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Hoffer, Mayer

CPSO#: 30856

MEMBER STATUS
Expired: Resigned from membership as of 01 Dec 2019
CURRENT OR PAST CPSO REGISTRATION CLASS
None as of 26 May 2008

Summary

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Former Name: No Former Name

Gender: Male

Languages Spoken: English

Education: University of Manitoba, 1978

Practice Information

Primary Location of Practice
Practice Address Not Available

Specialties

Specialty Issued On Type
Psychiatry Effective:06 Jun 1983 RCPSC Specialist

Registration History

Action Issue Date
First certificate of registration issued: Independent Practice Certificate Effective: 28 Jun 1979
Transfer of class of certificate to: Restricted certificate Effective: 26 May 2008
Terms and conditions imposed on certificate Effective: 26 May 2008
Terms and conditions amended by member Effective: 10 Nov 2010
Terms and conditions amended by Inquiries, Complaints and Repo Effective: 19 Oct 2017
Expired: Resigned from membership. Expiry: 01 Dec 2019

Previous Hearings

Committee: Discipline
Decision Date: 02 Dec 2019
Summary:

On December 2, 2019, on the basis of a Statement of Uncontested Facts, the Discipline Committee found that that Dr. Hoffer committed an act of professional misconduct, in that he has failed to maintain the standard of practice of the profession. Dr. Hoffer did not contest that based on these facts, he engaged in professional misconduct in that he failed to maintain the standard of practice of the profession in his care of 28 patients.

Dr. Hoffer is a 64-year-old psychiatrist who received his certificate of registration authorizing independent practice from the College in June 1979. At the relevant time, Dr. Hoffer practiced psychiatry in Toronto, Ontario. His practice focused on the treatment of attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) in both children and adults.

Between March 2016 and December 2018, the College received information of concern regarding Dr. Hoffer’s clinical practice, including reports from three psychiatrists working at local hospitals regarding Dr. Hoffer’s care of their mutual patients, and one complaint from the brother of a patient of Dr. Hoffer’s who had recently been hospitalized. The College commenced investigations into Dr. Hoffer’s psychiatric practice.

As part of its investigations, the College obtained independent opinions from Dr. Donald Duncan, a child and adolescent psychiatrist with expertise in the assessment and treatment of ADHD across the lifespan and Assistant Clinical Professor of Psychiatry at the University of British Columbia, practicing in British Columbia; Dr. Nicholas Delva, a general adult psychiatrist and former Head of the Department of Psychiatry at Dalhousie University; and Dr. Christopher Bryniak, a psychiatrist with experience in general adult psychiatry, forensic psychiatry and emergency psychiatry. Dr. Delva reviewed Dr Hoffer’s care of one patient(Patient A). Dr. Bryniak reviewed Dr. Hoffer’s care of one patient (Patient B). Dr. Duncan reviewed Dr. Hoffer’s care of 28 patients (including Patient A and Patient B).

Failure to Maintain the Standard of Practice of the Profession

A. Record Keeping

The expert opinions concluded that one or more of the following deficiencies with respect to record keeping and documentation were present in each of the 28 patient charts reviewed:

i. The charts were not legible. They were difficult to read and often disorganized. It was not possible to read all chart entries without first obtaining a transcription;

ii. The rationale behind treatment decisions was often missing, vague or contradictory (for example, despite a notation that the patient was “doing well”, the record indicated that the patient’s medication had been changed or the dosage increased);

iii. Records of medication dosing were often vague (for example, indicating "prescribing Dexedrine” or “Dexedrine 1/1” but failing to record the precise dosage prescribed);

iv. Medication changes were frequently made between recorded patient encounters, with no notation of when these changes were made or why. Although Dr. Hoffer frequently provided care over the telephone, he rarely documented phone-based reviews and treatment changes;

v. In some cases, Dr. Hoffer failed to document discussions regarding informed consent, including a review of medication risks, prior to initiating high doses of stimulants or other drugs, off-label medications, or multiple medications with similar mechanisms of action;

vi. For one patient reviewed by the College experts, the available chart did not document the basis for the diagnosis of ADD (although the expert acknowledged this did not necessarily mean the patient did not have this disorder);

vii. For some patients, Dr. Hoffer failed to document relevant clinical information, such as substance misuse, vitals or family history.

