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Publishedb
by:
TransitionallCouncil
CollegeofTTraditionalChinesseMedicinePracttitionersand
AcupuncturristsofOntario
163QueenStreetEast,4/F
Toronto,On
ntarioM5A1S1
Tel:(416)86624790 (866)66248483
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744078
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Copyrightt2012byR
RichardSteinecckeandtheCo
ollegeofTraditionalChinesseMedicinePrractitionersan
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AcupunctturistsofOntaario.

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Allrightsreseerved.

ImportantLegalPrinciplesPractitionersNeedtoKnow

TableofContents

1. ProfessionalismandSelfRegulation.................................................................... 4
a. Theconceptofselfregulation................................................................. 4
b. Ethics,professionalstandards,professionalmisconduct,incompetence,
incapacity.................................................................................................. 6
2. Communication.................................................................................................... 11
a. Introduction.............................................................................................. 11
b. Informedconsent..................................................................................... 12
c. Boundariesandsexualabuse................................................................... 19
d. Interprofessionalcollaboration................................................................ 26
e. Billing........................................................................................................ 28
3. Law....................................................................................................................... 30
a. Typesoflaw.............................................................................................. 30
b. RHPA......................................................................................................... 31
i. Controlledactsanddelegation..................................................... 31
ii. Scopeofpractice.......................................................................... 36
iii. Useoftitles................................................................................... 38
iv. Mandatoryreports....................................................................... 39
v. Publicregister............................................................................... 45
vi. Professionalcorporations............................................................. 46
c. TCMA,regulations,bylaws...................................................................... 48
i. Registrationregulation................................................................. 49
ii. Professionalmisconductregulation............................................. 51
iii. Recordkeeping............................................................................. 55
iv. Conflictsofinterest...................................................................... 59
v. Advertising................................................................................... 62
d. TheCollege............................................................................................... 64
i. Registrationprocess..................................................................... 64
ii. Complaintsanddisciplineprocess................................................ 66
iii. Incapacityprocess......................................................................... 72
iv. Qualityassuranceprogram........................................................... 75
e. Otherlaws................................................................................................. 78
i. PHIPA............................................................................................. 78
ii. PIPEDA........................................................................................... 85
iii. HealthCareConsentAct............................................................... 86
iv. ChildandFamilyServicesAct........................................................ 87
v. LongTermCareHomesAct........................................................... 89
vi. HumanRightsCodeandAccessibilityforOntariansWithDisability
Act.................................................................................................. 91
vii. Municipallicensing........................................................................ 96

IntroductionandOverview

Thepurposeofthisbookandthejurisprudencecourseistoprovideinformationontheethical
andlegalframeworkwithinwhichTCMPractitionersandAcupuncturistspracticeinOntario.

Thisbookwillfirstdiscusstheconceptsofprofessionalismandselfregulation.TheTraditional
ChineseMedicineActisbasedontheseconcepts.Thebookwillthenlookathowproper
communicationwithpatientsandcolleaguesisfundamentaltoaprofessionalpractice.For
example,informedconsentisnotpossiblewithoutcommunication.Thebookwillthenreview
thevariouslawsthatpractitionersaremostlikelytohavetodealwithintheirpractice.

InthisbookthereareanumberofActsthatarereferredtobytheirabbreviationsincludingthe
following:

AODAAccessibilityforOntarianswithDisabilityAct
CFSAChildandFamilyServicesAct
HCCAHealthCareConsentAct
PHIPAPersonalHealthInformationProtectionAct
PIPEDAPersonalInformationProtectionandElectronicDocumentsAct
RHPARegulatedHealthProfessionsAct
TCMATraditionalChineseMedicineAct

1. ProfessionalismandSelfRegulation

Aprofessionisdifferentfromabusiness.Membersofaprofessionbelievethattheyhelp
patients,notjustmakemoneyfromthem.Practitionershaveanumberofdutiestothepatients
theyserve.Forexample,practitionershavethedutytobehonestwithpatients.Practitioners
haveadutytoprovidegoodservicetopatients.Practitionershaveadutytotellpatientswhat
theyaregoingtodotothepatientandtoaskforthepatientsconsentbeforedoingit.

Beingamemberofaprofessionalsomeansthatpractitionershaveadutytoothermembersof
theprofession.Practitionershaveadutytobepolitetoeachother.Practitionershaveadutyto
workwithfellowpractitionerstoservethewelfareoftheirpatients.Forexample,practitioners
needtotrytocoordinatethecareofapatienttheyarebothtreatingwheneverpossible(and
thepatientconsents).

PractitionersalsohaveadutytoworkwiththeirregulatoryCollegetoprotectthepublicfrom
dishonestorincompetentpractitioners.Forexample,practitionersarerequiredtocooperatein
aninvestigationofacomplaint.

Professionalsmustalsoobeythelawsthatapplytothem.Therearemanydifferentlawsthat
applytoapractitioner.Thepurposeofthisbookistodescribesomeoftheselawsinageneral
waysothatpractitionersunderstandthebasicprinciples.Itdoesnotcoveralloftheexceptions
andspecialcircumstancesthatariseinreallife.Ifapractitionerhasaspecificlegalquestion
abouttheirowncircumstance,theyshouldseekadvicefromalawyer.

a. Theconceptofselfregulation

Theregulationofanactivitymeansthatthelawimposesrestrictionsontheactivitytoensure
thatthepublicarenotharmed,andactuallybenefit,fromit.Therearemanywaysinwhichan
activitycanberegulated.Forexample,thegovernmentcouldcreateoffencesforimproperly
doingtheactivity,orthegovernmentcouldhaveoneofitsMinistriesoverseeingtheactivity.

InOntario,mostprofessionsareselfregulated.Inmanyotherpartsoftheworld,professions
areregulateddirectlybythegovernmentorthroughgeneralconsumerprotectionlaws.Ontario
haschosenthismodelsothatthosewhobestunderstandtheprofessionareinvolvedinits
regulation.

SelfregulationmeansthattheOntariogovernmenthasmadeastatute(oftencalledanAct)
givingthedutytoregulatetheprofessiontoaseparatebody(calledaCollege)themajorityof
whoseCounciliselectedbytheprofession.TheCollegeisaregulatorybody,notaneducational
institution.TheCouncilistheBoardofDirectorsoftheCollege.TheCouncilestablishesthe
policiesoftheCollege(e.g.,itmakestheprofessionalmisconductregulations)andoverseesthe
administrationoftheregulatoryactivitiesoftheCollege(e.g.,itestablishesthebudgetforthe
qualityassuranceprogramoftheCollege).TheCollegeoperatesthroughcommittees(e.g.,the

RegistrationCommittee,theDisciplineCommittee)themajorityofwhosemembersarefrom
theprofession,withothermemberscomingfromthepublic.

ThemandateoftheCollegeistoservethepublicinterest.Itdoesthisbyregulatingthe
professioninthepublicinterest.Underitsstatute,theCollegehasadutytoserveandprotect
thepublicinterest.TheCollegecannotservetheselfinterestoftheprofession(e.g.,the
Collegecannotsetfeestobechargedtopatients,norcanitadvocatetothegovernmenton
behalfoftheinterestsoftheprofession);thatistheroleofaprofessionalassociation,nota
regulatoryCollege.Selfregulationdoesnotmeanselfinterest;infactitmeansexactlythe
opposite.Selfregulationmeansservingthepublicinterest.Thatis,theCollegeensuresthatthe
professionactshonestlyandcompetently.

ThereareanumberofsafeguardsthatensurethattheCollegeservesthepublicinterest,
includingthefollowing:

i. TheCouncilandthecommitteesoftheCollegealsohavepublicmembersonthem
(i.e.,nonpractitionersappointedbythegovernment).TheActrequiresthatpublic
memberscompriseasizeableminorityoftheCouncilanditscommittees.
ii. Councilmeetingsanddisciplinehearingsareopentothepublic.Observerscan
attendandwatchwhathappens.
iii. TheCollegemustconsultwithmembersoftheprofessionandthepublicbefore
makingaregulationorbylawaffectingthem.TheCollegemustcirculatefor
commenttheproposedwordingofaproposedregulationandmanybylawsfora
periodofatleast60days.
iv.
DecisionsofthecommitteesoftheCollegecanbereviewedbyotherbodies.For
example,decisionsoftheRegistrationCommitteeortheInquiries,Complaintsand
ReportsCommitteecanbereviewedbytheaffectedindividualstotheHealth
ProfessionsAppealandReviewBoard(HPARB).DecisionsoftheDiscipline
CommitteeortheFitnesstoPractiseCommitteecanbeappealedtotheDivisional
Court.
v.
ThegovernmenthasappointedtwobodieswhoensurethattheCollegeactsinthe
publicinterest.TheOfficeoftheFairnessCommissionermakessurethatthe
Collegesregistrationpracticesaretransparent,objective,impartialandfair.In
addition,theMinisterofHealthandLongTermCarecanreferconcernsaboutthe
CollegesregulationsorprogramstotheHealthProfessionsRegulatoryAdvisory
Council(HPRAC)forreview.
vi.
TheCollegehastoreporttotheMinister.Ithastomakeanannualreportandsuch
otherreportsastheMinisterrequests.TheMinisterhastheabilitytomake
recommendationsorevenissuedirectionstotheCounciloftheCollege.Ifthereare
seriousconcernstheMinstercanaudittheoperationsoftheCollegeandcan
appointasupervisortotakeoveritsoperations.Thus,whiletheCollegeisseparate
fromthegovernment,itisstillaccountabletotheMinisterofHealthandLongTerm
Care.

ThesesafeguardshelpensurethattheCollegeservesthepublicinterestinafairandopen
manner.

GiventhepublicinterestmandateoftheCollegeandthesafeguardsthatareinplace,
professionalmemberselectedtotheCouncilneedtobecarefulabouttheirrole.Asmentioned
above,Councilmembersarelikedirectorsofacorporationwhohaveadutyofloyaltyandgood
faithtothemandateoftheirorganization.Councilmembersarenotlikepoliticianswho
representandservethosewhoelectedthem.TheonlyroleofCouncilmembersistorepresent
thepublicandthepublicinterest

SampleExamQuestion

WhatsentencebestdescribestherolesoftheCollegeandprofessionalassociations?
i) TheCollegeservesthepublicinterest;professionalassociationsservethe
interestsoftheprofession.
ii)TheCollegeandtheprofessionalassociationsbothservethepublicinterest.
iii)TheCollegeandtheprofessionalassociationsbothservetheinterestsofthe
profession.
iv)TheprofessionalassociationsdirecttheoperationsoftheCollege.

Thebestanswerisi).TheCollegesmandateistoregulatetheprofessioninorderto
serveandprotectthepublicinterest.Answerii)isnotthebestanswerbecause
professionalassociationsaredesignedtoservetheinterestsoftheirmembers.While
professionalassociationscareaboutthepublicinterestandoftentakeactionsthatassist
thepublicinterest,theyareundernostatutorydutytodosoandareaccountableonlyto
theirmembers.Answeriii)isnotthebestanswerbecausetheCollegeisnotpermittedto
servetheinterestsofitsmembersunderitsstatute.Whileittriestoensurethatit
regulatesitsmemberssensitivelyandfairly,andconsultswithitsmembers,theColleges
mandateisthepublicinterest.Answeriv)isnotcorrect.WhiletheCollegeconsultswith
theprofessionalassociationsandconsidersseriouslytheirviewsandrespectstheir
expertise,theCollegeisnotunderthecontrolofanyprofessionalassociation.

b. Ethics,professionalstandards,professionalmisconduct,incompetence,incapacity

AmajorpartoftheCollegesroleistodevelopand,sometimes,enforceaCodeofEthicsand
professionalstandards.TheCollegetakesactionwherethereisprofessionalmisconduct,
incompetenceandincapacity.Eachoftheseconceptsisslightlydifferentinitsroleandpurpose.

Thissectionofthebooklooksateachofthem.

CodeofEthics

Professionshaveethicalprinciplestoguidetheirmembers.Theseethicalprinciplesinclude
beinghonestatalltimes,respectingtheconfidentialityofapatient,treatingclientswith
sensitivity,maintainingonescompetenceandallowingpatientstomakeinformedchoicesasto
theirhealthcare.ManyprofessionalassociationshavedevelopedaCodeofEthicsfortheir
members.

TheCollegeisauthorizedunderitsstatutetodevelopaCodeofEthicsforitsmembers.Assuch,
theCollegesCodeofEthicstakespriorityovertheCodesofEthicsofprofessionalassociations.

ThepurposeoftheCodeofEthicsistosetoutthegoalsoridealsthatpractitionerstrytoreach.
Theprinciplesareoftensetoutaspositivestatements(e.g.,apractitionerwillbehonest).This
isdifferentfromaprofessionalmisconductregulationwhichsetsouttheminimum
practitionersmustdotoavoiddiscipline(e.g.,apractitionerwillnotissueafalseormisleading
document).ManyprinciplesoftheCodeofEthicsalsoencouragepractitionerstocontinually
improve(e.g.,onecanalwaystrytobemoresensitivetotheclient).

TheCodeofEthicsisnotenforcedthroughthedisciplineprocess.Rather,theirroleistoguide
andencouragethepractitioner.IfapractitionerfollowstheprinciplesoftheCodeofEthics
(e.g.,beinghonest)theywillavoidengaginginprofessionalmisconduct(e.g.,theywillnotissue
afalseormisleadingdocument).

EthicsScenario

PractitionerXisalwayspolitetohispatients,inaformalway.Hefeelsgoodabout
himself.However,heoftensaysGodtoexpresssurprise.Thephrasemeansnothingto
himandnoonehaseverexpressedconcernsaboutit.Oneofhispatients,Paul,has
sharedthatheisveryreligious.WheneverXsaysGodPaulflinchesabit.Xnoticesand
asksPauliftheuseofthewordGodbothersPaul.Paulsaysthat,actuallyitdoes.X
makesapointofnotsayingGodanymoreinfrontofPaul.Afterdiscussingtheincident
withacolleague,Xdecidesthattheethicalthingforhimtodoistostopusingtheword
GodasanexpressionofsurprisewheneverheiswithapatientbecauseXcannottellin
advancewhowillbeoffended.

ProfessionalStandards

Professionalstandardsdescribethewayinwhichpractitionerspractisetheirprofession.For
example,itisaprofessionalstandardtoassessapatientbeforetreatingthem.

OftenthedetailsoftheprofessionalstandardarenotwrittendownanywherebytheCollege.
Forexample,theCollegemaynothaveadocumentdescribingexactlyhowapractitioner
assessesapatient.Indeed,oftenhowthestandardisappliedchangeswiththecircumstances
(e.g.,theanswersthepatientgivestothepractitionersquestionswillchangehowthe
assessmentisdone).Professionalstandardsarelearnedthroughoneseducation,professional

readingandlearning,experienceinpracticeandindiscussionswithotherpractitioners.
Professionalstandardsarealwayschanging.

However,toassistmembers,theCollegedevelopswrittenpublicationsthatdiscuss
professionalstandards.Thesepublicationscanhavedifferentnames(e.g.,Standardsof
Practice,Guidelines,Policies,PositionStatements)dependingontheircontextandpurpose.
Thepurposeofthesepublicationsistoremindpractitionersaboutthefactorsthatarerequired
topracticesafely,ethicallyandeffectively.ThesepublicationsareontheCollegeswebsiteand
coverawidevarietyoftopics.Whileprofessionalstandardsarenotlawinthesamewaythat
astatuteorregulationis,failingtocomplywithapublishedstandardwilloftenleadtoa
violationofthelaworwillresultinprofessionalmisconduct.

DiscontinuingProfessionalServicesScenario

PractitionerYwantstostoptreatingapatientbecausethepatienthasstoppedpaying.
ShereadsanarticleintheCollegesnewslettersuggestingthatpatientsshouldbegiven
atleasttwoweekstofindanewpractitionerbeforeonestopstreatingthepatient.Y
cannotseewhysheneedstoseeapatientwhoisnotpayingforherservicesanddoes
notfollowthenewslettersuggestion.Thepatientexperiencespainoncethetreatment
stopsandmissestendaysofworkbeforethepatientcanfindanotherpractitionerto
treathim.ThepatientcomplainstotheCollege.Afterinvestigatingthecomplaintthe
CollegerequiresYtoappearbeforeittoreceiveaverbalcautionbecauseYabandoneda
patientwhowasinpainwithoutgivingthepatientadequatetimetofindanother
practitioner.ThefactthatYwasnotpaiddidnotremoveherdutytothepatientwho
wasinpain.

ProfessionalMisconduct

Professionalmisconductisconductthatfallsbelowtheminimumexpectationsofasafeand
ethicalpractitioner.Professionalmisconductiswrittenineitherthestatuteortheregulations
thatapplytopractitioners.Theprovisionsinthestatuteandregulationsaredescribedinmore
detailbelowonprofessionalmisconductregulations.Asnotedabove,manyCollege
publicationswillassistpractitionerstorecognizehowtoavoidengaginginprofessional
misconduct.

Engaginginprofessionalmisconductcanleadtodisciplinaryproceedingsthatcouldresultin
seriousorders(e.g.,afine,suspensionorevenrevocationofonescertificateofregistration).It
isveryseriousforapractitionertoengageinprofessionalmisconduct.

PermittingIllegalConductScenario

PractitionerXisregisteredwiththeCollege.XsfatherisnotregisteredwiththeCollege.
PractitionerXsfathersometimesdropsintoXsofficetotreathislongtermpatients.The
officeassistantreferstoXsfatherasDoctorwhenbookingpatients.Apatient
complainstotheCollegewhenherextendedhealthinsurancerefusedtopayforXs
fathersservicesbecausehewasnotregisteredwiththeCollege.IsPractitionerX
responsibleforhisfathersconduct?

Theanswerisyes.Itisprofessionalmisconducttopermitapersontoholdthemselves
outaspractisingtheprofessionwhentheyarenotregistered.PractitionerXcondoned
theconductthatoccurredathisoffice.PractitionerX,bybeingregistered,gave
credibilityandstatustotheillegalconductofhisfather.Xcouldfaceadisciplinehearing.

Incompetence

Incompetenceiswhereapractitionershowsaseriouslackofknowledge,skillorjudgment
whenassessingortreatingapatient.Itisdefinedinthestatute.Aconcernthatapractitioneris
incompetentcanbeinvestigatedbytheCollegeandcanresultinadisciplinehearing.Ifthe
DisciplineCommitteefindsthatapractitionerisincompetent,itcanimposerestrictionsonthe
practitionersregistration(e.g.,thepractitionercannotpracticeinacertainway,suchaswith
children),oritcansuspendorrevokethepractitionersregistration.

InanyinvestigationofincompetencetheCollegewillusuallylookatthepractitionersrecords.
TheCollegewillinterviewthepatientandthepractitionerandaskotherpractitionersifthey
thinktheconductshowsincompetence.BothoftheCollegecommitteesdealingwiththecase
willhaveotherpractitionersonitwhoknowthedifferencebetweengoodandbadpractice.

IncompetenceScenario

PractitionerYdoesnotreallyassessherpatients.Sheisinahurrytotreatasmany
patientsaspossibleinaday.Shejustasksthepatientwhatiswrongandthenwill
proceedtogivetreatment.Shedoesnotbothertotakepatienthistoryorreview
progressofthepatient.Apatient,Paula,cameinwithaseriouscondition.Ydidnot
recognizeit.Paulabecameunresponsiveduringheracupuncturetreatment.Laterthat
night,Paulaendedupintheemergencydepartmentofthehospitalwithastroke.Paula
complainedaboutYsincompetence.TheInquiries,ComplaintsandReportsCommittee
lookedatYspatientrecordsandheardYsexplanationforwhatshehaddone.Itsent
thecasetodiscipline.TheDisciplineCommitteeagreedthatYshowedalackof
knowledge,skillandjudgment.ItorderedYtogobacktoschoolforayear.

Incapacity

10

Apractitionerisincapablewhenheorshehasahealthconditionthatpreventshimorherfrom
practisingsafely.Usuallythehealthconditionisonethatpreventsthepractitionerfrom
thinkingclearly.Evenaseverelydisabledpractitionercanpracticesafelysolongasthe
practitionerunderstandshisorherlimitsandgetsthenecessaryhelp.Mostpractitionerswho
arefoundtobeincapablearethosewhosufferfromaddictionsorcertainmentalillnessesthat
impairthepractitionersprofessionaljudgment.Forexample,apractitionerwhoisaddictedto
alcoholordrugsmaytrytoseepatientswhentheyareimpaired.

Underthelaw,incapablepractitionersarenottreatedinthesamewayaspractitionerswho
haveengagedinprofessionalmisconductorareincompetent.Theinvestigationlooksatthe
practitionershealthconditionandthetreatmentthattheyarereceiving.TheCollegecan
requirethepractitionertogoforaspecialistexaminationtogetmoreinformationaboutthe
practitionershealth.Iftheconcernisjustified,thepractitionerisreferredtotheFitnessto
PractiseCommitteeforahearing.TheFitnesstoPractiseCommitteecanorderthepractitioner
toundergomedicaltreatment,havemedicalmonitoringandtorestricthisorherpractice.Inan
extremecase(e.g.,wherethepractitionercontinuestoseepatientswhileimpaired)theFitness
toPractiseCommitteecansuspendorrevokethepractitionersregistrationinordertoprotect
thepublic.

IncapacityScenario

PractitionerZhasbeendrinkingalotmorealcoholoverthelastfewmonths.Hehas
beencomingtoworkwithahangover.Morerecentlyhehasbeendrinkingatlunch.One
dayZcomesbackafterlunchimpaired.Paul,apatient,noticesthatZsmellsofalcohol
andthatZisstumblingaroundtheoffice.PaultellstheCollege.AtfirstZdenieshehasa
problem.However,oninvestigating,theCollegelearnsthatsomeofZscolleagueshave
noticedasignificantchangeinZsbehaviourinrecentmonths.TheCollegealsolearned
thatZhasbeenchargedwithimpaireddriving.TheCollegesendsZtoamedical
specialistwhodiagnosesZwithaserioussubstanceabusedisorder.TheCollege
encouragesZtogofortreatmentattheHomewoodHealthCentre.Zagrees.Thematter
isreferredtotheFitnesstoPractiseCommittee.ZandtheCollegeagreetoanorder
requiringZtostopdrinking,attendAlcoholicsAnonymousgroupmeetings,seehisnew
substanceabusespecialistregularlyandhaveacolleaguewatchZatworkandsend
regularreportstotheCollege.

Conclusion

Eachoftheaboveprovisionslooksatdifferentaspectsofprofessionalpractice.Eachofthese
provisionsalsoservesadifferentpurpose.TheCodeofEthicsdealswiththeidealswhich
practitionerstrytoachieve.Professionalstandardsdealwithwaysinwhichtopractisesafely,
effectivelyandprofessionally.Professionalmisconductdealswiththeminimumconduct
necessarytoavoiddiscipline.Incompetencedealswithhavinganadequatelevelofknowledge,

11

skillandjudgmentintheassessmentandtreatmentofapatient.Incapacitydealswithhealth
conditionsthatpreventapractitionerfromthinkingclearly.

SampleExamQuestion

ThesentencePractitionersaresensitivetothewishesoftheirpatientsismostlikelyto
befoundinwhichofthefollowingprovisions?
i. Thedefinitionofincapacity.
ii. Thedefinitionofincompetence.
iii. Thedefinitionofprofessionalmisconduct.
iv.
ProfessionalstandardspublishedbytheCollege.
v.
TheCodeofEthics.

Thebestanswerisv).Beingsensitiveisanidealthatpractitionersstrivetowards.Answer
i)isnotthebestanswerbecauseincapacitydealswiththepractitionershealth
condition.Seriouslyinsensitivebehaviourmayaccompanysomeillnesses(e.g.,
addictions),butitistheillnessthatmustbetreatedfirst.Answerii)isnotthebest
answerbecauseincompetencedealswithpractitionershavinganadequatelevelof
knowledge,skillandjudgment.Answeriii)isnotthebestanswerbecauseprofessional
misconductdealswiththeminimumconductthatisnecessarytoavoiddiscipline.The
correspondingprofessionalmisconductprovisionwouldlikelybethatpractitionersshall
notabusetheirpatients.Answeriv)isnotthebestanswerbecauseprofessional
standardsdealwithwaysinwhichtopracticesafely,effectivelyandprofessionally.A
professionalstandardwouldlikelyprovidepracticalsuggestionsabouthowtopractice
sensitively(e.g.,adviceonhowtolistentothepatientfirstbeforedoinganythingelse).

2. Communication

a. Introduction

Manycomplaintsagainstpractitionerscouldbeavoidedbygoodcommunicationwithpatients,
staffandcolleagues.Goodcommunicationinvolves,first,listeningtoothers.Understandingthe
personswishes,expectationsandvaluesbeforedoinganythingisimportant.Askingquestions
toclarifyandexpandonwhatthepersonissayingalsohelps.Repeatinginformationbacktoa
patient,inthepractitionersownwords,canhelpensureunderstandingandreassuresthe
patientthatthepractitionerhasbeenlistening.Goodcommunicationalsoinvolvesmakingsure
theotherpersonknowswhatyouaregoingtodo,whyyouaregoingtodoitandwhatislikely
goingtohappen.Whentheotherpersonisconfusedbywhatyouaredoingorwhy,thereis
miscommunication.Also,peopledonotliketobesurprised(e.g.,bypain,anunexpectedside
effect).Tellingthepersonwhatwillormayhappenremovesthesurprise.Thefollowingsection
ofthisbookdealswithsomeoftheareasinwhichgoodcommunicationislegallyparticularly
important.

12

b. Informedconsent

Patientshavetherighttocontroltheirbodiesandtheirhealthcare.Practitionersdonothave
therighttoassessortreatapatientunlessthepatientagreestoit(i.e.,consents).A
practitionerwhoassessesortreatsapatientwithoutthepatientsconsentcanfacecriminal
(e.g.,achargeofassault),civil(e.g.,alawsuitfordamages)orprofessional(e.g.,adiscipline
hearing)consequences.Thissectionofthebookdealswithconsentfortheassessmentand
treatmentofpatients.Otherpartsofthebookdealwiththeneedforconsentwhendealing
withapatientspersonalhealthinformationorforbillingthem.

GeneralPrinciples

Tobevalid,apatientsconsentmustmeetthefollowingrequirements:

RelatetotheTreatment.Thepractitionercannotreceiveconsentforoneprocedure
(e.g.,takingahistoryofthepatientshealth)andthenuseittodoadifferentprocedure
(e.g.,physicallyexaminethepatient).Thepatientsconsentmustbeforwhatisactually
goingtobedone.
BeSpecific.Thepractitionercannotaskforavagueconsent.Forexample,onecannot
askforthepatienttoconsenttoanytreatmentthepractitionerbelievesisappropriate.
Theactualassessmentortreatmentproceduremustbeexplained.Thismeansthatthe
practitioneroftenhastoobtainthepatientsconsentmanytimesasnewprocedures
becomeadvisable.Thisalsomeansthatapractitionercannotobtainablanketconsent
whenthepatientfirstcomesintocovereveryprocedure.
BeInformed.Itisnecessarythatthepatientunderstandswhattheyareagreeingto.The
practitionermustexplaintothepatienteverythingthepatientneedstoknowbefore
askingthepatienttogiveconsent.Forexample,ifsomeoneasksforyourconsentto
driveyourcarwithouttellingyouthattheyintendtouseittoraceoverrockyfields,
yourconsentwasnotinformed.Tobeinformed,consentmustincludethefollowing:
o NatureoftheAssessmentorTreatment.Thepatientmustunderstandexactly
whatthepractitionerisproposingtodo.Forexample,doesthepractitioner
intendtojustaskquestionsorwillthepractitioneralsobetouchingthepatient?
Ifthepractitionerisgoingtobetouchingthepatient,describewhatthepatient
shouldexpect.
o WhowillbeDoingtheProcedure?Willthepractitionerbedoingtheprocedure
personallyorwillanassistantorcolleaguebeingdoingit?Ifitisanassistantor
colleague,isheorsheregisteredwiththeCollege,anotherCollege,ornot
registeredatall?
o ReasonsfortheProcedure.Thepractitionermustexplainwhyheorsheis
proposingthatprocedure.Whataretheexpectedbenefits?Howdoesthe
procedurefitinwiththeoverallplanofthepractitioner?Howlikelyisitthatthe
hopedforbenefitswillhappen?

13

o MaterialRisksandSideEffects.Thepractitionermustexplainanymaterialrisks
andsideeffects.Materialrisksorsideeffectsarethosethatareasonable
personwouldwanttoknowabout.Forexample,ifthereisahighriskofa
modestsideeffect(e.g.,sleeplessness),thepatientshouldbetold.Similarly,if
thereislowriskofaserioussideeffect(e.g.,deathorsuicide),thepatientneeds
tobetold.
o AlternativestotheProcedure.Iftherearereasonablealternativestothe
procedure(e.g.,amorecautiousapproach),thepatientmustbetold.Evenifthe
practitionerdoesnotrecommendtheoption(e.g.,itistooaggressiveandhasa
higherrisk),thepractitionershoulddescribetheoptionandtellthepatientwhy
thepractitionerisnotrecommendingit.Also,evenifthepractitionerdoesnot
providethealternativeprocedure(e.g.,itisprovidedbyamemberofadifferent
profession,suchasaphysician),thepractitionermusttellthepatientifitisa
reasonableoption.
o ConsequencesofNotHavingtheProcedure.Oneoptionforapatientisdo
nothing.Thepractitionershouldexplaintothepatientwhatislikelytohappenif
thepatientdoesnothing.Ifitisnotclearwhatwillhappen,thepractitioner
shouldsaysoandprovidesomelikelyconsequences.
o ParticularPatientConcerns.Iftheindividualpatienthasaspecialinterestin
someaspectoftheprocedure(e.g.,itsnature,asideeffect),thepatientneeds
tobetold(e.g.,theprocedurewouldviolatethepatientsreligiousbeliefs).
Voluntary.Thepractitionercannotforceapatientintoconsentingtoaprocedure.Thisis
particularlyimportantwhendealingwithyoungerorolderpatientswhomaybeoverly
influencedbyfamilymembersorfriends.Thisisalsoimportantwheretheassessment
ortreatmentwillhavefinancialconsequencesforthepatient(e.g.,thepatientwilllose
hisorherjoborwilllosefinancialbenefitsifthepatientrefusestoconsent).The
practitionershoulddiscusswiththepatientthatitisuptothepatientwhethertogive
consentandthatthepatientshouldnotletanyonepressurethemintodoingsomething
thepatientdoesnotwanttodo.
NoMisrepresentationorFraud.Thepractitionermustnotmakeclaimsaboutthe
assessmentortreatmentthatarenottrue(e.g.,tellingthepatientthatatreatmentwill
curethemwheninfacttheresultsareuncertain).Thissituationwouldnotresultina
trueconsent.Patientsmustbegivenaccuratefactualinformationandhonestopinions.

