Committee: Discipline
Decision Date: 10 Jan 2020
Summary:
On January 10, 2020, the Discipline Committee (the “Committee”) of the College of Physicians and Surgeons of found that Dr. Frederick Edward Aldrick McIntosh (“Dr. McIntosh”) committed an act of professional misconduct, and set out its penalty and costs order.
Dr. McIntosh is an 82-year-old otolaryngologist who received his certificate of registration authorizing independent practice from the College in 1969. He received his specialist certification in otolaryngology from the College in 1973.
At the relevant time, Dr. McIntosh practised at A+ Medical Clinic in Toronto, Ontario.
DIAGNOSTIC IMAGING REFERRALS
Failure to Maintain the Standard of Practice of the Profession
On January 22, 2016, the College received information from the Ministry of Health and Long-Term Care (the “Ministry”) advising that it had observed a pattern of referrals from Dr. McIntosh to an independent health facility where patients underwent multiple diagnostic studies on a single service date. Information from the Ministry indicated there was no medical necessity for the imaging tests.
Based on the information from the Ministry, the College commenced an investigation of Dr. McIntosh’s practice. In the investigation, the College obtained supporting documentation from the Ministry as well as patient records and requisition forms from A+ Medical Clinic.
The College retained Dr. Linda Klapwyk as a Medical Inspector to review Dr. McIntosh’s practice, in particular his ordering of diagnostic imaging, and to opine on whether Dr. McIntosh’s care met the standard of practice of the profession. Dr. Klapwyk is an experienced family physician and professor of family medicine at the University of Toronto. Dr. Klapwyk reviewed Dr. McIntosh’s OHIP billings and 19 of Dr. McIntosh’s patient charts and conducted an interview with Dr. McIntosh. Dr. Klapwyk provided a report to the College, dated July 23, 2018.
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Dr. Klapwyk concluded that Dr. McIntosh failed to maintain the standard of practice of the profession. Dr. Klapwyk opined that, in all 19 patient charts reviewed, almost all of the diagnostic imaging and cardiac tests ordered by Dr. McIntosh lacked documentation supporting an indication for doing the tests.
In his interview with Dr. Klapwyk, Dr. McIntosh blamed his office staff for adding tests onto his requisition forms without his knowledge by checking off additional tests on the requisition forms after Dr. McIntosh had signed them. Assuming this was the case, Dr. Klapwyk noted that there was no documented concern by Dr. McIntosh at follow-up
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visits with patients about the amount of testing that had been done without Dr.McIntosh’s authorization.
Dr. Klapwyk opined that if Dr. McIntosh ordered the diagnostic imaging tests, he displayed a lack of knowledge and judgment and did not maintain the standard of practice of the profession.
Dr. Klapwyk also opined that even if the tests were ordered by Dr. McIntosh’s office staff without his knowledge, Dr. McIntosh still failed to maintain the standard of practice of the profession as follows:
-Dr. McIntosh failed to protect his patients from harm due to unnecessary tests, worry, and radiation exposure;
-Dr. McIntosh demonstrated a lack of judgment in not documenting any concern about tests being done that he did not order; and
-Dr. McIntosh demonstrated a lack of judgment in failing to notify the appropriate authorities when he became aware of tests being ordered in his name.
In Dr. Klapwyk’s opinion, Dr. McIntosh exposed his patients to a risk of harm or injury.
Dr. Klapwyk’s opinion is that Dr. McIntosh failed to maintain the standard of practice of the profession in other aspects of his care, including:
-brief, illegible, and incomplete documentation;
-poor or lacking documentation of examination findings, documentation of pain histories, and standard tools for narcotic documentation, such as patient contracts, brief pain inventories, narcotic flow sheets, opioid risk tools, or urine drug screening;
-inadequate knowledge of guidelines for bone density screening or breast tests;
-lack of knowledge of allergy scratch testing techniques; and
-incorrectly documented billing codes and diagnostic codes at the bottom of each note, in that assessments were billed despite the absence of examination and brief histories in almost all encounters.
Disgraceful, Dishonourable or Unprofessional Conduct
Dr. McIntosh’s failure to ensure that his patients received only necessary diagnostic testing demonstrated a lack of judgment and professionalism. Dr. McIntosh ought to have been aware that diagnostic testing was being ordered without his authorization, documented his concerns once he became aware, and contacted the appropriate authorities about patients receiving testing that he did not order.
2 ORTHOTIC DEVICE PRESCRIBING
Failure to Maintain the Standard of Practice of the Profession
On January 18, 2017, the College received information from Health Canada’s Non-Insured Health Benefits (“NIHB”) program advising that it had concerns about Dr. McIntosh’s prescribing of soft orthoses over a two-day period in August 2016.
