practice of the profession in all 24 of the charts reviewed. In particular, he noted that: There is a clear pattern for concern regarding Dr. Goldstein’s assessment, documentation, and billing practices. It is practically ubiquitous that:
a) Notes are handwritten and difficult to decipher...;
b) Notes are very short, or sometimes there is no note at all, but only a date and time period for the appointment; and
c) Although Dr. Goldstein can clearly assess and formulate mental health disorders, as is evident when he writes letters regarding patients for insurance or legal purposes, there are no assessment notes or formulations written in the chart notes. Nor are there treatment plans.
These practices would make it very difficult for another psychiatrist to take over care of one of Dr.Goldstein’s patients, should he be unavailable to them. These documentation practices do not meet minimum standards of care.
Dr. Boachie also opined that Dr. Goldstein’s billing practices failed to meet the standard of practice of the profession. He noted: With regard to billing practices, there were numerous cases in which dates of treatment that were billed to OHIP did not have corresponding dates and/or chart notes in the patients’ files. In some cases, billing dates were not in sequence, not even roughly in sequence, but all over the place. These concerns require further investigation.
Dr. Boachie interviewed Dr. Goldstein and submitted a further report following that interview.
He noted that:
Dr. Goldstein appeared to have a very good memory of events when prompted, but because of inadequate documentation there were still certain cases where we could not get a clear idea why many decisions were made. He could also not give any appropriate explanation for the discrepancies in OHIP billing described in my first report.
Dr. Boachie, in his reports, raised certain issues with regard to Dr. Goldstein’s patient charts in assessments conducted for use in family court or in cases of family conflict. As Dr. Boachie did not practice in this area, the College retained Dr. Anthony Pignatiello, the Associate Psychiatrist-in-Chief at the Hospital for Sick Children, to review certain patient records previously reviewed by Dr. Boachie. Dr. Pignatiello reviewed five patient charts and interviewed Dr. Goldstein.
As with Dr. Boachie, Dr. Pignatiello’s review identified issues related to Dr. Goldstein’s documentation and billing. In particular, in his report Dr. Pignatiello commented: The patient files of Dr. Goldstein reviewed were consistently very disorganized, unclear, vague, often times with scant information provided. In some sections dates of service were identified; however, no content was written. Two of the files had beginning elements of an assessment note whereas with others there was no evidence of any assessment.
There was no clear approach to an impression, formulation or clear management plan, nor was there any periodic review of the service provided or further plans of action… There was also unclear documentation required for billing purposes Dr. Goldstein’s inadequate documentation and billing as set out in the reports of Dr. Boachie
and Dr. Pignatiello is unprofessional.
Relevant History
On August 27, 1999, the General Manager of the Ontario Health Insurance Plan (“OHIP”), based on the recommendation of the Medical Review Committee of the College (the “MRC”), directed Dr. Goldstein to reimburse OHIP for billing in the amount of $54,705.49.
Plea of No Contest
Dr. Goldstein does not contest the above facts. Dr. Goldstein does not contest that these facts constitute professional misconduct, in that:
a) he 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, under paragraph 1(1)33 of O. Reg. 856/93; and
b) he failed to maintain the standard of practice of the profession in his care of patients, under paragraph 1(1)2 of Ontario Regulation 856/93 made under the Medicine Act, 1991.
Agreed Statement of Facts Relevant to Penalty
In 2013, the Health Services Branch of the Ontario Ministry of Health and Long-Term Care (the“Ministry”) requested repayment by Dr. Goldstein of certain OHIP claims in the amount of $10,740, comprising those claims without any corresponding patient record for the encounter billed, and those claims where the records were created months after the patient encounter.
Dr. Goldstein repaid approximately $7,500, comprising only those claims without any corresponding patient record for the encounter billed.
Disposition
The Discipline Committee ordered that:
- Dr. Goldstein attend before the panel to be reprimanded.
- The Registrar suspend Dr. Goldstein’s certificate of registration for a period of three (3) months, commencing from June 27, 2019 at 12:01am.
- The Registrar place the following terms, conditions and limitations on Dr. Goldstein’s certificate of registration:
a. Dr. Goldstein shall comply with the College Policy #2-07 “Practice Management Considerations for Physicians Who Cease to Practise, Take an Extended Leave of Absence or Close Their Practice Due to Relocation”, a copy of which is attached at Schedule “A” to this Order;
PROBE Program
b. Dr. Goldstein shall participate in and unconditionally pass the PROBE Ethics & Boundaries Program offered by the Centre for Personalized Education for Professionals, with a report or reports to be provided by the provider to the
College regarding Dr. Goldstein’s progress and compliance. Dr. Goldstein shall complete this requirement within six (6 months) of the date of this Order.
