Committee: Discipline
Decision Date: 05 Dec 2018
Summary:
On December 5, 2018, Dr. Jackiewicz entered a plea of no contest and the Discipline Committee found that he committed an act of professional misconduct in that he has failed to maintain the standard of practice of the profession and that he is incompetent.
PART I – UNCONTESTED FACTS
1. Dr. Jackiewicz is 63 years old. He received his certificate of registration for independent practice in obstetrics and gynaecology from the College of Physicians and Surgeons of Ontario (“College”) in 1988. At the relevant times, he practised in Niagara Falls, Ontario, and held privileges at the Niagara Health System (“NHS”).
Registrar’s Investigation Arising from Information Received from the NHS
2. In November 2013, the College received information regarding Dr. Jackiewicz from Dr. Joanna Hope, Interim Chief of Staff of NHS. Dr. Hope advised that Dr. Jackiewicz had voluntarily ceased booking surgeries, following a hospital report with respect to his surgical practice. At the time of the report, Dr. Jackiewicz had full gynaecological surgery privileges, and was practising under a restricted certificate of registration with respect to his obstetrics practice. In accordance with an Order of the Discipline Committee of the College from 2010, Dr. Jackiewicz was prohibited from managing labour and delivery for all pregnancies with some exceptions: he was permitted to perform elective or on-demand caesarean-section deliveries and he was permitted to act as a surgical assistant to other hospital-based caesarean sections when a College-approved obstetrician is performing the caesarean-section as the most responsible physician and is in attendance for the duration of the procedure.
3. In her letter, Dr. Hope confirmed that Dr. Jackiewicz’s hospital privileges had not changed and that he was performing only surgical assists and pursuing his office-based practice in accordance with the 2010 Discipline Committee Order.
4. On the basis of this information, and the materials provided by NHS, the Inquiries, Complaints and Reports Committee (“ICRC”) approved the appointment of investigators under section 75(1)(a) of the Health Professions Procedural Code (“Code”) in order to conduct a broader investigation into Dr. Jackiewicz’s surgical practice.
5. On January 8, 2014, a College Investigator requested information from the NHS regarding Dr. Jackiewicz including: personnel and medical staff office files; minutes of meetings, correspondence, medical or hospital staff complaints or incident reports; internal or external reviews of his practice; patient complaints; and any patient hospital statistics pertaining to Dr. Jackiewicz.
6. The College subsequently received the information requested from NHS. This included the reports of two external experts who had been retained by NHS to review patient charts and to opine on the standard of practice with respect to gynaecologic surgeries performed by Dr. Jackiewicz. The experts retained by NHS were Dr. Mathias Gysler and Dr. Arthur Zaltz.
7. Dr. Gysler’s report was based on his review of 70 patient charts from NHS. In his report, dated August 30, 2013, Dr. Gysler opined in part as follows:
"Review of the information provided raises great concern regarding Dr. Jackiewicz’s practice. The recorded increase in complications is unacceptable in my opinion. Review of the material raises serious questions about the quality of care provided by Dr. Jackiewicz and his competency with preoperative assessments, accuracy in diagnosis and intraoperative care. Post-operative care is virtually absent. On initial review one could ask if this is only an issue of documentation, but in reviewing both the abstracted data and 70 records in great detail, I conclude that Dr. Jackiewicz does not recognize the hospitals’ standard of practice or just does not know about his responsibilities as a surgeon or physician. The stark contrast in care and documentation provided by his colleagues would indicate that he ought to know better and that the organization and medical staff at [NHS] are practicing at the standard expected in Ontario. This review would indicate that continuation of this practice presents a major risk to patients and the organization."
8. Similarly, Dr. Zaltz had been retained by NHS to review Dr. Jackiewicz’s standard of care with respect to gynaecologic surgery. In his report, dated November 4, 2013, Dr. Zaltz indicated that he reviewed 71 charts, wherein 18 had complications (a rate of 25%) – 11 of which were potentially avoidable and at least 6 were life threatening. Dr. Zaltz opined, in part, as follows:
"Based on my review of these charts, I believe that Dr. Jackiewicz has the pre-requisite surgical skills to handle the cases he has undertaken. In many cases, the patients had uncomplicated procedures and were discharged in one day. However, there were 7 cases that needed to go back to the operating room for the management of bleeding complications. Given that Dr. Jackiewicz has very rapid OR times, it is my opinion that the speed of his surgery appears to have led to a failure to insure that all bleeding was appropriately dealt with prior to the conclusion of the case. A careful and attentive surgeon will spend time checking and rechecking for bleeding at the end of the case. This necessarily adds time to every operation. Under one hour times for an LAVH would not allow for this.