Specifically, the NIHB program advised that Dr. McIntosh had prescribed to 38 NIHB clients over the two-day period and that over half of the patients seen were prescribed more than 10 orthoses, while nine patients were prescribed 14 devices.
Based on the information received from the NIHB program, the College commenced an investigation into Dr. McIntosh’s orthotic device prescribing.
During a College interview, Dr. McIntosh advised the College that he had been recruited by two men, Mr. AA and Mr. BB, to prescribe orthotic devices to First Nations patients.
Mr. AA is a chiropractor and Mr. BB has a suspended certificate of registration with the College of Chiropractors of Ontario.
Dr. McIntosh went to Sudbury with Mr. AA and Mr. BB in August, October, and November 2016. They drove together to a community centre in a nearby First Nations community. Patients would see a family member of one of the men in a van, who would take impressions for devices, and then Dr. McIntosh would assess the patient in a different van. Dr. McIntosh documented the patient encounters on a typed form that was provided to him by Mr. AA and Mr. BB and retained by them. Dr. McIntosh tested the blood or urine sugar of some diabetic patients and advised them to go to the hospital if their sugar was high. Dr. McIntosh billed OHIP for assessing the patients. Mr. AA and Mr. BB paid for Dr. McIntosh’s hotel, food, and transportation to Sudbury. On two occasions, Mr. AA and Mr. BB also paid Dr. McIntosh a fee for his services.
The College retained Dr. Nancy Merrow as a Medical Inspector to opine on whether the care provided by Dr. McIntosh met the standard of practice of the profession. Dr. Merrow is an experienced family physician and Chief of Staff at Orillia Soldiers Memorial Hospital. Dr. Merrow reviewed patient records provided by Mr. AA and Mr. BB and conducted an interview with Dr. McIntosh. Dr. McIntosh told Dr. Merrow that Mr. AA and Mr. BB had altered his prescriptions for orthotic devices after the fact, by adding additional devices to the prescription, and that the medical records provided by Mr. AA and Mr. BB to the College were not created by Dr. McIntosh in their entirety. Dr. Merrow’s report to the College was received on August 30, 2018. Dr. Merrow’s
addendum report to the College was dated November 2, 2018 Dr. Merrow concluded that Dr. McIntosh failed to maintain the standard of practice of the profession in his prescribing of orthoses to patients. In particular, Dr. Merrow opined that Dr. McIntosh failed to maintain the standard of practice in that Dr. McIntosh: 3
-prescribed devices to patients that he knew required proper care and follow-up without a plan to follow-up and reassess patients;
-used a template created by someone else which was poorly designed and inadequate for proper record keeping; and
-failed to safeguard any adequate records to represent the care provided and the follow-up required.
Dr. Merrow opined that Dr. McIntosh displayed a lack of judgment in his failure to maintain records, misjudgment of the intentions of Mr. AA and Mr. BB, and testing patients for diabetes and prescribing orthoses with no plan for follow-up.
Dr. Merrow also provided an addendum report, dated November 2, 2018, in which she opined that Dr. McIntosh failed to maintain the standard of practice of the profession, displayed a lack of knowledge, skill, and judgment, and exposed patients to a risk of harm in all the patient charts that she reviewed, in that:
-the side of the body to which the assessment pertained was not specified in the charts;
-there was no indication that any advice or treatment plan other than a prescription for devices was considered, such as exercise, physiotherapy, or analgesics;
-there was incomplete or inadequate history of complaints and examinations; and
-there was no evidence that patients received an appropriate assessment or treatment of their musculoskeletal conditions.
Disgraceful, Dishonourable, or Unprofessional Conduct
In allowing himself to be used in the orthotics scheme devised by Mr. AA and Mr. BB, Dr. McIntosh displayed a lack of judgment and professionalism. Dr. McIntosh ought to have known that the scheme was fraudulent.
UNDERTAKING TO RESIGN AND NEVER REAPPLY
On December 18, 2019, Dr. McIntosh entered into an undertaking with the College of Physicians and Surgeons of Ontario (the “College”), whereby he agreed to resign his certificate of registration with the College and never apply or reapply for registration as a physician in Ontario or any other jurisdiction.
PENALTY
Counsel for the College and counsel for Dr. McIntosh made a joint submission as to an appropriate penalty and costs order.
DISPOSITION
On January 10, 2020, the Discipline Committee ordered that:
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- Dr. McIntosh attend before the panel to be reprimanded.
- Dr. McIntosh pay costs to the College in the amount of $6,000.00 within 30 days of the date of this Order.
At the conclusion of the hearing, Dr. McIntosh (via counsel) waived his right to an appeal under subsection 70(1) of the Code. The Committee administered the public reprimand in the absence of Dr. McIntosh, who did not attend the hearing.