Committee: Discipline
Decision Date: 06 Jan 2020
Summary:
On January 6, 2020, on the basis of an Agreed Statement of Facts and Admission and Statement of Uncontested Facts, the Discipline Committee found that Dr. Henry Houshmand committed an act of professional misconduct, in that he 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, and that he is incompetent.
On January 20, 2020 the Committee held a hearing regarding penalty and reserved its decision, which was released on April 14, 2020.
FACTS
Dr. Henry Houshmand is a 65-year-old general practitioner anesthetist. He received his certificate of registration authorizing independent practice from the College of Physicians and Surgeons of Ontario (the “College”) on April 1, 2014. At the relevant times, Dr. Houshmand worked at Provis Rudd Endoscopy Services-Ottawa (the “Provis Clinic”) and at the Hawkesbury & District General Hospital (the “Hawkesbury Hospital”).
Dr. Houshmand ceased working at the Provis Clinic on June 8, 2015. Dr. Houshmand ceased working at the Hawkesbury Hospital on February 2, 2018, pending an external review of his practice. Dr. Houshmand’s privileges at the Hawkesbury Hospital were not renewed at the end of April 2018. Dr. Houshmand has advised the College that he did not re-apply for privileges at the Hawkesbury Hospital. Dr. Houshmand does not currently have hospital privileges. Dr. Houshmand has not practised medicine since February 2, 2018.
Incompetence / Failure to Maintain the Standard of Practice
Initial Section 75(1)(a) Investigation and Reports of Dr. Miller
In June of 2015, the College’s Out-of-Hospital Premises Inspection Program (the “OHPIP”) received information from a staff member at the Provis Clinic who had concerns about Dr. Houshmand’s anesthesia practice and conduct. On the basis of the information from that staff member, and other information, including a chart review conducted by the OHPIP that revealed concerns regarding Dr. Houshmand’s practice, the College commenced an investigation under section 75(1)(a) of the Health Professions Procedural Code (the “Code”) to investigate into Dr. Houshmand’s anesthesia practice.
The College retained the services of Dr. Paul Miller, a general practice anesthetist, to conduct an assessment of Dr. Houshmand’s anesthetic practice. Dr. Miller reviewed 20 charts from Dr. Houshmand’s out-of-hospital premises-based practice at the Provis Clinic and 25 charts from Dr. Houshmand’s hospital-based practice at the Hawkesbury Hospital. Dr. Miller also reviewed the Provis Clinic schedule of patients for June 8, 2015, Dr. Houshmand’s OHIP billing for June 8, 2015, and Dr. Miller interviewed Dr. Houshmand.
With respect to Dr. Miller’s report dated October 17, 2016, Dr. Houshmand does not admit the two paragraphs in the report immediately under the heading “Additional note re: endoscopy clinic”. Of the 20 charts reviewed from the Provis Clinic, Dr. Miller did not provide an opinion on the care provided by Dr. Houshmand in two charts. Of the remaining 18 charts, Dr. Miller opined that most elements of the patient’s care were at standard in 3 charts, some of the elements of the patient’s care fell below standard in 2 charts, most elements of the patient’s care fell below standard in 12 charts, and all elements of the patient’s care fell below standard in 1 chart. Of the 25 charts reviewed from the Hawkesbury Hospital, Dr. Miller opined that Dr. Houshmand’s performance was on balance within the standard of care in 6 charts, that some elements of the patient’s care were below standard while other elements met the standard in 8 charts, most elements of the patient’s care were below standard in 10 charts, and all elements of the patient’s care were at least in part below standard in one chart. Dr. Miller’s conclusions were that Dr. Houshmand did not meet the standard of practice of the profession in his care and treatment of 18 out of 18 patients whose charts Dr. Miller reviewed from the Provis Clinic and Dr. Houshmand did not meet the standard of practice of the profession in his care and treatment of 19 out of 25 patients whose charts Dr. Miller reviewed from the Hawkesbury Hospital. As Dr. Miller further opined, Dr. Houshmand demonstrated a lack of knowledge, judgment and/or skill in many of these cases.