Therefore,consenttoanassessmentortreatmentmustinvolveeffectivecommunication
betweenthepractitionerandthepatient.Thepractitionermustmakesurethatthepatient
understandswhatheorsheisagreeingto.Whileitmaysoundlikealotofwork,mostofthe
timeinformedconsentcanbeobtainedquicklyandeasily.Itisonlywhendealingwithcomplex
orparticularlyriskymattersthatalotoftimeisrequired.

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ConsentScenarioNo.1

PractitionerYmeetsanewpatientnamedPaula.Paulacomplainsaboutfeelingstressed
andtired.Ysays:Iwouldliketofullyunderstandyourpersonalandfamilybackground
andyourmedicalhistory.Therecouldbealotofthingsmakingyoufeeltiredand
stressedandthisinformationwillhelpmetrytofigureoutwhy.Ifyouareuncomfortable
withanyofmyquestions,pleaseletmeknow.OK?Yhasprobablyjustobtained
informedconsent.

SampleExamQuestion

Obtainingabroadconsent(oftencalledablanketconsent)inwritingfromthepatient
onhisorherarrivalattheofficeisprobablyabadideabecause:
i. Thepatientdoesnotknowiftheywillneedsomeonetodrivethemhome
afterwards.
ii. Thepatientdoesnothaveconfidenceinthepractitioneryet.
iii. Thepatientdoesnotunderstandtowhattheyarebeingaskedtoagree.
iv.
Thepatientdoesnotknowhowlongthevisitwillbe.

Thebestanswerisiii).Informedconsentrequiresthepatienttounderstandthenature,
risksandsideeffectsofthespecificprocedureproposedbythepractitioner.Itis
impossibleforthepatienttoknowthesethingsupontheirarrivalattheoffice.Answeri)
isnotthebestanswerbecauseitfocusesonasideissueanddoesnotaddressthemain
issue.Answerii)isnotthebestanswerbecausehavingconfidenceinthepractitioneris
notenoughfortheretobeinformedconsent.Apatientmaytrustthepractitionerand
thatmaymotivatethegivingofconsent,butthepatientstillneedstounderstandto
whattheyarebeingaskedtoagree.Answeriv)isnotthebestanswerbecauseitfocuses
onasideissueanddoesnotaddressthemainissue.

WaysofReceivingConsent

Therearethreedifferentwaysinwhichapractitionercanreceiveconsent.Eachhasits
advantagesanddisadvantages.

WrittenConsent.Apatientcangiveconsentbysigningawrittendocumentagreeingto
theprocedure.Awrittenconsentprovidessomeevidencethatthepatientdidgive
consent.Onedisadvantageofwrittenconsentisthatpractitionerssometimesconfusea
signaturewithconsent.Apatientwhosignsaformwithoutactuallyunderstandingthe
nature,risksandsideeffectsoftheprocedurehasnotgivenatrueconsent.Also,the
useofwrittenconsentdocumentscandiscouragetheaskingofquestions.Inaddition,
thepractitionermightnotthencheckwiththepatienttomakesurethepatient
understandstheinformationandisintrueagreement.

15

VerbalConsent.Apatientcangiveconsentbyaverbalstatement.Averbalconsentis
thebestwayforthepractitionerandthepatienttodiscusstheinformationandensure
thatthepatientreallyunderstandsit.Makingabriefnoteinthepatientrecordofthe
discussioncanprovideusefulevidencelateronifthereisacomplaint.
ImpliedConsent.Apatientcangiveconsentbytheiractions.Forexample,inConsent
ScenarioNo.1,above,thepatientPaulacouldjustnodherhead.Thatwouldbeimplied
consentforPractitionerYtobeginaskingherquestions.Themaindisadvantageof
impliedconsentisthatthepractitionerhasnoopportunitytocheckwiththepatientto
makesurethatthepatienttrulyunderstandswhatisgoingtohappen.

ConsentScenarioNo.2

PractitionerXproposesthathispatientPaultakeavitaminandmineralsupplement.X
says:Trythese:theywillmakeyouthinkmoreclearly.Paultakesoneimmediatelyand
buysabottlefromthereceptionist.WhenarrivingathomePaulreadsaboutthe
supplementontheinternetandlearnsthatitcontainsmegadosesofVitaminA1which,if
takenforalongperiodoftime,couldleadtoliverandotherdamage.Paulcomplainsto
theCollege.XtellstheCollegethathewasrelyingonPaulsimpliedconsentby
swallowingthefirstpillandbuyingabottlefromthereceptionist.TheInquiries,
ComplaintsandReportsCommitteeissueadecisioncriticalofXfornotobtaining
informedconsentbecause:
Xdidnotexplainthenatureofthepillincludingthatithadmegadosesof
VitaminA;
XdidnotexplainhowthesupplementwouldmakePaulthinkmoreclearly;
Xmisrepresentedthehopedforbenefitofthesupplementastherewaslittle
evidencetosupporthisverystrongstatementthatitwouldmakePaulthink
moreclearly;
Xdidnotexplainthewayinwhichthesupplementwastobeused(howoftento
takethesupplementandforwhatperiodoftime);
Xdidnotexplainthealternativestotakingthesupplementincludingnottaking
anything;and,perhapsmoreimportantly,
XdidnotexplaintherisksoftakingthesupplementtoPaul.

ConsentWherethePatientisIncapable

Apatientisnotcapableofgivingconsentifthepatienteither:
Doesnotunderstandtheinformation,or
Doesnotappreciatethereasonablyforeseeableconsequencesofthedecision.

AmegadoseofVitaminAprobablyresultsinthesupplementbeingclassedasadrug.Thusthisscenarioalso
raisesissuesaboutwhetherthepractitionerisengaginginacontrolledact.Seethediscussionofcontrolledacts
below.

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Forexample,ifthepractitionerrecommendsthatapatienthaveadailyseriesofhalfhour
acupuncturetreatmentsandthepatientinsistsonreceivingonesixhoursessionwithlonger
needlesinstead,itisprettyclearthatthepatientdoesnotappreciatetheconsequencesofthe
decision.

Apractitionercanassumeapatientiscapableunlessthereisevidencetothecontrary.A
practitionerdoesnotneedtoconductanassessmentofthecapacityofeverypatient.However,
ifthepatientshowsthattheymaynotbecapable(e.g.,thepatientsimplycannotunderstand
theexplanationofthepractitioner)thepractitionershouldassessthepatientscapacity.The
practitionercanassessthecapacityofthepatientbydiscussingtheproposedprocedurewith
thepatienttoseeifthepatientunderstandstheinformationandappreciatesitsconsequences.

Theissueiswhetherthepatientiscapableofgivingconsentfortheproposedprocedure.A
patientcanbecapabletogiveconsentforoneprocedurebutnotcapableforanother.For
example,afifteenyearoldpatientmightbecapableofconsentingtonutritionalcounsellingbut
notbecapableofconsentingtotreatmentforamajoreatingdisorder.(Thereisnominimum
ageofconsentforhealthcaretreatment.)

Ifapractitionerconcludesthatthepatientisnotcapableofgivingconsentforaprocedure,the
practitionershouldtellthepatient.Thepractitionershouldalsotellthepatientwhowillmake
decisionsontheirbehalfforexample,acloserelative.Thispersoniscalledasubstitute
decisionmaker.Thepractitionershouldstillincludethepatientinthediscussionsasmuchas
possible.Ofcoursetherearecircumstanceswhereinvolvingtheincapablepatientinthe
discussionswillnotbepossible(e.g.,ifitwillbequiteupsettingtothepatient,wherethe
patientisunconscious).

Unlessitisanemergency,thepractitionermustthenobtainconsentfortheassessmentor
treatmentfromasubstitutedecisionmaker.Asubstitutedecisionmakermustmeetthe
followingrequirements:
Thesubstitutemustbeatleast16yearsofage.2Thereisanexceptionwherethe
substituteistheparentofthepatient(forexample,a15yearoldmothercanbethe
substitutedecisionmakerforthecareofherchild).
Thesubstitutemust,themselves,becapable.Inotherwords,thesubstitutemust
understandtheinformationandappreciatetheconsequencesofthedecision.
Thesubstitutemustbeableandwillingtoact.
Theremustbenohigherrankedsubstitutewhoisableandwillingtoact.Therankingof
thesubstitutedecisionmakerisasfollows(fromhighestrankedtolowestranked):
o Acourtappointedguardianoftheperson.

Whilethereisnominimumageofconsentforacapablepatient,asubstitutedecisionmakermustnormallybeat
least16yearsold.

17

o Apersonwhohasbeenappointedtobeanattorneyforpersonalcare.The
patientwouldhavesignedadocumentappointingthesubstitutetoactonthe
patientsbehalfinhealthcaremattersifthepatienteverbecameincapable.
o ApersonappointedbytheConsentandCapacityBoardtomakeahealth
decisioninaspecificmatter.
o Thespouseorpartnerofthepatient.Apartnercanincludeasamesexpartner.
Itcanalsoincludeanonsexualpartner(e.g.,twoelderlysisterswholive
together).
o AchildofthepatientoraparentofthepatientortheChildrensAidSocietywho
hasbeengivenwardshipofthepatient.
o Aparentofthepatientwhodoesnothavecustodyofthepatient.
o Abrotherorsisterofthepatient.
o Anyotherrelative.
o ThePublicGuardianorTrusteeifthereisnooneelse.

Hereisascenariothatshowshowtheseruleswork.

ConsentScenarioNo.3

PractitionerYproposesaprocedureforherpatientPaula.Pauladoesnotunderstandthe
proposedprocedureatall.Sheisclearlyincapable.YknowsthatPaulaappointedher
friendPattobeherpowerofattorneyforpersonalcare.However,Patistravelling
outsideofthecountryandcannotbereached.ThereforePatisnotabletomakethe
decision.YcontactsPaulaselderlymother,butPaulasmotherisfrailherselfanddoes
notfeelconfidentinmakingthedecision.ThusPaulasmotherisnotwillingtoactasa
substitutedecisionmaker.Paulassisteriswillingandabletomakethedecisionon
Paulasbehalfandappearstounderstandtheinformationanditsconsequencesfor
Paula.Paulassisterisabletogivetheconsenteventhoughsheisnotthehighestranked
substitute.

Iftherearetwoequallyrankedsubstitutedecisionmakers(e.g.,twochildrenofthepatient),
andtheycannotagree,thePublicGuardianandTrusteecanthenmakethedecision.

Asubstitutedecisionmakermustcomplywiththefollowingrules:
Thesubstitutemustactinaccordancewiththelastknowncapablewishesofthe
patient,ifknown.Forexample,ifapatientclearlysaid,Neversendmetothehospital
beforehebecamesoillthathecouldnotthinkclearly,thesubstituteneedstoobey
thosewishes.
Thesubstitutemustactinthebestinterestsofthepatientifthesubstitutedoesnot
knowofthelastknowncapablewishesofthepatient.Forexample,ifaproposed
treatmentissimpleandpainless,wouldcauselittleriskofharmbutwouldmakethe
patientmorecomfortablethroughadifficultillness,thesubstitutedecisionmaker
shouldconsenttoit.

18

Whereitbecomesclearthatasubstitutedecisionmakerisnotfollowingtheaboverulesthe
practitionershouldspeakwiththesubstitutedecisionmakeraboutit.Ifthesubstitutedecision
makerisstillclearlynotfollowingtheaboverulesthepractitionershouldcalltheOfficeofthe
PublicGuardianandTrustee.ThecontactinformationofthePublicGuardianandTrusteeof
Ontarioisavailableontheinternet.

ConsentScenarioNo.4

PractitionerXproposesaprocedureforhispatientPaul.Pauldoesnotunderstandthe
proposedprocedureatall.Heisclearlyincapable.XknowsthatPaulappointedhisfriend
Pattobehispowerofattorneyforpersonalcare.PatisgoingtoinheritPaulsmoney
whenPauldies.Paulhasalotofmoney.Paulisgoingtodiewithinafewmonths.The
proposedprocedureissimpleandpainless,wouldmakethepatientmorecomfortable
throughadifficultillnessandhaslittleriskofharm.PatrefusestogiveconsentforPaul
toundergotheproposedprocedure.XisconvincedthatPatisrefusingtoconsenttothe
treatmentinordertoinheritmoremoney(eventhoughtreatmentisnotveryexpensive).
TherestofPaulsfamilyisveryupsetbecausetheywantPaultoreceivethetreatment.X
suggeststhatthefamilycontacttheOfficeofthePublicGuardianandTrustee.

Theaboverulesonobtaininginformedconsentwhenapatientisincapablecomefromthe
HealthCareConsentAct.Practitionersshouldbefamiliarwiththatstatute.Itisadifficult
statutetoread.PractitionersshouldchecktheCollegeswebsiteastheCollegewillbe
developingpoliciesoninformedconsentasithastime.

SampleExamQuestion

Whichofthefollowingisthehighestrankedsubstitutedecisionmaker(assumingthat
everyonewaswillingandabletogiveconsent):
i. Apowerofattorneyforpersonalcareforthepatient.
ii. Thepatientsliveinboyfriend.
iii. Thepatientsmother.
iv.
Thepatientsson.

Thebestanswerisi).Onlyacourtappointedguardianishigherrankedthanapowerof
attorneyforpersonalcare.Answerii)isnotthebestanswerbecausethepatients
spouseorpartnerisalowerrankedsubstitutedecisionmaker.Inaddition,itisnotclear
thattheliveinboyfriendisaspouse(undertheHealthCareConsentAct,theymusthave
beenlivingtogetherforatleastoneyear,havehadachildtogetherorhaveawritten
cohabitationagreementtobespouses).Answersiii)andiv)arenotthebestanswers
becausetheyarelowerrankedthanbothapowerofattorneyforpersonalcareora
patientsspouse.Inaddition,thepatientsmotherandsonareequallyrankedsoeither
theywouldhavetogivethesameconsentoronewouldhavetodefertotheother.

19

Emergencies

Oneexceptiontotheneedforinformedconsentisincasesofemergencies.Therearetwokinds
ofemergencies:
Wherethepatientisincapableandadelayintreatmentwouldcausesufferingor
seriousbodilyharmtothepatient.
Wherethereisacommunicationbarrier(e.g.,language,disability)despiteeffortsto
accommodatethebarrierandadelayintreatmentwouldcausesufferingorserious
bodilyharmtothepatient.

Ineithercasethepractitionermustattempttoobtainconsentassoonaspossible(eitherby
findingasubstitutedecisionmakerinthefirstexampleorbyfindingameansofcommunication
withthepatientinthesecondexample).

Emergenciesarerareforpractitionersofthisprofession,butcanoccur.

ConsentScenarioNo.5

PractitionerYisseeingherpatientPaulaattheoffice.Paulasuddenlycollapsesfroman
apparentheartattack.Yhasadefibrillatorintheoffice.Withouttryingtogetconsent
fromasubstitutedecisionmaker,Yusesthedefibrillator.Ywasabletoactwithout
consentinthesecircumstances.

Acrossthecity,X,apractitioner,isseeinghispatientPaulattheoffice.Paulhasterminal
cancerandhasfilledoutawalletcardsayingthathedoesnotwantanymeasurestaken
toresuscitatehimshouldhehaveacardiovascularaccident.Paulhasmentionedthisto
X.Paulsuddenlycollapsesinanapparentheartattack.Xhasadefibrillatorintheoffice.
Xisnotabletoactwithoutconsentinthesecircumstances.Xalreadyhasarefusalfrom
Paulthatappliestothesecircumstances.

c. Boundariesandsexualabuse

Practitionersmustbecarefultoactasaprofessionalhealthcareprovider,andnotasafriend,
topatients.Becomingtoopersonalortoofamiliarwithapatientisconfusingtopatientsand
willmakethemfeeluncomfortable.Patientswillbeuncertainastowhethertheprofessional
adviceorservicesaremotivatedbysomethingelseotherthanthebestinterestsofthepatient.
Itisalsoeasierforapractitionertoprovideprofessionalserviceswhenthereisaprofessional
distancebetweenthem(e.g.,tellingthepatientthetruthaboutthepatientscondition).

Maintainingprofessionalboundariesisaboutbeingreasonableinthecircumstances.For
example,oneshouldbecarefulaboutacceptinggiftsfrompatients,buttherearesome
circumstancesinwhichitisappropriatetodoso(e.g.,asmallNewYearsgiftfromapatient).In

20

otherareas,however,crossingprofessionalboundariesisneverappropriate.Forexample,itis
alwaysprofessionalmisconducttoengageinanyformofsexualbehaviourwithapatient.

Thefollowingaresomeoftheareaswherepractitionersneedtobeverycautioustomaintain
professionalboundaries.

SelfDisclosure

Whenapractitionersharespersonaldetailsabouthisorherprivatelife,itcanconfusepatients.
Patientsmightassumethatthepractitionerwantstohavemorethanaprofessional
relationship.Selfdisclosuresuggeststhattheprofessionalrelationshipisservingapersonal
needforthepractitionerratherthanservingthepatientsbestinterests.Selfdisclosurecan
resultinthepractitionerbecomingdependentonthepatienttoservethepractitionersown
emotionalneeds,whichisdamagingtotherelationship.

SelfDisclosureScenario

PractitionerYistreatingPaulaforworkplacestressrelatedillnesses.Paulaishaving
difficultydecidingwhethertomarryherboyfriendandtalkstoYaboutthisissuealot
duringtreatmentsessions.TohelpPaulamakeuphermind,YdecidestotellPaula
detailsofherdoubtsinacceptingtheproposalfromherfirsthusband.Ytellsofhow
thosedoubtsgraduallyruinedherfirstmarriageresultinginbothherandherhusband
havingaffairs.PaulaisoffendedbyYsbehaviourandstopscomingfortreatmentforthe
workplacestressrelatedillnesses.Ysselfdisclosurewasinappropriateand
unprofessional.

GivingorReceivingofGifts

Givingandreceivinggiftsispotentiallydangeroustotheprofessionalrelationship.Asmall
tokenofappreciationbythepatientpurchasedwhileonaholiday,aroundNewYears,orgiven
attheendoftreatmentmaybeacceptable.Inaddition,onemustbesensitivetothepatients
culturewhererefusingagiftisconsideredtobeaseriousinsult.However,anythingbeyond
smallgiftscanindicatethatthepatientisdevelopingapersonalrelationshipwiththe
practitioner.Thepatientmayevenexpectsomethinginreturn.

Giftgivingbyapractitionerwilloftenconfuseapatient.Evensmallgiftsofemotionalvalue,
suchasafriendshipcard,canconfusethepatienteventhoughthefinancialvalueissmall.
WhilemanypatientswouldfindaChristmas/holidayseasoncardfromapractitionertobea
kindgestureandgoodbusinesssense,somepatientsmightfeelobligedtosendoneinreturn.
Soevenherethoughtshouldbegiventothetypeofpatientsinonespractice(e.g.,somenew
Canadiansmightbeunfamiliarwiththetradition).

21

GiftGivingScenario

PractitionerXhasapatientfromanAsianculturewhobringsfoodforeveryvisit.X
thanksher,buttriesnottotreatitasanexpectation.OnonevisitXhappenstomention
hisspecialroastpigrecipe.ThepatientinsiststhatXbringitovertoherhouseforNew
Years.Xpolitelydeclines,givingthepatientawrittenrecipeinstead.Thepatientstops
bringinginfood,islessfriendlyduringvisitsandstartsmissingappointments.Xdidnot
doanythingwronginthisscenario,butitshowstheconfusionthatcanoccurwitha
patientwhentheboundariesstarttobecrossed.

DualRelationships

Adualrelationshipiswherethepatienthasanadditionalconnectiontothepractitionerother
thanjustasapatient(e.g.,wherethepatientisarelativeofthepractitioner).Anydual
relationshiphasthepotentialfortheotherrelationshiptointerferewiththeprofessionalone
(e.g.,beingboththeindividualspractitionerandemployer).Itisbesttoavoiddual
relationshipswheneverpossible.Wheretheotherrelationshippredatestheprofessionalone
(e.g.,arelative,apreexistingfriend),referringthepatienttoanotherpractitioneristhe
preferredoption.Whereareferralisnotpossible(e.g.,inasmalltown,wherethereisonlyone
practitioner),specialsafeguardsareessential(e.g.,discussingthedualrelationshipwiththe
patientandagreeingwiththepatienttobeformalduringvisitsandnevertalkabouttheissues
outsideoftheoffice).Itisneveragoodideatotreatarelative.

DualRelationshipsScenario

PractitionerXhasPaulaasapatient.Paulaisarefugeewithverylittlemoney.Paula
worksparttimeasahousecleaner.XdecidestohirePaulatocleanhishouse.Xalso
recommendsPaulatosomeofhisfriendswhoalsohirePaula.Paulaisextremely
grateful.LaterXrecommendsachangeintreatmentthatwillnotbecoveredbyPaulas
insurance.PaulawonderstoherselfifXisrecommendingthistreatmentinordertoget
backthemoneyforcleaninghishouse.Paulaalsofeelsthatshecannotsaynoorelse
shewillloseherjobcleaningthehousesofXsfriends.Didthedualrelationship
contributetoPaulasconfusion?

IgnoringEstablishedCustoms

Establishedcustomsusuallyexistforareason.Ignoringacustomconfusesthenatureofthe
professionalrelationship.Forexample,treatmentsessionsareusuallyheldduringregular
businesshoursattheclinicratherthanatarestaurant.Byignoringthiscustom,thepatient
mightbeginthinkingthatthemeetingisasocialvisit.Or,thepatientmightfeelthatheorshe
hastopayforthemeal.Treatingpatientsasspecial,ordifferentfromotherpatients,canbe
easilymisinterpreted.

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PersonalOpinions

Everyonehaspersonalopinions.Practitionersarenoexception.However,practitionersshould
notusetheirpositiontopushtheirpersonalopinions(e.g.,religion,politicsorevenavegan
lifestyle)onpatients.Similarly,stronglyheldpersonalreactions(e.g.,thatapatientis
unpleasantandobnoxious)shouldnotbeshared.Disclosingpersonalreactionsdoesnothelp
theprofessionalrelationship.

PersonalOpinionsScenario

Paul,apatient,discussingworldevents,pusheshispractitionerYforherviewson
immigration.AtfirstYresists,buteventuallysaysshehassomeconcernsaboutthe
abusesoftheimmigrationsystem.Ysaysshehasheard,oftendirectlyfrompatients,
abouthowtheyhaveliedtotheimmigrationauthorities.Paulloudlycriticizesthe
immigrationauthoritiesforallowingtoomanyimmigrantsintothecountry.Paulis
overheardbyotherpatientsintheclinicatthetime,includingsomewhoarenew
Canadians.Theotherpatientstellotherstaffattheclinicthattheyfeeluncomfortable
witheitherYorPaularound.

BecomingFriends

Beingapersonalfriendwithapatientisaformofdualrelationship.Patientsshouldnotbe
placedinthepositionwheretheyfeeltheymustbecomeafriendofthepractitionerinorderto
receiveongoingcare.Practitionersbearthemainresponsibilitytonotallowapersonal
friendshiptodevelop.Itisdifficultforallbutthemostassertiveofpatientstocommunicateto
thepractitionerthattheydonotwanttobefriends.

TouchingandDisrobing

Touchingcanbeeasilymisinterpreted,particularlywheredisrobingisinvolved.Apatientcan
viewanactofencouragementbyapractitioner(e.g.,ahug)asaninvasionofspaceorevena
sexualgesture.Extremecaremustbetakeninanytouchingbetweenpractitionersandtheir
patients.Thenatureandpurposeofanyclinicaltouchingmustalwaysbeexplainedfirstandthe
patientshouldalwaysgiveconsentbeforethetouchingbegins.Patientsshouldbeaskedto
disrobethemselveswhereverpossible.Culturalsensitivitiesshouldbeobserved.Thepresence
ofathirdpartyshouldbepermittedandevenofferedwhereappropriate.Thetouchingmust
alwayshaveaclinicalrelevancethatisobvioustothepatient.

Managingboundariesisimportantforbothpractitionersandpatients.

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SexualAbuse

TheRegulatedHealthProfessionsAct(RHPA)isdesignedtoeliminateanyformofsexual
contactbetweenpractitionersandpatients.Becauseofthestatusandinfluenceof
practitioners,thereisthepotentialforanysuchsexualcontacttocauseseriousharmtothe
patient.Evenifthepatientconsentstothesexualcontact,itisprohibitedforthepractitioner.

ThetermsexualabuseisdefinedbroadlyintheRHPA.Itincludesthefollowing:

sexualintercourseorotherformsofphysicalsexualrelationsbetweenthepractitioner
andthepatient;
touching,ofasexualnature,ofthepatientbythepractitioner;or
behaviourorremarksofasexualnaturebythepractitionertowardsthepatient.

Forexample,tellingapatientasexualjokeissexualabuse.Hangingacalendaronthewallwith
sexuallysuggestivepictures(e.g.,womeninbikinis,afirefighterscalendar)issexualabuse.
Nonclinicalcommentsaboutapatientsphysicalappearance(e.g.,youlooksexytoday)is
sexualabuse.Datingaclientissexualabuse.

Thisdefinitionofsexualabuseincludestreatingonesspouse.Therehavebeenanumberof
courtdecisionsthathaveestablishedthatapractitionercannottreathisorherspouse(with
verylimitedexceptions,likeanemergency).Practitionersneedtotransferthecareoftheir
spouseorlovertootherpractitioners.Itdoesnotmatterthatthespousalrelationshipcame
first.3

Touching,behaviourorremarksofaclinicalnatureisnotsexualabuse.Forexample,ifitis
necessaryforthetreatmentofapatienttoaskaboutthepatientssexualhistory,itcanbe
done.However,askingaboutapatientsromanticlifewherethisisunnecessaryfortreatment
issexualabuse.Similarly,touchingofthechestorpelvicareaofapatientmustbeclinically
necessary(and,asdiscussedabove,mustbedoneonlyafterreceivinginformedconsent).

Itisalwaystheresponsibilityofthepractitionertopreventsexualabusefromhappening.Ifa
patientbeginstotellasexualjoke,thepractitionermuststopit.Ifthepatientmakescomments
abouttheappearanceorromanticlifeofthepractitioner,thepractitionermuststopit.Ifthe
patientasksforadate,thepractitionermustsayno(andexplainwhyitwouldbe
inappropriate).Ifthepatienttouchesthepractitionerinawaythatmightbeviewedassexual
(e.g.,akiss),thepractitionermuststopit.

Therehasbeensomediscussionaboutchangingtherequirementpreventingpractitionersfromtreatingtheir
spouses.However,atthetimeofwriting,thischangehasnotbeenmade.Unlessanduntilthechangeismade,
practitionerscannottreattheirspouses.

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SexualAbuseScenarioNo.1

PractitionerYtellsacolleagueaboutherromanticweekendwithherhusbandat
NiagaraontheLakefortheiranniversary.Ymakesajokeabouthowwinehasthe
oppositeeffectonthelibidoofmenandwomen.Paula,apatient,issittinginthe
receptionareaandoverhears.WhenbeingtreatedbyY,Paulamentionsthatshe
overheardtheremarkandiscuriousastowhatYmeantbythis,asinherexperience,
winehelpsthelibidoofbothpartners.HasYengagedinsexualabuse?Yclearlyhas
crossedboundariesbymakingthecommentinaplacewhereapatientcouldoverhearit.
However,theinitialcommentwasnotdirectedtowardsPaulaandwasnotmeanttobe
heardbyher.ItwouldcertainlybesexualabuseforYtoanswerPaulasquestion.Y
shouldapologizeformakingthecommentinaplacewherePaulacouldhearit.Yneeds
tostateherfocusisonPaulastreatment.

Becausesexualabuseissuchanimportantissue,Collegesmusttakeitveryseriously.Each
Collegemusttakestepstopreventsexualabusefromoccurring.Forexample,thePatient
RelationsCommitteeoftheCollegemustdevelopasexualabusepreventionplanthatwill
educatepractitioners,trainingprograms,employersofpractitionersandthepublicabout
avoidingsexualabuse.

Inaddition,practitionersarerequiredtomakeareportwherethepractitionerhasreasonable
groundstobelievethatanotherhealthproviderhasengagedinsexualabuse.Thereportis
madetotheRegistrarofanyhealthCollegewheretheotherhealthproviderisamember.For
example,ifapatienttellsapractitionerthatherphysiotherapistfondledher,thepractitioner
mustmakeawrittenreporttotheRegistraroftheCollegeofPhysiotherapistsofOntario.This
reportingobligationisdiscussedinmoredetailbelow,undertheheadingMandatoryReports.

Therearealsoanumberofspecialprovisionsdealingwiththehandlingofsexualabusematters
inthecomplaintsanddisciplineprocess.Suchcomplaintsarealwaystakenseriously.Ifthe
complaintinvolvessexualtouchingandifthereisevidencetosupportthecomplaint,areferral
todisciplineforahearingislikely.Atthedisciplinehearingtheidentityofthepatientis
protected.Thepatientmayevenbegivenaroleatthedisciplinehearing(e.g.,tomakea
statementontheimpactofthesexualabuseonthepatientifafindingismade).Wherethe
sexualabuseinvolvedsexualintercourse,orsimilarsexualacts,andafindingismade,the
practitionersregistrationwillberevokedforaperiodofatleastfiveyears.Inallcaseswherea
findingofsexualabusehasbeenmade,thepractitionerwillbereprimanded.Ifafindingof
sexualabusehasbeenmade,thepractitionercanbeorderedtopayforthecostsofany
counsellingandtherapyofthepatient.