I have listed eight cases where the indication for surgery and/or the procedures chosen were questionable.… I am left with the impression that Dr. Jackiewicz favors a surgical approach for menstrual problems as a primary choice, as opposed to a rigorous trial of non- surgical alternatives. This is supported by the lack of pathology in many of the uteri removed and questionable management of other cases. Many patients having hysterectomies were very young.
In some of the more complicated cases, where there were extensive pelvic adhesions, having a bowel or bladder injury is not uncommon and he did seek the appropriate consultation. There was one unrecognized cystotomy, found at the work-up of a vascular complication that required only catheter management. The other unrecognized bowel injury is the index case. In this case, there was extensive adhesiolysis around the bowel which likely led to the complication. It was not recognized intraoperatively and the patient presented a week later in septic shock."
9. On December 31, 2013, Dr. Jackiewicz provided comments to Dr. Gysler and Dr. Zaltzin response to their respective reports.
10. On January 17, 2014, Dr. Hope wrote to the College to advise that Dr. Jackiewicz’s gynaecological privileges had been suspended, effective immediately, pending a special meeting of the NHS’s Medical Advisory Committee (“MAC”).
11. On or about January 18, 2014, Dr. Jackiewicz delivered the expert report of Dr. William Mundle to the MAC. Dr. Mundle had reviewed the surgical history of Dr. Jackiewicz, along with the reports of Dr. Gysler and Dr. Zaltz, Dr. Jackiewicz’s responses to each of those reports, as well as a collection of charts. Dr. Mundle’s opinion was supportive of Dr. Jackiewicz’s surgical practice.
12. A special meeting of the MAC was held on January 30, 2014 to consider the status of Dr. Jackiewicz’s gynaecological surgical practice. After hearing submissions by Dr. Jackiewicz, the MAC upheld the suspension of Dr. Jackiewicz’s gynaecological privileges and formulated a set of recommendations that had to be completed prior to any reinstatement of his privileges. The recommendations included, among other things, a restriction on Dr. Jackiewicz’s surgical procedures to one particular NHS site, the requirement for a second surgical opinion prior to scheduling major procedures and a mentorship arrangement with Dr. Joshua Polsky, who would act as a surgical assistant for all major procedures and would conduct pre- and post-surgical mentoring sessions with Dr. Jackiewicz.
13. Following the release of the MAC’s recommendations, Dr. Jackiewicz requested a hearing before the Board of Directors of NHS (“Board”). The six-day hearing took place in May 2014. During the hearing, Dr. Jackiewicz presented evidence to the Board including the report by Dr. William Mundle. On June 9, 2014, the Board issued its decision to accept the recommendations of the MAC and to uphold the restrictions on Dr. Jackiewicz’s hospital privileges.
14. In January 2015, Dr. Jackiewicz notified the College that he would not be renewing his surgical privileges. In response, the ICRC directed Dr. Jackiewicz to enter into an undertaking reflecting the restriction of his practice to office-based obstetrical/gynaecological practice. In May 2015, the College was further advised that Dr. Jackiewicz would not sign the undertaking, and would be applying to the College for a change in his scope of practice in respect of hyperbaric medicine.
15. At the College’s request, Dr. Tom Stewart, Chief of Staff at NHS, provided an update in June 2015 with respect to Dr. Jackiewicz. Dr. Stewart advised that, as directed by the MAC and adopted by the Board, Dr. Joshua Polsky had acted as Dr. Jackiewicz’s Mentor for the purpose of supervising a specified number and type of gynaecological surgical procedures. Dr. Polsky had submitted reports to NHS in July, October and December 2014 corresponding to three separate occasions in which he supervised Dr. Jackiewicz in the operating room.
16. In his third report, dated December 20, 2014, Dr. Polsky opined as follows: “In summary, Dr. Jackiewicz lacks the requisite skill to perform simple laparoscopic procedures, let alone more complicated cases. His techniques are out-dated and dangerous. He has done nothing to improve his skills. By his own admission, he has not attended a CME on laparoscopic surgery in years. His over confidence in his abilities leads to inappropriate case selection and unsafe intraoperative techniques.