Based on Dr. Miller’s review of patient charts and interview with Dr. Houshmand, Dr. Miller identified the following list of knowledge/performance gaps in Dr. Houshmand’s anesthesia practice:
- He tended to give the same anesthetic to all patients irrespective of their age and medical comorbidities. For example, he gave the same initial bolus dose of propofol for sedation to all of his endoscopy patients.
- He used the same ventilator parameters for normal, obese and asthmatic patients. This could lead to hypoventilation, atelectasis and hypoxia in some and potential barotrauma in others.
- He uses abnormally high flow rates (4 liters). While this would not cause harm to patients directly it does increase the cost and environmental impact of the volatile gases used.
- He uses unusually high doses of intrathecal opioids in his spinal blocks. This would lead to an increased risk of respiratory depression, pruritus and nausea.
- There were a number of instances where patients were hypotensive for prolonged periods of time. Nothing was documented regarding the probable cause(s) and no steps were taken to correct the derangement.
- His charted airway assessments were incomplete. In the interview he did not perform significantly better.
- He does not typically describe the extent or impact of a medical comorbidity on the patient's functional capacity. He merely documents that it is present. This is fundamental to assessing the likely impact that the illness will have on the patient's ability to tolerate the planned surgery and anesthetic.
- He rarely gives an assessment of the patient’s functional capacity.
- He proceeds with a spinal anesthetic in a patient with a significant infection (Fournier's gangrene) and possible sepsis. This may have been indicated but there needs to be a well detailed discussion of the risks and potential benefits.
- In the charts reviewed by Dr. Miller, there was no routine screening for obstructive sleep apnea and there was no detailed management plan for those who are found to have it.
- The dose of Toradol (an intravenous non-steroidal anti-inflammatory [NSAID]) should be reduced in elderly and those with renal impairment. This was not done in one of his cases.
- In several of his cases, a history of gastroesophageal reflux disease (GERD) was not documented though clearly identified elsewhere in the chart. A history of uncontrolled GERD should prompt a change in the approach to securing the airway.
- Long acting opioids were not routinely used in longer cases where significant pain might be expected.
- Neuromuscular monitoring is checked as being done but actual levels of block are not recorded. The timing and dosing of the reversal agents are not regularly documented. Inadequate neuromuscular block reversal can have significant impacts on post-operative respiratory function, aspiration risk and patient comfort.
- Dr. Houshmand’s approach to the difficult airway during the interview was substandard. He did not follow any of the difficult airway algorithms. His documented assessment of the airway was substandard throughout the majority of the cases reviewed.
- Dr. Houshmand’s approach to managing massive transfusion during the interview was substandard. He failed to ask for the appropriate blood work in a timely way. He failed to give platelets and either fresh frozen plasma or
cryoprecipitate when it was clearly indicated.
With respect to his assessment of Dr. Houshmand’s anesthetic practice, Dr. Miller concluded, “I believe that there are significant enough lapses in knowledge, judgement and skill so as to put patients at potential risk of harm.”
Dr. Houshmand provided a response to Dr. Miller’s October 17, 2016 report and provided a letter from a family practice anesthetist, Dr. Jesse Guscott. Upon reviewing these materials, Dr. Miller provided the College with an addendum to his initial report dated March 28, 2017. Following his review of Dr. Houshmand’s comments and the comments provided by Dr. Guscott, Dr. Miller did not change the conclusions reached in his initial report. Rather, Dr. Miller remained concerned that Dr. Houshmand had gaps in his knowledge and performance of anesthesia. Dr. Miller opined, “I believe that there are still significant lapses in knowledge, judgment and skill so as to put patients at potential risk for harm.”