TheCollegeisalsoresponsibletopayforthecostsofanycounsellingortherapyneededbythe
patientifafindingofsexualabuseismade.

25

Practitionersshouldthereforeconsiderwaysofpreventingsexualabuse(oreventhe
perceptionofsexualabuse)arising.Experienceindicatesthatmostsexualabuseisnotdoneby
predators.Rather,inmostcasesthepractitionerandthepatientdevelopromanticfeelingsfor
eachotherandthepractitionerfailstostopit.

Whereanyromanticfeelingsdevelop,thepractitionerhastwochoices:

putastoptothemimmediately,or
transferthecareofthepatienttoanotherpractitionerimmediately.

Othersuggestionsforpreventingeventheperceptionofsexualabuseincludethefollowing:

Donotengageinanyformofsexualbehaviour.
Ifapatientinitiatessexualbehaviour,putastoptoit.Besensitive,butfirmwhendoing
so.
Donotdatepatients.
Avoidselfdisclosure.
Avoidcommentsthatmightbemisinterpreted(Youarelookinggoodtoday).
Donottakeasexualhistoryunlessthereisagoodclinicalreasonfordoingso.Ifone
musttakeasexualhistory,explainwhyfirstandbeveryclinicalinonesapproach.
Donottouchapatientexceptwhennecessaryforassessingortreatingthem.Ifone
musttouchapatient,explainthenatureofthetouchingfirst,thereasonforthe
touchingandbeveryclinicalinonesapproach(e.g.,weargloves).Considerhavinga
thirdpersonintheroomifexaminingorotherwisetouchingadisrobedpatient.
Donotcommentonapatientsappearanceorromanticlife.
Documentwellanyclinicalactionsofasexualnatureoranyincidentsofasexualnature.

Datingformerpatientsisasensitiveissue.Technically,itisnotsexualabusebecausetheperson
isnolongerthepractitionerspatient.However,itcanstillbeunprofessionalwherethe
practitionerstillhaspoweroverthepatient.Thereshouldbeanappropriatecoolingoff
period.Thelengthofthecoolingoffperiodwilldependonthecircumstances(e.g.,howlong
thepersonwasapatient,howintimatetheprofessionalrelationshipwas).

SexualAbuseScenarioNo.2

PractitionerXisattractedtohispatientPaula.Xnoticesthatheislookingforwardto
workingonthedayswhenPaulawillbethere.Xextendsthesessionsafewminutesin
ordertochatinformallywithPaula.XthinksPaulamightbeinterestedaswellbythe
waythatshemakeseyecontact.XnoticesthatheistouchingPaulaonthebackandthe
armmoreoften.XdecidestoaskPaulatojoinhimforacoffeeafterhernextvisitto
discusswhetherPaulaisinterestedinhim.IfPaulaisinterested,hewilltransferPaulas

26

caretoacolleague.IfPaulaisnotinterestedthenhewillmaketherelationshippurely
professional.Xdecidestoaskacolleague,Y,foradvice.

Y,correctly,tellsXthathehasalreadyengagedinsexualabusebylettingtheattraction
developwhilecontinuingtotreatPaula.YalsosaysthatitisimportantforXtotransfer
thecareofPaularightawayandcertainlybeforetheygettogetherforcoffee.

SampleExamQuestion

Whichofthefollowingissexualabuse:
i. Takingasexualhistorywhenitisclinicallynecessarytodo.
ii. UsingglamourshotsofscantilydressedHollywoodstarsasyourinteriordesign
themeinordertoattractyoungerpatients.
iii. Tellinganemployeeasexualjokewhentherearenopatientsaround.
iv.
Datingaformerpatient.

Thebestanswerisii).Thesepicturessexualizetheatmosphereattheclinicwhichis
inappropriateinahealthcaresetting.Answeri)isnotthebestanswerbecausetakinga
sexualhistoryisappropriatewhenitisneededtoassessthepatientanditisdone
professionally.Answeriii)isnotthebestanswerbecausethesexualabuserulesonly
applytopatients.Sexualbehaviourwithemployeesmay,however,constitutesexual
harassmentundertheHumanRightsCodeandcouldotherwisebeunprofessional.
Answeriv)isnotthebestanswerbecausethepersonisnotapatientatthetimeof
dating.However,itmightstillbeunprofessionaltodateaformerpatientsoonafterthey
stopbeingapatient(or,sometimesever),particularlyifthepractitionerhadanintense
orintimateroleinthetreatmentofthepatient.

d. Interprofessionalcollaboration

Itisinthebestinterestofpatientsifalloftheirhealthcareprovidersworkwitheachother.
Membersofdifferentprofessionsworkingtogethertoservethesameclientiscalled
interprofessionalcollaboration.Suchcollaborationwouldhelpensurethattreatmentsare
coordinatedandaseffectiveaspossible.Collaborationwouldalsoreducethechancesofthere
beingconflictingorinconsistenttreatment(e.g.,drugandherbinteractions,phasingouta
patientsdrugprescriptionsasotherformsoftreatmentbegintowork).Collaborationcould
alsoreducethechancesofpatientsreceivinginconsistentinformationandadvice.

TheRegulatedHealthProfessionsActrequirestheCollegetopromoteinterprofessional
collaboration.TheCollegetriestomodelthiscollaborationbyworkingtogetherwithother
healthColleges(e.g.,sharinginformationoninvestigations,developingstandardstogetherto
promotetheirconsistency).Inaddition,theCollegeattemptstohelppractitionerscollaborate
withmembersofotherhealthcareprofessionswhentreatingthesamepatients.

27

Thepatientcontrolstheextentofinterprofessionalcollaboration.Ifapatientisuncomfortable
withit,thepatientcandirectpractitionersnottosharethepatientspersonalhealth
informationwithothers.Thepractitionermustcomplywithsuchadirectionunlessoneofthe
exceptionsinthePersonalHealthInformationProtectionAct(itisdiscussedinmoredetail
below)applies.

Practitionersshoulddiscussanyplannedinterprofessionalcollaborationwiththepatientwhen
possible.However,therearecircumstanceswherepriorpatientconsentisnotpossible(e.g.,
whenthepatientgoestothehospitalinanemergencyandthehospitalcallsaskingaboutwhat
treatmentthepatienthasreceived).Practitionerscandiscloseinformationneededforthe
treatmentofthepatientwithoutconsentsolongasthepatienthasnotprohibitedthe
practitionerfromdoingso.

Interprofessionalcollaborationonlysucceedsifpractitionersrespecttheircolleagues.Evenif
thepractitionerdoesnotagreewiththeapproachestakenbytheothercolleague,
communicationsshouldbepolite.Practitionersshouldshareinformationandcooperatewith
theircolleagueswheneverpossible.Reasonableattemptstocoordinatetreatmentshouldbe
made.Compromisesmaysometimesneedtobemade(e.g.,astowhichtreatmenttotryfirst).
Interprofessionalrivalriesshouldbesetaside;itisthepatientsbestintereststhatshouldcome
first.Attemptsshouldbemadetoavoidforcingthepatienttochoosewhichhealthcare
providertouse(avoidsaying:eithershegoesorIgo).

Whereinterprofessionalcollaborationinvolvesworkinginamultidisciplinarysetting(i.e.,a
placewheremembersofdifferentprofessionsworktogetherandwherepatientsareoften
seenbymultiplehealthcareproviders),otherissuesarise,includingthefollowing:

Willthesettinghavesharedrecordsorwilleachpractitionerhaveseparaterecords?
Iftherecordsareshared,willthepractitionerkeepanyprivatenotesoutsideofthe
sharedrecord?Ifsohowwillthepractitionermakesurethattheotherhealthcare
providershaveaccesstotheinformationtheyneed?
Howdoesthesettingdealwiththewordingusedintherecords?Forexample,will
everyoneusethesameabbreviations?
Whathappenstotherecordsifthepractitionerleavestopractiseelsewhere?Willthe
patientbetoldwherethepractitionerhasgone?Willanotherpractitionerfromthe
settingtakeoverthepatientscare?Willthepatientbegivenachoice?Thepatient
reallyshouldbegivenachoicealthoughsomesettingswillonlydosoifthepatientasks.
Whoisthehealthinformationcustodianthatownstherecords?
Willtherebeonepersonwhohasoverallresponsibilityforthecareofthepatient?Ifso
who?Ifnot,howwillthepatientscarebecoordinated?
Howwilldisagreementsintheapproachtothecareofthepatientbedealtwith?Ifitis
thepractitionerwhoisindisagreement,whenandhowdoesthepractitionertellthe
patient?

28

Isthepatientawareofalloftheabove?

Thisisoneofthemanyareascoveredinthisdocumentinwhichapractitionershouldconsider
consultingwithhisorherownlawyer.

Whileinterprofessionalcollaborationwillbemorecomplicatedandchallengingforthe
practitioner,thisisthewayhealthcareisnowpractisedinOntario.Itisalsointhebestinterest
ofmostpatients.

InterprofessionalCollaborationScenario

PractitionerXpractisesalone.Heprovidesherbalandacupuncturetherapies.His
patient,Paula,alsohasafamilyMD.PaulasfamilyMDcallsunexpectedlytosaythat
PaulaisnotrespondingtohermedicationastheMDhadexpected.TheMDhasjust
learnedthatXisalsotreatingPaula.TheMDwondersifanythingthatXisdoingmight
interferewithPaulasmedication.XremembersthathehashintedtoPaulathatheis
notsupportiveofthemedicationthatPaulaistaking.XwondersifPaulahasstopped
takingthemedicationwithouttellingtheMD.WhatshouldXsay?

Inmanyrespects,therehasalreadybeenafailureofinterprofessionalcollaborationin
thiscase.Xshouldhavediscussedthebenefitsofinterprofessionalcollaborationwith
Paula.RatherthanhintingathisconcernsaboutthemedicationthatPaulaison,X
shouldhavediscussedtheconcernsopenlywithPaulaandrequestedpermissionto
speakwithPaulasMD.Atthispoint,however,XshouldprobablyspeaktoPaulafirst
beforetalkingtotheMD.ItisnotclearthatPaulawouldwantsuchadiscussiontotake
placeanditisnotanemergency.XshouldobtainPaulaspermissiontospeaktotheMD.

e. Billing

TheCollegedoesnotsetfeesforpractitionerstocharge.Establishingfeesisnotpartofthe
mandateoftheCollege.Infact,theCollegedoesnotregulatetheamountapractitionercanbill
thepatientunlessthefeeisexcessive.Afeeisexcessivewhenittakesadvantageofa
vulnerablepatientorissohighthattheprofessionwouldconcludethatthepractitioneris
exploitingapatient.

However,theCollegedoesregulatethewayinwhichpractitionersbillpatients.Billingmustbe
openandhonest.Patientsmustbetoldtheamountofthepractitionersfeesbeforetheservice
isprovided.Thisincludesthecostofanyproductsbeforetheyaresoldtothepatient.Thebest
waytotellpatientstheamountofthefeesistogivepatientsawrittenlistordescriptionofthe
feesofthepractitioner.However,thepatientcanalsobetoldverballyortherecanbeasign
clearlydisplayingthefeesinthereceptionareaofthepractice.Theproblemwiththose
methodsofnotificationisthatthepatientmightforget.Thelistordescriptionofthefeesmust
includeallchargesincludinganypenaltiesforlatepayment.

29

Apractitionermustprovideanitemizedbillforanypatientwhoasksforit.Thebillmust
describetheservicesthatwereprovidedandtheproductsthatweregiven.Anydocument
relatingtofees(e.g.,abillorareceipt)mustbeaccurate.Forexample,itwouldbeinaccurate
forthedocumenttodothefollowing:

Indicatethatthepractitionerwasprovidedtheservicewhensomeoneelsedid.
Indicatethewrongdatefortheservice.Forexample,itisunprofessionaltoputinadate
whenthepatienthadinsurancecoverageratherthantheactualdateofservicebecause
thepatientwouldnothaveinsurancecoverage.
Indicatethatoneservicewasperformedwhen,infact,anotherservicewasprovided.
Forexample,itisunprofessionaltoindicatethatacupuncturewasperformedwhenin
factaherbalremedywasprovided.
Billforservicesatmorethanthepractitionersusualratebecausetheserviceisbeing
paidforbyaninsurancecompany.
Indicatethataservicewasperformedwhen,infact,noservicewasperformed.For
example,itisunprofessionaltoindicatethatapatientvisitoccurredwhen,infact,the
patientmissedtheappointmentandalatecancellationfeeisbeingbilled.
Billforaproductformorethanitsactualcost.Theactualcostcanincludeareasonable
amountforthestafftimeforstorageandhandling.

Nofeecanbebilledwhennoservicewasprovided.Theonlyexceptionisthatafeecanbe
billedwhenapatientmissesanappointmentorcancelstheappointmentonveryshortnotice.

Practitionerscannotofferareductionintheamountofabillifitispaidimmediately.That
wouldgivewealthypatientsanadvantageoverotherpatients.However,apractitionercan
chargeinterestinoverdueaccountsbecausethereisanactualcosttopractitionersincollecting
them.

Somepractitionersofferfreeinitialconsultations.Thisisoftenmoreofanadvertisingissue
thanabillingissue.Seethediscussionofadvertisingbelow.Themainpointisthatanysuch
offersmustbecompletelyhonest.Theinitialconsultationmustbecompleteandnotjusta
partialservice.Theremustbenorequirementtoattendasecondtime(e.g.,togettheresults).
Theremustbenohiddencharges.Theoffermustbeopentoeveryone.

BillingScenario

PractitionerX,hasapostedrateof$120pervisitinthereceptionareaofhisoffice.In
fact,ifthepatientispayingfortheservicepersonallyanddoesnothaveextendedhealth
insurancecoverage,Xwillprovideacreditreducingtherateto$99pervisit.Ifapatient
hasspecialfinancialneeds,Xwillconsiderreducinghisrateevenfurther;infacthehas
threeregularpatientswhopayonly$5pervisit.

30

Theabovescenarioiscontrarytotheprofessionalmisconductregulation.IneffectXs
postedfeesarenothonestandaccurate.Xis,ineffect,billingpatientswithinsurance
morethanhisactualregularrate.

Itisacceptable,however,forXtolowerhisactualfeeinindividualcasesoffinancial
hardship.Xhastodothisonacasebycasebasisandnotthroughageneralpolicy
intendedtohidehistruefee.

3. Law

a. Typesoflaw

Thereareanumberofsourcesoflaw.Theyincludethefollowing:

Statutes.Mostoftenwhenonethinksoflaw,onethinksofstatutes(alsocalledActs).
ThereareoverridingstatutesthattakepriorityoverotherstatutessuchastheCanadian
CharterofRightsandFreedoms.Thestatutesthatpractitionerswillneedtobemost
awareofaretheRegulatedHealthProfessionsActandtheTraditionalChineseMedicine
Act.StatutesaremadebytheLegislativeAssembly(inOntario,theLegislativeAssembly
isoftencalledQueensPark).
Regulations.Regulationsaremadebythegovernmentwhenastatutepermitsthemto
bemade.UndertheRegulatedHealthProfessionsActregulationscanbeproposedby
theCollege(e.g.,registration,professionalmisconduct,qualityassurance)orbythe
MinisterofHealthandLongTermCare(e.g.,controlledacts,professionalcorporations).
Bylaws.BylawsaremadebytheCollege.Theydealprimarilywiththeinternal
operationsoftheCollege.Somebylawsaffectmembers(e.g.,fees,professionalliability
insurance,informationthatmustbeprovidedbypractitionerstotheCollege,additional
informationthatcouldbeputonthepublicregister,electionofpractitionerstothe
CounciloftheCollege).
CaseLaw.Courtdecisionsareusedasaguidebylawyersandjudgeswhensimilarissues
ariseinthefuture.Courtstrytobeconsistent,solongastheresultisnotunfair.Court
decisionsareparticularlyimportantinguidingtheprocedureofCollegecommittees
(e.g.,investigationsbytheInquiries,ComplaintsandReportsCommittee,theDiscipline
Committee).
Guidingdocuments.TheCollegepublishesofficialdocumentscalledStandardsof
Practice,Guidelines,PolicyStatementsandPositionStatements.Thesedocumentsare
notactuallylaw.However,theyhelppractitionersandCollegecommittees
understandandinterpretthelaw.Assuchthesedocumentscanbeveryusefulfor
practitionerstoreadandunderstand.Thesedocumentsaresometimescalledsoft
law.

Belowisadiscussionofthelawsthataremostapplicabletothedailylifeofpractitioners.

31

b. RHPA

TheRegulatedHealthProfessionsActappliesequallytoall26healthColleges.Itsetsoutthe
dutiesandresponsibilitiesoftheMinisterofHealthandLongTermCare,theCollegesandeach
ofitscommitteesandofpractitioners.TheprofessionspecificstatuteofeachCollege
integratestheRegulatedHealthProfessionsActintothatstatutesothattheycanbetreatedas
oneAct.

i. Controlledactsanddelegation

Therearecertainhealthcareproceduresthatarepotentiallydangerousandshouldonlybe
donebyaproperlyqualifiedperson.Thesepotentiallydangerousprocedureshavebeenlisted
intheRegulatedHealthProfessionsAct.Theyarecalledcontrolledacts.Noonecanperform
controlledactswithoutlegalauthority.

Thefourteencontrolledactsareasfollows:

1. Communicatingtotheindividualorhisorherpersonalrepresentativeadiagnosis
identifyingadiseaseordisorderasthecauseofsymptomsoftheindividualin
circumstancesinwhichitisreasonablyforeseeablethattheindividualorhisorher
personalrepresentativewillrelyonthediagnosis.
2. Performingaprocedureontissuebelowthedermis,belowthesurfaceofamucous
membrane,inorbelowthesurfaceofthecornea,orinorbelowthesurfacesofthe
teeth,includingthescalingofteeth.
3. Settingorcastingafractureofaboneoradislocationofajoint.
4. Movingthejointsofthespinebeyondtheindividualsusualphysiologicalrangeof
motionusingafast,lowamplitudethrust.
5. Administeringasubstancebyinjectionorinhalation.
6. Puttinganinstrument,handorfinger,

i. beyondtheexternalearcanal,

ii. beyondthepointinthenasalpassageswheretheynormallynarrow,

iii.beyondthelarynx,

iv.beyondtheopeningoftheurethra,

v. beyondthelabiamajora,

vi.beyondtheanalverge,or

vii.intoanartificialopeningintothebody.
7. Applyingororderingtheapplicationofaformofenergyprescribedbytheregulations
underthisAct.
8. Prescribing,dispensing,sellingorcompoundingadrugasdefinedintheDrugand
PharmaciesRegulationAct,orsupervisingthepartofapharmacywheresuchdrugs
arekept.
9. Prescribingordispensing,forvisionoreyeproblems,subnormalvisiondevices,
contactlensesoreyeglassesotherthansimplemagnifiers.

32

10. Prescribingahearingaidforahearingimpairedperson.
11. Fittingordispensingadentalprosthesis,orthodonticorperiodontalapplianceora
deviceusedinsidethemouthtoprotectteethfromabnormalfunctioning.
12. Managinglabourorconductingthedeliveryofababy.
13. Allergychallengetestingofakindinwhichapositiveresultofthetestisasignificant
allergicresponse.
14. Treating,bymeansofpsychotherapytechnique,deliveredthroughatherapeutic
relationship,anindividualsseriousdisorderofthought,cognition,mood,emotional
regulation,perceptionormemorythatmayseriouslyimpairtheindividuals
judgment,insight,behaviour,communicationorsocialfunctioning.4

TheseventhcontrolledactreferstoformsofenergysetoutintheMinistersregulation.That
regulationliststhefollowingformsofenergythatcannotbeused:

1.Electricityfor,
i.aversiveconditioning,
ii.cardiacpacemakertherapy,
iii.cardioversion,
iv.defibrillation,
v.electrocoagulation,
vi.electroconvulsiveshocktherapy,
vii.electromyography,
viii.fulguration,
ix.nerveconductionstudies,or
x.transcutaneouscardiacpacing.
2.Electromagnetismformagneticresonanceimaging.
3.Soundwavesfor,
i.diagnosticultrasound,or
ii.lithotripsy.

Sinceonlydiagnosticultrasoundisprohibited,thatmeansthattherapeuticultrasoundisnota
controlledact.

The eighth controlled act refers to the definition of a drug in the Drug and Pharmacies
RegulationAct.Thatisanimportantdefinitionforpractitionerstoknow.Itreadsasfollows:

drugmeansanysubstanceorpreparationcontaininganysubstance,

(a) manufactured,soldorrepresentedforusein,

Itisanticipatedthatthelastcontrolledact,providingpsychotherapy,willbecomelawaroundthespringof2013.

33

(i)thediagnosis,treatment,mitigationorpreventionofadisease,disorder,
abnormalphysicalormentalstateorthesymptomsthereof,inhumans,
animalsorfowl,or

(ii)restoring,correctingormodifyingfunctionsinhumans,animalsorfowl,
(b) referredtoinScheduleI,IIorIII,
(c) listedinapublicationnamedbytheregulations,or
(d) namedintheregulations,
butdoesnotinclude,
(e) anysubstanceorpreparationreferredtoinclause(a),(b),(c)or(d)
manufactured,offeredforsaleorsoldas,oraspartof,afood,drinkorcosmetic,
(f) anynaturalhealthproductasdefinedfromtimetotimebytheNaturalHealth
ProductsRegulationsundertheFoodandDrugsAct(Canada),unlesstheproductisa
substancethatisidentifiedintheregulationsasbeingadrugforthepurposesofthis
Actdespitethisclause,eitherspecificallyorbyitsmembershipinaclassoritslisting
oridentificationinapublication,
(g) asubstanceorpreparationnamedinScheduleU,
(h) asubstanceorpreparationlistedinapublicationnamedbytheregulations,or
(i) asubstanceorpreparationthattheregulationsprovideisnotadrug;

Unfortunately,thisdefinitionreferstoanumberofotherprovisions.Practitionersmayneedto
dosomeresearchorobtainadvicewhendealingwithaspecificsubstance.Ageneralruleisthat
ifasubstancehasaDIN(drugidentificationnumber)itisusuallyconsideredtobeadrug.5

Itisimportantforpractitionerstobefamiliarwiththeabovelistofcontrolledacts.

ControlledActsScenarioNo.1

PractitionerXseeshispatientPaul.Paulmentionsanearachethathehashadfortwo
days.Xtakesalookandseesthatabughasgottenintohisearandhasbeenjammed
deepintotheinnerearcanal,perhapswithacottonstick.Xtakessometweezersand
gentlyworkshiswayintotheinnerearcanalandremovesthebug.Paulisgrateful.X
mentionstheincidenttoacolleaguewhoadvisedXthathehasjustperformeda
controlledactthatisnotauthorizedtoTCMpractitioners.XcheckstheRegulatedHealth
ProfessionsActandrealizesthathiscolleagueiscorrect.

Therearefourwaysinwhichahealthcareprovidercanreceivelegalauthoritytoperforma
controlledact:

Somenondrugsubstanceshavedifferentkindsofdrugnumberings,forexample,aNaturalProductNumber
(NPN)orHomeopathicMedicineNumber(DINHM).

34

Authorization.Beingauthorizedtoperformthecontrolledactbythehealthcare
providersenablingstatute.TheTraditionalChineseMedicineActauthorizes
practitionerstoperformthefollowingcontrolledacts:
o Performingaprocedureontissuebelowthedermisandbelowthesurfaceofa
mucousmembraneforthepurposeofperformingacupuncture.
o CommunicatingatraditionalChinesemedicinediagnosisidentifyingabody
systemdisorderasthecauseofapersonssymptomsusingtraditionalChinese
medicinetechniques
Exceptions.TheRegulatedHealthProfessionsActcreatesanumberofexceptions
permittingpeopletoperformcontrolledactsincertaincircumstances.Theseexceptions
includethefollowing:
o Helpingsomeoneinanemergency.
o WhileinformaltrainingtobecomeamemberofaCollegeauthorizedtoperform
thecontrolledact.
o Performingthecontrolledactundersupervision.
o Treatmentbyprayerorspiritualmeanspursuanttoonesreligion.
o Administeringasubstancebyinjectionorinhalationorenteringabodyopening
orcommunicatingdiagnosis(e.g.,tellingoneschildthatshehadacold)when
doneforamemberofoneshousehold.
o Helpingapersonwithhisorherroutineactivitiesoflivingwhereitincludes
administeringasubstancebyinjectionorinhalationorenteringabodilyorifice
(e.g.,onahomevisithelpingapatientwiththeirinsulininjection).
o Counsellingaperson(solongasthecounsellingdoesnotamountto
communicatingadiagnosisorprovidingpsychotherapy).Inmanywaysthe
counsellingexceptionprovisionissimplyintendedtoconveythepointthat
counselling,itself,doesnotnormallyfallwithinanyofthecontrolledacts.Itis
notreallyatrueexception.
o Providingaboriginalhealingwithintheaboriginalcommunity.
Exemptions.InadditiontotheexceptionslistedintheRegulatedHealthProfessionsAct,
theMinisterofHealthandLongTermCarehasprovidedanumberofexemptionsina
Ministersregulation.Mostofthoseexemptionsarelimitedinscope(e.g.,dentistsare
permittedtoapplyelectricityforelectrocoagulation).Afewoftheexemptionshave
broaderapplication,includingthefollowing:
o Anyonecanperformcosmeticbodypiercingsandtattooing.
o Anyonecanperformelectrolysis.
o MembersofsevenhealthCollegescanperformacupunctureunderexemption.6
o Anyonecanperformmalecircumcision.

Theyare:chiropody,chiropractic,massagetherapy,nursing,occupationaltherapy,physiotherapyanddentistry.
NaturopathsregulatedundertheDruglessPractitionersActhavetheirownexemptionandwillbeaddedtothelist
whenthenewCollegeisfullyestablished.TherearemembersofotherColleges,suchastraditionalChinese
medicineandphysicians,whocanperformacupunctureundertheauthorizationoftheirprofessionspecificActs.

35

Delegation.Ahealthcareproviderwhoispermittedtoperformacontrolledactcan
delegatethecontrolledacttoothers.Forexample,inthecontrolledactscenario
describedabove,ifXhadcalledPaulsphysicianandthephysicianhaddelegatedtoX
theremovalofthebugfromtheinternalearcanal,Xwouldbeauthorizedtoperform
theprocedure.Delegationcanbemadetoanotherhealthcareproviderortoan
unregisteredperson.Delegationissubjecttoanumberofrules,includingthefollowing:
o Thepersongivingthedelegationislimitedbyanyregulationsorprofessional
standardsofhisorherCollege.Forexample,theprofessionalmisconduct
regulationoftheCollegeprohibitsthedelegationofacontrolledactby
practitionersunlessthepractitionerhastakenstepstoensurethattheperson
receivingthedelegationhastheknowledge,skillsandjudgmenttoperformthe
procedureandthepractitionerhasdocumentedthosesteps.
o Thepersonreceivingadelegationislimitedbyanyregulationsorprofessional
standardsofhisorherCollege.Forexample,apractitionerwouldnotbe
complyingwithprofessionalstandardsbyperformingbrainsurgeryonapatient
evenifthatprocedurehadbeendelegatedbyaphysician.
o Thepersondelegatingtheprocedureisresponsiblefortheactionsoftheperson
receivingthedelegation.Forexample,ifapractitionerdelegatedacupunctureto
anassistantandtheneedlepuncturedavitalorgan,thepractitionercouldbe
suedordisciplinedforthatevent.

ControlledActsScenarioNo.2

Y,atraditionalChinesemedicinepractitioner,performsacupunctureonherpatient
Paula.AcupunctureisacontrolledactauthorizedtopractitionersundertheTraditional
ChineseMedicineAct.Yisauthorizedtoperformthatcontrolledact.

ControlledActsScenarioNo.3

PractitionerXhasaplateofcookiesinhiswaitingroom.Paul,apatient,eatsoneand
goesintoanaphylacticshock.Xiscalledintotheroom.XrecallsthatPaulhasapeanut
allergyandrealizesthatthecookiesmayhavepeanutsinthem.XlooksinPauls
briefcaseandfindsanEpiPencontainingameasureddoseofepinephrine.Xinjectsthe
epinephrineintoPaulsmuscleandcalls911.Paulrecovers.WhileXdidperforma
controlledactnotauthorizedtohim(injectingadrugbyinjection),hedidsounderan
emergencywhichisarecognizedexceptiontothecontrolledactsrule.

ControlledActsScenarioNo.4

Y,apractitioner,onlyworksparttime.Herotherjobistoperformartisticbodypiercings.
Herprofessionaltrainingcomesinhandywhenperformingthisprocedure.Eventhough
suchpiercingsgobeyondthedermis,thisprocedureisexemptedundertheMinisters
regulationoncontrolledacts.

36

ControlledActsScenarioNo.5

X,apractitioner,workswithaphysician.BecauseofXsexperiencewithacupuncture
andknowledgeofanatomy,thephysiciantrustsXtoperforminjectionsonpatientsina
sterilemanneratpreciseanatomicallocations.Thephysiciandelegatesintramuscular
injectionsoflocalanaesthesiatopatientsaspartoftheirpainmanagementtreatments.
Xisauthorizedbythedelegationtoperformtheseinjections.However,bothXandthe
physicianwillberesponsibleifsomethinggoeswrong.

SampleExamQuestion

Whichofthefollowingisacontrolledact:
i. Removingbrokenglassthathasbeendeeplyembeddedinachildsleg.
ii. Cleaningascrapeonachildselbowwithsoapandwater.
iii. Applyingalcoholtothatscrapeonachildselbow.
iv.
Wrappingthechildswounds.