B. Communication with Family/Referring Physician

Dr. Hoffer did not provide any initial or ongoing reports to family physicians or referral sources regarding findings, treatment recommendations, treatment plans or changes in clinical status or treatment plan. The charts reviewed contained no evidence of any communication between Dr. Hoffer and family physicians/referral sources. Dr. Hoffer relied instead on patients to update their family physicians regarding their treatment and prescriptions. The expert opinions concluded that this lack of communication with referral sources and reliance on patients to keep their family physicians informed of their treatment was not reliable, adequate or appropriate.

C. Prescribing

The expert opinions concluded that the following deficiencies with respect to prescribing were present in some of the charts reviewed:

i. Failure to optimize dose before changing prescription
 
In two cases reviewed by the College experts, Dr. Hoffer added new medications without first optimizing the dose of medications already prescribed or before sufficient time had elapsed to assess the treatment response to currently prescribed medications.

ii. Failure to review ongoing need for medications

In two cases reviewed by the College experts, there was no evidence in the chart that Dr. Hoffer reviewed the need to continue prior medications after a new medication had been introduced and resulted in a positive response. This practice could potentially result in patients being on multiple unnecessary medications.

iii. Failure to meet criteria before prescribing high stimulant doses

For some patients, Dr. Hoffer prescribed stimulant doses well above the maximum doses set out in the product monographs or recommended by the Canadian ADHD Resource Alliance (CADDRA) without meeting necessary conditions, such as:

1. First trialling alternative medications prescribed within the normal dosage range (for example, trialling normal doses of methylphenidate before exceeding the maximum recommended dose of dextroamphetamine, or vice versa);

2. Documenting his discussion about explaining the risks and benefits with the patient and informing patients that the proposed doses are beyond the typically recommended doses;

3. Documenting the outstanding clinical concerns and medication-responsive target symptoms believed to justify the exceptionally high doses;

4. Documenting vital [sign]s regularly.

While prescription of stimulants above the maximum doses recommended by CADDRA or the product monographs may be appropriate for some patients, higher doses involve increased risk to patients and require careful consideration of risks and benefits and fully informed consent.

ii. Use of Stimulants in Psychotic Patients
The expert opinions concluded that Dr. Hoffer failed to maintain the standard of practice in his treatment of patients who exhibited psychosis.

a. Patient A

Patient A was a pre-existing patient who returned to Dr. Hoffer’s practice in 2010 after a multi- year absence. Dr. Hoffer’s chart for Patient A did not include the visits prior to 2010.

Two experts retained by the College opined that Dr. Hoffer’s care of Patient A failed to meet the standard of practice of the profession, demonstrated a lack of judgment and placed this patient at a risk of harm in that:

a. His record keeping was substandard, lacking relevant positive and negative findings at each visit, and failing to document the clinical decisions made and the rationale behind decisions;

b. Despite multiple indications in the records that Patient A had a problem with substance misuse, there was no documentation of whether she might meet the criteria for Substance Use Disorder. Dr. Hoffer failed to diagnose or adequately deal with the misuse of amphetamines in this case;

c. The dose of amphetamines used was excessive (up to three times the recommended maximum of the product monographs and more than double the CADDRA recommended daily maximum), and Dr. Hoffer failed to meet appropriate conditions for providing such a high dose of amphetamines (as set out above);

d. There was no evidence Dr. Hoffer monitored the patient’s physiological safety while on these high doses of stimulants, or communicated with the patient’s family physician so they could monitor accordingly;

e. His response to evidence of severe medication intolerance, when Patient A was diagnosed with amphetamine-induced psychosis on more than one occasion when she presented to the hospital, was inadequate:
o He minimized the validity of the psychotic episodes;
o He explicitly questioned the possibility that a patient with ADHD can experience stimulant induced psychosis;
o After the patient required three admissions for episodes of psychosis while on amphetamines (a condition which cleared each time shortly after discontinuation of the amphetamine), Dr. Hoffer continued to prescribe stimulants against the advice of two inpatient treatment teams;

b. Patient C

Patient C was referred to Dr. Hoffer by her family physician in 2007 for treatment of ADD diagnosed 10 years previously. Dr. Hoffer confirmed the diagnosis and started her on Dexedrine 32.5 mg in three divided doses. Over three years, the dose was gradually increased to a maximum dose of 60mg daily.

