On March 5, 2014, the Discipline Committee found that Dr. Muirhead committed an act of professional misconduct, in that he failed to maintain the standard of practice of the profession, and that he has engaged in conduct or 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. Muirhead admitted to the allegations.
Dr. Muirhead is a general practitioner, whose practice was limited to psychotherapy. He is no longer a member of the College, having allowed his certificate of registration to expire on August 15, 2013.
Dr. Muirhead engaged in numerous boundary violations including:
Financial transactions with patients.
Repeatedly hugged certain patients in therapy sessions;
Exchanged gifts with two patients;
Employed two patients to work in his office and perform his yard work, and also requested and permitted one patient to perform administrative tasks in his office;
Had contact with four patients outside of therapy, meeting two of these patients at restaurants and/or movies;
Visited two patients at their homes;
Told six patients that he loved them;
In emails, encouraged several patients to delete their communications with him and keep the nature of their relationship with him a secret.
In email exchanges with two patients, disclosed confidential information about another patient in relation to her complaint to the College and requested and permitted a patient to assist him in the preparation of his response to the complaint;
Offered to pay for car repairs for a patient; and
Offered to pay for concert tickets for a teenaged patient being seen by Dr. Muirhead for counseling in the context of her parents' marital difficulties.
Email messages that Dr. Muirhead exchanged with five patients obtained in the College's investigation appear to describe romantic and/or sexual relationships between Dr. Muirhead and these patients. The patients deny actual sexual contact.
Independent experts retained by the College opined that Dr. Muirhead failed to maintain the standard of practice in the following respects:
Recordkeeping with inadequate progress notes; some files failing to contain basic information such as address or birthdate; the patient's family history, history of psychiatric disorder and developmental history, diagnosis or treatment plan ; there were no complete Mental Status Examinations recorded;
In one case, the chart note was inaccurate and misleading with regard to suicidal intent;
Did not adequately explain or obtain informed consent and document this for his challenging form of therapy;
Frequently told his female patients that if they allow themselves to be close to him and feel strong feelings as well as physical sexual arousal, this would improve the result or outcome of their therapy. There is no evidence that this amount of closeness is either necessary or sufficient to have a good outcome;
Placed excessive pressure on patients for positive feelings, affection and sexual and physical sensations of arousal. Sometimes the pressure for closeness was demanded with the threat that without it, therapy would stop;
Saw many patients who know each other. He did ask them not to talk about therapy with one another but they did. This complicates the resistance and the competitiveness for love that patients feel, especially when he commented to patients that those who are very close to him do well and those who are not close to him do not do well;
In six cases, exchanged emails with patients which characterize an intimate, loving relationship rather than a therapeutic relationship, with inappropriate self-disclosure by him;
Engaged in inappropriate contact with some patients outside therapy.
Occasionally talked to his patients about other patients and had one patient type his response to a College complaint made by another patient;
Engaged in unacceptable boundary crossings and violations, including hugging patients, signing his emails "Love H", borrowing money from patients, visiting patients in his home or theirs, telling patient they are very special, and engaging in inappropriate self-disclosure to patients;
In his email exchanges, the interactions characterize a personal relationship more than a therapeutic one. He does not firmly indicate that this is not and never will be a personal relationship. This is a failure to maintain boundaries and a failure in knowledge of clinical practice guidelines for psychotherapy;
Asked patients to delete their emails with each other;
In respect of one complainant, he failed to maintain the standard of practice in his assessment in his medical records, in failing to establish an alliance, in his selection of the type of therapy and in his failure to obtain informed consent. In addition, he inappropriately offered to meet the patient outside the office, told the patient to delete emails from him and gave her his cell phone number.
In respect of three patients, he failed to maintain the standards of family or couple psychotherapy.
In the opinion of expert retained by Dr. Muirhead, Dr. Muirhead had knowledge and skill in this type of treatment, but there were deficits in recordkeeping including failures to document mental status examinations, and boundary violations including hugging patients, employing patients, lending money to patients and giving and receiving large gifts. The expert also noted that emails discussing emotions and love, sexual fantasies or closeness can be confusing to patients.