Thebestanswerisi).Deeplyembeddedglassalmostcertainlyhasgonebeyondthe
dermisandissittingindeepertissue.Theremaybeanissueastowhetherthisisan
emergency(likelynotasinmostcasesitwouldbepossibletotakethechildtoahospital
orphysiciansclinicfortreatment),butthatdoesnotchangethefactthatremovingthe
glassisacontrolledact.Similarly,thehouseholdexemptiondoesnotapplytothesesorts
ofprocedures.Answerii)isnotthebestanswerbecauseascrapeontheskinimpliesthat
ithasnotgonebeneaththedermis.Answeriii)isnotthebestanswerbecauseapplyinga
substancetotheskinisnotadministeringasubstancebyinhalationorinjection.Answer
iv)isnotthebestanswerbecausetheprocedureisabovetheskinanddoesnotfall
withinanyoftheothercontrolledacts.

ii. Scopeofpractice

BecausetheRegulatedHealthProfessionsActusescontrolledactstoprotectthepublicfrom
potentiallydangeroushealthprocedures,thescopeofpracticeofeachprofessionisnotas
significant.Noprofessionhasanexclusivescopeofpractice.Membersofotherprofessionscan
dothesamethingsthatpractitionerscando.Therearetwoexceptions:

Peoplecannotperformacontrolledactunlesstheyhavelegalauthoritytodoso.
Thereisariskofharmprovisionthatpreventspeoplefromperformingpotentially
dangerousprocedureseveniftheyarenotcontrolledacts.

37

RiskofHarmProvision

Theriskofharmprovisionprohibitsapersonfromtreatingoradvisingapersonwithrespectto
hisorherhealthincircumstancesinwhichitisreasonablyforeseeablethatseriousbodilyharm
mayresultfromthetreatmentoradviceorfromanomissionfromthem7.Thisprovisionis
designedtopreventindividualsfromtakingadvantageofvulnerablepatients,inwaysother
thanperformingacontrolledact.Forexample,encouragingacancerpatienttotrydietasthe
onlymeansoftreatmentmightfallwithinthisriskofharmprovision.

However,theriskofharmprovisiondoesnotapplytopractitionerspractisingwithintheir
scopeofpractice.Thusitisnotanoffenceforapractitionertoprovidetreatmentwithinthe
scopeofpracticeoftraditionalChinesemedicineevenifthereisaninherentrisktothe
treatment.Iftherewasincompetentcare,thepractitionerisaccountabletotheCollege(notto
provincialoffencescourt)forhisorherconduct.However,ifapractitionerprovidestreatment
outsideofthescopeofpracticeoftheprofession,theriskofharmprovisiondoesapply.For
example,ifapractitionertreatedapatientscancerbyusingproceduresassociatedwith
MedicalDoctorsandwhicharenotpartofthescopeofpracticeoftraditionalChinese
medicine,thenthepractitionercouldfaceprosecution.

Thusitisimportantforpractitionerstoknowtheirscopeofpractice.

ScopeofPracticeStatement

Aprofessionsscopeofpracticeisadescriptionofwhatthatprofessiondoes.

UndertheTraditionalChineseMedicineAct,thescopeofpracticestatementreadsasfollows:

3.ThepracticeoftraditionalChinesemedicineistheassessmentofbodysystem
disordersthroughtraditionalChinesemedicinetechniquesandtreatmentusing
traditionalChinesemedicinetherapiestopromote,maintainorrestorehealth.

Whilefairlybroadlystated,thisscopeofpracticestatementdoesnotallowapractitionerto
providetreatmentsthatareoutsideoftheusualpracticesofpractitioners.Forexample,any
formofsurgeryisnotincludedinthisscopeofpractice.

Practitionersarepermittedtoperformproceduresthatarenotinherentlydangerousthatlie
outsideoftheirscopeofpractice.Forexample,providingnutritionalcounsellingandnatural
healthproductstopatientswouldoftenbepermissible.However,theCollegehasapolicythat
patientsneedtoknowwhetherapractitionerisactingasapractitioner,orasanotherhealth
careprovider.ThispolicyapplieswhetherthepractitionerisregisteredwithanotherCollegeor

Section30oftheRegulatedHealthProfessionsAct.

38

not.Thepatientmustbetoldwhichprofessionalhatthepractitioneriswearing.Infact,to
ensurethatapatientisnotmisled,separateappointments,recordsandbillingsshouldbe
made.

ScopeofPracticeScenario

Y,apractitioner,isseeingPaula,apatientdiagnosedwithStageIVcancer.Paulais
scheduledforsurgerynextweektobefollowedbychemotherapy.Paulasphysiciansays
thatthetreatmenthasa50%chanceofsuccess(i.e.,meaningshewillbealiveand
cancerfreeinfiveyearstime).Paulasphysicianalsosaidthatwithouttreatment,Paula
hadalessthan5%chanceofsurvivingforfiveyears.Afteracarefulassessment,Y
advisesthepatienttocancelboththesurgeryandthechemotherapy.Yrecommendsa
combinationofrelaxationtapesandafastingcleansingprogramfollowedbyanallfruit
dietinstead.PauladieswithintwomonthsandthefamilygotothepoliceaskingthatY
beprosecutedundertheriskofharmclause.

Inthiscase,Yappearstohaveprovidedtreatmentthatisoutsideofthescopeofpractice
forpractitioners.Thetreatmentalsoappearstohavenoevidencetosupportit.There
wasaninherentriskofharminadvisingthepatienttorejecttheproposedmedical
treatmentthathadevidenceofareasonablechanceofrecoveryforatreatmentthat
hadnotbeenfullyresearched.

iii. Useoftitles

Thereareanumberofrulesabouttheuseofprofessionaltitlesanddesignationsby
practitioners.

ThefirstgeneralruleisthatonlyapprovedpersonscanuseanyformofthetitleDoctorwhen
providingorofferingtoprovidehealthcareservicesinOntario.Ifapersonisnotfromoneof
theapprovedhealthprofessions,heorshecannotusethetitleinaclinicalsettingevenifthe
personhasanearneddoctoraldegree(i.e.,thepersonholdsaPh.D).Allowingastaffpersonto
callthehealthcarepractitionerDoctorwouldconstituteanoffence.Underthisprovision,
peoplecanusethetitleDoctorinothersettings,suchassociallyorinapurelyteaching
setting,wheretherearenopatients.

PractitionersarenotallowedtousethetitleDoctoryet.Practitionerswillbepermittedtouse
thetitleDoctoroncetheclassofregistrationforDoctorsofTraditionalChineseMedicineis
created.ThatclassofregistrationwillnotbeavailablewhentheTraditionalChineseMedicine
Actisfirstproclaimedintolaw.Itwilllikelybeafewyearsbeforethatclassofregistration
becomesavailable.

Thesecondruleisthateachprofessionspecificstatuteregulatestheuseoftitlesrelatingto
theirprofession.Eachprofessionhasspecifictitlesthatonlypersonsregisteredwiththeir

39

Collegecanuseasaprofessionaltitle.Forexample,onlypractitionerscanusethetitles
traditionalChinesemedicinepractitioneroracupuncturistoranyvariationofthosetitles.In
addition,evenifthepersondoesnotusetheprotectedtitle,heorshecannotholdhimselfor
herselfoutasapractitioner.Thispreventspeoplefrompretendingthattheyarepractitioners
whentheyarenot.

Thuspractitionersneedtobecarefulnottouseasaprofessionaltitleadesignationthatis
permittedtomembersofotherColleges.Forexample,unlessapractitionerisregisteredwith
thatCollege,theycannotcallthemselvesaphysiotherapistoraphysicaltherapist.

ThethirdsetofrulesiscreatedbyeachCollegeforitsmembersintheregistrationand
professionalmisconductregulations.Forexample,eachclassofregistrationisgivenaspecific
designationforthemtouse(e.g.,R.TCMP,orR.Ac).Practitionerswithotherclassesof
registrationcannotusethosedesignationsunlessspecificallypermittedtodoso.Inaddition,
sincetheprofessiondoesnothaverecognizedspecialties,practitionerscannotusetitlesor
designationsinferringspecialiststatusorcertification(e.g.,paediatrician,gerontologist).
However,practitionersarefreetodescribetheirareasofpracticesolongasitdoesnotimply
specialiststatusorcertification(e.g.,practicelimitedtochildren).Finally,therearegeneral
professionalmisconductregulationspreventingtheuseofmisleadingtitlesordesignationsor
engaginginfalseormisleadingadvertising.Forexample,itwouldbeprofessionalmisconduct
forapractitionertorefertoaneducationaldegreethathadnotbeenreceived.

UseofTitlesScenario

X,apractitioner,teachesataschoolthattrainspractitioners.ThereisnoDoctorof
TraditionalChineseMedicineclassofregistrationinOntarioyet.Theschoolhasaclinic
whereitseespatients.Xsupervisesthestudentsattheclinic.Thestudentsrefertohim
asDoctorXattheclinic.TheDeanoftheschoolpullsXasideandtellshimtoaskhis
studentstostopcallinghimDoctorintheclinicwheretherearepatients.ItisOKinthe
classroom,butnottheclinic.XreviewstheRegulatedHealthProfessionsActandrealizes
thattheDeaniscorrect.Xisassistinginthetreatmentofpatientsthereandthusisnot
permittedtocallhimself(orallowotherstocallhim)Doctorthere.Xalsorecognizes
thathewasbeingapoormodelforthestudents.

iv. Mandatoryreports

Partofbeingamemberofaregulatedhealthprofessionisthatonecannotremainsilentwhen
anotherhealthcareproviderisharmingapatient.Apractitionermustspeakupinthose
circumstances.Inotherwords,makingareportismandatory.TheRegulatedHealthProfessions
Actcarefullybalancestheneedtoprotectpatientsbyrequiringpractitionerstomakeareport
anddisruptingthehealthcaresystemwithmanyunnecessaryreports.Thestatutealso
recognizesthatifpractitionersunnecessarilyreportontheircolleagues,itwillharmthe
atmospherenecessaryforinterprofessionalcollaboration.Thissectionofthebookdescribes

40

themandatoryreportingprovisionsoftheRegulatedHealthProfessionsAct.Therearesome
mandatoryreportingprovisionsinotherstatutes(e.g.,theChildandFamilyServicesAct)which
areeitherdealtwithbeloworaretoouncommonforpractitionerstowarrantdiscussioninthis
book.

BoththeRegulatedHealthProtectionActandcaselawprovideimmunitytopractitionerswho
makeamandatoryreportingoodfaith.

Themandatoryreportingrequirementsalsocreateanexceptiontothepractitionersdutyof
confidentiality.Inaddition,thePersonalHealthInformationProtectionActpermitsareportto
theCollegetobemadeasanexceptiontotheprivacydutiesunderthatstatute.

SexualAbuse

Apractitionermustreportsexualabuseofapatientbyanotherhealthcareprovider.Theduty
arisesifthepractitionerhasreasonablegroundstobelievethesexualabuseoccurredinthe
courseofpractisingtheprofessionorwhileoperatingahealthfacility(whichprobablyincludes
anofficeorclinic).Thereasonablegroundscouldariseevenifthepractitionerdidnot
personallyobservethesexualabuse.Forexample,ifapatienttellsthepractitionerdetailsof
theabuse,thatwouldlikelyconstitutereasonablegrounds.Apractitionerdoesnothaveto
investigatetheeventsfirstnordoesthepractitionerhavetoactuallybelievethatthe
informationistrue(e.g.,thepractitionermightknowtheallegedabuserandcannotbelieve
thatheorshewoulddosuchathing).Iftheinformationconstitutesreasonablegrounds,the
reportmustbemade.Reasonablegroundsmeansinformationthatareasonablepersonwho
doesnotknowtheindividualinvolvedwouldconcludethatitismorelikelythannotthatthe
informationiscorrect.

ThereportmustbemadeinwritingtotheRegistraroftheCollegetowhichtheallegedsexual
abuserbelongs.Thereporthastocontainthereportingpractitionersnameandthegroundsof
thereport.However,thereportcannotcontainthepatientsnameunlessthepatientagrees
inwritingthatthenamecanbeincluded.Thislimitationisintendedtoprotecttheprivacyof
patientswhomaybeinavulnerableposition.Thereportmustbemadewithinthirtydaysof
receivingtheinformation.Ifitappearsthatpatientsarecontinuingtobeharmedandthereis
anurgentneedforintervention,thereportmustbemaderightaway.

SexualAbuseMandatoryReportScenario

Y,apractitioner,istoldbyPaula,apatient,thatshehadanaffairwithherfamilydoctor.
YasksPaulaifherfamilydoctorwastreatingherwhiletheaffairwasongoing.Paula
saysyes.YtellsPaulathatsheisrequiredbylawtoreportthisinformationtothe
RegistraroftheCollegeofPhysiciansandSurgeonsofOntario(CPSO).Yexplainsthatthe
CPSOwillwanttoinvestigatethereport.ItwillbeverydifficultfortheCPSOto
investigatethereportifPaulasnameandcontactinformationisnotincludedinthe

41

report.TheCPSOwilllikelywanttointerviewPaulaabouttheaffair.Theinvestigation
couldleadtoadisciplinehearing.However,thelawisclearthatYcannotincludePaulas
nameandcontactinformationunlessPaulaispreparedtosignawrittenconsent
permittingYtodoso.YsaysthattheycancalltheCPSOrightaway,onananonymous
basis,toseewhattheprocesswouldbelike.Paulaagreestothetelephonecall.Afterthe
calliscompletedPaulasaysthatshewillnotgiveherconsenttoincludehernameand
contactinformation.YthenprovidesthereportinwritingwithoutidentifyingPaula.

Incompetence,IncapacityandProfessionalMisconduct

Apractitionermustreportifheorsheendsabusinessrelationshipwithanotherhealthcare
provideronthebasisthattheotherhealthcareproviderisincompetentorincapacitatedor
engagedinprofessionalmisconduct.Examplesofbusinessrelationshipsincludeemployer
employee,partners,shareholdersinaprofessionalcorporationorspacesharing.Ifthe
practitionerwasgoingtomakeareport,thereportmustbemadeevenifthepersonquitsor
resignsfirst.

ThereportmustbemadeinwritingtotheRegistraroftheCollegethatregulatestheother
healthcareprovider.Thereportmustbemadewithinthirtydaysofending(orproposingto
end)thebusinessrelationship.Underthismandatoryreportingobligationthenameofthe
patientcanbeincludedwithoutthepatientsconsent.

Inaddition,ifapractitioneroperatesahealthfacility(whichprobablyincludesanofficeor
clinic),thepractitionermustreportanyreasonablegroundstobelievethatanotherhealthcare
providerisincompetentorincapacitated.Thisdutytoreportdoesnotincludejustprofessional
misconduct.Thisreportmustbemadeevenifthebusinessrelationshipwiththeotherhealth
careproviderisnotended.Forexample,ifahealthcareprovideratthefacilityisfoundtohave
adrugaddictionandgoesintoatreatmentprogramwhilethejobiskeptforhimorher,the
reportwouldstillhavetobemade.

Again,thereportmustbemadeinwritingtotheRegistraroftheCollegetowhomthealleged
healthcareproviderbelongs.Thereporthastocontainthereportingpractitioner'snameand
thegroundsofthereport.Underthismandatoryreportingobligationthenameofthepatient
canbeincludedwithoutthepatient'sconsent,solongasitisnotinvolvingsexualabuse.The
reportmustbemadewithinthirtydaysofreceivingtheinformation.Ifitappearsthatpatients
arecontinuingtobeharmed,thereportmustbemaderightaway.

Incompetence,IncapacityandProfessionalMisconductMandatoryReportScenario

X,apractitioner,learnsthathisemployer(atraditionalChinesemedicinepractitioner)is
analcoholic.Xtriestohelphisemployergettreatment,buttheemployerkeeps
relapsing.Thedaybefore,theemployercamebackafterlunchtotallyimpairedsuchthat
Xhadtocallinhisemployerswifetopickhimupandtakehimhome.Xhadtocoverfor

42

thepatients.WhatscaredXthemostwasthathisemployertreatedthreepatientsafter
lunchbeforeXfoundoutabouthiscondition.Xispreparinghisletterofresignation.He
consultsalawyeraboutwhattodo.XslawyeradviseshimthatXmustmakeawritten
reporttotheRegistraroftheCollegeofXsemployer.

OffencesSelfReport

Practitionershavetoreportthemselveswhentheyhavebeenfoundguiltyofanoffence.All
offencesaresupposedtobereported.Thuscriminaloffences,offencesunderfederaldrugor
otherlegislationandprovincialoffences(includinghighwaytrafficoffences)needtobe
reported.Onlycourtscanmakeoffencefindings.Thusanyfindingsbyabodythatisnotacourt
(calledtribunals)arenotreportableunderthisprovision.Allcourtfindingsarereportable
regardlessofwhetherornottheyresultedinaconviction.Afindingofguiltthatleadstoan
absoluteorconditionaldischargemustbereportedeventhoughtheyarenotconvictions.

ReportsaretobemadetotheRegistraroftheCollegeassoonaspossibleafterthefindingand
shouldcontainthefollowinginformation:

thenameofthepractitionerfilingthereport;
thenatureof,andadescriptionoftheoffence;
thedatethepractitionerwasfoundguiltyoftheoffence;
thenameandlocationofthecourtthatfoundthepractitionerguiltyoftheoffence;
and
thestatusofanyappealinitiatedrespectingthefindingofguilt.

ThereportwillbereviewedbytheCollegeandmayresultinaninvestigation.However,the
reportdoesnotautomaticallygetputonthepublicregister(seethediscussionoftheregister
below).

Ifthereisanappealthatalterstheinformationreported,anupdatedreportmustbemade.

OffenceMandatoryReportScenario

Y,apractitioner,isfoundguiltyofcarelessdrivingundertheHighwayTrafficAct.Onthe
Collegesannualrenewalformsheseesaquestionaskingifshehasbeenfoundguiltyof
anyoffence.Shecannotbelievethatthisquestionismeanttoincludinghercareless
drivingcharge.ShecallstheCollegeforclarification.SheistoldthattheRegulated
HealthProfessionsActrequiresalloffencestobereported.Theintentofrequiringsuch
reportswastopreventpractitionersfromdeterminingwhetherthefindingswere
relevantornot.ThestatutewantsthatdecisiontobemadebytheCollege.Infact,Y
shouldhavereportedthefindingwhenitoccurredandnotwaitedsixmonthsforthe
annualrenewalform.Ymakesthereport.Afewweekslatershereceivesaletterfrom
theCollegethankingherforherreport,statingthattheCollegedoesnotbelievethatthis

43

findingisworthinvestigatingfurtherandremindingherthatinthefuturesuchfindings
needtobereportedrightaway.

ProfessionalNegligenceSelfReport

Practitionershavetoreportthemselveswhentheyhavebeenfoundtohaveengagedin
professionalnegligenceormalpractice.Findingsofprofessionalnegligenceormalpracticeare
onlymadebythecourts.Thusanyfindingsbyatribunalarenotreportableunderthisprovision.
Settlementsofclaimsforprofessionalnegligencemaynotbeincludedinthereporting
requirementiftheydidnotresultinacourtfinding.

ReportsaretobemadetotheRegistraroftheCollegeassoonaspossibleafterthefindingand
shouldcontainthefollowinginformation:

thenameofthepractitionerfilingthereport;
thenatureof,andadescriptionofthefinding;
thedateofthefinding;
thenameandlocationofthecourtthatmadethefinding;and
thestatusofanyappealinitiatedrespectingthefinding.

ThereportwillbereviewedbytheCollegeandmayresultinaninvestigation.Thereportis
automaticallyputonthepublicregister(seethediscussionoftheregisterbelow).

Ifthereisanappealthatalterstheinformationreported,anupdatedreportmustbemade.

ProfessionalNegligenceMandatoryReportScenario

X,apractitioner,issuedinSmallClaimsCourtbyapatient,Paul.Paulclaimsthathetold
XaboutpaininhislowerabdomenbutthatXattributedthosesymptomstostress.After
twoweeksofacupunctureforthestress,despiteincreasingpain,Paulwenttothe
emergencydepartment.Paulwasrushedintosurgeryforappendicitisandstayedinthe
hospitalforalmostaweek.PaulclaimsXshouldhavereferredhimtoanotherhealth
careprovidertoruleoutappendicitisbeforetreatingthesymptomsaspurelystress
related.TheSmallClaimsCourtjudgeagreedandorderXtopayPaul$10,000forthe
malpractice.XreportedthefindingtotheCollege.TheCollegeplacedanoteaboutthe
findingonthepublicregister.

DutytoWarn

Undercaselaw,apractitionerwhohasreasonablegroundstobelievethatanotherpersonis
likelygoingtocauseseverebodilyharmhastowarntheappropriatepeopleoftherisk.The
Collegehasincludedaversionofthisdutytowarninitsprofessionalmisconductregulation.
Whereapractitionerlearnsofanincidentofunsafepracticebyanotherpractitioner,thefirst

44

practitionermustreportthistotheRegistrar.Thisdutytoreportdoesnotincludeallformsof
incompetence,incapacityorprofessionalmisconduct.Itonlyapplieswherethepractitioner
riskedthesafetyofaperson(normally,butnotalways,apatient).

Thisprovisiondoesnotapplywheretheproviderengaginginriskybehaviourisamemberof
anotherprofession.However,inthosecircumstancestheremaybeanethicalorevenacase
lawdutytointerveneinanappropriatewaytopreventharmtoapatientorotherperson.

ThereportmustbemadepromptlytotheCollege.Itwouldbeadvisabletomakethereportin
writingwithallnecessarydetails.Underthismandatoryreportingobligationthenameofthe
patientcanbeincludedwithoutthepatientsconsent.

DutytoWarnMandatoryReportScenario

Y,apractitioner,learnsfromPaula,apatient,thatanotherpractitioner,X,strongly
recommendedthatPaulaundergoamonthlongcleanse.Thecleanseinvolvednofood
anddrinkingonlylemonjuiceandwater.Paulaisinherfiftiesandisunderweight.Paula
saysthatatleasttwootherpatientsofXhadbeengivensimilaradvice.Yisconcerned
thatsuchacleanseisnotsafeformanypeopleandcertainlynotsomeonelikePaula.Yis
alsoconcernedthatXlikelydoesnothavetheexpertisetooverseefastingforsuchalong
time.YmakesareporttotheRegistraroftheCollege.

SampleExamQuestion

Isamandatoryreportrequiredwhereapractitioneroverheardanotherpractitioner
tellingtwomalepatientsasexuallyexplicitjoke,wholaughloudly?
i. No.Dirtyjokesarenotsexualabuse.
ii. Yes.Thisissexualharassment.ThereportshouldbemadetotheHumanRights
Tribunal.
iii. No.Thepatientslikedthejokeandwouldnothavebeenharmedbyit.
iv.
Yes.Thisconstitutessexualabuse.

Thebestanswerisiv).Sexualabuseincludescommentsofasexualnaturetoapatient.
Reportingsexualabuseismandatory.Whileitisunlikelythatsignificantactionwillbe
takenbytheCollege(perhapsasensitivitycourse),itisstillimportantthatpractitioners
learnthatsuchconductcanbeharmfultosomepatients.Oneneverknowswhat
experiencespatientshavehadintheirpastthatmightmakeevenadirtyjokeharmful.
Answeri)isincorrectbecausedirtyjokesaresexualabuseasthattermisdefinedinthe
RegulatedHealthProfessionsAct.Answerii)isnotthebestanswerbecausethereareno
mandatoryreportingrequirementsundertheHumanRightsCode.Also,theRegulated
HealthProfessionsActusesthetermsexualabuseratherthansexualharassmentand
givesthattermamuchdifferentmeaning.Answeriii)isnotthebestanswerbecause
whetherthepatientwasawillingparticipantornotisirrelevant.Thecommentstill

45

shouldnothavebeenmade.Also,oneneverknowswhatexperiencespatientshavehad
intheirpastthatmightmakeevenadirtyjokeharmful.Inaddition,sexualizingthe
practiceoftheprofessionisinherentlyconfusingtopatientswhoassumethatthereisno
sexualaspecttotheirrelationshipwithpractitioners.

v. PublicRegister

TheRegulatedHealthProfessionsActrequiresthatthepublicbeabletogetcertaininformation
aboutpractitioners.Thisinformationhelpsthepublic(e.g.,patients,employers)todecide
whethertochooseaparticularpractitioner.Thisinformationalsohelpsthepublictoseehow
welltheCollegeisregulatingpractitioners.Theregisteralsohelpsensurethatpractitioners
practiseonlyastheyarepermittedbytheCollege.Forexample,ifapractitionerissuspended
forthreemonths,peoplecanmoreeasilyreporttotheCollegeifthepractitionerisstillworking
duringthesuspensionperiod.

Theregistermustcontainthefollowinginformationabouteachpractitioner:

Name;
Businessaddressandtelephonenumber;
Name,businessaddressandtelephonenumberofeachprofessionalcorporation
Classofregistration;
Anyterms,conditionsandlimitationsontheregistration;
ReferralstotheDisciplineCommitteeforadisciplinehearing;
Asummaryofeveryfindingofprofessionalmisconduct,incompetenceorincapacity;
Findingsbyacourtofprofessionalnegligence;
Everysuspensionofregistration;
Everyrevocationofregistration;
Anyagreementtoresignandneverreapplyforregistration;and
Anyotherinformationthatthebylawssayshouldgoontheregister.

ThereareveryfewcircumstanceswheretheCollegecanchoosenottoputthisinformationon
theregisterortoremoveinformationfromtheregister.However,itcandosointhefollowing
circumstances:

Theinformation(e.g.,contactinformation)wouldjeopardizethesafetyofapractitioner
(e.g.,ifapractitionerisbeingstalked).
Theinformationisobsoleteornolongerrelevant(e.g.,thefindingofprofessional
misconductrelatestoconductthatisnowacceptable,forexampleiftheadvertising
ruleshappentochange).
Unnecessaryinformationaboutthepersonalhealthofapractitioner(e.g.,inincapacity
matters).

46

Aftersixyears,wheretherewasonlyareprimand,afineorafindingofincapacityand
theDisciplineCommitteeorFitnesstoPractiseCommitteeagreesthatthereisnopublic
interestinkeepingtheinformationontheregister.

Theregisterisavailabletothepublicinanumberofways.ItisontheCollegeswebsite.Itis
availableattheCollegesoffice.Apapercopycanberequested.TheCollegecanalsogive
informationontheregisteroverthetelephone.Whereapersonasksaboutapractitioner,the
Collegemusthelpthepersonfindwhateverinformationthatpersonwantsthatisonthe
register.

PublicRegisterScenario

Y,apractitioner,hasseparatedfromherhusband.Yshusbandhashitherafewtimes.
Sincetheseparation,Yshusbandhasbeenfollowingher.Thepolicecannotseemtostop
him.Ymovestoanothercity.SheaskstheRegistrarnottoputherbusinessaddressor
telephonenumberonthepublicregistersothatherhusbandcannotfindher.Yprovides
documentsfromthepoliceandthecourtsaboutherhusbandsbehaviour.TheRegistrar
removesYscontactinformationfromtheregister.

vi. ProfessionalCorporations

Practitionerscanchoosetopractisepersonally(i.e.,intheirownnames),throughapartnership
orthroughaprofessionalcorporation(i.e.,aspecialtypeofcorporationforregulated
professionals).Practitionerscannotpracticethroughregularbusinesscorporations;theycan
onlypracticethroughaprofessionalcorporation.Practitionerswhohavearegularbusiness
corporationwillhavetochangethatcorporationtoaprofessionalcorporationoncethey
becomeregisteredwiththeCollege.

Professionalcorporationshaveanumberofconditionsandrestrictions.Theseincludethe
following:

onlypractitionerscanholdshares;
theofficersanddirectorsoftheprofessionalcorporationmustbeshareholders;
thenameofthecorporationmustincludethewords"ProfessionalCorporation";
theprofessionalcorporationcannotbeanumberedcompany(e.g.,1234567Ontario
Inc.);and
theprofessionalcorporationcanonlypractisetheprofession,orproviderelatedor
ancillaryservices.Itcannot,forexample,practiseanotherprofessionlikemassage
therapy.

Practitionerscannotavoidprofessionalliabilitythroughaprofessionalcorporation.Injured
patientscansuethepractitionerpersonally.However,practitionersworkingthrougha
professionalcorporationdohaveprotectionagainsttradecreditors.Forexample,ifsuppliersor

47

othercreditorsarenotpaidbytheprofessionalcorporation,theycannotsuethepractitioner
personally.

Anumberofprovisionshavebeenmadetopreventpractitionersfromhidingbehindthe
professionalcorporationwhenfacingquestionsfromtheCollege.Theseincludethefollowing:

theRHPAappliestopractitionersdespitetheirpractisingthroughaprofessional
corporation;
apractitioner'sfiduciary(i.e.,loyaltyandgoodfaith)andethicalobligationstopatients
remaininplaceandnowapplyequallytotheprofessionalcorporationaswell;
duringinvestigationsandotherproceedingsinvolvingpractitioners,theCollegehasthe
samepowersovertheprofessionalcorporation(e.g.,accesstopremisesand
documents)asitdoesagainstthepractitioner;
anymonetaryordersagainstpractitionersarealsopayablebytheprofessional
corporation;
anydutytoapatient,thepublicortheCollegetakesprecedenceoverthedutiesofthe
practitionerasanofficerordirectoroftheprofessionalcorporation;
anyterms,conditionsandlimitationsagainstapractitionerapplytotheprofessional
corporationaswell;and
anyknowinglyfalserepresentationmadetoobtainacertificateofauthorizationisan
offence.