The expert opinion identified the following deficiencies in Dr. Hoffer’s care of Patient C (in addition to record keeping and failing to communicate with the family physician):

i. Dr. Hoffer failed to notice or acknowledge collateral reports of paranoia while the patient was on relatively high doses of Dexedrine;

ii. Dr. Hoffer never trialled Patient C on alternate ADHD medications despite her repeated destabilization on Dexedrine;

iii. He increased her dose of Dexedrine, despite documenting that she was “doing much better” – with the sole documented rationale being “only on Dexedrine spansules 10 mg b.i.d.”;

iv. In a vulnerable patient, he restarted Dexedrine between documented appointments without making a record.

The College expert opined that Dr. Hoffer’s care likely exposed this patient to harm or injury on the basis of repeated use of stimulant medication in psychotic patient who repeatedly decompensates.

c. Patient D

Patient D had a history of ADHD and was referred to Dr. Hoffer by a family physician. He was started on Dexedrine with good effect. Later, he developed psychosis and was diagnosed with schizophrenia.

Dr. Hoffer trialled several medications to treat the patient’s psychosis, but the patient stopped them. Dexedrine was then prescribed to treat Patient D’s concentration problems.

The expert opinion identified the following deficiencies in this patient’s care (in addition to record keeping and failure to communicate with the family physician):
i. Dr. Hoffer used Dexedrine to treat concentration problems in a patient with uncontrolled and untreated schizophrenia, which was likely to expose this patient to harm or injury;
ii. The prescription for Dexedrine included 20mg “at bedtime”. There was no record of this prescription or of the clinical rationale for a bedtime stimulant in the clinical notes;
iii. Dr. Hoffer maintained Patient D on weekly Dexedrine dispensing with no detailed record of in-person contact with this schizophrenic patient for over one year (between April 2015 and June 2016);
iv. Medication was dispensed weekly with no explanation for this mode of dispensing in the chart;
v. Dr. Hoffer provided Dexedrine prescriptions above the recommended daily maximum (Dexedrine 60 mg/day) in a psychotic individual who was not being seen regularly for review.

 
iii. Patient E

Patient E was diagnosed with ADHD and also suffered from comorbid depression, diabetes and hypertension. He was referred to Dr. Hoffer in 2005. After trialling several stimulants (all dextroamphetamine), Dexedrine was chosen as the treatment of choice.

On several occasions between 2007 and 2012, Dr. Hoffer recorded that the patient had unilaterally increased the dose or frequency of his Dexedrine.

Dr. Hoffer continued to prescribe Dexedrine to Patient E for 68 months (between March 21, 2013 and November 20, 2018) without ever seeing the patient in person. During this 68-month period, Dr. Hoffer was subject to an Undertaking with the College which required him to see patients at least once per year, prior to renewing any prescriptions. As such, his prescribing to Patient E during this period was in breach of his undertaking with the College.

In November 2018, Patient E’s case worker called 911 after visiting his home and finding him doing poorly and the house in disarray. He was admitted to hospital. Per the hospital documentation, Patient E stated that he had taken too much behaviour/mood medication and ended up sleeping for 3 days. He also reporting having run out of his Dexedrine several days prior to his admission, and sleeping. As a result, he had not managed his insulin injection during the days he was sleeping.

While in hospital, Patient E’s Dexedrine prescription was discontinued, as the Consultation Liaison Psychiatry service concluded he did not have ADHD and did not need Dexedrine. When Patient E attempted to use his own supply of Dexedrine (he had 540 tablets with him at admission), the medication was confiscated. This led to an altercation between the patient and security staff.

During hospitalization, the Consultation Liaison Psychiatry service spoke with Dr. Hoffer. It is documented that Dr. Hoffer indicated that he had seen the patient within the last year and that he was not aware that the patient was taking higher doses than were prescribed, or more frequently than prescribed. These statements were not true, and were contradicted by Dr. Hoffer’s clinical record.