The Discipline Committee ordered and directed that:
Dr. Muirhead appear before the panel to be reprimanded;
The Registrar suspend Dr. Muirhead's Certificate of Registration for a period of eighteen (18) months, commencing immediately;
The Registrar impose the following terms, conditions and limitations on Dr. Muirhead's Certificate of Registration:
a) After the completion of the suspension referred to in paragraph 3 above, Dr. Muirhead shall complete a remedial program in psychotherapy under the guidance and supervision of a preceptor or preceptors acceptable to the College (the "Remedial Program"). The Remedial Program must be approved in advance by the College and shall consist of any remedial elements the College deems appropriate, including, without limitation, the following:
(i) A period of no less than three months, or such longer period as deemed appropriate by Dr. Muirhead's preceptor(s) and the College, of high supervision during which time Dr. Muirhead shall be restricted from being the Most Responsible Physician and during which he shall see patients only under the direct supervision of his preceptor(s);
(ii) A period of no less than three months following the completion of the high supervision period referenced above, or such longer period as deemed appropriate by Dr. Muirhead's preceptor(s) and the College, of moderate supervision, during which time Dr. Muirhead will meet with his preceptor(s) on a bi-weekly basis to review patient records and discuss any issues or concerns arising therefrom;
(iii) A period of no less than six months following the completion of the moderate supervision period referenced above, or such longer period as deemed appropriate by Dr. Muirhead's preceptors and the College, of low supervision, during which time Dr. Muirhead will meet with his preceptor(s) on a monthly basis to review patient records and discuss any issues or concerns arising therefrom;
(iv) Direct observation of Dr. Muirhead's patient care by the preceptor(s) as deemed appropriate by the preceptor(s) and the College;
(v) College-approved courses, which may include, without limitation, courses in psychotherapy and the maintenance of appropriate physician-patient boundaries; and
(vi) A comprehensive practice assessment (the "Assessment") following the completion of the above-referenced remediation, to be conducted by an assessor appointed by the College, and Dr. Muirhead shall abide by any recommendations of the College's assessor.
b) Dr. Muirhead may not have any professional contact with female patients, except in the presence of a female chaperone (the "Practice Monitor"). In particular:
(i) The Practice Monitor shall be a member of a registered health profession pursuant to the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as amended, who is approved by the College and who has executed an undertaking with the College in the form attached to this Order as Appendix "A";
(ii) The Practice Monitor shall make a note in the relevant patient chart documenting each patient interaction for which she is present, and there will be a second written record kept chronologically for each patient seen (the "Log"). The Log shall be kept by the Practice Monitor. Dr. Muirhead shall ensure that contemporaneously with any interaction with any female patient in his office, the Practice Monitor initials the Log;
(iii) If the Practice Monitor has concerns that Dr. Muirhead's practice exposes his patients to risk of harm or injury, the Practice Monitor must agree to report this to the College immediately;
(iv) Dr. Muirhead shall place a sign in the form attached to this Order as Appendix "B" in his waiting room and each of the examination rooms in his office stating that Dr. Muirhead shall not see female patients unless the Practice Monitor is present and observing all of the interaction with the female patient as it is occurring.
c) Dr. Muirhead shall use a College-approved Electronic Medical Records system for the purposes of keeping all clinical notes and records associated with his practice, and shall make audit reports from this system available to the College on request;
d) Dr. Muirhead shall provide a written notice (the "Notice") to each patient he sees in a form acceptable to the College advising them that Dr. Muirhead has agreed that:
(i) He shall not tell patients that he loves them, or imply that he loves or has loving feelings towards them, and he shall not solicit expressions of affection from patients;
(ii) He shall not hug patients, or engage in any other physical display of affection with patients;
(iii) He shall not disclose information to patients about his personal life, including, without limitation, information concerning his financial situation;
(iv) He shall refrain from accepting loans or gifts from patients, and he shall not make loans or gifts to patients;
(v) He shall not employ patients or accept assistance from patients with administrative tasks;
(vi) He shall not communicate with patients outside of therapy sessions in his office, including, without limitation, by means of telephone or e-mail, save and except for the sole purpose of scheduling appointments; and
(vii) He shall not meet with patients outside his office.
The Notice shall advise patients that the College may contact them to inquire whether they have experienced any inappropriate comments or behaviour during their treatment by Dr. Muirhead.Dr. Muirhead shall ensure that patients sign this written notice to acknowledge they have reviewed it, and Dr. Muirhead shall keep this signed document in each patient file; and
e) Dr. Muirhead shall bear any costs associated with the Remedial Program, the Assessment or any other terms of this Order.
Dr. Muirhead pay costs to the College in the amount of $4,460.00 within 150 days from the date of this Order.