Committee: Discipline
Decision Date: 12 Oct 2018
Summary:
On October 12, 2018, the Discipline Committee found that Dr. Allan Selig Gordon committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession, and in 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. Gordon is a physician who received his certificate of registration authorizing independent practice from the College of Physicians and Surgeons of Ontario in 1969. He holds Royal College of Physicians and Surgeons of Canada certification in neurology and practised at the Pain Management Centre at a Hospital in Toronto, until January 2018. Dr. Gordon has expertise in the evaluation and treatment of widespread pain, neuropathic pain, and pelvic and genital pain.
Patient A
Patient A suffers from a complex and painful nerve condition in her feet and fibromyalgia. She was referred to Dr. Gordon by her family physician for investigation of her nerve pain. When she presented at Dr. Gordon’s office for an appointment her main concern was the pain in her feet. She was in her mid-thirties.
Prior to conducting a physical examination, Dr. Gordon reviewed Patient A’s chart and inquired into her medical history. He noted, among other things, widespread pain, foot pain, and pain with intercourse. She also complained of cold allodynia. Dr. Gordon indicated that he wanted to do an examination and took Patient A to the examination room across from his office. He left her alone to gown. Dr. Gordon did not offer or provide Patient A with a chaperone for the examination. When Dr. Gordon returned to the examination room, he began by testing Patient A’s reflexes and did a strength assessment. He proceeded to conduct an examination with a cotton swab. Dr. Gordon ran the swab along Patient A’s arms, legs and feet. Without asking and without an adequate explanation to Patient A, he slightly exposed Patient A’s breast and touched it with the swab. He also tested various areas with a cold tuning fork (looking for cold allodynia) and a pointed object. Dr. Gordon asked Patient A to stand and face the wall, and stood behind her. He examined various muscles for strength, tenderness and pain. Without asking and without an adequate explanation to Patient A, he pulled up the back of Patient A’s hospital gown to expose her buttocks. He began touching various spots on her buttocks with the cotton swab, to test for tenderness. Patient A felt uncomfortable and “creeped out.” Dr. Gordon asked Patient A to lie down on the bed to check for vulvar pain. He wondered if she had provoked vestibulodynia as a cause for her intercourse pain. Patient A felt uncomfortable. She has a history of sexual abuse. She attempted to avoid the exam by telling Dr. Gordon she had her period, but Dr. Gordon said he was fine to proceed if she agreed. She complied. She removed her underwear and lay down on the examination table. Dr. Gordon did not explain to Patient A why he wanted to examine her vagina or what he was about to do. Without an explanation adequate for Patient A, Dr. Gordon used a cotton swab to lightly touch various parts of Patient A’s labia, including her internal labia and around where her tampon was. Patient A indicated that this did not hurt. The experience left Patient A feeling caught off guard and very upset. After the physical examination concluded, Dr. Gordon left Patient A to dress and returned to his office. Patient A dressed and joined him in his office.
Dr. Gordon felt that a small fibre sensory neuropathy could account for the foot pain. He asked if Patient A had ever experienced any emotional or physical trauma. Patient A did not understand how this was relevant to the assessment. She explained that she had been sexually abused as a child, but that she didn’t remember the details. Dr. Gordon commented it was probably better she did not. Patient A reiterated that her main concern was the pain in her feet. He offered a variety of other evaluations, tests and treatments to her including psychological therapy, rhythmic sensory stimulation therapy, and a promise to explore virtual reality therapy. He wrote her doctor and copied Dr. Vera Bril for information on the small fibre testing. Patient A left the appointment with Dr. Gordon feeling extremely upset but made no mention of this to Dr. Gordon.
The next month, Patient A complained to the College regarding her experience with Dr. Gordon. An expert retained by the College to review the care provided to Patient A opined, in part, that:
- based on the information provided the patient was appropriately examined;
- the use of a cotton applicator to systematically search for mechanical allodynia is a routine part of the pain physical examination. It is routinely taught to Residents and other pain trainees;
- the use of a cotton applicator has particular importance in a patient with chronic pelvic pain, whether the patient has an isolated regional pain, or whether there is also a concurrent generalized pain disorder as was the case with Patient A;
- the use of a cotton applicator has been validated as a bedside provocative maneuver in chronic pelvic pain, to look for the presence of pain sensitization. It is relevant in assessment of patients who likely have neuropathic pain and also can be present in pelvic pains which have other mechanisms;
- whether for assessing pelvic pain or for assessing pain elsewhere such as in the feet, patients do not always understand why they would be examined in this peculiar manner with a cotton applicator, even in this instance where the patient presented with, using her own description, “allodynia”;
- on examination it is common that the physician finds either greater or less mechanical allodynia than what might be anticipated based on the history, and often in a pattern of distribution different than what is expected. Thus, a systematic approach to the use of a cotton applicator during the physical examination of a chronic pain patient is standard practice in pain medicine.
However, the expert noted that a competent pain physician will directly ask the pain patient for consent to examine them and should be attuned to ongoing consent, for example:
- to alert the patient that an upcoming part of the exam might be uncomfortable;
- to ask for feedback about any discomfort that arises in the course of the exam;
- to ask again, “can I examine you here to look for tenderness?”
- The expert further opined that:
It is unclear whether there was any breast exam performed. While the patient reported that Dr. Gordon “slightly exposed my breast, but not the nipple”, Dr. Gordon’s report indicates the patient described bilateral axillary pain. Exposing an area where there was a report of tenderness is standard practice in examining a pain patient, but there appears to have been miscommunication about what Dr. Gordon was going to do during the examination;
- It is standard practice to directly inspect the back and buttocks, including the skin, when there is chronic pain in those regions. Scars from some forgotten major surgery, birth defects, muscleatrophy, evidence of spondylolisthesis or scosoliosis, and many other serious contributing factors can often be discerned only by direct observation. It is clear from the consultation that Dr. Gordon was assessing for the presence of tender points. Examination of the buttocks by pressing specific areas where tender points are found is standard practice in the assessment of a pain patient who might have fibromyalgia.
The expert concluded that the care Dr. Gordon provided to the patient met the standard of practice of the profession, but that there was clearly miscommunication in that the patient did not understand why the physical examination of the axilla, buttocks and perineum was conducted.
An expert retained by Dr. Gordon to review the care he provided to Patient A, agreed with the College expert that the tests done were clinically indicated.
Dr. Gordon does not contest that he similarly did not provide adequate explanations to some other patients before proceeding with sensitive examinations and inquiries.
Interim Suspension Order and Undertaking to Resign On January 26, 2018, the Inquiries, Complaints, and Reports Committee (“ICRC”) made an interim directing the Registrar to suspend Dr. Gordon’s certificate of registration. Dr. Gordon has not practiced since that Order took effect. Dr. Gordon has undertaken to resign his certificate of registration effective immediately and not to apply or re-apply for registration as a physician to practise medicine in Ontario or any other jurisdiction.
Disposition
On October 12, 2018, the Discipline Committee ordered and directed that:
- Dr. Gordon attend before the panel to be reprimanded.
- Dr. Gordon pay costs to the College in the amount of $6,000 within thirty (30) days from the date of this Order.
Decision: Download Full Decision (PDF)
Hearing Date(s): Motion: May 31, and September 14, 2018;
Hearing: October 12, 2018 half day start time 9:00 a.m.