Upon discharge, it was recommended that Patient E not restart Dexedrine. His supply of Dexedrine was not returned to him. These recommendations, contained in the discharge summary, were copied to Dr. Hoffer.

Dr. Hoffer saw Patient E three days after discharge. His records state:
i. “ out of Dexedrine – sleeping for 3 days and got ill; may have been due to the flu”
ii. “Dex ... every 2 hours (recent change) ... 7-9 tabs per day”
iii. “no changes to his medication during hospitalization”
iv. “had recently changed his dosing (schedule which has minimized the “up and down” affective Dexedrine (along with the elimination of “sleep attacks” during the day)”
 
At the November 20, 2018 visit, Dr. Hoffer restarted Patient E’s Dexedrine prescription at 5 mg. t.i.d., giving the patient a prescription for 1 month with 2 refills.
30. The expert opinion identified several concerns in Dr. Hoffer’s care of Patient E (in addition to the deficiencies with record-keeping and follow-up reporting outlined above), set out below.

i. Failure to address medication misuse

Although the patient began taking Dexedrine at higher doses and at a higher frequency than prescribed, there was no record of Dr. Hoffer cautioning the patient against this practice. Even after the patient was hospitalized for challenges potentially due in part to excessive use of stimulants, Dr. Hoffer continued to prescribe the Dexedrine without any documented discussion regarding the misuse.

During an interview with the medical assessor, Dr. Hoffer indicated that he would not consider Substance Use Disorder in this patient because there was no history of using medication “to get high”. This indicates an error in judgment for two reasons: first, patients do not only misuse medications “to get high”; and second, Dr. Hoffer had in fact documented that patient’s history of misusing testosterone in the past and was aware of a history of medication misuse for this patient.

ii. Continued prescription renewals without regular face-to-face visits

Dr. Hoffer should not have continued to prescribe Dexedrine, a controlled substance, for almost 6 years without seeing the patient. This failed to meet the standard of practice in prescribing.

iii. Exposure to harm

Dr. Duncan concluded that Dr. Hoffer’s care of Patient E exposed the patient to serious risk of harm. Although Dr. Hoffer was not directly responsible for the patient taking more medication than prescribed, he was indirectly responsible by failing to address the patient’s ongoing pattern of medication misuse and by continuing to prescribe the medication without seeing the patient for almost 6 years.

FACTS ON PENALTY

On November 27, 2019, Dr. Hoffer entered into an undertaking with the College, whereby he agreed to resign his certificate of registration and never apply or reapply for registration as a physician in Ontario or any other jurisdiction as of December 1, 2019.

Discipline History with the College

In 2008, the Discipline Committee of the College found Dr. Hoffer to have engaged in professional misconduct, in that he failed to maintain the standard of practice of the profession. Dr. Hoffer failed to assess Patient AA [identified as Patient A in the Discipline Committee’s 2008 decision and reasons] in person between 2002 and 2004, which constituted a failure to maintain the standard of practice of the profession. Dr. Hoffer also failed to maintain the standard of practice of the profession in record-keeping for Patient AA (including the absence of clinical notes and inadequate medication records from October 2000 to September 2004) and Patient BB [identified as Patient B in the Discipline Committee’s 2008 decision and reasons] (specifically, deficiencies in documentation of the medications prescribed, changes in dosage, reasons for medication and dosage changes and follow-up plans). Dr. Hoffer was ordered to complete a medical record-keeping course, a prescribing course, and to undergo clinical monitoring and a re-assessment of his practice. He was also reprimanded and ordered to pay costs. Dr. Hoffer complied with the terms of the Order.

Past Inquiries, Complaints and Reports Committee Decisions

In May 2007, the College’s Complaints Committee issued a written caution to Dr. Hoffer.

In August 2010, the ICRC agreed to accept an undertaking from Dr. Hoffer following its consideration of the results of a s. 75(a) investigation and a reassessment conducted pursuant to the Order of the Discipline Committee.

In June 2015, the College’s Inquiries, Complaints and Reports Committee (“ICRC”) issued a caution in person to Dr. Hoffer.

DISPOSITION

On December 2, 2019, the Discipline Committee ordered that:

- Dr. Hoffer attend before the panel to be reprimanded.