In response to further information, Dr. Miller provided a second addendum to his initial report dated June 26, 2017. Dr. Miller did not change the conclusions reached in his initial report or his addendum report. Dr. Miller concluded that the additional information did not dissuade him from his original assessment that Dr. Houshmand did not meet the standard of care.
Dr. Houshmand admits that he failed to maintain the standard of practice of the profession in his care and treatment of 37 patients whose charts were reviewed by Dr. Miller. Dr. Houshmand does not contest that his care of 37 patients, whose charts were reviewed by Dr. Miller, displayed a lack of knowledge, skill or judgment of a nature or to an extent that demonstrates that Dr. Houshmand is unfit to continue to practice or that his practice should be restricted.
Interim Undertaking, Clinical Supervision and Resignation of Clinical Supervisor
In July 2017, the College gave notice to Dr. Houshmand that the Inquiries, Complaints and Reports Committee of the College (the “ICRC”) would be considering whether to suspend or to impose restrictions on Dr. Houshmand’s certificate of registration pursuant to s. 25.4 of the Code. On September 5, 2017, Dr. Houshmand signed an interim undertaking with the College, in lieu of the ICRC making an order under s. 25.4 of the Code. The Undertaking required, among other things, that Dr. Houshmand practice in a hospital setting only, and that he practice under the guidance of a Clinical Supervisor who would conduct monthly chart reviews.
Pursuant to the Undertaking, Dr. Richard McCall was retained as Dr. Houshmand’s Clinical Supervisor on September 18, 2017. On November 19, 2017, Dr. McCall wrote to the College expressing concerns about Dr. Houshmand’s practice. These concerns included Dr. Houshmand’s management of an obstetrical patient on October 19, 2017 (the “index case”). Dr. McCall advised that, in light of the situation, the hospital decided to take the unusual action of restricting Dr. Houshmand’s hospital privileges to providing anesthesia services for endoscopy sedation only while waiting for further guidance from the hospital Medical Affairs Committee and the College.
On February 4, 2018, Dr. McCall resigned as Dr. Houshmand’s Clinical Supervisor. In his letter to the College, Dr. McCall wrote, among other things:
I have been the clinical supervisor for Dr. Houshmand since September 28th, 2017. As per my letter of letter [sic] November 13th, 2017, Dr. Houshmand has been restricted to preforming sedation for endoscopy procedures only…
I have been spending a lot of time on the clinical supervision of Dr. Houshmand for the last 4 months. It has been one of my most difficult responsibilities. I have been trying to balance the supervisory role of mentoring my friend and colleague Dr. Houshmand while protecting the public as part as my role of Chief of Anesthesia, at the Hawkesbury General Hospital. I have come to the conclusion that Dr. Houshmand's practice falls below the standard of practice of the profession and that his patients may be exposed to risk of harm or injury. I therefore resign as the clinical supervisor of Dr. Henry Houshmand effective immediately.
As a result of Dr. McCall’s resignation as Dr. Houshmand’s Clinical Supervisor, pursuant to the terms of Dr. Houshmand’s September 5, 2017 Undertaking, Dr. Houshmand was required to cease to practice medicine.
ICRC’s s. 25.4 Interim Order
On April 24, 2018, the ICRC ordered terms, conditions and limitations to be placed on Dr. Houshmand’s certificate of registration pursuant to s. 25.4 of the Code (the “ICRC’s s. 25.4 Interim Order”). Pursuant to the ICRC’s s. 25.4 Interim Order, among other things:
- Dr. Houshmand shall practice only in a hospital setting and shall not practice or seek to practice in any out of hospital premises, independent health facility or health clinic.
- Dr. Houshmand shall practice only under high-level supervision of a Clinical Supervisor acceptable to the College. The Clinical Supervisor must be on site and available at all times that Dr. Houshmand is providing care or treatment to patients and must review and approve treatment plans, and observe Dr. Houshmand during the administration of sedation and during intubation of a patient.