In my opinion the three sessions are a representative sample of operative cases that allow me to make my assessment. In accordance with the MAC directive, I have evaluated Dr. Jackiewicz’s selection criteria for surgical cases and his operative technique and I find them both deficient. It is for these reasons that I must resign the mentorship of Dr. Jackiewicz.”
17. Dr. Stewart further advised in his June 26, 2015 letter that Dr. Jackiewicz had given an undertaking not to exercise his NHS privileges at that time.
18. In October 2015, Dr. Stewart advised the College that the MAC had considered an application for reappointment by Dr. Jackiewicz at a special meeting held on August 18, 2015. The MAC recommended that the Board deny his application for re-appointment on the basis that Dr. Jackiewicz did not meet the criteria for re-appointment; specifically, a demonstrated ability to provide patient care at an appropriate level of quality and efficiency.
19. With the intention of relying on the independent reports prepared for NHS, the College retained Drs. Gysler and Zaltz in June 2015 and November 2015, respectively. The College also retained Dr. Polsky to opine on Dr. Jackiewicz’s standard of care with respect to the surgical procedures he observed while acting as his Mentor in 2014. On June 27, 2016, the College received Dr. Polsky’s report regarding the nine surgical procedures that he had observed and discussed with Dr. Jackiewicz. Dr. Polsky opined that in all of the cases reviewed, Dr. Jackiewicz fell below the standard of care and that, due to his lack of knowledge, judgment and ability, Dr. Jackiewicz placed patients at undue risk and potential harm. Dr. Polsky stated: As stated previously in this report, Dr. Jackiewicz’s patient positioning and trocar placement techniques are antiquated. There were instances where I told him how I perform my cases in my centre, and the visualization techniques that I teach the residents. Dr. Jackiewicz ignored all my suggestions and offers to display and teach the techniques. During one of our OR change overs, I asked if he had been to a CME event for laparoscopy recently. He stated that it was all the same people giving the same talks about things that he already knew. In further discussions about some of the professors that I had studied under at the University of Western Ontario and the University of Toronto, he stated that he taught them and that there was nothing that he needed to learn from them. It was at this time that I realized that Dr. Jackiewicz was not amenable to suggestion or recommendation. I am concerned that he will not alter any of his techniques or seek further CME in the future.
20. On or about July 15, 2016, Dr. Jackiewicz sent a letter to the College in response to the report of Dr. Polsky.
Dr. Jackiewicz’s Care and Treatment of Patient A
21. In his letter of June 26, 2015, Dr. Stewart referred to the care and treatment provided by Dr. Jackiewicz to a patient on November 17, 2014. Patient A had experienced a perforation and excessive bleeding following an endometrial ablation. Shortly after the adverse event, NHS retained Dr. Zaltz to review the standard of care provided to Patient A. In his report, dated December 2, 2014, Dr. Zaltz concluded: "In summary, I have concerns about Dr. Jackiewicz’s insight and judgement in managing this life threatening post-operative complication. The patient’s care was guided by the nurses, anaesthesiologist and his colleague, rather than by the attending surgeon who wanted to proceed by an approach that all others present agreed was not safe. In my discussion with Dr. Jackiewicz, I was surprised that even several weeks later he could not simply state, that in retrospect, LAVH was the wrong decision. Revisiting this repeatedly, he finally agreed that a laparoscopic approach was wrong and stated “maybe I was not quite aware of her condition”.
In my opinion, Dr. Jackiewicz demonstrated a complete lack of judgment when faced with this complication. Even at this point I cannot be confident that he has the insight to realize that he did not make the appropriate decisions in the management of this case. Thankfully for the patient, the team was able to override his decision. Therefore, Dr. Jackiewicz did not meet the standard of care required of a gynecologist in managing [Patient A]’s care.
22. As Dr. Jackiewicz was under the mentorship/supervision of Dr. Polsky at the time he performed the procedure on Patient A, Dr. Polsky was also asked by NHS to review the standard of care provided to Patient A pre-, intra- and post-operatively. In his report, dated May 8, 2015, Dr. Polsky concluded:
"In summary there are two areas where Dr. Jackiewicz falls below the standard of practice in [Patient A’s] case. First, he did not properly evaluate the bleeding that occurred intraoperatively and rule out a perforation prior to placement of the Foley balloon. Second, he did not properly decide to abandon the laparoscopic approach to the exploration given [Patient A]’s clinical scenario and reluctantly proceeded to laparotomy only after debate with colleagues and co-workers.
