Committee: Discipline
Decision Date: 23 May 2018
Summary:
On May 23, 2018, the Discipline Committee found that Dr. Hoda Mohamed Mahmoud Aly committed an act of professional misconduct in that: she has failed to maintain the standard of practice of the profession; and she has engaged in 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. Dr. Aly is a family physician who received her certificate of registration authorizing independent practice in September 2011 after completing her residency at the University of Toronto and obtaining her certification by the College of Family Physicians of Canada. At all relevant times, she was practising at the Don Mills Family Health Team (the Clinic) in Toronto.
In August 2016, following the receipt of information of concern from York Regional Police regarding the arrest of an individual who was wrongfully in possession of Fentanyl that had been prescribed by Dr. Aly to a patient (Patient C as discussed below), College investigators were appointed. Prescribing data obtained from the Narcotics Monitoring System ("NMS") for the time period January 1, 2015 to August 25, 2016 indicated that narcotics prescribing was not a large part of Dr. Aly's practice. The data showed 161 prescriptions filled by 35 unique patients during that time period, including 17 prescriptions for Fentanyl, prescribed to four patients.
An expert retained by the College reviewed Dr. Aly's care in respect of the four patients to whom she prescribed Fentanyl during the time period in question and two of whom were Dr. Aly's close personal relatives. According to the expert, Dr. Aly failed to maintain the standard of practice of the profession in her care of all four patients, her care for those patients displayed a lack of knowledge, skill or judgment, and her narcotics prescribing practice would pose a risk of harm to other patients in her practice.
Patient A
Dr. Aly became Patient A's family physician in 2012. Patient A had a number of health issues, including obesity, difficult mobility, and chronic back pain. She had been escalating use of Tylenol #2 obtained from a friend as well as extra strength Tylenol. She reported these medications to be insufficient for her pain. She was seen in the Emergency Department by another physician at one point and was given morphine, but was unable to tolerate it. She was also given Percocet and experienced nausea, vomiting, and difficult urination. Dr. Aly prescribed a trial of Fentanyl 100 microgram patches to Patient A in January 2016, noting "I gave her enough patches and instructed her to apply them [every] 48-72 hrs on an area where she doesn't sweat." A few weeks later the patient advised Dr. Aly that she did not want the patches and would not get them again.
Dr. Aly's prescribing of narcotics to Patient A did not meet the standard of practice of the profession. She did not demonstrate an awareness of how to titrate narcotics safely and progressively, and instead started Fentanyl at a maximum dose without appropriate use of an opioid analgesic conversion. When interviewed by the expert, Dr. Aly indicated that she knew that there were opioid conversion guidelines, but that because she did not prescribe narcotics often, she did not know at the time how to do the conversion and had made a mistaken estimate. Nor did Dr. Aly have Patient A sign an opioid contract.
Patient B
Dr. Aly was Patient B's family physician from October 2014 to March 2015. Patient B had osteoarthritis, scoliosis, peptic ulcer disease, hypothyroidism, hypercholesterolemia, and migraines. Patient B had been receiving Oxycodone and Fentanyl, as well as Tylenol #3 for over 20 years and was aware that she was dependent on them, though she advised Dr. Aly that she did not escalate or take more than the prescribed dose, or "double doctor." Patient B also had been taking a benzodiazepine. Dr. Aly had Patient B sign an opioid contract in November 2014 and continued to prescribe 200 micrograms of Fentanyl per day to Patient B, as well as Oxycodone and a benzodiazepine. However, in March 2015 Dr. Aly terminated the doctor-patient relationship, noting in the patient chart that the patient was reluctant to follow medical advice and insisted on receiving narcotics rather than exploring other remedies for chronic pain. Dr. Aly noted in the chart that the patient would return to her previous physician.
Dr. Aly' s care of Patient B did not meet the standard of practice of the profession. She prescribed high doses of narcotics and did not seek to wean the patient gradually from her dependency. She also failed to monitor the patient consistently, particularly by way of urine drug screening.