ProfessionalcorporationshavetoobtainfromtheCollegea"certificateofauthorization",
similartoacertificateofregistration,forindividualpractitioners.Toobtainacertificateof
authorization,ahealthpractitionergoesthroughthefollowingprocess:

Selectanamefortheprofessionalcorporation.Ministryregulationsrequirethatthe
namemustcontainthesurnameofatleastoneshareholder(assetoutintheCollege
register).Thenamecanalsoincludetheperson'sgivennameandinitials.Thenameof
thecorporationmustalsoindicatethenameofthepractitionershealthprofession.The
namemustalsoincludethewords"professionalcorporation".Thenamecaninclude
nothingelse.
Theprofessionalcorporationmustthenbeincorporatedwiththegovernment.This
involvespreparingarticlesofincorporation,corporatebylaws,payingafeeand
submittinganapplicationformwiththegovernment.Ifthepaperworkisacceptable,the
governmentwillissueacertificateofstatusandacertificateofincorporation.
Within30daysofobtainingone'scertificateofstatus,theprofessionalcorporationmust
applytotheCollegeforacertificateofauthorization.Suchanapplicationwillrequire
thefollowing:
o CompletingtheapplicationformthatcanbeobtainedfromtheCollege.The
applicationformwillrequirethename,registrationnumbersandaddressesof
eachshareholder.Theapplicationformwillrequiretheapplicantstospecify

48

o
o
o
o

whichshareholdersholdwhichpositionswiththecorporation.Thebusiness
premisesorpracticelocationsofthecorporationwillhavetobeidentified.
PayingthefeerequiredbytheCollegeinitsbylaws.
EnclosingthecertificateofstatusissuedbytheMinistrythatisnomorethan
thirtydaysold.
Enclosingacertifiedcopy(i.e.,sworntobeatruecopybyalawyerornotary
public)ofthecertificateofincorporationissuedbythegovernment.
Providingastatutorydeclaration(i.e.,aswornwrittenstatement)froma
directorofthecorporationthatwascompletednotmorethanfifteendays
beforetheapplicationdate.Thestatutorydeclarationcertifiestheaccuracyof
thedocumentssubmittedwiththeapplicationandthatthecorporationwillonly
practicetheprofessionorrelatedorancillaryactivities.

Onceincorporated,thecorporationmustnotifytheCollegeimmediatelyifitsnameorarticles
ofincorporationchange.Also,theCollegeneedstobenotifiedpromptlyofanychangein
shareholder,officerordirectoroftheprofessionalcorporationorifthecorporationchangesits
locationorlocationsofpractice.Eachyeartheprofessionalcorporationmustrenewits
certificateofauthorization.Therenewalprocessinvolvescompletingthesamesortof
paperworkaswasinvolvedintheinitialapplication.Therenewalprocessupdatesthe
informationaboutthecorporationanditsshareholders.

Acertificateofauthorizationcanberevokedifitdoesnotfollowtherules.

TheCollegecannotgiveadvicetopractitionersastowhetheraprofessionalcorporationisgood
forthem.Practitionerswillneedtoobtainadvicefromtheirownaccountantsorlawyers.

ProfessionalCorporationScenario

X,apractitioner,hashadabusinesscorporationformanyyearsbeforetheCollegewas
created.Hiswifeandchildrenareshareholders.Itisnotaprofessionalcorporation.
Whatarehisoptions?Xhastodosomething.Hecannotcontinuetooperatearegular
businesscorporationoncehebecomesaregisteredmemberoftheCollegebecause
businesscorporationsdonotfollowtherulesforprofessionalcorporations.Xhasto
eitherchangehisbusinesscorporationintoaprofessionalcorporation,orgiveupthe
businesscorporation.Xswifeandchildrencannotbeshareholdersoftheprofessional
corporationunlesstheyarealsoregisteredwiththeCollege.IfXgivesupthebusiness
corporation,hecannotpracticetheprofessionthroughit.Xshouldspeaktohis
accountantorlawyertogetadviceastowhatisbestforhim.

c. TCMA,Regulations,Bylaws

TheTraditionalChineseMedicineActistheprofessionspecificstatuteoftheCollegeof
TraditionalChineseMedicinePractitionersandAcupuncturistsofOntario.Asmentioned

49

before,theTraditionalChineseMedicineActworkstogetherwiththeRegulatedHealth
ProfessionsActsothattheycanbetreatedasoneAct.Together,theseActsauthorizethe
Collegetodevelopregulationsandbylawstoregulatetheprofession.

Regulationsandbylawsarebothformsoflaw.Themajordifferencebetweenabylawanda
regulationisthatabylawismadedirectlybytheCouncil,whilearegulationmustbeapproved
bythegovernmentofOntario.Bylawstypicallyrelatetotheadministrationandinternalaffairs
oftheCollege.Regulationsgenerallydealwithmattersofbroaderpublicconcern.

i. RegistrationRegulation

Registrationregulationsetsouttherequirementsforobtainingandmaintainingregistration
withtheCollege.ItisintendedtomakesurethatmembersoftheCollegearecompetentand
havegoodcharacter.

Theregistrationregulationestablishesfiveclassesofmembers:
1. GrandparentedRegistrationintendedforthosewhoarecurrentlypracticing
TraditionalChineseMedicineorTCMacupunctureinOntarioandwhomeetbasic
requirementstoentertheprofession;
2. GeneralRegistrationintendedformemberswhoarenormallyentitledtothe
independentpracticeofTraditionalChineseMedicineandTCMacupuncture;
3. StudentRegistrationintendedforanyoneintheprocessofqualifyingtobecomea
traditionalChinesemedicinepractitionerorTCMacupuncturist;
4. InactiveRegistrationintendedforexistingmemberswhoforwhateverreasonare
notcurrentlypracticingtheprofessionbutwishtoremainmembersoftheCollege;
and
5. TemporaryRegistrationintendedtopermitrecognizedandskilledtraditional
ChinesemedicinepractitionersandTCMacupuncturistsfromotherjurisdictionsto
practiseinOntarioforashortperiodoftime.

GeneralRequirements

Therearecertainrequirementsthatmustbemetbyallapplicantsforregistrationwiththe
profession.Allapplicantsmustcompleteanapplicationformfullyandpayapplicablefees.A
policereportisrequiredtobeprovidedtotheCollege.Theapplicantmustalsoinformthe
Collegeofanycriminalorregulatoryproceedingsorfindingsagainstthem.Theapplicationform
requiresapplicantstoprovideinformationregardingtheapplicantstrainingandexperience,
pastprofessionalexperiences(includingpreviousregistrationwithanotherregulatorybody).
Theapplicantmustalsoprovideotherinformationthatmayaffecthisorherabilitytopractise
effectivelyandsafely(i.e.,professionalliabilityinsurance).Theapplicantmusthave
immigrationstatustoworkinCanada.Theymustbeabletospeak,readandwriteineither
EnglishorFrenchwithreasonablefluency(thereisanexceptionforGrandparentedapplicants
seebelow).Theapplicantmustnotbeincapacitated(i.e.,haveanillnessthatpreventsthem

50

frompractisingsafely,likeadrugaddictionthatisnotundercontrol)unlessadequate
safeguardsareinplace.

AllapplicantsotherthanforStudentRegistrationmusthavecompletedajurisprudencecourse
onbasichealthregulationandlawthatappliestotheirpractice.

AnapplicantwhoappliesforGrandparentedregistrationdoesnotneedtobeabletospeak,
readorwriteEnglishorFrenchwithreasonablefluencysolongastheapplicantprovidesa
writtenplanonhowheorshewillcommunicatewithothersabouthisorherpatients.Theplan
mustdealwithhowtocommunicatewithotherpractitionersandhospitalsaboutpatients(e.g.,
ifthereisanemergencyorifthepatientgoestoanotherpractitionerwhoonlyspeaksEnglish
orFrench).Forexample,aGrandparentedmembercouldpractiseinassociationwithanother
memberwhoisfluentwithEnglishorFrench.Theremaybeotherwaystoachievethisgoal
withtheapprovaloftheRegistrationCommittee.

ApplicantsforInactiveregistrationdonotneedproofofprofessionalliabilityinsurance.

SpecificRequirements

Therearespecificrequirementsforeachclassofregistration.Forexample,underthe
GrandparentedregistrationcategoryanapplicantmustcompleteaSafetyprogram.
Grandparentedmembersthenhavefiveyearstocompleteapriorlearningassessmentsothat
theycanbecomeGeneralmembers.

ApplicantsforGeneralmembership(otherthanGrandparentedmembers)mustcompletean
acceptableeducationprogram,havesupervisedclinicalexperience,completeaSafetyprogram
andmustpasstheregistrationexamination.

Thereareregistrationregulationprovisionsthatallowforoutofprovinceregistrantsfrom
elsewhereinCanadatotransfertoOntariowithrecognitionoftheirqualifications.Theseare
calledmobilityprovisions.TheOntarioCollegewillnotrequirequalifiedapplicantsregistered
elsewhereinCanadatoonceagainprovethattheyhaveadequateeducation,experienceand
examinationcredentials.

GeneralConditions

OnceapersonisregisteredwiththeCollege,heorshemustcontinuetomeetcertaingeneral
terms,conditionsandlimitations.Forexample,ifamemberisfoundguiltyofacriminalor
otheroffence,themembermusttelltheCollege.Ifamemberisdisciplinedbyanother
professionalregulator,themembermusttelltheCollege.Ifthemembernolongerhas
professionalliabilityinsurancecoverage,themembermusttelltheCollege.Membersofeach
classofregistrationareassignedaspecifictitlethatthemembersmustusesothatthepublic

51

canidentifytheirregistrationstatus.Membersmustdisplaytheircertificateofregistration
prominentlywheretheypractice.

RegistrationRegulationsScenario

XisaTCMacupuncturistwhopracticesinBCandisregisteredwiththeCollegeinBC.He
hasbeeninvitedbyacolleaguetocometoOntariotodemonstrateaparticular
techniqueataconference,andprovidedemonstrationswithpatientsinOntario.Ithas
beensuggestedthathecomeoverforthreemonthsandseepatientsunderthe
supervisionofaregisteredTCMacupuncturistinOntariosothatotherscanlearnand
benefitfromhisexpertise.Xdoesnotwanttotaketheregistrationexamination.Canhe
beregisteredwithoutdoingit?TheCollegehasaTemporaryclassofregistrationthat
allowsXtoregisterforupto6monthsinOntariosolongasheisalreadyregisteredand
isholdingacertificateingoodstandinginBC.Inaddition,ifhewantedto,Xcouldrelyon
themobilityprovisionstoregisterasaFullmembertopracticeasanAcupuncturist.

[NOTE:Atthetimeofwriting,theRegistrationRegulationisstillundergoingreviewbythe
MinistryofHealthandLongTermCare.]

ii. ProfessionalMisconductRegulation

Asdiscussedabove,sometypesofprofessionalmisconductarecontainedintheRHPAitself.
Forinstance,theRHPAmakesbreakingthelawprofessionalmisconduct(e.g.,tobefoundguilty
ofanoffencerelevanttoapractitionerssuitabilitytopractisetheprofession).Also,being
foundguiltyofprofessionalmisconductoutsideofOntariocanleadtodisciplinaryactionin
Ontarioaswell.Sexualabuseofapatientisalsoprofessionalmisconduct.Soisfailingto
cooperatewiththequalityassuranceprogram.

However,theCollegesprofessionalmisconductregulationdescribesadditionalexamplesof
professionalmisconduct.Someprovisionsfoundintheprofessionalmisconductregulationare
commontomanyoftheprofessionsundertheRHPA,whileothersaremorespecifictothis
profession.

Thefollowingarethemaintopicsfoundintheprofessionalmisconductregulations.

StandardsofPractice
Theprofessionalmisconductregulationmakesfailingtomeetthestandardofpracticeofthe
professionprofessionalmisconduct.Usually,thisrelatestotheassessmentandtreatmentof
patientsbythepractitioner.Thestandardsofpracticemaybewritten,orunwritten.They
reflectasharedunderstandingoftheprofessionandhowitshouldbepracticedeffectivelyand
safely.Thisisbasedonwhatwouldbereasonablyexpectedoftheordinarycompetent
practitionerinhisorherfieldofpractice.Expertwitnessesareoftenusedtodeterminea
standardofpracticewhenitisunwritten,orunderconsideration.

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Onespecificstandardofpracticeintheprofessionalmisconductregulationisthatapractitioner
mustreferapatienttoanotherhealthcareproviderwherethepatienthasaconditionthatis
beyondtheknowledge,skillandjudgmentofthepractitioner.Forexample,ifapatienthad
symptomsthatsuggestedadvancedcardiacdisease,thepractitionershouldnottrytohandle
thisalone.Areferraltoamedicaldoctorwouldberequired.

InappropriateBehaviourtowardsPatientsorthePublic
Manyprovisionsinprofessionalmisconductregulationrelatetoinappropriatebehaviour
towardspatientsorthepublic.Forexample,physicalorverbalabuseofpatientsisprofessional
misconduct.Thisincludesrudeorunbecomingbehaviourtowardspatients,membersofthe
publicorotherhealthprofessionals.Inaddition,ifapatienthasaconcernaboutapractitioners
conductandwishestomakeacomplaint,thepractitionerhasaprofessionalobligationto
advisethepatientabouttheCollegesregulatoryroleandhowtogetincontactwiththe
College.

RecordKeeping
Failingtomakeandkeepappropriateandadequaterecordsisprofessionalmisconduct.Thisis
animportantareatounderstandforpractitioners,soitisdiscussedindepthinitsownsection
below.

InformedConsent
Informedconsenthasbeendiscussedinmoredetailaboveinthesectiononcommunication,
andisalsomentionedinregardstorecordkeeping.Theregulationmakesitprofessional
misconducttofailtoobtaininformedconsentbeforeassessingortreatingapatient.

ControlledActs,DelegationandSupervision
Delegationofcontrolledactsisdiscussedindetailabove.Todelegateacontrolledactmeansto
allowanotherpersontoperformacontrolledactononesbehalf.Theprofessionalmisconduct
regulationsaysthatmembersshouldnotdelegateacontrolledactunless:a)itwouldbesafe
andeffectivetodoso;b)thepractitionerhasensuredthatthepersonperformingithasthe
knowledgeskillsandjudgmenttoperformtheprocedure;c)thepractitionerhasdocumented
thepersonsknowledge,skillandjudgmenttoperformthecontrolledact;andd)the
practitionerhasdocumentedtheconditionsunderwhichtheprocedurewasdelegated.

Inadditiontodelegating,amembermayalsoassigncertaintaskswhicharenotcontrolledacts
toaperson.TheCollegeexpectsthatthepractitionersupervisesthosedoinganyprocedureon
thepractitionersbehalf.

Confidentiality
Practitionersmustkeepallpatientinformationconfidential.Failingtomaintainconfidentiality
canbeconsideredprofessionalmisconduct.Theremaybeexceptionsdependingonthe
circumstancestothisdutyofconfidentiality.Forexample,patientscanconsenttothe

53

practitionerdisclosinginformation.Also,whereapractitionerisrequired(e.g.,byacourt
summons)orpermitted(e.g.,whensellingonespractice)bylawtodisclosepatient
information,itcanthenbedisclosed.Theconceptofconfidentialityisdiscussedfurtherinthe
sectionbelowonPHIPA.

ConflictofInterest
Practitionershaveadutytoactinthebestinterestoftheirpatients.Aconflictofinterestarises
whenthepractitionerappearstobeactinginsomeoneelsesinterestinstead.Forexample,a
practitionerhasadutytoonlyreferpatientstootherswhereitisinthebestinterestofthe
patient.Whereahealthfoodstorepaysapractitionertoreferpatientstothem,the
practitionerhasaconflictinginterest(i.e.,gettingpaidbythestore)thatisunprofessional.This
topicisdiscussedinitsownsectionbelow.

ImproperBillingandFees
Practitionersmustbehonestintheirbillings.Becauseofthis,theprofessionalmisconduct
regulationprohibitsimproperbilling.Billinghasbeendiscussedabove.

Misrepresentation
Itisprofessionalmisconducttobedishonestinonesdealingswithclients,colleagues,third
partypayersortheCollege.Dishonestywiththirdpartiesisalsonotacceptable(evenifthe
intentistohelpapatient).Thirdpartiesoftenassumethatpractitionersarehonestbecauseof
theirprofessionalstatusandrelyupontheirintegrity.Forexample,itwouldbeprofessional
misconducttoissuealetterorcertificatesayingthatapatientwastoosicktoworkwhenthe
practitionerdoesnotknowthistobetrue.

ImproperUseofNames,TitleorDescriptions
Therearespecificrulesintheprofessionalmisconductregulationthatrestrictuseofcertain
names,titlesordescriptions.Forexample,thetitleofthememberwilldependontheirclassof
registration(classesofregistrationarediscussedaboveintheregistrationregulationsection).
Thisisintendedtoensureconsistent,appropriateandclearuseoftitlesthathelpthepublic
knowwithwhomtheyaredealingandtopreventconfusion.Also,membersoftheCollege
cannotuseaterm,titleordesignationindicatingorimplyingthattheyhaveaspecializationin
anareaorareasofpractice(e.g.,sayingtheyareapaediatrician).Also,practisingtheprofession
underanamethatisnotregisteredwiththeCollegemaybeconsideredprofessional
misconduct(e.g.,ifapractitionerusesanicknamewhenpractising,theCollegemustbetoldof
thatnicknamefirst).

ImproperAdvertising
Itisprofessionalmisconducttoengageinfalseormisleadingadvertising.Thereisasection
belowdescribingmoredetailsregardingimproperadvertisingforpractitioners.

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ConducttowardsColleagues
Practitionersmusttreattheircolleagueswithcourtesyandcivility.Forexample,ifapatient
goestoanotherpractitionerandthatpractitionerasksforacopyoftherecord(withpatient
consent),onecannotsimplyignoretheletter.Ifapractitionerdisagreeswiththetreatment
beingprovidedbyanotherhealthcareprovider,thepractitionermustnotmakeinsulting
commentsabouttheotherhealthcareprovidertothepatient.

ConducttowardstheCollege
Obligationscomewiththeprivilegesofselfregulation.Oneobligationisthatpractitionersmust
accepttheregulatoryauthorityoftheCollege.ExamplesofconducttowardsonesCollege
whichcanconstituteprofessionalmisconductinclude:
PubliclychallengingtheintegrityoftheCollegesroleoractions.
BreachinganundertakinggiventotheCollege.
Failingtocooperatein,orobstructing,aninvestigationbytheCollege.
Failingtoparticipateinthequalityassuranceprogram.
FailingtorespondappropriatelyandpromptlytocorrespondencefromtheCollege.
FailingtoreportapractitionertotheCollegewhohasjeopardizedthesafetyofa
patient.

DisregardingRestrictionsonCertificateofRegistration
Apractitionermustconfinehisorherpracticetowhatislegallypermissible.IftheActora
committeeoftheCollegerestrictapractitionerincertainareas,itwouldbeprofessional
misconducttoexceedthoserestrictions.Forexample,apractitionerwhoislimitedbythe
RegistrationCommitteetoTCMacupuncturecannotofferherbalremedies.

GeneralCatchallProvisions
TheCollegehastwogeneralcatchallprovisions.Thesecovertypesofconductthatarenot
specificallydealtwithelsewhere.Oneprovisionprohibitsconductthatwouldbereasonably
regardedasdishonourable,disgracefulorunprofessional.Thisprovisionassumesthatthereisa
generalconsensusintheprofessionofconductorbehaviourthatwouldbeconsidered
unacceptable.Forexample,thereisnospecificprovisionthatsaysthatapractitionercannot
abuseapatientsmotherduringavisit.However,noonedoubtsthatthisconductwouldbe
unprofessional.

Thesecondcatchallprovisionmakesitprofessionalmisconducttoengageinconduct
unbecomingamemberoftheprofession.Thisprovisionreferstoconductinapractitioners
privatelifethatbringsdiscredittotheprofession.Forexample,apractitionerwhoengagedina
fraudonthestockexchangecouldbedisciplinedforthedishonesty.

ProfessionalMisconductRegulationsScenario

Yhasrecentlybeencriticizedbyhercolleague,W,whoworksinthesamepracticeasher
thatsometimesYistooloudwithherpatients.Wmentionsthatinspeakingloudlysheis

55

disruptingotherpractitionersintheoffice.YtellsWthatsheissorryfordisruptinghim,
andanyofhispatients,andthatshewilltrytokeephervoicedownorloweritoutof
respectfortherestofthepractice.ButWfeelsthisisaseriousproblem,andthathe
shouldreportYtotheCollegeforprofessionalmisconduct.Hecannotstandloudnoise
duringhispatientsvisits.Wwantstheverybestatmospherecreatedforhispatients,
andthinkstalkingloudlyiscompletelyunprofessional.IsWcorrectinsayingthiswould
beprofessionalmisconductaccordingtotheregulations?Probablynot.Wholdsa
particularviewaboutYslevelofvoicethatmaynotbeconsistentwiththerestofthe
profession.Unlesstheconductpersistsandunlessitissoloudthatmostneutral
observerswouldagreethatYisdisruptingtherestoftheoffice,itisnotprofessional
misconduct.WhileitwasappropriateforWtoraisetheissuewithYsothattheycan
cometoareasonableresolution,professionalmisconductisnotmeanttoapplyto
uniquelypersonalviewsofunacceptablebehaviour.Instead,itisintendedtobebasedon
conductthatisconsideredunacceptablebyageneralconsensusintheprofession.

SampleExamQuestion

Whichoneofthefollowingsituationsis(are)possibleprofessionalmisconduct
accordingtotheprofessionalmisconductregulation?
i.
Failingtomaintainpatientconfidentiality.
ii.
Usingverbalthreatsandinsultstoapatientinanemailtothemwhenthey
didnotshowupforanappointment.
iii.
Givingapatientareducedrateforservicesiftheydonothaveinsurance.
iv.
Alloftheabove.

Thebestanswerisiv).Theregulationdescribesmanytypesofprofessionalmisconduct.
Allofthesituationsdescribedinvolveconductthatisspecificallyprohibitedin
professionalmisconductregulation.

iii. Recordkeeping

Oneimportantaspectofthestandardofpracticeisrecordkeeping.Keepingrecordsisessential
forprovidinggoodclientcare;evenpractitionerswithexcellentmemoriescannotrecallallof
thedetailsoftheirpatientshealthstatusandtreatment.Recordspermitthemonitoringof
changesinpatients.Recordsassistotherpractitionerswhomayseethepatientafterwards.
Recordsalsoenableapractitionertoexplainwhattheydidforpatientsifanyquestionsarise.
Recordshelpapractitionerdefendthemselvesifapatientrecallsthingsdifferentlythanthe
practitioner.Failuretomakeandkeepadequaterecordscanbeafailuretomaintainminimum
professionalstandardsandisprofessionalmisconduct.

Collegeregulationsandstandardsonrecordkeepingdealwithmatterssuchas:
Theinformationthatmustberecorded;
Theforminwhichrecordscanbekept(e.g.,written,computerized);

56

Howlongtheinformationmustbekept;
Maintainingortransferringrecordsuponleavingapracticeorretiring;
Confidentialityandprivacyissues;and
Patientaccesstorecords.

Theinformationthatmustberecorded

Thepatientrecordisintendedtorecordwhatwasdoneandwhatwasconsideredbythe
practitioner.Itactsasacommunicationaidtoensurethatthereiscontinuityofcareforthe
patient.Properrecordsalsoenhancepatientsafety.Thefollowingisadescriptionofgeneral
requirementsofthehealthrecord.

Therecordshouldalwayscontainidentifyinginformationsuchasthenameanddateofbirthof
thepatient.Itshouldbeoneachdocumentintherecordsothataparticulardocumentmaybe
returnedtotherecordifseparated.

Therecordshouldincludeallrelevantsubjectiveandobjectiveinformationgatheredregarding
thepatient.Thisincludesallrelevantinformationprovidedbythepatient(orhisorher
authorizedrepresentative,orotherhealthcareprofessionalsinvolvedinthepatientscare)to
thepractitionerregardlessofthemediumorformat(e.g.,communicatedinperson,onpaper,
email,fax,telephone,etc.).Italsoincludesanyrecordsregardingfindingsfromassessmentsor
duringobservations(e.g.,howthepatientwalkedintotheoffice).

Anyresultsoftestingdone(includingphysicaltesting,laboratoryresults,etc.)bythe
practitionershouldberecorded.Ifapatientdisclosestestresultsfromanotherhealth
professionalitshouldbenotedintherecord.However,practitionersdonothavetoaskfor
copiesofreportsiftheyarenotneeded.

Thetreatmentplanshouldberecorded.Thentheactualtreatmentprovidedshouldbenoted.
Therecordshouldalsoincludeanyprogressnotesofhowthepatientprogressedduring
treatment,anychangesinthepatientscondition,oranyreassessmentsormodificationsofthe
treatmentplan.Itshouldbecleartoanypractitionerreadingtherecordwhathappened.

Ifthepatientwasareferral,thepersonwhomadethereferralandthereasonforthereferral
shouldbeintherecord.

Anyconsentthatisobtainedshouldbeincludedintherecord.Pleaseseetheconsentsection
aboveforspecificguidelinessurroundingconsent.

Theforminwhichrecordscanbekept

Recordsmustbelegible.Failuretomaintainalegiblerecordwoulddefeatthepurposeof
maintainingacompleteandaccuraterecord.

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Recordscanbeonpaperoroncomputer.Computerizedrecordsshouldbeprintableand
viewableandshouldhaveanaudittrailofchangesmade.Theserequirementsarediscussed
furtherinthesectiononthePersonalHealthInformationProtectionAct(PHIPA)sectionbelow.

Itshouldbeclearwhomadeeachentryintothehealthrecord,andwhenthatentrywasmade.
Anychangeoramendmenttotherecordshouldbeindicated,thedateofwhichthechangewas
madeshouldbenoted,andwhomadethechangeshouldberecorded.Importantly,any
changestotherecordshouldstillpermitthereadertoreadtheoriginalentry.

Practitionerscannotfalsifyrecords;thismeansthatifanerrorismadeinapreviousentryit
cannotberemoved(e.g.,whitedout,ordeleted).Therecordshouldbemaintainedwith
correctiontotheerror(usuallyasimplelinethroughtheerrorwiththedateandinitialofthe
personcorrectingtheerror).

TherecordshouldbeinEnglishorFrench.Theinformationcanberecordedinotherlanguages
solongasalltheinformationisalsorecordedinEnglishorFrench.Thegenerallyaccepted
languagesinthehealthcaresysteminOntarioareEnglishorFrench.Thispermitsotherhealth
careprovidersonthepatientshealthcareteam(e.g.,hospitals,otherpractitioners,other
healthcareproviders)tounderstandtherecord.

Howlongtheinformationmustbemaintained

Thepractitioner(orhealthinformationcustodianforwhomthepractitionerworks)needsto
keeptherecordfortenyearsfromthelastinteractionwiththepatient,orthepatients
eighteenthbirthday,whicheverislater.Forexample,ifapatientiseightyearsofagethelast
timethepractitionerseesthepatient(i.e.,lastpatientvisit)thenthepractitionerwouldhaveto
keeptherecordfortwentyyearssincethatlastinteraction.Aninteractioncaninvolveany
contactwiththepatient,includingaphonecalloranemail.

Theruleregardingkeepingrecordsfortenyearsincludesfinancialrecords,appointmentand
attendancerecords,andwhereappropriate,equipmentrecords,inadditiontothehealth
record.

Maintainingortransferringrecordsuponleavingapracticeorretiring

Theentireoriginalrecordshouldbekeptbythepractitioner(orthehealthinformation
custodianforwhomthepractitionerworks)andonlycopiesaretobesuppliedtoothers.

Evenwhenapractitionerretiresorleavesthepractice(i.e.,resignsasamemberoftheCollege)
theoriginalrecordshouldbekeptforthetenyearretentionperiod,unlesstherecordhasbeen
transferredtoanotherpractitionerwhowillmaintaintherecord.Thepatientmustbenotified

58

ofthetransfer.Inthosecircumstances,theoriginalrecordcanbetransferredtothenew
practitioner.

However,ifthepatienthasjustbeenreferredtoanotherhealthcareprofessionalandthe
patientrecordhasnotbeentransferred,thentheretentionperiodoftheentireoriginalrecord
(i.e.,tenyearsfromlastcontactorthepatientseighteenthbirthday)isstillmandatory.

Theonlyexceptiontothisisifthereissomelegalcompulsiontoprovidetheoriginalrecord
(i.e.,inapolice,CoronersorCollegeinvestigation,orwithasummons).Ifthiscircumstance
occurs,thepractitionershouldkeepalegiblecopyoftherecordforthemselves.

Whenthetimeperiodforkeepingtherecordhasexpired,thedestructionoftherecordsshould
bedoneinasecuremannerthatpreventsanyonefromaccessing,discovering,orotherwise
obtainingtheinformation(i.e.,shredding,completeelectronicdestruction).Ifapractitioner
destroysanyrecords,agoodpracticewouldbetokeepalistorrecordofthenamesofwhich
thefilewasdestroyedandthedateitwasdestroyed.

Iftransferringfrompaperrecordstoelectronicrecords,andtheoriginalpaperrecordhasbeen
scannedintoanelectronicform,thentheoriginalmaybedestroyed.Theelectronicversionof
thedocumentbecomestheoriginal.

Confidentialityandprivacyissues

Practitionersshouldtakereasonablestepstokeeprecordssafeandsecure.Ingeneral,noone
outsideoftheauthorizedcircleofcareofhealthprofessionalsshouldbeabletoaccessthe
records.Privacyprotectionsmustbeinplacetoensuretherecordscannotbeseenortakenby
others.Paperrecordsshouldbekeptunderlockandkey.Computerrecordsneedtobe
passwordprotectedoncomputersthathavefirewallandvirusprotectionsandmustbebacked
upregularly.ParticularprivacyissuesarediscussedlaterinthesectiononthePersonalHealth
InformationProtectionAct(PHIPA)below.