In my opinion, Dr. Jackiewicz lacks the clinical judgment to evaluate the situation at hand, and he is also unable to make timely decisions to appropriately manage surgical cases in order to ensure patient safety. In addition, Dr. Jackiewicz does not have insight into his own surgical abilities and is unable to realize his limitations. These deficiencies would affect all surgical scenarios.
Other areas of concern include the evaluation and counseling of [Patient A] preoperatively, and Dr. Jackiewicz’s ability to respond to pages promptly. Ultrasound results can affect the risks and benefit profile of the procedures offered. If large fibroids are found, then the option of an endometrial resection may not be appropriate. There is also possibility that [Patient A]’s counseling on her surgical options and the surgical complications of an endometrial resection may have been deficient. By the incident reports, Dr. Jackiewicz needed to be paged three times in order to have him arrive at the PARR. Any delay in response, may result in further complications.
Registrar’s Investigation Arising from Information Received from Dr. Amie Cullimore
23. On October 1, 2015, the College received information regarding Dr. Jackiewicz from Dr. Amie Cullimore of the Department of Obstetrics and Gynecology at St. Joseph’s Healthcare in Hamilton. The letter outlined her concerns of substandard care provided to a patient by Dr. Jackiewicz.
24. On the basis of this information, the ICRC approved the appointment of investigators under section 75(1)(a) of the Code in order to conduct a broader investigation into Dr. Jackiewicz’s office practice.
25. The College retained Dr. Andrew Browning to opine on Dr. Jackiewicz’s care and treatment of patients. Dr. Browning reviewed 25 charts, observed Dr. Jackiewicz in his office on March 21, 2016, and interviewed Dr. Jackiewicz on June 17, 2016. Dr. Browning opined that Dr. Jackiewicz’s care and treatment in 10 of 25 patient charts fell below the standard of practice of the profession and displayed a lack of judgment which exposed those patients to harm. Dr. Browning stated, in part:
"Interactions with Dr. Jackiewicz provided the impression that he feels he does not need to follow guidelines because he thinks he knows best. When not following the guidelines and preferred treatment modalities, Dr. Jackiewicz does not document any explanation for the deviation. When he does not use a preferred treatment for CIN3 there was no documentation that the patient was aware they were receiving the non-preferred treatment and there was no documentation that the preferred treatment was offered in the form of a referral to a colposcopist who performs excisional procedures.
In several cases there appeared to be a trend to perform cryotherapy to the cervix when the procedure was not indicated based on December of 2012 SOGC guidelines. Dr. Jackiewicz’s attitude at the interview appeared to be that he felt the procedure was “harmless” hence it is justified. Like most procedures in medicine, cryotherapy to the cervix can have complications, can as well be quite uncomfortable and it can alter the anatomy of the cervix. Cryotherapy should not be performed on women unless it is clearly indicated.
In a couple of cases Dr. Jackiewicz did not sample the endometrium in women over the age of 40 with abnormal bleeding. There was no explanation for the omission of this important test to rule out endometrial pathology. Similarly, there was no real understandable explanation for how an abnormal lab test was reviewed and dealt with. Dr. Jackiewicz suggested that it was “all on the computer”, but a reviewer of the chart had no means of confirming appropriate treatment secondary to the documentation provided.
26. Dr. Browning also indicated that after reviewing the 25 charts, he could not find evidence of a case where a treatment option was mentioned that involved a referral to a gynaecologist with surgical privileges that Dr. Jackiewicz did not have. Dr. Browning stated: When I asked Dr. Jackiewicz what he did with cases where patients requested or required surgical management that he could not provide, the answer was concerning. It implied that no one could do the things he did, i.e. for example “endometrial resection” and “difficult hysterectomies”. It also implied that he was hesitant to refer patients to other gynecologists in his region and hence sometimes he just referred them “to Toronto”.
27. Dr. Browning requested and reviewed further charts of the last five cases that Dr. Jackiewicz referred to other gynaecologists for possible surgical intervention. In reviewing the cases received, Dr. Browning noted
"one of them was referred after he would have received the College request.
… The other four cases did have scenarios where patients were referred to the same gynecologist in all four cases. The last referral forwarded was in November of 2015 with no other cases forwarded until the one that occurred after the College letter went out.