Patient C
Patient C was Dr. Aly's close personal relative. Patient C had a number of serious comorbidities. Dr. Aly acted as Patient C's family physician from 2012 until early 2016, including prescribing Fentanyl to Patient C and writing Patient C notes excusing Patient C from school and from attending court due to illness. She did not bill the Ontario Health Insurance Plan for this care, which was primarily provided in Patient C's home.
Patient C had been prescribed morphine and hydromorphone in the past. Dr. Aly first prescribed Fentanyl to Patient C in August 2014 in response to Patient C's complaint of pain associated with surgery. Dr. Aly continued to prescribe Fentanyl to Patient C on occasion.
Dr. Aly's care of Patient C did not meet the standard of practice of the profession. She did not demonstrate an awareness of how to titrate narcotics safely and progressively, nor did she use an opioid contract for Patient C. She demonstrated a significant lapse in judgment in acting as her close personal relative's family physician and in prescribing Patient C narcotics. Dr. Aly stated in her interview with the expert that the reason she did not have Patient C sign an opioid contract was that she was not objective because Patient C was her close personal relative.
The College's Policy on Treating Self and Family Members provides, among other things, that physicians should not treat their family members except for minor conditions or in an emergency situation, and only when other qualified health professionals are not readily available. Where it is necessary to treat themselves or family members, physicians must transfer care to another qualified health professional as soon as is practical. Dr. Aly was aware of this policy while she was engaging in the conduct above, and was aware that her conduct contravened the policy. Dr. Aly stated that she felt "pressure" from her family and felt "emotionally involved."
Patient D
Patient D is Dr. Aly's close personal relative. Patient D had a number of serious comorbidities. While Patient D was registered to another family physician from 2008 onwards, Dr. Aly stated in her interview with the expert that Patient D had only seen that physician once and not returned. Instead, Patient D received primary care from Dr. Aly, beginning in approximately November 2013. This included prescribing Gabapentin, Oxycontin, and, beginning in December 2014, 100 microgram patches of Fentanyl. The care was provided in Patient D's home. Dr. Aly stated that she told Patient D she was not allowed to provide treatment to Patient D, but felt emotional pressure because Patient D wanted to be treated by her and not to travel for care. Dr. Aly did not bill the Ontario Health Insurance Plan for care provided to Patient D.
Dr. Aly failed to have Patient D sign an opioid contract. When initiating Patient D on Fentanyl, she did not have the requisite knowledge to titrate the dose appropriately and instead relied on advice from another relative who was a pharmacist. Dr. Aly states that she then looked up the dose and thought it was "pretty high" and should go down, but her pharmacist relative said that it was appropriate and the dose that "most doctors" would give. Dr. Aly demonstrated a significant lapse in judgement in treating her close personal relative as a primary care physician for several years and in prescribing narcotics to her close personal relative, and failed to meet the standard of practice of the profession in this regard.
Summary
Dr. Aly' s care of the patients noted above did not meet the standard of practice of the
profession:
- Dr. Aly's prescribing was not in keeping with the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (2010);
- Dr. Aly did not demonstrate an awareness of how to titrate narcotics safely and progressively;
- Dr. Aly did not use an opioid contract with three of the four patients;
- Dr. Aly used Fentanyl, a potent drug, in high doses with non-compliant patients who were refusing to participate in chronic pain clinics or follow up with chronic pain specialists, in an attempt to reduce their pain;
- Dr. Aly prescribed narcotics to and acted as a primary care provider for two close personal relatives for years despite being aware of the College policy on the topic and despite her relationship with them affecting her objectivity;
- Dr. Aly did not consistently initiate referrals for her patients on high dose opioid therapy to a chronic pain specialist;
- Dr. Aly relied on a relative who is a pharmacist to guide her as to dosages and approach in prescribing potent narcotics such as Fentanyl, rather than familiarizing herself with the appropriate prescribing and monitoring practices.