Patientaccesstorecords

Generally,apatienthastherighttoreviewandreceiveacopyofallclinicalrecordskeptbya
practitionerunlessaccesswouldsignificantlyjeopardizethehealthorsafetyofaperson.
Althoughthepractitionermayownthehealthcarerecordandberesponsibleforit,patients
areauthorizedbyPHIPAtoaccesstherecord.Also,thepatienthastherighttocorrectany
errorsinthehealthrecord.Ifapatientrequestsanyrelevantpartsoftherecord,the
practitionershouldprovidethemwithacopyandnottheoriginal.Thistopicisdiscussedlater
inthesectiononthePersonalHealthInformationProtectionAct(PHIPA)below.

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RecordKeepingScenario

Xhasbeenpractisingfor45yearsinthesamepractice,andhasbuiltupabusyand
successfulpractice.Hedecidesheisreadyforretirementbutwonderswhatheis
supposedtodowithhispatientrecords.Doeshehavetoretainthemhimself?Ordinarily
hewouldhavetoretainpatientrecordsfortenyearsfromthelastinteractionwiththe
patient,orthepatientseighteenthbirthday,whicheverislater.But,inthiscaseXmay
betransferringhispracticetoanotherpractitionertotakeoverthebusinessand
patients.Ifthisisthecase,hedoesnothavetoretaintherecordshimselfbutneedsto
notifythepatientsofthetransferoftheirpatientrecords.Thiscanbedonethrougha
combinationoftellingpatientsontheirnextvisitandplacinganoticeinthelocal
newspaper.

SampleExamQuestion

Whichoneofthefollowingdoesnotneedtoberecordedinthepatientsrecord?
i.
Thepatientsbirthdate.
ii.
Thepersonwhorecommendedthepatienttoyou.
iii.
Thepatientshealthconcerns.
iv.
Thetreatmentplanforthepatient.

Thebestanswerisii).Onlyifthepatientwasreferredbyanotherhealthcareprovider
musttherebearecordofwhorecommendedthepatient.Ifanotherpatientreferredthe
personorthepersonfoundoutaboutyourofficethroughadvertising,thatdoesnothave
toberecorded(althoughinsomecasesitwouldbehelpfultorecordthisinformation).
Answeri)isnotthebestanswerbecausepractitionersneedtorecordthepatientsbirth
date.Itisrelevanttomanytreatmentdecisions.Answeriii)isnotthebestanswer
becausepractitionersneedtorecordthepatientshealthconcerns(sometimescalled
chiefcomplaints).Itisrelevanttomanytreatmentdecisions.Answeriv)isnotthebest
answerbecausepractitionersneedtorecordthetreatmentplanforthepatient.Itis
relevanttofollowingthroughwiththetreatmentonfuturevisitsandforjustifyingones
actionsshouldquestionsberaisedlater.

iv. ConflictsofInterest

Apractitionercannotengageinaconflictofinterest.Inordertoavoidaconflictofinterest,
practitionersmustputtheinterestsoftheirpatientsfirst,andnotallowpersonalorother
intereststointerfere.Aconflictofinterestariseswhereapractitionerdoesnottakereasonable
stepstoseparatehisorherownpersonalinterestsfromtheinterestofpatients.Wherethe
personalinterestwouldreasonablyaffectthepractitionersprofessionaljudgment,aconflictof
interestexists.Forexample,ifapractitionerrefersapatienttoahealthstoreownedbythe
practitionersspousetobuyproducts,areasonablepersonwouldquestionwhetherthe

60

practitionerrecommendedthatproductbecausethepatientneededitorinordertohelphisor
herspouse.

Thereisnoneedforproofofanactualconflictofinterestbecausethiswouldrequirereading
thepractitionersmind(toknowiftheywereinfluencedbytheconflictinginterest).Instead,
onelookstowhatareasonablepersonmightconcludefromthecircumstancesregardlessof
whatisactuallygoingoninthemindofthepractitioner.Aconflictofinterestcanbeactual,
potentialorperceived.Inthatway,theconflictofinterestrulesareintendedtoprevent
concernsfromarising.

Aconflictofinterestcanbedirectorindirect.Forinstance,itwouldbeaconflictofinterestfor
acloserelative(i.e.,parent,grandparent,child,spouse,orsibling)toreceiveabenefitonbehalf
ofthepractitioner.

Somecommonexamplesofconflictsofinterestareasfollows:
Splittingfeeswithapersonwhohasreferredapatient;
Receivingbenefitsfromsuppliersorpersonsreceivingreferralsfromthepractitioner;
Givinggiftsorotherinducementstoclientswhousethemembersserviceswherethe
serviceispaidforbyathirdparty(e.g.,insurance);
Workingforanunregisteredpersonwhocaninterferewithprofessionaldecisions(e.g.,
howmuchtimeissetasideforeachappointment);
Usingorreferringapatienttoabusinessinwhichonehasafinancialinterest;and
Sellingaproducttoapatientforaprofit.

Manyoftheexamplesdependonthereasonablenessofthecircumstanceindeterminingifa
conflictofinterestexists.Thepractitionershouldalwaysaskthemselveswouldanother
objectiveandreasonablepersonthinkthatthereisaconflictofinterest,giventhis
circumstance?Forexample,itprobablywouldbeappropriatetogiveapatientasmallcalendar
torecordtheirfutureappointmentsevenifaninsurancecompanypaysforthetreatment.
However,givingthepatientanewpairofexpensiverunningshoesisunreasonableinthe
circumstances(evenifthepatientneedstoexercise).

Mostconflictsofinterestareprohibitedoutright.But,therearecertaincircumstanceswhere
takingcertainsafeguardscouldremovetheconcern.Intheexampleaboveaboutreferringa
patienttoahealthstoreownedbythepractitionersspousetobuyaproduct,suchareferral
wouldnotraiseconcernsifthepractitionerdidthefollowing:

Disclosethenatureoftherelationshipwiththehealthstore(e.g.,myspouseownsthe
store);
Providealternativeoptions(e.g.,herearethreeotherplacesyoucouldgettheproduct
Iamrecommendingforyou);and

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Reassurethepatientthatchoosinganotherstorewillnotaffectthepatientscare(e.g.,
Youarefreetochooseanyoftheplacestogettheproduct;youwillstillbewelcome
hereasmypatient).

PractitionersmustprovidetheCollegewithanydocuments,explanationsorinformation
regardingasuspectedconflictofinterestifrequested.ThisistoenabletheCollegetoassess
whetheraconflictofinterestisaconcern.Forexample,iftheCollegereceivesinformationthat
apractitionerismakingunusualpaymentstoahealthfoodstorewheneverthestorerefers
patientstothepractitioner,thentheCollegecouldaskforanexplanationofthosepayments,
andanyfinancialrecordsrelatedtothem,todeterminewhetherthereisaconflictofinterest.

ConflictofInterestScenarioNo.1

Yownsapracticedownthestreetfromagym.Shehasbeenpracticingthereforless
thanayear.Sheistryingtobuildherpracticeandwantspeopletoknowsheisnewto
theneighbourhood.Yofferstogivethemanagerofthegymafreecruisetothe
Mediterraneaninreturnforhavinghimandhisstaffreferpatientstoherpractice.The
managerofthegymthinksthisisagreatidea,andoffersYafreemembershiptothe
gymandpersonaltrainingifYalsoreferspatientstohisgym.Whilethismayseemlikea
goodbusinessdecision,Yisinaconflictofinterestfortworeasons.Ycannotgiveafree
triptothemanagerofthefitnesscenterinordertogetreferralsasthiswouldconstitute
acollateral(orside)benefit.PatientsshouldbereferredtoYbecausetheyneedher
servicesandnotbecausethereferringpersonisgettingafreecruise.Further,Ycannot
acceptfreemembershipandfreepersonaltrainingatthegymasthiswouldconflictwith
herdutytoreferpatientstoagymonlyifshehonestlybelievedthatthiswouldbein
theirbestinterest.Inaddition,unlesstherewassomethingspecialaboutthelocalgym,Y
shouldrecommendthatthepatientgotothegymthattheyaremostlikelytogoto
regularly.Thereferralswouldbebasedonprofessionaljudgmentandnotonany
kickbacksshemayreceive.

ConflictofInterestScenarioNo.2

Xisanacupuncturistwhohasabusyandsuccessfulpractice.Recently,hebeganusing
newacupunctureneedlesthathehasnoticedreducethepainofinsertionforhis
patients.Theyhaveanewtypeofsiliconcoatingthatallowsthemtoglideintotheskin,
unlikemanyotheracupunctureneedleswithoutthecoating.Hecallsthecompanytotell
themhisfeedbackfromhispatientsandthathelikesusingtheproduct,andtoorder
moreboxesofneedles.Thecompanyaskshimifhewouldliketobeinanewadvertising
campaigntheyaregoingtoputintosomehealthandwellnessmagazineswherehe
wouldprovidestatementssimilartowhathejustgavetothecompanyforpromotingthe
product.Theyplantoputapictureofhimwithintheadvertisementandidentifyhimby
nameandqualifications.Theysaytheycannotpayhimbecausetheyarestillasmall

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company,anddonthavethebudgetforit.Hethinks,whynot?Helikestheproduct,and
sinceheisnotgettingpaidheisnotinappropriatelybenefitingfromtherelationship.

Unfortunately,thiswouldstilllikelybeaconflictofinterestandwouldbeprofessional
misconduct.Anacupuncturistcannotusetheirprofessionalstatustopromoteaproduct
commercially.Thisissoeventhoughhehasnotbeenpaidfortheendorsement.Itcanbe
assumedthathewillbenefitfromtheadvertisementinsomeindirectmanner(for
example,hemayhaveincreasedpatientinfluxfromthosepeoplewhoseethe
advertisement).Also,withoutmakinganyobservationsorassessmentsofanindividual,
theacupuncturistshouldnotbemakinganysortofclinicalrecommendations.Xcangive
adviceonproductsandremedies,includinginchoosingwhattypeofacupuncture
needlestouse,providedthatitisbasedonprofessionaljudgmentregardingapatients
individualneedsthroughproperassessment.

v. Advertising

Advertisingisanappropriatewaytoprovideinformationtopotentialnewpatients.
Practitionerscanuseappropriateadvertisingtocommunicatethetypeandavailabilityof
serviceswithintheirscopeofpracticetothepublic,ortootherhealthprofessionals.The
purposeofadvertisingshouldbetoproviderelevantinformationtothepublicinorderforthem
tomakeinformedchoicesinregardstotheirhealthcareneeds.However,advertisingmustnot
bedishonest,misleadingorirresponsible.

Advertisingisanymessagethatcommunicatesinformationaboutapractitioner,hisorher
practiceandwhatservicesheorshemayoffer,underthepractitionerscontrol.Advertising
maybeinanymediumandmayinclude(butisnotlimitedto)thefollowing:
Radio
Television
Websites
Printbasednoticesi.e.,letterheads,newspapers,magazines,journals,flyers
Contactlistingservicesi.e.,yellowpages.

Advertisingshouldbefactual,accurate,objectivelyverifiable,independentofpersonalopinion,
comprehensibleandprofessionallyappropriate.Itshouldnotincludeanyinformationthatis
misleadingbyeitherleavingoutrelevantinformation,orincludingnonrelevant,false,or
unverifiableinformation.Forexample,providingbeforeandafterpicturesofhowones
servicescanenhanceapatientsappearanceisinherentlymisleadingandunverifiable.
Practitionersshouldalsotakereasonablestepstoensurethattheadvertisementsplacedby
others(i.e.,employees,marketingconsultants)meetthesestandards.

Inparticular,referencestoqualificationsintheadvertisementshouldbeconsistentwiththe
Collegesrules.Forinstance,thetitlethemembercanusewilldependontheirclassof

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registration.NopractitionercanusethetitleofDoctoratthepresenttime.Offshore
qualificationsneedtobeclearlystated.

Importantinformationsuchasofficehoursanddaysofoperation,telephoneorfaxnumbers,
languagesspoken,websiteaddress,locationandmethodsofpaymentareacceptableinclusions
inadvertising.Feesorpricesadvertisedshouldmeetexpectationsforhonestyandaccuracy.

Further,advertisementsareprohibitedifthey:
promoteademandforanyunnecessaryservices,
makeaclaimorpromisearesultthatcannotalwaysbedelivered(i.e.,orbeinterpreted
asaguaranteeastothesuccessofaserviceprovided),
usecomparative(e.g.,better),superlatives(e.g.,best),suggestionofuniqueness,or
appealstoapersonsfearsaboutanyservicequality,productsorpeople(e.g.,
comparingonesservicestoanothers,orclaimsthatonesserviceissuperiortoothers,
isnotverifiable),and
containtestimonialsfromapatient,formerpatient,orotherpersoninrespectofthe
memberspractice.

Advertisingshouldalsonotinvolvethepressuringofvulnerableclientsorpatients.Solicitingor
permittingthesolicitationofanindividualinperson,bytelephone,throughelectronic
communicationsorbysimilarmeans,isunprofessional.However,itisnotsolicitationtoremind
existingpatientsofappointments,newdevelopmentsorchangesintheoffice.

AdvertisingScenario

Yhasjuststartedperforminganewprocedurewithherpatientsthathelpsreduce
rednessandinflammationoftheskinandisnoticinggreatresults.Shewantstoletother
peopleknowshenowdoesthisproceduresothatpatientscanchoosetocometoherfor
it,ormaybeevenhaveanotherhealthcareproviderreferpatientstoher.Sheaddsher
weeklyadvertisementinthecommunitypaperwithadescriptionoftheservice.She
makessurethedescriptiononlydescribestheprocedureanddoesnotofferany
guaranteedoutcomes,compareittootherproceduresorprovidereasonswhyshemight
beabetterchoicebecausesheperformsthisprocedure.However,shewantspeopleto
knowthegreatresultsshehasbeenseeingwithherpatients.So,withtheconsentofa
fewofherpatients,shetakessomebeforeandafterpicturesandpublishestheminthe
localpaper.Shefeelsthatpeoplecandecideforthemselvesbasedonthepicturesifthey
wanttotrytheprocedure.Unfortunately,indoingsoYhasviolatedtheadvertising
standardsofherprofession.Beforeandafterpicturesareinherentlymisleadingasthey
cannotbeverifiedforauthenticity,andinvolvecomparisonsinordertopromotea
specificprocedure.Also,beforeandafterpicturesmaybeconstruedassuggestingan
outcome,oraguarantee,thatcannotalwaysbeexpected.

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SampleExamQuestion

1. Advertisingneedstobe:
i.Accurate.
ii.Verifiable.
iii.Notcontainpersonalopinions.
iv.Alloftheabove

Answeriv)isthebestanswer.Allofthequalitiesarethosethatarerequiredof
advertising.Therearemorequalitiesthatadvertisementsshouldbesuchasfactual,
objective,comprehensible,andappropriate.Answeri)isnotthebestanswerbecauseall
ofthequalitieslistedinthequestionarefine.Answerii)isnotthebestanswerbecause
allofthequalitieslistedinthequestionarefine.Answeriii)isnotthebestanswer
becauseallofthequalitieslistedinthequestionarefine.

d. TheCollege

TheCollegedoesanumberofthingsinordertoprotectthepublic.UnderitsAct,theCollege
hastosetupvariouscommitteesandoperatevariousprograms.Thefollowingaresomeofthe
mostimportantprocessestheCollegecarriesoutintheregulationoftheprofession.

i. Registrationprocess

Asmentionedabove,registrationisthewayforapersontoenterintotheprofessionand
becomeamemberoftheCollegeiftheymeettherequirementssetoutintheregistration
regulation.Theprocessofregistrationitselfisfairlystructured.

TobecomeamemberoftheCollegeapersonfilesanapplicationformwiththeRegistrar,and
paystheapplicablefees.TheformisavailableontheCollegewebsite.Throughtheapplication
formtheapplicantprovidestheCollegewithinformationabouthisorhertrainingand
experience,hisorherpastconduct,andotherinformationthatmayaffecthisorherabilityto
practiseeffectively(e.g.,languageskills,professionalliabilityinsurance,currentexperience,
etc.).Theapplicantshouldprovideenoughinformationtodemonstratethatheorshemeets
therequirementsforregistration.Theapplicantmustnotmakeanyfalsestatementsonthe
application.

Wheretheapplicantmeetstherequirements,theRegistrarsofficewillsimplyacceptthe
application.Inthiscase,acertificateofregistrationisissuedtothenewmemberoftheCollege.

However,ifitappearsthattheapplicantdoesnotmeettheregistrationrequirements(oreven
iftheRegistrarisnotsure)theRegistrarwillrefertheapplicationtotheRegistration
Committee.Theapplicantwillbetoldoftheconcernandwillbegivenanopportunityto
provideawrittenresponsetotheconcerns.TheRegistrationCommitteewillconsiderthe

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applicationfurtheranddeterminesuitabilitytobecomeamember.IftheRegistration
Committeeconcludesthattheapplicantmeetstherequirements,acertificateofregistration
willbeissued.IftheRegistrationCommitteeconcludesthattheapplicantdoesnotmeetthe
requirementsitcanmakeanumberofdecisionsincluding:

1. Directingtheapplicanttocompletefurthertrainingorexaminations.
2. Registertheapplicantwithterms,conditionsandlimitations(forexample,ifthe
missingrequirementisexemptibleandthepubliccanbeprotectedinthe
circumstances).
3. Refusetheapplication.

IfacertificateisnotgrantedbytheRegistrationCommitteetheapplicanthasfurtheroptions.
ThedecisionmaybeappealedtotheHealthProfessionsAppealandReviewBoard(HPARB).
HPARBisappointedbythegovernmentandisindependentoftheCollege.HPARBwillreview
thefileand,iftheapplicantwishes,hearfromwitnesses.HPARBcandeterminethatan
applicantmeetstheregistrationrequirementsorrequirestheRegistrationCommitteetoobtain
additionalinformationandmakeanewdecision.HPARBsdecisioncanbeappealedtothe
courts.

ToensurethataCollegesregistrationprocessisfair,theregistrationsystemitselfisaudited
andreviewedthroughtheOfficeoftheFairnessCommissionerofOntario.Further,theRHPA
hasprovisionstoensurethattheregistrationprocessofCollegesistransparent,objective,
impartialandfair.

WhereanapplicantisregisteredinanotherpartofCanada,theCollegemust,withrare
exceptions,accepttheapplicantseducation,experienceandexaminationcredentialswithout
furtherinquiry.TheCollegecanstillreviewtheotherregistrationrequirements(e.g.,good
character,professionalliabilityinsurance,jurisprudence,and,ifnotpreviouslydetermined,
languagerequirements).

RegistrationProcessScenario1MakingFalseStatements

Xfilledouthisapplicationformforregistration,butwhenaskedifhehadanyprevious
criminalfindingshedidnotwanttoputdowntheshopliftingconvictionhereceived
twentyyearsago.Hewasworrieditwouldaffecthisapplication.So,onhisapplication
hereportedthathedidnothaveanypreviouscriminalfindings.Onthebasisofthe
applicationform,theCollegeregistersX.AfewyearslatertheCollegeistoldaboutXs
previousconviction.TheCollegerealizesthatXmadeafalsestatement.TheCollegecan
revokeXsregistrationbecausehemadethefalsestatementontheapplicationform.
Ironically,ifXhaddisclosedtheconviction,theRegistrationCommitteewouldprobably
haveacceptedXforregistrationsincehehadhadnodifficultiesintwentyyears.
However,makingafalsestatementontheapplicationformissoseriousandreflects
currentdishonesty,suchthatnowhewillberemovedfromtheprofession.

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Anapplicantwhohasreceivedapardonorwhohasreceivedaconditionalorabsolute
dischargefromcourtmuststillreporttheoffence.

ii. Complaintsanddisciplineprocess

Inordertoprotectthepublic,investigatingconcernsaboutapractitionersprofessional
conductorcompetenceisanessentialelementofselfregulation.Whereaconcernappears
serious,disciplinaryactionmustbetaken.TheCollegedealswithprofessionalmisconductand
incompetenceinaneducationalmannerasoftenaspossible.Ifamatterisreferredfor
discipline,theCollegeprovidesafairproceduretothepractitioner.

Thefollowingoutlineshowthecomplaintsanddisciplineprocessworks.

TheICRC
TheInquiries,ComplaintsandReportsCommittee(ICRC)isthestatutorycommitteeofthe
Collegethathandlesmemberspecificconcerns(e.g.,professionalmisconduct,incompetence
andincapacity).

TheICRCcanonlyhandleconcernsregardingmembersandsomeformermembersofthe
College.Further,theICRCisonlyinvolvedinallegationsregardingprofessionalmisconduct,
incompetenceorincapacity.Itdoesnothandleclaimsaboutprofessionalnegligence(i.e.,civil
lawsuits),criminalorquasicriminaloffencesofamember.

Forprofessionalmisconductandincompetenceissuestherearetwomainsourcesforconcerns:
1. Formalcomplaints;and
2. Formalinvestigativereports(calledRegistrarsReports).

IncapacityconcernsarealsohandledbytheICRCbutwillbediscussedinalatersectionbecause
theyarehandledinadifferentwaythancomplaintsthatbringapractitionersconductor
competenceintoquestion.

IntakeofComplaints
Foracomplainttobeaformalcomplaintthefollowingrequirementsmustbemet:
thecomplaintmustbeinwritingorrecordedontape,film,diskorothermedium(asset
outintheHealthProfessionsProceduralCode);
thecomplainantmustbeidentified;
themembermustbeidentifiable(theICRCmaybeabletoassistinidentifyingthe
memberbasedontheinformationprovidedbythecomplainant);
thecomplaintmustidentifysomeconductoractionsthatareofconcern(i.e.,notjust
thecomplaintthatamemberisunprofessional,incompetentorincapablebut
insteadincludingsomelevelofdetailtodemonstratethosecomplaints);and
thecomplainantmustintendthemattertobeacomplaint.

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TheRegistrarmustgivethemembernoticeofthecomplaint.Thismustbedonewithin
fourteendaysofthereceiptoftheformalcomplaint.

IntakeofRegistrarsReportsInvestigations

Asmentionedbefore,thedisciplineprocesscanbeinitiatedbyaRegistrarsReport.Inthis
methodthefollowingoccurs:
aconcernarisesthattheRegistrarbelieveswarrantsinvestigationanditisbroughtto
theICRCwiththerequestfortheICRCtoapproveappointmentofaninvestigator;
aninvestigatorisappointed;
theinvestigationisconductedandtheinvestigatormakesareporttotheRegistrar;and
theRegistrarthenmakesaRegistrarsReporttotheICRC.

OnceaRegistrarsReportismadetotheICRC,thematterproceedsverysimilartothewayit
doeswithacomplaint.

Investigations

TheinvestigationsbytheICRCshouldbethoroughbutneutral,objectiveandfair.

1. ComplaintsInvestigations:
FrivolousorVexatiousComplaints:ThereisoneexceptiontotheICRCinvestigating
everycomplaint.Whenitisfrivolousorvexatious,madeinbadfaith,mootoris
otherwiseanabuseofprocesstheICRCcanchoosenottoinvestigateit.This
happensrarely.Generally,itmustbefairlyobviousthatthereislittlemerittothe
complaintandtheprocessingofthecomplaintisunfairinthecircumstances.For
example,acomplainantrepeatingacomplaintwithoutanynewevidencewouldbe
frivolousandvexatious.NoticeisgiventothememberandcomplainantiftheICRC
intendstotakenoactioninthesecases.
InvestigativeSteps:Bothcomplainantandmemberareusuallyfirstaskedtoprovide
alldocumentationavailabletothem.TheICRCstaffgathersadditionalinformation
untiltheydetermineitislikelythatallreasonableandavailableevidencehasbeen
obtained.InformationisgatheredfromavarietyofsourcesincludingCollegefiles,
publicdatabases(i.e.,courtfiles),otherregulators,witnessesandother
practitioners.
ICRCDecision:AtthecompletionoftheinvestigationtheICRCmakesitsdecision
aboutthecomplaint.
TimeLimits:AcomplaintisfiledwhenitisdeliveredinwrittenformtotheRegistrar
oftheCollege.Acomplaintissupposedtobecompletedwithin150daysofitbeing
filedwiththeCollege.Afterthatthepartiesmustbenotifiedregularlyaboutthe

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progressofthecomplaint.IftheCollegetakestoolong,thecomplainantorthe
membercanasktheHealthProfessionsAppealandReviewBoardtotakeaction.

2. RegistrarsReportsonInvestigations:
Therearethreetypesofappointmentofinvestigatorsthatcanoccurfromthis
method:1)ConcernsthatcometotheattentionoftheRegistrar;2)Requestmade
bytheICRCtohelpinvestigateacomplaint,and;3)InformationfromtheQuality
AssuranceCommittee.
Anyconcernthatisabouttheconductoractionsofamemberthatisnotaformal
complaintisgenerallybroughttotheattentionoftheRegistrar.IfaRegistrarisof
theviewthattherearereasonableandprobablegroundsthatthememberengaged
insignificantprofessionalmisconductorisincompetent,theRegistrarbringsthe
concernstotheattentionoftheICRC.TheICRCisaskedtoapproveappointmentof
aninvestigator.
ComplaintsInvestigations:IftheICRCcannotobtainimportantinformationabouta
complaintonitsown(e.g.,apersonrefusestoprovideit),theICRCcanaskthe
Registrartousehisorherspecialpowerstohelp.
AppointmentsbasedonQualityAssuranceCommitteeInformation:Wherea
memberdoesnotcooperatewiththequalityassuranceprocess,ortheprocesshas
revealedsignificantconcernsregardingprofessionalmisconduct,incompetenceor
incapacity,theQualityAssuranceCommitteecanbringtheconcerntotheICRC.The
ICRCcandecidewhethertoappointaninvestigator.
TheInvestigation:TheinvestigatorappointedbytheRegistrarhasspecialpowers.
Forexample,heorshecanentertheofficeofthepractitionerandexaminefiles,can
summonsdocumentsandcancompelwitnessestoanswerquestions.
Timelimits:ThereisnosetdeadlinetocompleteaRegistrarsReporton
Investigationandrenderadecision.However,theyshouldbecompletedwithina
reasonabletime.

ICRCDisposition(Decision)

OncetheinvestigationiscompletedtheICRCmakesadecisionontheissues.Therearemany
optionsfortheICRC.Disciplineisnottheonlyoption.TheICRCisascreeningbody.TheICRC
cannotmakefindingsofcredibilityondisputedfacts,findwrongdoing(i.e.,professional
misconduct,incompetence),orimposeadisciplinarysanction(i.e.,fineorsuspension).Onlythe
DisciplineCommitteecandothesethings.Thefollowingaresomeofthedispositionsthatcan
takeplace.

WithdrawalofComplaint:Ifacomplainantwishestowithdrawacomplaint,theICRC
canstilldecidetoproceedwiththeinvestigation.TheICRChastodecidewhetherto
acceptawithdrawalofacomplaint.

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DispositionbyUndertaking:Thismeansthatamemberpromisestodocertainthings(or
refrainfromdoingcertainthings).AnundertakingthenresultsintheICRCtakingno
furtheractionbecausetheundertakingaddressestheconcern.
ReferraltoDiscipline:Disciplineisintendedforseriousconcerns(e.g.,dishonesty,
breachoftrust,wilfuldisregardofprofessionalvalues,inabilitytopractice
competently).EventhentheICRCmustensurethatthereisreasonableevidenceto
supporttheconcern.
ReferralforIncapacityProceedings:Thisiswheretheconductmaybeduetoanillness
orhealthcondition.Theprocedureisdescribedseparatelybelow.
AppearanceforaCaution:ThemembercanberequiredtoappearbeforetheICRCfora
verbalcaution.Usuallythisisaccompaniedwiththestatementthat,ifthecircumstances
donotchange,thememberwillfacemoreformalaction.
OtherActions:TheICRCcanbecreativeintheirdecisionsandsolutions.Forexamplethe
ICRCcanrequirethemembertoundergoaspecifiedcontinuingeducationand
remediationprogram(e.g.,arecordkeepingcourse).
TakingNoAction:IfthereisnobasisforconcerntheICRCcanclose(ordismiss)the
complaint.Reasonsmustbegivenfortakingnoaction.

ReviewBeforeHPARB

Inacomplaintmatter,eitherparty(i.e.,thecomplainantorthepractitioner)mayseekareview
ofanICRCdecisionbeforetheHealthProfessionsAppealandReviewBoard(HPARB)(unlessthe
decisionwasreferredtodisciplineproceedingsorforincapacityproceedings).HPARBmay
confirmadecisionoftheICRCorreturnthemattertotheICRCtomakeanewdecision.HPARB
canalsomakerecommendationstotheICRC.

DisciplineProceedings

AlldisciplinemattersarereferredtodisciplinebytheICRC.Formalcomplaintsandother
mattersfirstgothroughtheICRC,andareinvestigatedbytheICRC.TheICRCrefersspecified
allegationstothedisciplineprocess,andthedisciplineprocessisconfinedtoevaluatingthose
allegations.

InveryseriouscasestheICRCmaymakeaninterimorder(forexample,thesuspensionofthe
memberscertificateofregistration)toprotectthepublicwhileawaitingadisciplinehearing.It
isonlyusedwhenabsolutelynecessarytoprotectpatientsfromharm.

ProcedurebeforetheHearingStarts

NoticeofthehearingofficiallyinitiatesproceedingsbeforetheDisciplineCommittee.
Thenoticecontainsinformationnecessarytoensurethatthemembercanparticipate
effectivelyinthehearing.Itusuallyisaccompaniedbyastatementofallegations

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outliningthefacts,andlegalconclusionstobedrawnfromthefacts(i.e.,incompetence,
orcategoryofprofessionalmisconduct).
DisclosureofallrelevantinformationintheCollegesfilesismadetothepractitioner.
Disclosurewillenablethepractitionertopresentthebestpossibledefence.
TheChairoftheDisciplineCommitteeselectsapanelfromamongthemembersofthe
DisciplineCommitteetoholdthehearingforanyallegationsreferredtoit.Itisusually
fivepeople(twomustbepublicmembers,andthreeareusuallyprofessionalmembers).
Thesedecisionmakersmustbedisinterestedandunbiased.
Prehearingconferencesmaybeheldbeforethedisciplinehearings.Thisistoreachan
agreementonasmanyissuesaspossible,andtoplanthehearing.Discussionsatpre
hearingconferenceareofftherecord.Ifaresolutionisagreedupon(e.g.,settlement)
itispresentedtothepaneloftheDisciplineCommitteeforacceptance.

