News Release

2014 - 09 - 26 Discipline Committee Decisions

Dr. Alexander Milton Haines; Dr. Robert Louis Reid; Dr. Samir Barsoum Aziz

Sep 26, 2014

The College of Physicians and Surgeons of Ontario (“the College”) released the results of its most recent disciplinary hearings. The College is the licensing and disciplinary body for physicians in Ontario. Hearings are held to review allegations of professional misconduct and incompetence, and are open to the public. The following are brief summaries of recent discipline hearing results. The Discipline Committee’s full decisions and reasons for decisions are posted on the College’s website as they become available. Full decisions are located by entering the doctor’s name in the Doctor Search section of the College’s website at www.cpso.on.ca.

Dr. Alexander Milton Haines, Barrie.  On July 25, 2014, the Discipline Committee found that Dr. Haines committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession in his care and treatment of 16 patients. Dr. Haines admitted to the allegation.

The College began an investigation into Dr. Haines's practice following the receipt of information from the Office of the Chief Coroner for Ontario regarding the death of one of his patients. The cause of the patient's death was determined to be Oxycodone toxicity.

As part of its investigation, the College retained a medical inspector, Dr. X. Dr. X reviewed the charts of 25 of Dr. Haines's patients. The patients whose charts were reviewed had all been treated with pain control medications for chronic pain due to various causes and clinical backgrounds.

Dr. X noted that Dr. Haines's charts were generally clear to read, organized and reflected genuine concern by Dr. Haines for his patients. Nonetheless, Dr. X opined that certain concerning issues recurred a number of times in Dr. Haines's practice. The areas of concern identified by Dr. X were as follows:

  • There were ongoing prescriptions for opiates and benzodiazepines in patients with substance abuse problems as proven by urine drug testing; or with written concerns by other doctors who saw these patients and advised that prescribing such medications was likely causing problems for the patients.  The office records did not address such concerns.
  • Combining high dose opiates and benzodiazepines. This combination is known to be a factor in opiate related deaths.
  • Prescribing multiple opiates and multiple benzodiazepines simultaneously. This increases the risk of adverse effects without potential benefit.
  • Two patients were given ongoing prescriptions for opiates without any office assessment for over a year.
  • Many patients had blood cholesterol testing, however Dr. X did not find any chart using the cholesterol results to calculate the patient's heart risk - the "Framingham risk score".  Such a risk calculation is needed to establish the need for medication and treatment goals.  Similarly, two patients with heart disease had cholesterol (LDL) levels above target.
  • There was a lack of screening for colon cancer.  Many patients came in for an Annual Health Exam and some had colonoscopy exams.  Dr. X did not find any home kit Fecal Occult Blood Testing results.  The standard of care in Ontario now is to utilize this test widely in patients over 50.

With respect to the specific patient who was the subject of the coroner's report, Dr. X opined that Dr. Haines did not meet standard of care, demonstrated a lack of skill and knowledge, and that it is probably a danger to safety in combining benzodiazepines with moderately high opiate dosing in a patient who could unpredictably take other illicit drugs and who has shown significant impulsivity in overdosing.

Overall, Dr. X concluded that the care provided in 16 of the 25 charts reviewed did not meet the standard of practice of the profession and demonstrated a lack of knowledge, skill or judgment.  Dr. X also concluded that Dr. Haines's care in 10 of the charts exposed patients to potential harm or injury, ranging from mild or minimal danger to serious safety concerns.

Dr. Haines entered into an undertaking in response to the College's concerns to protect the public. Further to the undertaking, Dr. Haines was required, among other things, to practice under the guidance of a clinical supervisor acceptable to the College. Dr. Haines’ supervisor consistently indicated in his monthly reports to the College that he has identified no material deficiencies with respect to Dr. Haines' standard of practice.

After learning of the College's investigation, Dr. Haines took steps at his own initiative to update his medical knowledge and his prescribing practices in respect of narcotics. In addition, throughout 2013, Dr. Haines completed several continuing medical education programs, targeted at addressing deficiencies identified by Dr. X specifically, as well as reviewing family medicine issues generally.

Following an interview, Dr. X made a number of observations about Dr. Haines's generally heightened knowledge and skill, and also highlighted the various improvements in Dr. Haines's practice.