Disposition
On May 23, 2018, the Committee ordered and directed that:
- the Registrar suspend Dr. Aly’s certificate of registration for a period of four (4) months, effective immediately.
- the Registrar impose the following terms, conditions and limitations on Dr. Aly’s certificate of registration:
Prescribing Log
- Dr. Aly shall keep a log of prescriptions (“Prescribing Log”) until such time as the College has conducted the reassessment described below and has deemed it successfully completed.
The Prescribing Log will include all prescriptions for:
(a) Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
(b) Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
(c) Controlled Drugs (from Schedule G of the Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);
(d) Benzodiazepines and Other Targeted Substances (from the Benzodiazepines and Other Targeted Substances Regulations made under the Controlled Drugs and Substances Act., S.C., 1996, c. 19);
(e) (A summary of the above-named drugs [from Appendix I to the Compendium of Pharmaceuticals and Specialties] is attached as Schedule “A” to the Order; and the current regulatory lists are attached as Schedule “B” to the Order)
(f) All other Monitored Drugs (as defined under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22 as noted in Schedule “C” of the Order).
- The Prescribing Log shall be in the form set out at Schedule “D” of the Order, which will
include at least the following information:
- the date of the prescription;
- patient identifier;
- the medication, dose, direction, number of tablets to be dispensed and frequency (if applicable);
- the clinical indication for use;
- whether it is a new prescription; and
- physician initials.
Education
-Dr. Aly shall, at her own expense, participate in and successfully complete individualized instruction in medical ethics, in accordance with the Individualized Education Plan set out at Schedule “E” of the Order, to the satisfaction of the College. Dr. Aly will initiate contact with the instructor within one (1) month of the date of this Order. Dr. Aly will provide proof of successful completion within six (6) months of the date of this Order. The instruction will involve one-on-one sessions with a College-approved instructor (“the Instructor”), incorporating principles of guided reflection, tailored feedback, and other modalities customized to the specific needs of Dr. Aly as assessed by the Instructor. The Instructor will report to the College regarding Dr. Aly’s progress and compliance.
Clinical Supervision
- Prior to resuming practice following the suspension of her certificate of registration described in the paragraph above, Dr. Aly shall retain a College-approved clinical supervisor or supervisors (the “Clinical Supervisor”) with respect to her prescribing of narcotics and controlled substances, who will sign an undertaking in the form attached as Schedule “F” to the Order.
- Dr. Aly shall practice under the guidance of the Supervisor for a period of nine (9) months (“Clinical Supervision”).
- Clinical Supervision of Dr. Aly’s prescribing of narcotics and controlled substances shall contain the following elements:
Moderate-Level Supervision
- For an initial period of two (2) months, the Clinical Supervisor will engage in a period of moderate-level supervision, during which time the Clinical Supervisor will meet with Dr. Aly every two weeks and will at minimum:
- review charts and prescriptions for twenty (20) of Dr. Aly’s patients, to be selected from the Prescribing Log at the sole discretion of the Clinical Supervisor. If the Prescribing Log contains fewer than twenty (20) patients, the Clinical Supervisor shall review all charts and prescriptions contained in the Prescribing Log. The review shall include charts and prescriptions for all patients to whom Dr. Aly initiated a new prescription for a Narcotic Drug, Narcotic Preparation, Controlled Drug, Benzodiazepine and Other Targeted Substance or other Monitored Drug since the Clinical Supervisor’s prior review;
- evaluate whether the assessment, clinical examination, risk assessment for addiction
and on-going management and follow up is appropriate in all cases reviewed;
- discuss with Dr. Aly any concerns the Clinical Supervisor may have regarding
assessment, clinical examination, risk assessment for addiction and on-going
management and follow up, and make recommendations for improvement; and
- submit written reports to the College at least once every two weeks, or more
frequently if the Clinical Supervisor has concerns about Dr. Aly’s prescribing
practices.