This would mean that from November of 2015 to May of 2016 (five months), Dr. Jackiewicz had no cases where the patient was referred to another gynecologist for consultation regarding surgical options that Dr. Jackiewicz could not perform in his office practice.
When we discussed this surprising lack of cases that were referred to other gynecologists, Dr. Jackiewicz’s response was that he just did not have many cases that he needed to refer out. If this is the case, it would be helpful if Dr. Jackiewicz documented the treatment options that were discussed with applicable cases.
As previously mentioned, there was very little evidence or documentation that the surgical options not offered by Dr. Jackiewicz, i.e. endometrial ablation for example, are being discussed as options for appropriate patients."
28. During Dr. Browning’s half day of direct observation, he also noted that in discussing treatment options with patients, Dr. Jackiewicz’s discussions did not involve explanations of procedures that Dr. Jackiewicz did not offer: For example, endometrial ablation was not mentioned in cases of menorrhagia and diagnostic laparoscopy was not mentioned in cases of pelvic pain. When I asked Dr. Jackiewicz about this observation, he noted that he would discuss other surgical options at follow up visits if initial treatments did not work. At my day of observation, I did not witness patients being offered education on treatment modalities that Dr. Jackiewicz could not perform. In my opinion, patients need to be educated on all of their treatment options for their diagnoses. To not offer and convey all reasonable treatment options would be a deviation from the standard of care.
29. On or about August 10, 2016, Dr. Jackiewicz sent a letter to the College in response to the report of Dr. Browning.
30. Dr. Browning reviewed Dr. Jackiewicz’s response to his report and provided additional comments to the College. In his response, Dr. Browning did not change the conclusions reached in his initial report.
Interim Order
31. On December 8, 2016, after the referral to discipline was made, the ICRC ordered terms, conditions and limitations to be placed on Dr. Jackiewicz’s certificate of registration.
32. Pursuant to the Order, Dr. Jackiewicz was required to obtain a clinical supervisor acceptable to the College by January 9, 2017 for his gynaecological office practice. As of January 9, 2017, Dr. Jackiewicz had not obtained a clinical supervisor acceptable to the College and, as such, he was required to cease practising medicine until he obtains a clinical supervisor.
DISPOSITION
Dr. Jackiewicz did not renew his membership with the College in 2018. As a result, his certificate of registration expired on August 16, 2018. Dr. Jackiewicz entered into an Undertaking to the College on November 19, 2018, by which he agreed never to apply or re-apply for registration as a physician in Ontario or any other jurisdiction.
In light of the undertaking to not reapply, on December 5, 2018, the Discipline Committee ordered and directed that:
- Dr. Jackiewicz attend before the panel to be reprimanded.
- Dr. Jackiewicz pay to the College costs in the amount of $10,180.00, within thirty (30) days of the date of this Order.
Committee: Discipline
Decision Date: 22 Nov 2010
Summary:
On November 22, 2010, the Discipline Committee of the College of Physicians and Surgeons of Ontario found that Dr. Jackiewicz has committed an act of professional misconduct in that hefailed to maintain the standard of practice of the profession and in that he engaged in conduct oran act or omission relevant to the practice of medicine that, having regard to all thecircumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional.
Significant deficiencies were identified in Dr. Jackiewicz's obstetrical practice in relation to multiple patients and in his charting relating to both his obstetrical and gynaecological practices.
Among other things, the Discipline Committee found that Dr. Jackiewicz:
a) failed to follow accepted antenatal clinical practice in both low and high risk pregnancies, such as failing to assess symphysis - fundal heights prior to 30 weeks;
b) failed to appropriately manage second stage labour by, for example, performing unindicated operative vaginal deliveries;
c) failed to abandon in a timely manner operative vaginal deliveries if deliveries were not forthcoming;
d) undertook high risk procedures such as trial of forceps and twin vaginal delivery in the Labour and Delivery suite when they ought to have been done in an operating room;
e) failed to have the customary and necessary help available for planned high risk procedures, such as a paediatrician, anaesthesiologist and operating room staff;
f) failed to conduct and document an adequate fetal assessment before and after performing an external cephalic version;
g) failed to promptly assess a patient at risk of placental abruption when requested to do so by nursing staff;
h) failed to adequately interpret the results of fetal heart rate tracing; and
i) failed to thoroughly inspect a patient's vagina following post-partum hemorrhaging.