As of January 6, 2019, Dr. Houshmand has not commenced Clinical Supervision under the terms of the ICRC’s s. 25.4 Interim Order. Dr. Houshmand has not been in medical practice since February 2, 2018.
Second Section 75(1)(a) Investigation and Report of Dr. Knox
Based in part on concerns raised by Dr. McCall, the College commenced a second investigation under section 75(1)(a) of the Code, including an additional chart review.
The College retained the services of Dr. Andrew Knox, a general practice anesthetist, to conduct an assessment of Dr. Houshmand’s anesthetic practice. Dr. Knox reviewed 25 charts from Dr. Houshmand’s practice at the Hawkesbury Hospital including the ‘index case’ and interviewed Dr. Houshmand.
Dr. Knox’s report was received by the College on June 4, 2018. Dr. Knox concluded that Dr. Houshmand fell below the standard of practice of the profession in his care and treatment of 15 out of 25 patients whose charts Dr. Knox reviewed. Dr. Knox concluded that Dr. Houshmand met the standard of practice in the ‘index case’.
Based on Dr. Knox’s review of patient charts and interview with Dr. Houshmand, Dr. Knox raised the following concerns about Dr. Houshmand’s anesthesia practice, and his knowledge, skill, and judgment:
- Dr. Houshmand erroneously ordered acetaminophen for a patient in the preoperative period, failing to recognize that another physician had already ordered the same medication, and then erroneously ordered acetaminophen again in the postoperative period;
- with respect to a patient who reported dysphoria and then dizziness in the post-operative period, Dr. Houshmand did not consider a diagnosis of acute emergence reaction to ketamine and during questioning was unable to identify an appropriate approach to emergence phenomenon, such as the use of benzodiazepines;
- in three cases Dr. Houshmand incorrectly documented the Ramsey Sedation Score for a patient on the anesthetic record. He then was unable to accurately describe the scale during the interview;
- in six cases, the time of administration of anesthetic agents was incorrect and had been estimated by Dr. Houshmand after the case had begun;
- in four cases, oxygen saturation and/or blood pressure were not monitored for significant periods of time during the intraoperative period;
- in an endoscopy case where the patient suffered from asthma, Dr. Houshmand inappropriately gave metoprolol to treat intraoperative hypertension, which could have induced bronchospasm in a patient who was already hypoxic;
- in a case where sevoflurane was used as the primary anesthetic agent with a concurrent low dose ketamine infusion for lengthy surgery (reversal of Hartmann’s procedure), Dr. Houshmand permitted the end-tidal Sevoflurane percentage concentration to be as a low as 0.28%, and at less than 1.0% for a lengthy period of time, corresponding to Minimum Alveolar Concentration (“MAC”) of less than 0.5%, placing the patient at risk of intraoperative awareness and subsequent emotional distress, PTSD and life-changing suffering;
- in a case involving dental extractions, Sevoflurane end-tidal percentage concentration was allowed to fall to 0.98% in the middle of the case, corresponding to MAC of 0.49%, again placing this patient at risk of intraoperative awareness and subsequent emotional distress;
- in an endoscopy case involving a patient with Reynaud’s syndrome, Dr. Houshmand failed to take appropriate steps to obtain an alternate monitoring site for oxygen saturation, leading to a failure to respond to the warning signs of respiratory compromise.
Dr. Knox concluded that of the 15 cases in which Dr. Houshmand failed to meet the standard of practice, the patients were put at risk of harm by Dr. Houshmand’s actions in six cases. These risks were caused by poor or absent intraoperative monitoring, a lack of care, or poor judgment with respect to anesthetic depth. The errors occurred in areas of expertise that should be considered key competencies for an anesthetist.
Dr. Houshmand responded to Dr. Knox’s report by letter dated July 20, 2018. In response to this letter, Dr. Knox provided a supplementary report to the College dated August 12, 2018. Dr. Knox’s opinion that Dr. Houshmand failed to meet the standard of practice remained unchanged. Dr. Knox further noted that Dr. Houshmand’s pattern of practice repeatedly placed his patients at risk by failing to monitor them appropriately during anesthesia.