- After two (2) months, and only upon recommendation by the Clinical Supervisor and
approval of the College, the Clinical Supervision may be reduced to a low level for the
remaining seven (7) months.
Low-Level Supervision
- If the transition is recommended by the Clinical Supervisor and approved by the College,
for a period of a further seven (7) months, the Clinical Supervisor will engage in a period
of low-level supervision, during which time the Clinical Supervisor will meet with Dr.
Aly on a monthly basis and will, at minimum:
- review charts and prescriptions for fifteen (15) of Dr. Aly’s patients, to be selected from the Prescribing Log at the sole discretion of the Clinical Supervisor. If the Prescribing Log contains fewer than fifteen (15) patients, the Clinical Supervisor shall review all charts and prescriptions contained in the Prescribing Log. The review shall include charts and prescriptions for all patients to whom Dr. Aly initiated a new prescription for a Narcotic Drug, Narcotic Preparation, Controlled Drug, Benzodiazepine and Other Targeted Substance or other Monitored Drug since the Clinical Supervisor’s prior review;
-evaluate whether the assessment, clinical examination, risk assessment for addiction and on-going management and follow up is appropriate in all cases reviewed;
- discuss with Dr. Aly any concerns the Clinical Supervisor may have regarding assessment, clinical examination, risk assessment for addiction and on-going management and follow up, and make recommendations for improvement; and
-submit written reports to the College at least once every month, or more frequently if the Clinical Supervisor has concerns about Dr. Aly’s prescribing practices.
Other Elements of Clinical Supervision
- Throughout the period of Clinical Supervision, Dr. Aly shall abide by all recommendations of her Clinical Supervisor.
- If a person who has given an undertaking in Schedule “F” to the Order is unable or unwilling to continue to fulfill its provisions, Dr. Aly shall, within twenty (20) days of receiving notice of same, obtain an executed undertaking in the same form from a similarly qualified person who is acceptable to the College and ensure that it is delivered to the College within that time.
- If Dr. Aly is unable to obtain a Clinical Supervisor as set out in this Order, she will cease prescribing Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances and other Monitored Drugs until such time as she has obtained a Clinical Supervisor acceptable to the College.
- If Dr. Aly is required to cease prescribing as a result of the paragraph above, this will constitute a term, condition or limitation on her certificate of registration and that term, condition or limitation will be included on the public register until such time as she has obtained a Clinical Supervisor acceptable to the College.
Reassessment of Practice
- Approximately nine (9) months after the completion of the Education and Clinical Supervision, Dr. Aly shall undergo a reassessment of her practice by a College-appointed assessor or assessors (the “Assessor”). The Assessor shall report the results of the reassessment to the College.
-The reassessment may include (at the College’s discretion) a review of a minimum of twenty (20) of Dr. Aly’s patient charts, direct observation of Dr. Aly’s practice, an interview with Dr. Aly, interviews with colleagues and co-workers, and any other tools deemed necessary by the College. Dr. Aly shall abide by all recommendations made by the Assessor.
- Dr. Aly shall consent to the sharing of information among the Assessor, the Clinical Supervisor, the Instructor, and the College, as any of them deem necessary or desirable in order to fulfill their respective obligations.
Monitoring
- Dr. Aly shall inform the College of each and every location where she practices, in any jurisdiction (her “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.
- Dr. Aly shall cooperate with unannounced inspections of her practice location(s) and patient charts and to any other activity the College deems necessary in order to monitor her compliance with the provisions of this Order.
- Dr. Aly shall consent to the College making appropriate enquiries of the Ontario Health Insurance Plan, the Narcotics Monitoring System and/or any person or institution that may have relevant information, in order for the College to monitor and enforce her compliance with the terms of this Order.
- Dr. Aly shall be responsible for any and all costs associated with implementing the terms of this Order.
- Dr. Aly attend before the panel to be reprimanded.
- Dr. Aly pay costs to the College in the amount of $10,180.00 within thirty (30) days from the date this Order.