The Discipline Committee ordered a public reprimand and directed that terms, conditions and limitations be imposed on Dr. Haines's certificate of registration, including that:

  1. Dr. Haines, at his own expense, is to submit to an assessment of his practice by an assessor selected by the College. The assessment shall pertain to Dr. Haines's practice overall, with a specific focus upon the areas of concern outlined in the reports of Dr. X, including safe prescribing and overall preventative care.
  2. Dr. Haines shall abide by reasonable recommendations made by the assessor, and any recommendations that are limitations or restrictions on practice shall constitute terms, conditions or limitations on Dr. Haines's certificate of registration and be included on the public register.

Dr. Haines was further ordered to pay the College costs in the amount of $4,460.

Dr. Robert Louis Reid, Woodstock.  On September 8, 2014, the Discipline Committee found that Dr. Reid committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession with respect to Patient A, and he has engaged in disgraceful, dishonourable or unprofessional conduct. The Discipline Committee also found that Dr. Reid is incompetent. Dr. Reid admitted to the allegations.

Patient A first saw Dr. Reid in November 2011. Patient A had been prescribed opioids since 2009 through at least May 2011, initiated by another physician. There is no documented history of early dispensing of opioid medication for Patient A prior to the commencement of treatment by Dr. Reid.

In June 2013, a pharmacist contacted the College to voice concerns regarding Dr. Reid's prescribing practices in respect of Patient A. Records indicate that pharmacists had expressed concerns to Dr. Reid on more than one occasion that Patient A was filling prescriptions for opioids at multiple pharmacies and that early dispensing was often authorized by Dr. Reid.

There were approximately two dozen episodes of Patient A obtaining early releases or replacement prescriptions for what were described as "stolen" or "lost" opioid medications or opioid patches that were said to have fallen off between February 2012 and the end of July 2013. Dr. Reid recognized and was aware of Patient A's aberrant drug-related behaviours by at least the summer of 2012. Dr. Reid asserted that he took steps in response, but he failed to document having done so.

Dr. Reid failed to:

  1. seek to arrange with a local pharmacy to prescribe opioids to Patient A on the condition that they be dispensed to him in daily or weekly allotments, to reduce the risk of large amounts of medication being lost should events such as theft occur;
  2. require Patient A to undergo regular urine drug screens and pill counts to ensure that he was not overusing or selling the medications;
  3. require Patient A to enter into an opioid agreement that explicitly stated that no early releases or replacement of medications for lost or stolen medications or patches that had fallen off prematurely would be permitted;
  4. document measures to mitigate the possible diversion, misuse and/or abuse of opioids by Patient A through education, strict monitoring, and changes in prescribing patterns;
  5. document any re-evaluation to assess whether opioids were the most appropriate choice for Patient A under the circumstances;
  6. document any consideration of opioid rotation;
  7. document any exploration of psychological methods of pain control; or
  8. document any discussion with Patient A regarding initiation and titration of other non-opioid analgesics.

Dr. Reid lacked judgment when, despite recognizing Patient A's drug-aberrant behaviour, he repeatedly permitted numerous early repeats and provided replacement scripts, contrary to common practices of chronic pain practitioners for dealing with drug-aberrant behaviour in their patient populations. This exposed the patient to risk of harm.

After reporting to the College that he had discharged Patient A from his practice, Dr. Reid wrote a further prescription for Patient A during the evening of the day on which allegations had been referred to the Discipline Committee of the College regarding his conduct towards and care of Patient A.

This further prescription authorized early release of medications for what was said to be a trip. When a pharmacist contacted Dr. Reid with concerns about the prescription, Dr. Reid validated the prescription.

Dr. Reid also violated appropriate professional boundaries with Patient A:

  1. On approximately five occasions in 2013, Dr. Reid accompanied Patient A to the pharmacy to assist him in obtaining medication.
  2. On one occasion when accompanying Patient A to the pharmacy, Dr. Reid withdrew money from an automated teller machine to pay for the medication, and paid for the medication for Patient A;
  3. On one occasion in September 2012 when Patient A stated that he was homeless, Dr. Reid drove Patient A to London and took him to a place to stay;
  4. On one occasion in May 2012, Dr. Reid attended a meeting of a religious men's club held during the evening with Patient A and then drove him home.

On January 7, 2014, the Inquiries, Complaints and Reports Committee made an interim order against Dr. Reid pending disposition of the allegations against him. The interim order, among other things, prohibited Dr. Reid from issuing new prescriptions or renewing existing prescriptions for narcotic drugs, narcotic preparations, controlled drugs, and benzodiazepines/other targeted substances, or all other monitored drugs. It came into effect at 12:01 a.m. on January 9, 2014. Dr. Reid violated the interim order by way of two prescriptions dated January 9, 2014 which were faxed to pharmacies on the morning of January 9, 2014.