ProcedureattheDisciplineHearing

Theprocedureofadisciplinehearingisformal.Itissimilartoacourtcaseinthatthere
aretwosidesthateachpresenttheirargumentsandevidencetothepanel.Usuallyboth
theCollegeandthepractitionerarerepresentedbylawyers.TheDisciplineCommittee
panelensuresthatthecasesarepresentedfairly,theylistenimpartiallytotheevidence
andarguments,andafterbothpartieshavecompletedtheirpresentationsthepanel
decidesontheissues.
Thehearingisopentothepublicunlessthereissomecompellingreasonforprivacyin
ordertoupholdtransparencyandfairnessintheprocess.Thereareonlyafewlimited
exceptionswherethehearingmaybeclosed(e.g.,apersonshealthprivacyinterests
mightbedisclosedandoutweightheinterestsinapublichearing).
TheCollegepresentsitswitnessesfirst.Thenthepractitionerispermittedtocallhisor
herwitnesses.Thepractitionermaychoosetotestify.TheCollegecanthencall
witnessestoreplytowhatthepractitionerswitnessessaid.

EvidenceattheDisciplinehearing

Generally,rulesofevidencethatapplytocivilcourttrialsapplytodisciplinehearings.
Decisionsaretobebasedexclusivelyontheevidenceadmittedbeforeit.The
Committeecannotrelyonanyknowledgetomakeafindingthatwasnotpresentedas
evidence.
Arecordiskeptcompilingalltheexhibitsofevidence.

FindingsofProfessionalMisconduct

OnceaDisciplineCommitteedetermineswhatapractitionerhasdone,itmustthen
decidewhetherornotthatbehaviourconstitutesprofessionalmisconductasisoutlined
intheRHPAandtheregulations(asdescribedabove).

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FindingsofIncompetence

Incompetenceisdifferentfromprofessionalmisconduct.Itgenerallydoesnotinvolve
unethicalordishonestconduct,butratherthatthepractitionerdoesnothavethe
knowledge,skillandjudgmenttopractisesafely.Itisassessedbasedonthecareofone
ormoreofthepractitionerspatients.
Afindingofincompetencecaneitherbethatthepractitionerisunfittocontinueto
practice,orthatthememberspracticeshouldberestricted.

DecisionsandOrdersinDisciplineCases

Ifapractitionerhasbeenfoundtohaveengagedinprofessionalmisconduct,theDiscipline
Committeecanmakeoneormoreofthefollowingorders:

Revocationtheremovalofthememberfromtheprofession(lastsatleastayear,then
thepractitionermustsatisfytheDisciplineCommitteetheheorsheoughttobe
permittedbackintotheprofession).
Suspensionthetemporaryremovalofamemberfromtheprofession.Itcanbefixed
orflexible,ordependentonaneventoccurring(e.g.,successfulcompletionofacourse).
Terms,conditionsorlimitationscaneitherbeforaspecifiedperiod(e.g.,untilthe
practitionersuccessfullycompletescertainremedialtraining)orforanindefiniteperiod
(e.g.,thepractitionercannotconsumeanyalcohol).Theterms,conditionsorlimitations
mustberelatedtothefindingmadebytheDisciplineCommittee.Forexample,ifthe
practitionerwasdishonestbecauseofasubstanceabuseproblem,theconditioncannot
betotakeremedialeducationcoursesbecausetherewasnofindingthatthe
practitionerlackedanybasicknowledge.
ReprimandconversationbetweentheDisciplineCommitteeandthepractitioner
wheretheCommitteetellsthepractitioneritsviewsofhisorherconductandhowto
avoidsimilarproblemsinthefuture.
FinetheDisciplineCommitteecanimposeafineofupto$35,000.
Reimbursementforfundinginsexualabusecasesinafindingofsexualabusethe
DisciplineCommitteecanrequireapractitionertoreimbursetheCollegeforanyfunding
providedtothepatient.
Minimumorderinsexualabusecasescasesinvolvingfranksexualactshavea
mandatoryminimumorderofbothareprimandandrevocation.Noreinstatementcan
bemadeforfiveyearsafterrevocationonthesegrounds.
CostscanbeorderedbytheDisciplineCommitteetocoveraportionoftheexpenses
associatedwiththehearing.

Inincompetencecases,theDisciplineCommitteecanorderrevocation,suspensionorterms
conditionsandlimitations.

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TheDisciplineCommitteemustissuebothawrittendecisionandwrittenreasons.

Appeals

ThereisanoptionforappealtotheDivisionalCourtbyanypartyatthedisciplinehearing.The
DivisionalCourthasthepowertoconfirm,amendorreverseadecisionoftheDiscipline
Committeeifitactedunreasonablyormadeanerroroflaw.

ComplaintsandDisciplineScenarioTheTypicalComplaint

ApatientsendsaletterofcomplainttotheCollegesayingthatX,apractitioner,was
rudetoher.ThepatientsaysthatXbecameangrywhensheexpressedconcernthatthe
treatmentwasnotworking.ThepatientsaysthatXthrewheroutoftheoffice.The
RegistrarsendsaletternotifyingXofthecomplaintandaskingforaresponse.X
respondsthatthepatientwasextremelychallengingandafterdoingallthathecouldfor
thepatientthepatientbecameverballyabusiveandXhadtoterminatetheprofessional
relationship.Xsletterissenttothepatientwhorepliesthatshewasneververbally
abusivetoXandthatXismakingthisuptodefendhimself.TheInquiriesReportsand
ComplaintsCommittee(ICRC)obtainsstatementsfromthepatientshusband,Xs
receptionistandacoupleofpatientswhowerearoundatthetime.Itisdifficultto
reconcilethestoriesbutthepicturethatemergesisthattherewasaverbal
confrontationinwhichbothpartiesmayhaveusedintemperatelanguage.TheICRC
decidesthatthisisnotacasefordiscipline,particularlysincetherehavebeenno
previouscomplaintsaboutX.However,theICRCsendsXaletterofcautionreminding
himoftheneedtobeprofessionalinhisdealingwithpatientseveninchallenging
circumstances.

iii. Incapacityprocess

Asnotedabove,incapacityhasaparticulardefinitionwhenitreferstoapractitionerunderthe
RegulatedHealthProfessionsAct.Itrelatestoapractitionerhavingaphysicalormental
conditionwhichmaywarrantsomerestrictionsonhisorherpractice.Thissectionfocuseson
whathappenswhenincapacitybecomesaconcern.

Theintentoftheincapacityprovisionsisnottopunishapractitionerwhoisill.Thegoalofthe
incapacityprocessistoensurethatthememberreceivesappropriatetreatmentandis
supervisedandmonitoredsufficientlycloselysothatheorshecancontinuetopracticewithout
unduerisktothepublic.Onlyonrareoccasionswillthepractitionerhavehisorhercertificate
ofregistrationsuspendedorrevokedbytheFitnesstoPractiseCommittee.

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ConcernofIncapacityInitiated

Whenincapacitybecomesaproblemforapractitioner,theconcernisbroughttotheInquiries,
ComplaintsandReportsCommittee(ICRC)eitherbytheRegistrar,orbyanotherpanelofthe
ICRC.Theinformationofpossibleincapacitycancomefromanumberofsourcesincludingalaw
enforcementagency,amandatoryreportbyanemployer,oranexpressionofconcernbya
memberoftheprofessionorthepublic.

ICRCInquiry

OnceanICRCpanelisselected,noticeisgiventothememberthattheICRCpanelintendsto
inquireintowhetherthememberisincapacitated.TheICRCinquiriespanelisaninvestigative
body.Itsroleistogatherinformationandthendetermineifformalproceedingsshouldbe
initiated.Theinquirymayinvolveany(orall)ofthefollowing:

aninterviewwiththepractitioner;
areviewofanyrelevantinformationthatmightbecontainedinotherCollegefiles;
obtainingwitnessstatementsfrompatients,coworkers,colleagues,familymembers,
andotherswhohaveobservedthepractitionersbehaviourrecently,particularlyany
unusualbehaviour;
obtaininghospitalandofficechartsofrelevanttreatmentofthepractitioner;
obtainingareportfromhealthpractitionerswhohavetreatedthemember;and
orderingaspecialistexaminationofthepractitioner.

TheICRCmustprepareareportofitsinquiries,andacopymustbesenttothepractitioner.The
ICRCdeterminesifthemattershouldbereferredtotheFitnesstoPractiseCommitteefora
hearing.

ICRCDecisiontorefertoFitnesstoPracticeCommitteeforhearing(ornot)

Thematterisonlyreferredwhenthepractitionersproblemisserious.Thedecisiontoreferto
theFitnesstoPracticeCommitteeforahearingisnottakenlightlyandtheremustbesufficient
evidenceof,andareasonableprospectoffinding,incapacity.Thisisusuallywhenthereissome
concernthatthemembersillnesswill,noworinthefuture,affecthisorherprofessional
practicenegatively.Typically,itinvolvesalackofinsightbythepractitionerintotheextentof
hisorhercondition.

TheICRCcanmakeanorderthatdirectstheRegistrartosuspendthecertificateofregistration
ofthemember,ortoimposeterms,conditions,orlimitationsonthemember,temporarilyuntil
theFitnesstoPracticeCommitteeaddressesthematter.

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HearingbeforetheFitnesstoPracticeCommittee

ThehearingsbeforetheFitnesstoPracticeCommitteesharemanysimilaritieswiththehearings
beforetheDisciplineCommittee.Generally,theprocedureataFitnesstoPracticehearingisas
follows:
PanelisselectedbythechairoftheFitnesstoPracticeCommitteeconsistsofatleast
threepeople,atleastoneofwhomispublicmemberofCollegeCouncil.
DisclosureofevidencetheCollegehasthesamedisclosureobligationsasindiscipline
hearings.
Closedhearingordinarilyfitnesstopracticehearingsareclosedtothepublic(asset
outbytheRHPA)becauseofthepersonalnatureofsuchahearing(andbecausethe
hearingisnotmeanttobepunishmenttothepractitioner).Onlythepractitionercan
requestthatthehearingbeopenedtothepublic.
Orderofhearingsimilartodisciplinehearing.Theburdenofprovingthepractitioneris
incapacitatedliesupontheCollege.TheCollegepresentsitscasefirst.

DecisionsofFitnesstoPracticeHearing

TheFitnesstoPracticeCommitteemustdetermineifthepractitionerisindeedincapacitated.
Asmentioned,thisrequiresthatthememberhasaphysicalormentalconditionandthatthe
conditionwarrantsinthepublicinterestsomerestrictionsonthememberspractice(e.g.,
supervisionortreatment).Thiswillbebaseduponevidencepresentedatthehearing,usually
involvingexpertevidenceonthemembershealthstatus.Itisdeterminedwithconsiderationof
thepresentstatusofthemembershealth,andnotinthepast(whichisdifferentfroma
disciplinehearing).

IftheFitnesstoPracticeCommitteefindsthemembertobeincapacitated,itmustalsodecide
whatrestrictiontoplaceonthememberscertificateofregistration.Itcanrevokeamembers
certificate,suspendamemberscertificate,orimposeterms,conditionsorlimitationsonthe
memberscertificateofregistration.Usuallyterms,conditionsorlimitationsonthecertificate
aremade.Forexample,anorderfortreatmentfollowedbymonitoringandsupervision.

TheCommitteecanvarytheirorders,meaningtheycanadjustthedecisiontosuitthesituation
moreasitchangesovertime.ApartycanbringamotionfortheCommitteetovaryanorder.
Forinstance,ifapractitionerestablishesaperiodoftimethathisorherillnesshasbeenin
remission(i.e.,sobriety)therecanbealooseningoftherestrictionsonhisorhercertificateof
registration.

Appeals

ThereisanoptionforappealtotheDivisionalCourtbyanypartyatthehearingbeforethe
FitnesstoPracticeCommittee.Despiteanappealbeingmade,anyorderfromtheFitnessto
PracticeCommitteetakeseffectwhiletheappealispending.

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FitnesstoPractiseScenarioTheTypicalCase

XisapractitionerworkingwithJ,anotherpractitioner.JreportstotheCollegethatheis
terminatinghispartnershipwithXbecauseXsdrinkingisbeginningtoaffecthiswork.J
istiredofcoveringforXwhenhecomestotheofficetwohourslateafterabinge.The
RegistrarmakessomeinquiriesthattendtoconfirmJsreport.X,however,denieshehas
anyproblems.TheRegistrarreportsthemattertotheICRC.TheICRCasksXforconsent
toobtainacopyofhismedicalrecords,whichXprovides.ThoserecordsindicatethatX
hasseparatedfromhiswifewhoaccuseshimofdrinkingandthatXhasrecentlybeen
chargedwithimpaireddriving.TheICRCdirectsthatXattendanassessmentwitha
specialistinsubstanceabusedisorders.ThereportfromthespecialistindicatesthatX
clearlyhasasubstanceabusedisorder.TheICRCrefersXtotheFitnesstoPractise
CommitteeforahearingandsuspendsXscertificateofregistrationuntilthehearingcan
becompleted.Xentersandsuccessfullycompletesathirtydayinpatienttreatment
programforsubstanceabuseandisanactiveparticipantintherecommendedaftercare
program.AttheFitnesstoPractiseHearingXslawyerandtheCollegeslawyerpresenta
jointsubmissionaskingtheCommitteetofindthatXisincapacitated,asdefinedinthe
statute,andorderingthatXscertificateofregistrationberestoredontheconditionthat
hecontinuesinregulartreatment;thatheworkswithanotherpractitionerwhowill
monitorhisperformanceatworkandmakeregularreportstotheCollegeonhis
progress.

iv. QualityAssuranceProgram

(a) Purposesoftheprogram

EveryCollegemusthaveaqualityassuranceprogram.Thequalityassuranceprogramis
intendedtoassistpractitionersimproveandenhancetheirpracticebyparticipatingin
professionaldevelopmentactivitiesandreceivingconstructivefeedback.

Thequalityassuranceprogramisnotaformofdiscipline.Noinformationaboutapractitioner
thattheCollegeobtainsthroughthequalityassuranceprogrammaybeusedbytheCollegeto
disciplineapractitionerorbyanypersoninanylegalproceeding.AtmosttheQualityAssurance
CommitteecanreportthepractitionersnameandallegedmisconducttotheInquiries,
ComplaintsandReportsCommittee.Theonlyexceptioniswherethemembermakesafalse
statementtotheCollegeorfailstocooperatewiththeprogram.

ThequalityassuranceprogramisadministeredbytheQualityAssuranceCommitteeofthe
College(theCommittee).Thequalityassurancehasthefollowingcomponents:
Professionaldevelopment,
Self,peerandpracticeassessments,and
Monitoringofmembersparticipationinandcompliancewiththeprogram.

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(b) Selfassessmentandprofessionaldevelopment

Practitionersmustparticipateinselfassessmentandprofessionaldevelopmentactivities.For
example,practitionersmaybeaskedtofilloutaformpreparedbytheCollegethatdescribes
thenatureofhisorherpractice,theskillsneededtopracticewellandadescriptionofwhatthe
practitionercoulddotoimprovethoseskills.Thepractitionercouldthentakeacourseor
otherwiseimprovethoseskills.Practitionersarerequiredtorecordtheseactivitiessothatthe
Collegecanmonitorthem.Apractitionermustproducehisorherrecordupontherequestof
theCollege.

Professionaldevelopmentactivitiesallowpractitionerstoremaininformedaboutchangesand
innovationsinpracticestandardsandtechniques,anddevelopskillsandknowledgeofinter
professionalcollaboration.

(c) Peerandpracticeassessmentandremediation

Everyyear,theCommitteeselectspractitionerstoparticipateinpeerandpracticeassessments.
ThisallowstheCommitteetoassesspractitionersskill,knowledgeandjudgment.

Selectionofmembers

Practitionersmayberandomlyselectedforapeerandpracticeassessment.Apractitionermay
alsobeselectediftheCollegeaskstoseethepractitionersrecordofselfassessmentand
professionaldevelopmentactivities,andtherecordisincompleteorinadequate.TheCollege
mayalsodevelopothercriteriaforselectingpractitionersforpeerandpracticeassessments
(e.g.,practitionerswhohavenotpractisedmuchforafewyearsandwhoseknowledge,skill
andjudgmentmaynotbequiteuptodate).ThesecriteriawillbepublishedontheColleges
website.

Practiceassessors

Apeerandpracticeassessmentisconductedbyanindependentpracticeassessorappointedby
theQualityAssuranceCommittee.Oftenthoseassessorswillbepractitioners.Apractice
assessormayreviewapractitionerseducation,professionaldevelopmentandselfassessment
records.Apracticeassessorcanalsoobtaininformationaboutapractitionerspracticeby
variousmethodsincludingvisitingthepractitionersoffice.

Practitionersmustcooperatewithanassessment.Inparticular,duringapeerandpractice
assessment,practitionersmust:
Permittheassessortoenterandinspectthepremiseswherethepractitionerpractices;
however,assessorsmaynotenterapractitionershome;

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Permittheassessortoinspectthepractitionersrecordsofthecareofclients,evenif
theyareconfidential;
Givetheassessoranyinformationrequestedregardingthecareofclientsorthe
practitionersrecords,and
Meetwiththeassessoruponrequest.

Atthetimeofwriting,theCollegehasnotyetdecidedhowitwillconductitspractice
assessments.

RoleoftheCommittee

Followingapeerandpracticeassessment,thepracticeassessorwillprepareareportforthe
Committee.Thepracticeassessorsroleissimplytoreviewandreportonapractitioners
practice,andnottomakeanyrulingsaboutthepractitionerspractice.

TheCommitteesroleistodetermineifthepractitionersknowledge,skillsorjudgmentare
satisfactory.IftheCommitteeisoftheopinionthatthepractitionersknowledge,skillsor
judgmentarenotsatisfactory,theCommitteemaydoanyofthefollowing:

Requireapractitionertoparticipateincontinuingeducationorremediationprograms;
DirecttheRegistrartoimposeterms,conditionsorlimitationsonthepractitioners
certificateofregistrationforaspecifiedperiodoftime;or
IftheCommitteebelievesthepractitionermayhavecommittedanactofprofessional
misconduct,ormaybeincompetentorincapacitated,theCommitteemaydiscloseonly
thenameofthepractitionerandtheallegationsagainstthepractitionertotheInquiries,
ComplaintsandReportsCommittee.

Sincethequalityassuranceprogramiseducationalandsupportiveinnature,itwillberarefor
theCommitteetodirectanythingotherthanupgrading(e.g.,coursesorseeingamentor)even
incaseswheretherearesignificantgapsinthepractitionersknowledge,skillandjudgment.

TheCommitteemustconsideranywrittensubmissionsbythepractitionerbeforetakingany
action.

QualityAssuranceScenarioNo.1

Y,apractitioner,isaskedbytheCollegetoprovideherrecordofprofessional
developmentandselfassessmentactivities.Yhasnotkeptanyrecordofprofessional
developmentactivities.Apracticeassessorisappointed.Thepracticeassessormeets
withY,andreviewsherprofessionaldevelopmentandselfassessmentactivities.The
practiceassessorpreparesareportfortheCommitteethatdescribestheprofessional
developmentactivitiesthatYparticipatedin.TheCommitteemaydecidethatthereisno

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reasontotakeanyactionbecauseYhaslearnedfromthisexperienceaboutthe
importanceofkeepingrecordsofprofessionaldevelopmentactivities.

QualityAssuranceScenarioNo.2

X,apractitioner,israndomlyselectedforapeerandpracticeassessment.Apractice
assessorisappointed.Xcooperateswiththepracticeassessorsreviewofhisrecordsand
inspectionofhisoffice.ThepracticeassessorprovidesareporttotheCommittee,who
reviewsthereportandfindsthatXhasnotbeenkeepingadequateclinicalrecords.The
CommitteegivesXanopportunitytorespondinwriting.AfterreviewingXsresponse,
theCommitteedecidesthatXmusttakearecordkeepingcourse.TheCommitteealso
directsthatXspracticebereassessedinoneyearstimetoseeiftherehasbeenan
improvement.

SampleExaminationQuestion

Ifapractitionerisselectedforapeerandpracticeassessment,thepractitionershould:
i. Cooperatewiththepracticeassessorsreview,includingpermittingtheassessor
toinspecthisorherofficeanduponrequestprovideanyrequestedrecords.
ii. Permitthepracticeassessortoinspecthisorherhome.
iii. Givetheassessorallrecordsexceptthosethatareconfidential.
iv. Completeallrequiredprofessionaldevelopmentrecordsandfillingapsinclient
recordsbeforesendingthemtothepracticeassessor.

Thebestanswerisi).Practitionershaveadutytocooperatewithpeerandpractice
assessments.Answerii)isthenotbestanswerbecausepracticeassessorsarenot
permittedtoenterprivatehomes.Answeriii)isnotthebestanswerbecausethepractice
assessorsrighttoaccesspremisesandrecordsoverridespatientconfidentiality.Answer
iv)isnotthebestanswerbecausewhileapracticeassessmentisagoodopportunityto
improverecordkeepingandotherpractices,apractitionershouldalwaysupdateclient
recordsimmediatelysothattheyareaccurate.Practitionersshouldneverwaituntilthey
areselectedforanassessmenttoupdatetheirrecords.Additionally,ifrecordsare
falsified,theCommitteemayreportthepractitionersnameandthisallegationtothe
Inquiries,ComplaintsandReportsCommittee.

e.
Otherlaws

i.
PHIPA

(a) Personalhealthinformation

Practitionershavealegalandprofessionaldutytoprotecttheprivacyofpatientspersonal
healthinformation.ThePersonalHealthInformationProtectionAct(PHIPA)governs

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practitionersuseofpersonalhealthinformation,includingitscollection,use,disclosureand
access.ThisActhelpsguidethegeneraldutyofconfidentialitydescribedabove.

Personalhealthinformationreferstoalmostanythingthatwouldbeinapractitionersfilesona
patient.ItisdefinedinPHIPAaswrittenororalidentifyinginformationaboutaperson,ifthe
information:

(a) Relatestothepersonsphysicalormentalhealth,includingthepersonsfamily
healthhistory;
(b) Relatestotheprovidingofhealthcaretotheperson,includingtheidentificationofa
personassomeonewhoprovidedhealthcaretotheperson;
(c) IsaplanofservicewithinthemeaningoftheHomeCareandCommunityServices
Act,1994fortheperson;
(d) Relatestothepersonspaymentsoreligibilityforhealthcare,oreligibilityfor
coverageforhealthcare:
(e) Relatestothedonationbytheindividualofanybodypartorbodilysubstanceofthe
personorisderivedfromthetestingorexaminationofanysuchbodypartorbodily
substance;
(f) Isthepersonshealthnumber;or
(g) Identifiesapersonssubstitutedecisionmaker.

(b) HealthInformationCustodians

AHealthInformationCustodian(Custodian)isthepersonororganizationresponsibleforall
healthrecords.TheCustodianmustcreate,implementandoverseeaprivacypolicythatmeets
therequirementsofPHIPA.

AsolepractitioneristheCustodianoveranyhealthinformationandrecordsthatthe
practitionercollects.

Ifapractitionerworksforahealthservicesorganizationsuchasahospitalorlongtermcare
home,theorganizationistheCustodianofhealthrecords.

Twoormorepractitionerswhoworktogethermaydecidetoactasasingleorganizationforthe
purposesofPHIPA.Thismaybehelpfulbecausethepractitionerscancreateasingleprivacy
policy.Thiswouldallowforconsistenthealthrecordkeepingpractices.Inthiscasethe
practitionerswillhavesharedresponsibilityforcomplyingwithPHIPA.

(c) InformationOfficers

PHIPArequireseverypractitionerandorganizationtoappointacontactperson(oftencalledan
InformationOfficer).AnInformationOfficeristhepersonwhoensurescompliancewiththe
privacypolicyandrequirementsofPHIPA.TheInformationOfficersdutiesincludereviewing

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theorganizationsprivacypractices,providingtraining,andmonitoringcompliance.The
InformationOfficerisalsothecontactpersonforpublicinformationrequests.

AsolepractitionerhastoactasInformationOfficerhimselforherself.Ahealthservices
organizationmayappointapersonwithintheorganization,ormayhireapersonoutsideofthe
organizationtobeitsInformationOfficer.

PHIPAScenario

Threepractitionersworktogetherinanoffice.Theydecidetheywillactasan
organizationforprivacypurposes.TheirorganizationistheHealthInformation
Custodian.Thepractitionerscreateaprivacypolicytogether.Thepractitionersdecideto
appointthemostseniorpractitionertobetheInformationOfficer.TheInformation
Officercreatesaproceduretoprotectpersonalinformation,developsaprivacy
complaintsprocedure,andensuresthatallpractitionerscomplywiththeprivacypolicy.

(d) Protectingpersonalhealthinformation

Custodiansmustputinplacepracticestoprotectpersonalhealthinformationintheircustody
orcontrol.

Practitionersororganizationsmusttakeappropriatemeasurestoprotectpersonalhealth
informationfromunauthorizedaccess,disclosure,useortampering.Thenatureofthose
safeguardswillvarydependingonthesensitivityoftheinformationandthecircumstances.
Personalhealthinformationisgenerallyconsideredhighlysensitive.Thosesafeguardsmust
includethefollowingcomponents:

physicalmeasures(e.g.,restrictedaccessareas,lockedfilingcabinets),
organizational measures (e.g., needtoknow and other employee policies, security
clearances),and
technologicalmeasures(e.g.,passwords,encryption,virusprotection,firewalls).

Practitionersororganizationsneedtosystematicallyreviewalloftheplaceswheretheymay
temporarilyorpermanentlyholdpersonalhealthinformationandassesstheadequacyofthe
safeguards.Almosteveryorganizationwillfindthatitneedstomakechanges.

Practitionersororganizationsalsoneedtosecurelyretain,transferanddisposeofrecordsin
accordancewiththeCollegesrequirements.Forexample,theCollegerequiresthatpatient
recordsbekeptfortenyearsfromthelastcontactwiththepatient(orifthepatientwasnotan
adultatthelastcontact,tenyearsfromwhenthepatientturned18).

Apractitionerororganizationsprivacypolicyshouldexplainhowhealthinformationwillbe
protected.

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(e) Collection,useanddisclosureofpersonalhealthinformation

Apractitionerororganizationmustonlycollect,use,ordiscloseapersonspersonal
informationifthepersonconsentsandtheinformationisnecessary,orifthecollection,useor
disclosureisotherwisepermittedorrequiredbylaw.Apractitionershouldcollect,useor
disclosenomoreinformationthanisreasonablyrequiredinthecircumstances.

Apractitionersoranorganizationsprivacypolicyshouldclearlyexplainhowandwhen
personalhealthinformationwillbecollected,usedanddisclosed.

UnderPHIPA,collection,useanddisclosureofpersonalhealthinformationispermittedwithout
consentinlimitedcircumstances.

CircleofCare

Apractitionercansharepersonalhealthinformationwithotherindividualswithinapatients
circleofcareforthepurposesofprovidinghealthcare,withoutthepatientsexpressconsent.
Acircleofcaremayincludeotherhealthprofessionalswhoprovidecaretothesamepatient.A
practitionermayassumethatheorshehasapatientsimpliedconsenttodisclosepersonal
healthinformationtootherhealthprovidersinthepatientscircleofcare.

Apractitionerwhoisworkinginamultidisciplinarysettingmaysharepersonalhealth
informationwithotherhealthcareprofessionalswhoareprovidingcaretothesamepatient,
becausetheseotherhealthcareprofessionalsarewithinthepatientscircleofcare.

Apractitionerwhorefersapatienttoanotherhealthprofessionalmayconsiderthathealth
professionaltobewithinthepatientscircleofcare.

Thecircleofcareofasolepractitionerspatientmayalsoincludeotherhealthcareprovidersin
otherinstitutions,ifitisnecessaryforprovidinghealthcaretotheindividual,anditisnot
reasonablypossibleforconsenttobeobtainedinatimelymanner.However,many
practitionersdonotshareinformationwithothersinthehealthcareteamwithoutthepatients
explicitconsentunlessitisanemergencysoastoavoidmisunderstandings.Thiscautionis
particularlyimportantwheretheinformationissensitive.

Theexceptiontothisprincipleisthatifapatientorpatientssubstitutedecisionmakersays
thatheorshedoesnotwanttheinformationtobeshared.Theinformationmustthenbeputin
alockboxandcannotbesharedunlessanotherprovisioninPHIPApermitsit.

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CircleofCareScenario

Y,apractitioner,receivesatelephonecallfromaregisterednurseatalocalhospital.The
nurseadvisesYthatherpatienthasjustbeenadmittedtothehospital.Thenursereports
thatshehasbeenunabletocontactthepatientssubstitutedecisionmaker(SDM).The
nursewantstoknowaboutwhattreatmentYhasbeenprovidingtothepatient.Yrecalls
thattheSDMtoldhernevertosharethepatientspersonalhealthinformationwithany
otherhealthcareprovider.Inthiscase,thecircleofcareprincipledoesnotallowYto
discloseherpatientspersonalhealthinformation.However,anexception,notedbelow,
appliesifYbelievesonreasonablegroundsthatthedisclosurewouldreduceariskof
seriousharmtothepatient(oranyotherperson).ThusYtellstheregisterednurseabout
thepatientstreatmentsothatthepatientcanreceiveemergencycare.

Familyandfriends

Generallyspeaking,consentshouldbeobtainedbeforesharingpersonalhealthinformation
withmembersofapersonsfamily.

However,personalhealthinformationmaybedisclosedforthepurposesofcontactingfamily
members,friends,orotherpersonswhomaybepotentialsubstitutedecisionmakers,ifthe
individualisinjured,incapacitated,orill,andcannotprovideconsent.Thismaybeparticularly
relevantforpractitionersworkinginacutecaresettings.