- Dr. Hoffer pay costs to the College in the amount of $6,000.00 within 30 days of the date of this Order.


Decision: Download Full Decision (PDF)
Hearing Date(s): December 2, 2019

 

Committee: Discipline
Decision Date: 26 May 2008
Summary:

On May 26, 2008, the Discipline Committee of the College of Physicians and Surgeons of Ontario found that Dr. Mayer Hoffer committed acts of professional misconduct in that he failed to maintain the standard of practice of the profession. The Discipline Committee ordered and directed:

1. Dr. Hoffer to appear before the panel to be reprimanded, with the fact of the reprimand to be recorded on the register.

2. The Registrar to impose the following terms, conditions and limitations on Dr. Hoffer s certificate of registration:

(1) Dr. Hoffer shall successfully complete, at his own expense:

a. the College s Medical Record-Keeping for Physicians course (attendance at the instructional portion of the course by July 31, 2008 and complete the follow-up portion by September 30, 2008); and
b. the Physicians Prescribing Skills course on or before October 16, 2008 and provide proof thereof to the College;

(2) Dr. Hoffer shall maintain a detailed prescription log during the monitoring period (as defined in paragraph 3), which will be available for review by the monitor, an expert in Attention Deficit Disorder, acceptable to the College (the Monitor);

(3) Dr. Hoffer is required to undergo bi-weekly clinical monitoring at his own expense by the Monitor for a period of six months or, at the discretion of the Monitor, monthly clinical monitoring (instead of bi-weekly) for the second half of the monitoring period. The monitoring period shall commence no later than 30 days from the date of this Order;

(4) The Monitor s review shall include the following:

a. A review of a representative sample of Dr. Hoffer s charts;
b. Discussion and review with Dr. Hoffer of his prescribing and charting; and
c. A review of the prescription log (including verification of corresponding chart entries);

(5) The Monitor will provide reports to the College after one month of monitoring, at the end of the monitoring period, and at any time during the monitoring period if the monitor has concerns regarding Dr. Hoffer s practice;

(6) Dr. Hoffer shall undergo, at his own expense, a re-assessment of his practice six months after the end of the monitoring period by an assessor acceptable to the College (the Assessor ). The Assessor shall report in writing to the College and to Dr. Hoffer; and
 
(7) Dr. Hoffer shall abide by any reasonable recommendations provided by the Assessor.

3. That Dr. Hoffer pay costs to the College in the amount of $3,650.00 within 60 days of the date of this Order.

4. The results of this proceeding to be included on the register.

Therefore, the terms, conditions and limitations on the certificate of registration in the Province of Ontario issued in the name of Dr. Mayer Hoffer are effective May 26, 2008 at 12:00 noon.


Decision: Download Full Decision (PDF)
Appeal: No Appeal
Hearing Date(s): May 26, 2008

Concerns

Source: Member
Active Date: December 1, 2019
Expiry Date:
Summary:
Summary of the Undertaking given by Dr. Mayer Hoffer to the College of Physicians and Surgeons of Ontario, effective December 1, 2019:

i. Between the date of the Undertaking and the Effective Date:

Dr. Hoffer shall not issue prescriptions or renew existing prescriptions for a duration which extends beyond March 1, 2020.

ii. As of the Effective Date

Dr. Hoffer was referred to the Discipline Committee on allegations of professional misconduct and incompetence. In the face of these allegations, Dr. Hoffer resigned from the College and has agreed never to apply or reapply for registration as a physician in Ontario or any other jurisdiction.
Download Full Document (PDF)

 

Source: Compliance and Monitoring Department
Active Date: June 3, 2015
Expiry Date:
Summary:
Caution-in-Person:

A summary of a decision of the Inquiries, Complaints and Reports Committee in which the disposition includes a "caution-in-person" is required by the College by-laws to be posted on the register, along with a note if the decision has been appealed. A “caution-in-person” disposition requires the physician to attend at the College and be verbally cautioned by a panel of the Committee. The summary will be removed from the register if the decision is overturned on appeal or review. Note that this requirement only applies to decisions arising out of a complaint dated on or after January 1, 2015 or if there was no complaint, the first appointment of investigators dated on or after January 1, 2015.
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