The Discipline Committee directed and ordered that:
1. Dr. Jackiewicz attend before the panel to be reprimanded, with the fact of the reprimand to be recorded on the Register;
2. The Registrar impose the following terms, conditions and limitations on Dr. Jackiewicz's certificate of registration:
a. For an indefinite period of time, Dr. Jackiewicz shall be prohibited from engaging in the management of labour and delivery for all pregnancies with the following exceptions:
i. Dr. Jackiewicz shall be permitted to perform elective or on-demand caesarean-section deliveries; and
ii. Dr. Jackiewicz may act as a surgical assistant to other hospital-based caesarean-sections when a College-approved obstetrician is performing the caesarean-section as the most responsible physician and is in attendance for the duration of the procedure;
b. For an indefinite period of time, Dr. Jackiewicz shall inform all obstetrical patients of the term, condition and limitation referenced in paragraph 3(a) above;
c. Dr. Jackiewicz shall contact the College immediately to arrange at his own expense to attend a program in communications that is satisfactory to the College, which will involve multiple one-on-one sessions with a College-approved instructor (the "Instructor"), incorporating principles of counseling, guided reflection, tailored feedback, and other modalities customized to the specific needs of Dr. Jackiewicz as assessed by the Instructor. The Instructor will make reports to the College regarding Dr.Jackiewicz's progress and compliance and Dr. Jackiewicz shall successfully complete this program;
d. With respect to his gynecological and office-obstetrical practices, Dr. Jackiewicz shall, within 30 days from the date of this Order, retain a College-approved clinical supervisor, who will sign an undertaking in the form attached hereto as Schedule "A" (the "Supervisor"). For a period of six months commencing on the day the Supervisor is retained, Dr. Jackiewicz may practice only under the supervision of the Supervisor. Upon completion of this period of supervision, Dr. Jackiewicz shall undergo an assessment of his office-obstetrical and gynecological clinical practices by a College-appointed assessor who has not previously assessed Dr. Jackiewicz's practice in any respect. This assessment will be limited to determining if Dr. Jackiewicz is in compliance with this Order and whether or not Dr. Jackiewicz's practice is below the standard of practice of the profession. The assessment may include a review of Dr. Jackiewicz's hospital and office charts and interviews by the assessor. The assessor shall report the results of this assessment to the College.
e. With respect to his practice of elective or on-demand caesarian-sections, as set out in paragraph 3(a)(i) above, Dr. Jackiewicz shall advise the College when and if he begins performing elective or on-demand caesarian-sections and shall comply with the following conditions:
i. for a period of six months commencing the date on which he begins performing elective or on-demand caesarean-sections, Dr. Jackiewicz shall obtain a consultation for all proposed elective or on-demand caesarian-sections contemplated or performed, which consultation shall be documented on the patient chart. This consultation will consider whether the elective or on-demand caesarian-section is appropriate;
ii. for a period of six months commencing the date on which he begins performing elective or on-demand caesarean-sections, Dr. Jackiewicz shall practice only under the supervision of the Supervisor. Upon completion of this period of supervision, Dr. Jackiewicz shall undergo an assessment of his elective or on-demand caesarian section clinical practice by the same assessor identified in paragraph 3(d) above or another College-appointed assessor who has not previously assessed Dr. Jackiewicz's practice in any respect. This assessment will be limited to determining if Dr. Jackiewicz is in compliance with this Order and whether or not Dr. Jackiewicz's practice is below the standard of practice of the profession. The assessment may include a review of Dr. Jackiewicz's hospital and office charts, interviews by the assessor and direct observation of Dr. Jackiewicz's patient care. The assessor shall report the results of this assessment to the College; and
iii. for eighteen months, after the period of supervision set out in paragraph 3(e)(ii) above is complete, Dr. Jackiewicz shall undergo a review every six months by the same assessor identified in paragraph 3(e)(ii) above or another College-appointed assessor who has not previously assessed Dr. Jackiewicz's practice in any respect, who shall:
1. review the files of up to thirty randomly selected patients for whom Dr. Jackiewicz has performed an elective or on-demand caesarian-section to determine whether the caesarean-sections were appropriate in the cases under review; and
2. report the results of this review to the College.
f. Dr. Jackiewicz shall be responsible for any and all costs associated with implementing the terms of this Order.
3. Dr. Jackiewicz shall within 30 days pay the College its costs of this proceeding in the amount of $3,650.00.