The Committee ordered a public reprimand and directed the Registrar to suspend Dr. Reid's certificate of registration for three months. In addition, a number of terms, conditions and limitations are imposed on Dr. Reid's certificate of registration, summarized as follows:

  1. Dr. Reid shall participate in and successfully complete the Safe Opioid Prescribing program offered by the University of Toronto, or an equivalent program acceptable to the College.
  2. Dr. Reid shall participate in and successfully complete the Understanding Boundaries in Managing the Risks Inherent in the Doctor-Patient Relationship course offered by Western University, or an equivalent program acceptable to the College.
  3. Until Dr. Reid has obtained a clinical supervisor who has been approved by the College, he shall not issue new prescriptions or renew existing prescriptions for  Narcotic Drugs, Narcotic Preparations, Benzodiazepines, Other Targeted Substances, Controlled Drugs and All Other Monitored Drugs (“Narcotics or Restricted Substances”), and shall post a sign to that effect in his waiting room.
  4. After Dr. Reid obtains a clinical supervisor, he shall only issue new prescriptions or renew existing prescriptions for any of the following substances, hereinafter referred to as “Narcotics or Restricted Substances”, in accordance with the Remediation Program described below, until it has been completed.
    1. Throughout the Remediation Program, Dr. Reid shall maintain an up-to-date log of all prescriptions issued or renewed for Narcotics or Restricted Substances, in a form approved by the College.
    2. In Phase One of the Remediation Program, Dr. Reid shall prescribe Narcotics or Restricted Substances to no more than 20 patients, who must be approved by the clinical supervisor. Dr. Reid shall submit an initial treatment plan for each patient to the clinical supervisor for review and approval prior to prescribing Narcotics or Restricted Substances to the patient. Thereafter, the clinical supervisor(s) will meet with Dr. Reid every two weeks to review these patients' charts including documentation of the prescriptions and the Narcotics Log and they will discuss the care of these patients and any concerns that the clinical supervisor(s) may have.
    3. If reports from the clinical supervisor indicate that it is appropriate to do so and if approved by the College, after at least three months of Phase One, Dr. Reid may commence Phase Two of the Remediation Program, during which he shall prescribe Narcotics or Restricted Substances to no more than 40 patients, whose charts shall be reviewed at least once a month by his clinical supervisor(s) together with the Narcotics Log. During Phase Two, Dr. Reid shall meet with his clinical supervisor once a month to discuss the care of these patients and any concerns that the clinical supervisor may have.
    4. If reports from the clinical supervisor indicate that it is appropriate to do so and if approved by the College, after at least three months of Phase Two, Dr. Reid may commence Phase Three, which shall include a monthly review by the clinical supervisor of at least 20 charts of patients to whom Dr. Reid prescribes Narcotics or Restricted Substances, to be randomly selected by the clinical supervisor, and monthly review of the Narcotics Log.
    5. If reports from the Clinical Supervisor indicate that it is appropriate to do so and if approved by the College, after at least six months of Phase Three, Dr. Reid may complete the Remediation Program, but shall continue to maintain a Narcotics Log pending completion of the assessment described below.
    6. Throughout the Remediation Program, Dr. Reid shall cooperate with the clinical supervisor and shall abide by his or her recommendations, including with respect to patient care, practice management, and continuing education.
  5. Dr. Reid shall undergo an assessment by a College-appointed assessor approximately 12 months after the conclusion of the Remediation Program, focusing on patients to whom Dr. Reid prescribes Narcotics or Restricted Substances. The assessment may include a review of charts, interview(s), and observation. The assessor shall report the assessment results to the College, and Dr. Reid shall abide by the recommendations of the assessor.
  6. Dr. Reid shall consent to the sharing of information among the College and the clinical supervisor and assessor as they deem it necessary and desirable.
  7. Dr. Reid shall not post-date prescriptions for Narcotics or Restricted Substances.
  8. Dr. Reid shall cooperate with unannounced inspections of his practice and patient charts by the College for the purpose of monitoring and enforcing his compliance with the terms of this Order and shall consent to the College making appropriate enquiries of the Ontario Health Insurance Plan, Narcotics Monitoring System and/or Ontario Drug Benefit Program, and/or any person or institution who may have relevant information for this purpose.
  9. Dr. Reid shall be responsible for any and all costs associated with implementing the terms of this Order. 