Clinical Supervision
c. Within twenty (20) days of this Order, Dr. Goldstein shall retain a College- approved clinical supervisor or supervisors (the “Clinical Supervisor”) with respect to his psychiatry practice, who has signed an undertaking in the form attached hereto as Schedule “B”.
d. For a period of twelve (12) months commencing on the date that Dr. Goldstein resumes practice following the suspension of his certificate of registration, Dr. Goldstein may practise psychiatry only under the supervision of the Clinical Supervisor (“Clinical Supervision”), who shall facilitate the education program set out in the Individualized Education Plan (“IEP”), attached hereto as Schedule “C”; as follows:
e. For an initial period of two (2) months, Dr. Goldstein will meet with the Clinical Supervisor every week, at which meetings the Clinical Supervisor will:
i. review a minimum fifteen (15) of Dr. Goldstein’s patient records, to be selected at the sole discretion of the Clinical Supervisor, and the associated OHIP claims submissions or planned OHIP claims submissions, and discuss any issues or concerns arising from this review with Dr. Goldstein;
ii. make recommendations to Dr. Goldstein for practice improvements and ongoing professional development, and inquire into Dr. Goldstein’s compliance with the recommendations; and
iii. keep a log of all patient charts reviewed along with patient identifiers.
f. After the initial period of two (2) months, if the Clinical Supervisor is satisfied that Dr. Goldstein’s patient records and associated OHIP billings reflect the knowledge, skills and judgment necessary for Dr. Goldstein to practise in a less highly supervised environment, the Clinical Supervisor may recommend to the College that supervision be reduced for the balance of the Clinical Supervision period of twelve (12) months.
g. Upon the recommendation of the Clinical Supervisor and approval of the College of a reduction in supervision, Dr. Goldstein will meet with the Clinical Supervisor every month, at which meetings the Clinical Supervisor will:
i. review a minimum fifteen (15) of Dr. Goldstein’s patient records, to be selected at the sole discretion of the Clinical Supervisor, and the associated OHIP claims submissions or planned OHIP claims submissions, and discuss any issues or concerns arising from this review with Dr. Goldstein;
ii. make recommendations to Dr. Goldstein for practice improvements and ongoing professional development, and inquire into Dr. Goldstein’s compliance with the recommendations; and
iii. keep a log of all patient charts reviewed along with patient identifiers.
Other Elements of Clinical Supervision
h. Throughout the period of Clinical Supervision, Dr. Goldstein shall abide by all recommendations of his Clinical Supervisor regarding his recordkeeping and OHIP billing, practice improvements, and ongoing professional development.
i. The Clinical Supervisor shall submit written reports to the College at least once every month, or more frequently if the Clinical Supervisor has concerns about Dr. Goldstein’s standard of practice.
j. If a person who has given an undertaking in Schedule “A” to this Order is unable or unwilling to continue to fulfill its provisions, Dr. Goldstein shall, within twenty (20) days of receiving notice of the same, ensure that an executed undertaking is delivered to the College in the same form from a similarly qualified person who is acceptable to the College.
k. If Dr. Goldstein is unable to obtain a Clinical Supervisor as set out in this Order, he shall cease practising medicine until he has obtained a Clinical Supervisor acceptable to the College.
l. If Dr. Goldstein is required to cease to practise medicine as a result of section (5)(k) above, this will constitute a term, condition or limitation on his certificate of registration and that term, condition or limitation will be included on the public register.
Reassessment of Practice
m. Approximately six (6) months after the completion of Clinical Supervision, Dr. Goldstein shall undergo a reassessment of practice by a College-appointed assessor (the “Assessor”). The re-assessment shall include a review of Dr. Goldstein’s patient charts and associated OHIP claims submissions or planned OHIP claims submissions. The results of the re-assessment shall be reported to the College.
n. Dr. Goldstein shall consent to such sharing of information among the Assessor, the Clinical Supervisor, and the College, as any of them deem necessary or desirable in order to fulfill their respective obligations.
Monitoring
o. Dr. Goldstein shall inform the College of each and every location where he practises, 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 a t that location.
p. Dr. Goldstein shall cooperate with unannounced inspections of his practice, patient charts and OHIP claims submissions by a College representative(s) for the purpose of monitoring and enforcing his compliance with the terms of this Order.
q. Dr. Goldstein 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.
r. Dr. Goldstein shall be responsible for any and all costs associated with implementing the terms of this Order.
- Dr. Goldstein pay costs to the College in the amount of $6,000.00 within 30 days of the date of this Order.