Dr. Houshmand admits that he failed to maintain the standard of practice of the profession in his care and treatment of 15 patients whose charts were reviewed by Dr. Knox.
Dr. Houshmand does not contest that his care of 15 patients, whose charts were reviewed by Dr. Knox, displayed a lack of knowledge, skill or judgment of a nature or to an extent that demonstrates that Dr. Houshmand is unfit to continue to practice or that this practice should be restricted.
Additional Information
The College also obtained a report prepared for the Hawkesbury Hospital by an external reviewer, Dr. Paul Kenny, a general practice anesthetist who retired from practice in 2017. Dr. Kenny’s review raised concerns regarding Dr. Houshmand’s standard of practice and his risk of harm to patients. Dr. Kenny’s review consisted of the ‘index case’, as well as 25 additional charts that had been pre-screened for possible problems by the head of the anesthesia department. Dr. Kenny also interviewed Dr. Houshmand.
Dr. Kenny’s report is dated February 7, 2018.
Dr. Kenny opined that Dr. Houshmand did not meet the standard of practice in the ‘index case’. With respect to his review of 25 of Dr. Houshmand’s pre-screened patient charts from the Hawkesbury Hospital, Dr. Kenny opined, among other things, that:
- None of the charts met the standard of care, although some of the deficiencies were minor.
- 8 out of 25 charts demonstrated a significant violation of the standard of care of an anesthetist practising in a community hospital in Canada, although in 3 of those cases, the loss of patient records secondary to a problem with the new electronic medical record had not been ruled out.
- 11 out of 25 charts provided evidence of non-standard drug use, some of which could cause patient harm.
- In 15 out of the 25 cases reviewed by Dr. Kenny, the patient suffered harm or potential harm, but in no case was the harm serious and permanent harm was not foreseen in any of the cases reviewed.
- Dr. Houshmand’s standard general anesthetic management did not appear to vary much according to patient age, procedure, comorbidities, or length of procedure. Young healthy patients with short procedures received remarkably similar techniques to those having longer techniques or those with multiple comorbidities.
Dr. Kenny also concluded that there was evidence of other clinical practices that did not meet the standard of practice of the profession, including that Dr. Houshmand admitted that he has occasionally, maybe three times in the recent past, reused the same syringe containing a drug, for more than one patient, after changing the infusion line that connects the drug-containing syringe to the main line, which introduces the risk of blood borne infection, and which practice is absolutely contraindicated.
Dr. Houshmand admits that he failed to maintain the standard of practice of the profession in his care and treatment of 25 patients whose charts were reviewed by Dr. Kenny. Dr. Houshmand does not admit that he failed to maintain the standard of practice of the profession in his care and treatment of the patient in the ‘index case’.
Dr. Houshmand does not contest that his care of these 25 patients, whose charts were reviewed by Dr. Kenny, displayed a lack of knowledge, skill or judgment of a nature or to an extent that demonstrates that Dr. Houshmand is unfit to continue to practice or that his practice should be restricted.
PENALTY
The Committee ordered:
-Dr. Houshmand is to be reprimanded;
-The Registrar is to impose terms and conditions and limitations on Dr. Houshmand’s certificate of registration as set out in detail in the public decision available on the College’s website, to include a Practice Restriction to practising in a hospital setting only; Clinical Supervision by a Clinical Supervisor acceptable to the College for a minimum period of 15 months.
Dr. Houshmand is pay to the College costs of two days of hearing, in the amount of $20,740 within 30 days of the date of the Order.
Decision: Download Full Decision (PDF)
Hearing Date(s): January 6, 2020 Penalty Hearing: January 20, 2020 Reprimand: August 27, 2020 at 10:00 a.m