On January 10, 2017, the Discipline Committee found that Dr. Gerald Powell committed an act of professional misconduct in that: he failed to maintain the standard of practice of the profession; and, he 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, with respect to his billing practices.
Psychotherapeutic Frame, Documentation and Medication Monitoring Dr. Powell is a psychiatrist practising in Ottawa. In 2009, following a complaint from a former patient, the College retained an expert to provide an independent opinion with respect to Dr. Powell’s care of this patient. As a result of the concerns raised in this opinion, the College conducted a broader investigation into Dr. Powell’s psychiatric practice under section 75(1)(a) of the Health Professions Procedural Code.
In this broad investigation, three main areas of concern with respect to Dr. Powell’s care and treatment of patients were identified by an expert retained by the College. These included: Dr. Powell failed to maintain an appropriate psychotherapeutic frame in 19 of the 25 charts;
- Dr. Powell had lapses in his documentation, such as omitting start and stop times in 11 of the
- 25 charts and failing to document the monitoring (by himself or a family doctor) of metabolic
side effects from atypical antipsychotic medications in 8 of the 25 charts; and
-Dr. Powell demonstrated inadequate knowledge regarding the monitoring of atypical antipsychotic medications in at least 1 of the 25 charts.
The College expert opined, in part, about Dr. Powell’s failure to recognize and maintain the psychotherapeutic frame of the physician-patient relationship, as follows: “ sessions lasted longer, sometimes significantly longer, than scheduled… In addition, our discussion revealed that Dr. Powell’s justification for extending sessions instead of scheduling longer sessions in advance was based on a lack of knowledge and misunderstanding about psychodynamic principles as related to the frame. He indicated that scheduling a patient for a longer session would be treating them as “special.” In fact, the opposite is true: extending sessions in the manner in which Dr. Powell practices is more likely to gratify a patient’s sense of being special because they are repeatedly “gifted” with extra time. Dr. Powell’s system of scheduling also reveals poor judgment when it comes to deciding how and when to start and stop sessions.…Appropriately managing no shows and cancellations is also part of maintaining the frame. As I learned from the interview, Dr. Powell told patients they would be held financially responsible for missing appointments and late cancellations, yet he did not hold them to that expectation. At one point he told me that when he did collect payment, he returned it because he felt bad about charging the patient. I believe this represents what is called a counter- transference enactment. Rather than working with albeit difficult and uncomfortable transference material, the issue was avoided, modelling an approach that did not reinforce responsible behaviour and dismissed problematic behaviour.
In an addendum to his report, the College expert amended his finding with respect to Dr. Powell’s lack of skill with reference to the frame regarding one patient. However, he noted two additional concerns with respect to the documentation of important clinical changes/situations and a lack of judgment in all of the 19 patient charts in which Dr. Powell failed to maintain an appropriate psychotherapeutic frame. In addition to these revisions, the College expert withdrew his concern regarding Dr. Powell’s lack of knowledge of monitoring lipid levels with respect to one patient. The remainder of the opinions reached in his initial report were maintained.
Inappropriate Billing Practices
The College expert also opined that all 25 charts showed evidence of inappropriate billing and that Dr. Powell’s billing practices did not meet the standard of practice of the profession.
Concerning billing practices included:
- Billing one unit for missed appointments;
- Billing one unit for cancelled appointments (including at least one appointment that was - cancelled by Dr. Powell);
- Billing one unit for telephone calls to patients and telephone prescription renewals;
- Routinely billing for long sessions. Dr. Powell’s average appointment for the patients reviewed is between 80 and 110 minutes; 50 minutes is the generally accepted length for a psychiatric appointment;
- Billing special visit premium codes (A990A and A994A) when appointments were not always eligible for a premium rate. These premiums are available to a psychiatrist when he or she attends the office on an urgent basis, when they were not otherwise scheduled to attend.
Dr. Powell claimed these premiums in circumstances that did not meet the required criteria;
and
- Double billing for the same block of time. There are several instances where a patient was fit in or had their appointment extended on account of a cancellation and claims were submitted to OHIP for both patients.
Penalty and Costs
The Discipline Committee ordered and directed on the matter of penalty and costs that:
- The Registrar suspend Dr. Powell’s certificate of registration for four (4) months, to commence at 11:59 p.m. on January 10, 2017.
- The Registrar impose the following as a term, condition and limitation on Dr. Powell’s certificate of registration:
(a) Prior to resuming practice after the period of suspension of his certificate of registration, Dr. Powell shall retain a College-approved clinical supervisor, who will sign an undertaking in the form attached hereto as Schedule “A” (the “Clinical Supervisor”). For a period of twelve (12) months, Dr. Powell may practice only under the supervision of the Clinical Supervisor and will abide by all recommendations of his Clinical Supervisor with respect to his practice, including but not limited to practice improvements, practice management, and continuing education. The period of Clinical Supervision will commence on the expiry of the period of suspension, or on the date that the Clinical Supervisor is approved, if one is not approved during the period of suspension;
(b) If, prior to completion of Clinical Supervision, the Clinical Supervisor is unable or unwilling to continue in that role for any reason, Dr. Powell shall retain a new College-approved Clinical Supervisor who will sign an undertaking in the form attached hereto as Schedule “A”. If Dr. Powell fails to retain a Clinical Supervisor on the terms set out above within thirty (30) days of receiving notification that his former Clinical Supervisor is unable or unwilling to continue in that role, he shall cease practicing medicine until such time as he has obtained a Clinical Supervisor acceptable to the College. If Dr. Powell is required to cease practice as a result of this paragraph, this will constitute a term, condition and limitation on his certificate of registration and such term, condition and limitation shall be included on the public register;
(c) Upon completion of the twelve (12) month period of Clinical Supervision, as described above, within approximately six (6) months, Dr. Powell shall undergo a re-assessment of his practice by a College-appointed assessor (the “Assessor”). This re-assessment by the Assessor will include a review of Dr. Powell’s office charts and an interview with Dr. Powell. Dr. Powell shall abide by all recommendations made by the College-appointed Assessor. The Assessor shall report the results of this re-assessment to the College;
(d) Dr. Powell shall inform the College of each and every location where he practices, in any jurisdiction (his “Practice Location(s)”) within fifteen (15) days of this Order and shall inform the College of any and all new Practice Locations within fifteen (15) days of commencing practice at that location;
(e) Dr. Powell shall consent to the sharing of information between the Clinical Supervisor, Assessor and the College as any of them deem necessary or desirable in order to fulfill their respective obligations;
(f) Dr. Powell shall consent to the monitoring of his OHIP billings and cooperate with inspections of his practice and patient charts by the Clinical Supervisor and College representatives for the purpose of monitoring and enforcing his compliance with this term of the Order. Monitoring this term shall include making enquiries of the Ministry of Health and Long-Term Care regarding Dr. Powell’s billings;
(g) Dr. Powell shall co-operate with unannounced inspections of his office practice and patient charts by the College for the purpose of monitoring and enforcing his compliance with the terms of this Order and shall provide his irrevocable consent to the College to make appropriate enquiries of any person or institution who may have relevant information for the purposes of monitoring and enforcing his compliance with the terms of this Order; and
(h) Dr. Powell shall be responsible for any and all costs associated with implementing the terms of this Order.
- Dr. Powell shall, within three (3) months, pay a fine to the Minister of Finance in the amount of $20,000.00, and Dr. Powell shall provide proof of this payment to the Registrar of the College.
- Dr. Powell to attend before the panel to be reprimanded.
Dr. Powell pay to the College its costs of this proceeding in the amount of $5,000 within thirty (30) days from the date of this Order.