Dr. Reid was further ordered to pay the College costs in the amount of $4,460.

Dr. Samir Barsoum Aziz, Burlington.  On September 17, 2014, the Discipline Committee found that Dr. Aziz committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession, and he has engaged in disgraceful, dishonourable or unprofessional conduct. Dr. Aziz admitted to the allegations.

The Committee found that Dr. Aziz failed to maintain the standard of practice for an emergency physician regarding Patients A and B.

Patient A presented to the emergency department in September 2010, complaining of retrosternal chest pain that radiated to the back and the left arm, lasting one hour and twenty minutes. The patient's EKG, vital signs and troponin were normal. Dr. Aziz discharged the patient home with a final diagnosis of chest pain/anxiety and prior to discharge, arranged for an outpatient stress test.

Dr. X, the independent expert retained by the College, opined that Dr. Aziz failed to maintain the standard of care in failing to repeat in six hours the troponin and EKG, displayed a lack of knowledge of the appropriate way to assess patients with chest pain who may have an acute coronary syndrome and displayed a lack of clinical judgment by discharging the patient prematurely without a second set of cardiac enzymes and with a premature diagnosis of anxiety. Dr. X indicated that Dr. Aziz's assessment of this particular patient may reflect a clinical practice which is so deficient in clinical judgment that other patients who present with chest pain will also be improperly assessed and treated. Dr. Y, the expert retained by Dr. Aziz, agreed that Dr. Aziz failed to maintain the standard of practice of the profession by failing to repeat the EKG and troponin prior to discharge.

Patient B presented to the emergency department in November 2009, complaining of blurred vision. There was a history of some blurred vision to the right eye with the onset approximately two hours prior to coming to the emergency department that started while the patient was at rest. At Triage, there were no neurological deficits noted. It was noted that the patient was diabetic and had a history of hypertension.

Dr. X determined that Dr. Aziz's handwriting was for the most part illegible and very difficult to decipher. There was no documented visual acuity or complete physical examination. Dr. X opined that Dr. Aziz failed to maintain the standard of practice of the profession. Dr. Y disagreed with Dr. X's opinion that Dr. Aziz's care fell below the standard of practice of the profession. Dr. Aziz admitted that his documentation was deficient in respect of Patient B and that he failed to maintain the standard of practice of the profession with respect to his record keeping.

In respect of the finding of disgraceful, dishonourable and unprofessional conduct:

Dr. Aziz failed to cooperate in the College's s. 75 (1)(a) investigation in that he failed to complete and return a Physician Questionnaire to provide detailed information regarding his practice to facilitate the investigation and failed to transcribe his entries in 30 patient records, despite repeated requests and notice that his failure to respond was obstructing the investigation.  After the allegations of professional misconduct had been referred to the Discipline Committee, Dr. Aziz provided the transcriptions of the charts and the completed Physician Questionnaire. The section 75(1)(a) investigation was completed and Dr. Aziz entered into an undertaking with the College dated November 21, 2013.

Dr. Aziz breached an undertaking dated September 12, 2012 made in lieu of an Order under s. 37 of the Code. Dr. Aziz undertook to practice under the guidance of a clinical supervisor who was to meet weekly with Dr. Aziz to review a minimum of 10 patient charts at each meeting and discuss any issues arising therefrom.

Between September 2012 and October 2013, Dr. Aziz breached his undertaking with the College in that he failed to meet his supervisor weekly on 24 occasions. On 15 of the 24 occasions, Dr. Aziz and his supervisor reviewed approximately twice the amount of charts required under the undertaking in an attempt to account for the missed weeks of supervision. Dr. Aziz made no attempt to seek prior approval of the College to proceed in this manner.

The Committee ordered a public reprimand and directed the Registrar to suspend Dr. Aziz's certificate of registration for three months, to commence on October 1, 2014. In addition, the terms of Dr. Aziz's undertaking that he made with the College on November 21, 2013 will be imposed as terms, conditions and limitations on his certificate of registration. All steps taken by Dr. Aziz between November 21, 2013 and September 17, 2014 in satisfaction of the undertaking will be deemed to have been made in satisfaction of this Order. The period of clinical supervision will be suspended during the period of his suspension.

Dr. Aziz was further order to pay costs to the College in the amount of $4,460.