Disclosurerelatedtorisk

Apractitionermaydiscloseapersonspersonalhealthinformationifthepractitionerbelieves
onreasonablegroundsthatthedisclosureisnecessarytoeliminateorreduceasignificantrisk
ofseriousbodilyharmtothepersonoranyoneelse.

Forexample,ifapatienthasthreatenedtokillsomeone,thepractitionercanwarntheperson
beingthreatenedandthepolice.Thepractitionercouldshareinformationaboutthepatient
thatwillhelpthepolicetodealwiththethreat.

Otherlaws

PHIPApermitsdisclosureofpersonalhealthinformationthatispermittedorrequiredbymany
otherActs,includingthefollowing:
TheHealthCareConsentActorSubstituteDecisionsActforthepurposesofdetermining,
assessingorconfirmingcapacity;
DisclosuretoaCollegeactingundertheRegulatedHealthProfessionsAct;and
Disclosuretoaninvestigatororinspectorwhoisauthorizedbyawarrantorbyany
provincialorfederallaw,forthepurposesofcomplyingwiththewarrantorfacilitating
theinvestigationorinspection.

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Additionally,asdiscussedaboveinthesectionofthebookonMandatoryReports,thereare
somecircumstancesinwhichdisclosureofpersonalhealthinformationismandatory.

(f) Accesstopersonalhealthinformation

Everypatienthasarighttoaccesshisorherownpersonalhealthinformation.Oneimportant
exceptionisifgrantingaccesswouldlikelyresultinariskofseriousharmtothepatients
treatmentorrecovery,orariskofseriousbodilyharmtothepatientoranotherperson.Many
studentsofprivacylawbelievethatbodilyharmincludesmentaloremotionalharm.

Ifapersonmakesarequesttoaccesspersonalhealthinformation,thepractitioneror
organizationmust:
permitthepersontoseetherecordandprovideacopyatthepersonsrequest;
determineafterareasonablesearchthattherecordisunavailable,andnotifythe
personofthisaswellashisorherrighttocomplaintotheInformationandPrivacy
Commissioner;or
determinethatthepersondoesnothavearightofaccess,andnotifythepersonofthis
aswellashisorherrighttocomplaintotheInformationandPrivacyCommissioner.

TheInformationandPrivacyCommissionermayreviewthepractitionersororganizations
refusaltoprovidearecord,andmayoverrulethedecision.

Ifthelawdoesnotpermitdisclosureforanyreason,apractitionershouldblackoutthoseparts
thatshouldnotbedisclosedifitisreasonabletodoso,sothatthepatientmayaccesstherest
oftherecord.

SampleExamQuestion

Whichofthefollowingbestdescribesapatientsrighttoaccesspersonalhealth
informationcontainedinapractitionersrecords?

i.
Apatienthasanunrestrictedrighttoaccesshisorherpersonalhealth
information.
ii.
Apatientgenerallyhasarighttoaccesshisorherhealthinformation,andhasa
righttocomplaintotheInformationandPrivacyCommissionerifaccessis
refusedforanyreason.
iii.
Apatienthasarighttoaccesshisorherhealthinformationunlessthe
practitionerbelievesitisnotinthepatientsbestintereststoseethe
information.
iv.
Apatientcanrequestacopyofarecordcontaininghisorherpersonalhealth
information,butapractitionerdoesnothavetoprovideit.

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Thebestanswerisanswerii).Apatientsrighttoaccesshisorherhealthinformationis
broadbuthassomelegallimits.However,evenifaccessisrefusedforanappropriate
reason,thepatientisentitledtobringacomplainttotheInformationandPrivacy
Commission.Answeri)isnotthebestanswerbecausetherighttoaccesspersonalhealth
informationmayberestrictedinsomecircumstances(e.g.,wherethereisaseriousrisk
ofsignificantbodilyharm).Answeriii)isnotthebestanswerbecauseapractitioners
opinionaboutwhetheritisgoodforthepatienttoseetherecordisirrelevant.Onlyifthe
practitionerbelievesonreasonablegroundsthatviewingtheinformationwould
seriouslyharmthepatientstreatment,mayaccessberefused.Answeriv)isnotthebest
answerbecauseapractitionerdoesnothaveageneralrighttorefuseapersonaccessto
personalhealthinformation.

Correctionofpersonalhealthinformation

Individualsgenerallyhavearighttorequestcorrectionstotheirownpersonalhealth
information.Apractitionerororganizationreceivingawrittenrequestmustrespondtoitby
eithergrantingorrefusingtherequestwithinthirtydays.Itiswisetorespondtoverbal
requestsassoonaspossibleaswell.Iftherequestcannotbefulfilledwithinthirtydaysthe
personshouldbeadvisedofthisinwriting.

Correctionstorecordsmustalwaysbemadeinawaythatallowstheoriginalrecordtobe
traced.Theoriginalrecordshouldneverbedestroyed,deleted,orblackedout.Iftherecord
cannotbecorrectedonitsface,itshouldbepossibleforanotherpersonaccessingtherecordto
beinformedofthecorrectionandwheretofindthecorrectinformation.Thepersonshould
alsobenotifiedofhowthecorrectionwasmade.

Atthepersonsrequest,thepractitionershouldnotifyanyonetowhomthepractitionerhas
disclosedtheinformationofthecorrection.Theexceptiontothisisifthecorrectionwillnot
impactthepersonshealthcareorotherwisebenefittheperson.

Thepractitionerororganizationmayrefusetherequestifthepractitionerororganization
believestherequestisfrivolousorvexatious;ifthepractitionerdidnotcreatetherecordand
doesnothavetheknowledge,expertiseandauthoritytocorrectit;oriftheinformation
consistsofaprofessionalopinionmadeingoodfaith.Inotherwords,correctionsarelimitedto
factualinformation,notprofessionalopinions.

Apractitionerwhorefusestomakeacorrectionmustnotifythepersoninwriting,withreasons,
andadvisethepersonthatheorshemay:

prepareaconcisestatementofdisagreementthatsetsoutthecorrectionthatthe
practitionerrefusedtomake;

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requirethepractitionertoattachthestatementofdisagreementtohisorherclinical
records,anddisclosethestatementofdisagreementwheneverthepractitioner
disclosesrelatedinformation;
requirethepractitionertomakeallreasonableeffortstodisclosethestatementof
disagreementtoanyonetowhomthepractitionerhaspreviouslydisclosedtherecord;
or
makeacomplaintabouttherefusaltotheInformationandPrivacyCommissioner.

Complaints
Everyorganizationmusthaveasysteminplacetodealwithcomplaintsregardingpersonal
healthinformation.PatientsshouldalsobeawareoftheirrighttocomplaintotheCollege
and/ortotheInformationandPrivacyCommissioner.

ii.
PIPEDA

AnotherprivacylawthatpractitionersshouldbeawareofisthePersonalInformation
ProtectionandElectronicDocumentsAct(PIPEDA).PIPEDAisafederallawthatgovernsthe
collection,use,anddisclosureofpersonalinformationinrelationtocommercialactivityother
thanhealthcare.

PIPEDAappliesonlytocommercialactivitiesofpractitioners,suchasthesaleofproductsat
practitionersoffices,andtheofferingofeducationalsessions.UnlikePHIPA,whichgoverns
personalhealthinformation,PIPEDAgovernsalltypesofnonhealthpersonalinformation.
Examplesofpersonalinformationincludethepersonsname,dateofbirth,andhomeaddress.

Thefollowingtenprivacyprinciplesapplytopractitionerscommercialactivities:
1. Accountability:Someoneinanorganization(theprivacyofficer,sometimescalledan
informationofficer)mustbeaccountableforthecollection,use,anddisclosureof
personalinformation.Theprivacyofficermustdevelopprivacypoliciesandprocedures,
andensurethatstaffreceivesprivacytraining.
2. IdentifyingPurposes:Anorganizationmustidentifythepurposesforwhichpersonal
informationwillbeusedatthetimethattheinformationiscollected.
3. Consent:Informedconsentisrequiredtocollect,use,anddisclosepersonalinformation
exceptinlimitedcircumstances(e.g.,inemergenciesorwherethelawotherwise
permitsthis).
4. LimitingCollection:Anorganizationmustonlycollecttheinformationthatisnecessary
tocollectfortheidentifiedpurposes.
5. LimitingUse,Disclosure,andRetention:Anorganizationmustonlyuse,discloseand
retainpersonalinformationthatisnecessary,fortheidentifiedpurposesandisobtained
withconsent.Itshouldberetainednolongerthannecessary.
6. Accuracy:Anorganizationmustmakereasonableeffortstoensurethatanypersonal
informationcollectedisaccurate,complete,anduptodate.

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7. Safeguards:Anorganizationmustprotectpersonalinformationwithappropriate
safeguardsinordertoprotectagainstloss,theft,unauthorizedaccess,disclosure,
copying,use,ormodification.
8. Openness:Anorganizationmustmakeitsprivacypoliciesreadilyavailable.
9. IndividualAccess:Uponrequest,anindividualmustbeinformedoftheexistence,use,
anddisclosureofhisorherpersonalinformation,andbegivenaccesstoit.Anindividual
canrequestcorrectionstotheinformation.Accessmaybeprohibitedinlimited
circumstancessuchastheprivacyofotherpersons,prohibitivecosttoprovideit,or
otherlegalreasons.
10. ChallengingCompliance:Anorganizationmusthaveacomplaintsprocedurerelatingto
personalinformationandmustinvestigateallcomplaints.

Asyoucansee,PHIPAandPIPEDAarebasedonthesameprinciples.PHIPAsimplyprovides
moredetailsabouthowtoachievethoseprinciplesinthehealthcarecontext.

iii.
HealthCareConsentAct

TheHealthCareConsentAct(HCCA)setsoutrulesaboutconsenttotreatmentespecially
wherethereisconcernaboutthecapacityofthepatienttoconsenttotreatment.Thetopicof
informedconsentisdealtwithindetailabove.Inbrief,exceptincasesofemergency,informed
consentforanyassessmentortreatmentmustbeobtainedfromeitherthepatient.Ifthe
patientisincapable,informedconsentisobtainedfromthepatientssubstitutedecisionmaker.

Wherethereisadisputeaboutthecareofincapablepatients,thedecisionmakingbody
responsibleformakingdecisionsregardingconsentandcapacityinOntarioistheConsentand
CapacityBoard(CCB).Apractitioner,patient,orsubstitutedecisionmakermayapplytothe
CCBwhenadecisionrelatingtoapatientsconsentorcapacityneedstobemade.Thepowers
oftheCCBincludethefollowing:

TheCCBcanconsiderapatientschallengetoadecisionbyapractitionerthatheorshe
isincapablewithrespecttoatreatment.TheCCBmayagreewiththehealth
practitioner,ormayoverrulethepractitionerandfindthatthepatientiscapablewith
respecttothetreatment.IftheCCBoverrulesthepractitioner,thepractitionercannot
administerthetreatmentunlessthepatientconsents.
TheCCBcanprovidedirectiontoasubstitutedecisionmakerwithrespecttoan
incapablepersonswishes(e.g.,whetherthewishappliestothecircumstances,or
whetherornotthewishwasexpressedwhenthepersonwascapable).
TheCCBcanalsoconsiderarequestfromasubstitutedecisionmakertodepartfroma
personswishthatwasexpressedwhilethepersonwascapable.
TheCCBcanreviewdecisionsregardingapersonscapacitytoconsenttotreatment,
admissiontocarefacilities,ortheuseofapersonalassistiveservice.

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TheCCBcanappointasubstitutedecisionmakertomakedecisionsforanincapable
personwithrespecttotreatment,admissiontoacarefacilityoruseofapersonal
assistanceservice.
TheCCBcanamendorterminatetheappointmentofarepresentative.
TheCCBcanreviewadecisiontoadmitanincapablepersontoahospital,psychiatric
facility,nursinghomeorhomefortheagedforthepurposeoftreatment.
TheCCBcanreviewasubstitutedecisionmakerscompliancewiththerulesfor
substitutedecisionmaking.

ApatientmaychallengeadecisionoftheCCBbyappealingtothecourts.

HealthCareConsentActScenario

X,apractitioner,isoftheopinionthatapatientisnotcapablewithrespecttoa
proposedtreatment.Thepatientdoesnotagreewiththisdecision,anddecidesto
challengeitattheCCB.TheCCBholdsahearing.ItreceivestestimonyfrombothXand
thepatient,andconcludesthatthepatientiscapableofconsentingtothetreatment.
ThepatienttellsXheisrefusingtotheconsenttothetreatment.Inthissituation,X
cannotadministerthetreatment,evenifXbelievesthetreatmentisinthepatientsbest
interests.

iv. ChildandFamilyServicesAct

Apractitionerwhosuspectsthatanychildisinneedofprotectionmustreportthistoa
childrensaidsociety(CAS).Thisdutyoverridesallprivacyandconfidentialitydutiesandlaws,
includingPHIPA.Nolegalactioncanbetakenagainstapractitionerformakingareport,unless
thereportismademaliciouslyorwithoutreasonablegrounds.TheCollegecannotdisciplinea
practitionerformakingsuchareportingoodfaithandwithreasonablegrounds.

Asaresultofareport,aCASworkermayinvestigatethereportfurther,andwhereactionis
needed,inmanycasesaCASwillofferafamilysuchservicesascounselingandparenting.A
reporttoaCASwillnotusuallyresultinachildbeingtakenawayfromafamily.

Apractitionerhasadutytoreportwithrespecttoanychildundertheageof16(orwhois16or
17yearsoldandunderachildprotectionorder).Thisincludesallchildren,includingachildofa
patient,orachildwhoisapatient,oranyotherchild.However,apractitionerhasaspecial
responsibilitytoreportinformationaboutachildwhoisapatientorclientiftheinformation
wasobtainedwhileprovidingtreatmentorservicestothechild.Apractitionermaybefinedup
to$1000forfailingtomakeareportinthiscircumstance.

Thedutytoreportisongoingevenifapreviousreporthasbeenmaderespectingachild.A
practitionermustmakeareportpersonally.

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Apractitionermustmakeareportifheorshehasreasonablegroundstosuspectanyofthe
following:

Thechildhasbeenorisatriskofharm
Areportisrequiredifachildhasbeenorisatriskoflikelybeingphysicallyharmedbyaperson
havingchargeofthechild(e.g.,aparentorguardian),eitherdirectlyorasaresultofneglector
apatternofneglect.

Areportisalsorequiredifachildhasbeenorisatriskofbeingsexuallymolestedorsexually
exploited,eitherbyapersonhavingchargeofthechild,orbyanotherperson,iftheperson
havingchargeofthechildknowsorshouldknowoftheriskofthishappeningandfailsto
protectthechild.

Failuretoprovideorconsenttoservicesortreatment
Therearenumerouscircumstanceswhereareportisrequiredbecausethepersonhaving
chargeofachilddoesnotorcannotprovideservicesortreatmenttoachild,ordoesnotor
cannotconsenttoservicesortreatmentforachild.

Areportisrequiredwhereachildisnotreceivingservicesortreatment,and:
thechildrequiresmedicaltreatmenttocure,preventoralleviatephysicalharmor
suffering;
thechildhassufferedorislikelyatriskofsufferingemotionalharm,demonstratedby
seriousanxiety,depression,withdrawal,selfdestructiveoraggressivebehaviour,or
delayeddevelopmentbelievedtobecausedbyactionorinactionofthepersonhaving
chargeofthechild;
thechildhasamental,emotionalordevelopmentalconditionthat,ifnotremedied,
couldseriouslyimpairthechildsdevelopment;orif
thechildisundertheageof12,haskilledorseriouslyinjuredanotherpersonorhas
causedseriousdamagetoanotherpersonsproperty,andservicesortreatmentare
neededtopreventarecurrence.

Abandonment
Areportisrequiredifachildhasbeenabandonedbyaparentorguardian,orisotherwiseleft
withoutacaregiver.Thisincludesthedeathofachildsparents.

Failuretosuperviseachild
A report is also required if a child has injured another person or damaged another persons
propertymorethanoncebecauseapersonhavingchargeofachildhasnotorcannotsupervise
achildadequately.

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MandatoryReportingScenario1

Y,apractitioner,hasapatientwhodisclosesthatshehasphysicallyharmedherson.Yhasa
duty to make a report, even if the patient reported this in confidence or in the course of
assessment or treatment. If two months later the patient says something that makes Y
suspectthatthepatienthasphysicallyharmedhersonagain,Yhasadutytomakeanother
report.

MandatoryReportingScenario2

X,apractitioner,hasan11yearold patientwhohasbeendisplayingsignsoferraticand
violentbehaviour,andreportsthatheviolentlyattackedhisfriendlastweek.Xbelievesthat
specialized health careservices are necessary to prevent the patient from causing serious
injurytootherpeopleagain,andrecommendsareferraltoanotherhealthcarepractitioner.
The patients parents do not believe that their 11 year old son would hurt anybody, and
refusetoconsenttoanyfurthertreatment.InthiscaseXhasadutytomakeareport.This
dutytoreportexistsevenifthechilddoesnotwantanyonetoknowabouttheincidentand
theparentsrefusetobelieveitandareangrywiththepractitioner.

v. LongTermCareHomesAct

TheLongTermCareHomesActregulateslongtermcarehomesinOntario,whicharefacilities
thatprovide24hournursingcareandsupervision.

Residentcareandrights
TheLongTermCareHomesActsetsoutaResidentsBillofRightsrequiringlongtermcare
homestoensureresidentsaretreatedfairlyandwithdignityandrespect.Thisincludesthe
righttoparticipateindecisionmakingabouttheresidentscare,therighttoprivacyin
treatmentandcare,andtherighttoreceivecareandassistancethatisaimedatmaximizingthe
residentsindependenceasmuchaspossible.

Alongtermcarehomemusthaveazerotolerancepolicywithrespecttoabuseandneglectof
residents.Abuseincludesphysical,sexual,emotional,verbalorfinancialabuse.

Complaints
Practitionershaveadutytoreportabuseandneglectofresidentsandcertainotherconductto
theMinistryofHealthandLongTermCare.Areportisrequiredifapractitioner(oranyother
person)suspectsonreasonablegroundsthatanyofthefollowinghaveoccurred:
Improperorincompetenttreatmentorcareofaresidentthatresultedinharmorarisk
ofharmtotheresident;
Abuseofaresidentbyanyone;
Neglectofaresidentbystaff,includingmanagement,thatresultedinharmorariskof
harmtotheresident;

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Unlawfulconductthatresultedinharmorariskofharmtoaresident;
Misuseormisappropriationofaresidentsmoney;or
Misuseormisappropriationoffundingprovidedtoalongtermcarehome.

Itisanoffenceforapractitionertofailtomakeareportinanytheabovecircumstancesifthe
practitionerprovidescareorservicesinalongtermcarehome.Apractitionermaybefinedup
to$25,000forfailingtomakesuchareport.

Complaintsandreportsaboutthecareofaresidentortheoperationofalongtermcarehome
mustbeinvestigatedbytheMinistryofHealthandLongTermCareiftheyinvolvecertain
mattersincludingabuseofaresidentbyanyone,andneglectofaresidentbystaff.

Everypersonincludingapractitionerisprotectedfromretaliationformakingareportorfor
cooperatingwithaninvestigation.Thisincludesprotectionfrombeingfired,disciplinedor
suspended.

SampleExamQuestion

Apractitionerisnotrequiredtoreportthefollowing:
i.
Aresidentssonfrequentlyyellsandswearsattheresident.
ii.
Astaffmemberisborrowingmoneyfromaresidentwithmemory
difficulties.
iii.
Anursehasnotbeenmonitoringaresidentoverthepastseveralshifts.
iv.
Aresidentsdaughterhasstoppedvisitingtheresident.

Thebestanswerisiv).Alloftheaboveexceptiv)mustbebothreportedand
investigated.Whilearesidentsfamilymembermayneglectthatperson,thisdoesnot
havetobeinvestigatedunlesstheneglectistothepointofemotionalabuse.Answeri)is
notthebestanswerbecausethismayconstituteemotionalabuse,andemotionalabuse
byanypersonmustbereportedandinvestigated.Answerii)isnotthebestanswer
becausethismaybeconsideredfinancialabuse,andanypersonwhofinanciallyabusesa
residentmustbereportedandinvestigated.Answeriii)isnotthebestanswerbecausea
nursewhohasnotbeenmonitoringaresidentmaybeneglectingthatpatient.Neglectof
apatientbyastaffmembermustbereported.

Similarprovisionshavealsobeenenactedforresidentsofretirementhomesunderthe
RetirementHomesAct.Retirementhomestypicallyareforresidentswhorequirelesscare.

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vi.

HumanRightsCode

(a) HumanRightsCode

Everypersonisentitledtoaccessandreceivehealthcareservicesinamannerthatrespectshis
orherhumanrights.TheOntarioHumanRightsCoderequireseverypractitionertotreat
patients,potentialpatients,employeesandothersequally,regardlessofthepersonsrace,
ancestry,placeoforigin,colour,ethnicorigin,citizenship,creed,sex,sexualorientation,age,
maritalstatus,familystatusordisability.

IfapersonfeelsthatapractitionerororganizationhasviolatedtheHumanRightsCode,the
personcancomplaintotheHumanRightsTribunalofOntario.IftheHumanRightsTribunal
findsthatapractitionerhasviolatedtheHumanRightsCode,itmayorderthepractitioneror
organizationtopaydamagesandrequireapractitionerororganizationtotakeaction,suchas,
undergotrainingorimplementahumanrightspolicy.However,theHumanRightsTribunal
doesnothavethepowertosuspendorrevokeapractitionerscertificateofregistration.For
thatreason,apersonwhobelieveshisorherhumanrightshavebeenviolatedmayalsobringa
complainttotheCollege.

Dutynottodiscriminate

Apractitionermustnotdiscriminateagainstanypersononanyprohibitedground.Examplesof
discriminationmayincludethefollowing:
Refusingtoacceptanewpatientforaprohibitedreason;
Refusingtocontinuetreatingapatientforaprohibitedreason;
Makingatreatmentdecisionforaprohibitedreason;
Insultingapatientinrelationtoaprohibitedreason;
Refusingtopermitapatientwithadisabilitytomeetwiththepractitionerwitha
supportperson;and
Makingassumptions,notbasedonclinicalobservationorprofessionalknowledgeand
experience,aboutapersonshealthorabilitiesbecauseofhisorherageoranother
prohibitedreason.

Itisnotdiscriminationtomakeclinicaldecisionsortoacceptorrefusetocontinueseeinga
patientforreasonsotherthanprohibitedgrounds.Forexample,ifapractitionerdoesnothave
thecompetencytotreatorcontinuetotreataperson,orifthetreatmentrequiredisnotwithin
thepractitionersscopeofpractice,apractitionershouldnotacceptorcontinuetotreata
patient.

InordertomeettheobligationsoftheCollegeandtoavoidamisunderstandingthatcouldlead
toahumanrightscomplaint,practitionersshouldalwaysclearlycommunicatetheirreasonsfor
makingclinicaltreatments,referralsandotherdecisions.Practitionersshouldalwaysmake
decisionstorefuseorendtreatmentingoodfaith,andshouldnotusetheirownlackof

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competencyasanexcusetorefusetoprovideservicestoapersonifthereisnoreal
competencyissue.

Practitionersaresimilarlyentitledtorelyonprofessionalknowledge,judgmentandexperience
tomakecommentsuponclinicallyrelevantmattersthatrelatetoapersonsageorgender.

Itisdiscriminationtotreatsomeoneunequallyevenifthepractitionerdidnotintendtodoso.
Forexample,apolicythatdoesnotpermitanyanimalsinabuildingdiscriminatesagainst
personswhorelyonaseeingeyedog,evenifthepolicywasnotintendedtodiscriminate
againstanyone.Thepolicywouldhavetomakeexceptionsforserviceanimals.

Dutytoaccommodate

TheHumanRightsCoderequiresthatpersonswithdisabilitiesbeaccommodatedunlessthe
accommodationwouldresultinunduehardship(e.g.,becauseofarealrisktohealthorsafety
orbecauseofunduecost).

Accommodationmustbeindividualized.Notallpersonswiththesamedisabilitywillrequireor
requestthesameaccommodation.Individualaccommodationsshouldbediscussedwiththe
personwherepossible,andmustbeprovidedinamannerthatrespectsthepersonsdignity
andautonomy.However,apractitionerisnotrequiredtoprovidetheexactaccommodation
thatapersonrequests,ifanotherformofaccommodationisreasonableandacceptable.

Examplesofaccommodationmayincludethefollowing:
Permittingapatientwhousesawheelchairtorescheduleanappointmentwithlessthan
24hoursnoticeiftheelevatorinthepractitionersofficeistemporarilyoutofservice;
Offeringanextendedappointmenttimetoapatientwithanintellectual,learning,or
mentalhealthdisabilitywhomayneedalongertimetoexplainhisorhersymptoms;
Permittingapersonwithadisabilitytoenteryourpremiseswithasupportperson,
serviceanimal,orassistivedevice;and
Communicatinginwritingifapersonwithahearingimpairmentorotherdisability
requeststhis.

Thedutytoaccommodatealsoappliestootherprohibitedgroundsofdiscrimination.

HumanRightsCodeScenarioNo.1

Y,apractitioner,determinessheisnotcompetenttocontinuetotreatherpatient
becausethepatientshealthconditionhasbecomeincreasinglymorecomplex.The
patientisunhappyaboutYsdecision,andbelievesthatYhasalwayshadaproblemwith
himbecauseofhisraceandreligion.Yshouldcarefullycommunicateherreasonsfor
terminatingthepractitionerclientrelationship,sothatthepatientisnotleftwitha
misunderstandingsuchasthatthedecisionwasforaprohibitedreasonsuchasthe

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patientsraceorreligion.Yshouldalsoprovideanappropriatereferralifpossibleandin
atimelymanner.

HumanRightsCodeScenario2

X,apractitioner,hasapotentialnewpatientwhohasanintellectualdisability.Xfindsit
difficulttocommunicatewiththepotentialpatient.Xshouldaskhowhecanhelp
communicatebetterwiththepatient.Ifthepatienthasasupportpersonwhosometimes
providesassistance,thepatientmayasktobringhersupportpersontoXsoffice.Xis
requiredbylawtopermitasupportpersontoaccompanyapatient.However,Xshould
notassumethatthepatientneedsasupportperson.Additionally,ifthepatientdoesnot
havethecapacitytomaketreatmentdecisions,thepatientmayneedasubstitute
decisionmaker.Inanyofthesecircumstances,Xcannotrefusetoacceptthepatient
becauseofherdisabilityevenifitwilltakeXmoretimeforthosevisits.

HumanRightsCodeScenarioNo.3

Yhasapatientwhohasbeendiagnosedwithamentalillness.Yhasbeenhaving
increasingdifficultiesinteractingwithherpatient.Thepatienthasalsobeenrude
towardsYandstaff.Whilenopatienthasarighttobeabusivetowardspractitionersand
staff,Ymayconsiderwhetherthebehaviouriscausedorexacerbatedbythepersons
mentalillness.Ycannotstopprovidingtreatmentorhealthservicesbecauseofthe
patientsmentalillness,unlessYconcludessheisnotcompetenttocontinuetreatingthe
patient.IfYbelievesareferraltoanotherhealthcareproviderwiththeappropriate
competenciestomanagethepatientshealthcareneedsisnecessary,Yshouldclearly
explainthereasonsforthedecision.Yalsoshouldconsiderwhetherany
accommodationsarepossible.Forexample,apatientwhoisuncomfortableina
crowdedwaitingroombecauseofhisorhermentalhealthdisabilitymightbeofferedan
alternativespacetowait.Theremaybeotherpracticalmeasuresthatthepatientmay
beabletosuggestthatwillhelpthepatientmanagehisdisabilityrelatedsymptoms.

(b) AccessibilityforOntarianswithDisabilitiesAct

TheAccessibilityforOntarianswithDisabilitiesAct(AODA)providesforaccessiblecustomer
service,informationandcommunications,transportation,employment,andbuiltenvironment
(i.e.,physicalfacilities).TheAODAappliestoeverypersonandorganizationinOntario.The
intentionofthestandardsistoachieveaccessibilityforOntarianswithdisabilitiesby2025.A
practitionerororganizationmaybefinedfornotcomplyingwiththeAODA.

Thestandardscurrentlyapplyonlytopersonsandorganizationswithatleastoneemployeein
Ontario.Differentstandardsapplydependingonthenumberofemployeesanorganizationhas.
Asoleproprietororagroupofpersonsinapartnershiparenotconsideredemployees,and
thereforetheAODAstandardscurrentlydonotapplytosomepractitioners.

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InteractionbetweenAODAandotherlaws

Accessibilitystandardsareregulationsandlegallymustbeobeyed.Ifastandardprovidedinthe
AODAisdifferentfromastandardrequiredunderadifferentlaw,thehigherstandardalways
prevails.However,theAODAwillnotnecessarilyprevailoverotherlegalrequirementssuchas
occupationalhealthandsafetylaws.

AbreachofanAODAstandardisnotnecessarilyabreachoftheHumanRightsCode.However,
itispossiblethattheAODAstandardswillbeusedasareferencepointinHumanRights
Tribunalhearings.

CustomerServiceStandard

PractitionerswithatleastoneemployeeinOntariomustcomplywiththeaccessiblecustomer
servicestandardbyJanuary2012.Fororganizationswithfewerthan20employees,theAODA
requiresthefollowing:

Implementpolicies,practicesandproceduresregardingtheprovisionofgoodsand
servicestopersonswithdisabilities,
o thatareconsistentwiththeprinciplesofdignity,independence,integration,and
equalopportunity,and
o thatdealwiththeuseofassistivedevicesandtheavailabilityofanymeasures
thatmakeservicesaccessible(e.g.,TTY,elevator).
Permitserviceanimalsandsupportpersonsinpublicareasofpremises.
Providereasonablenoticeofanytemporarydisruptionstoanyaccessibilityfeaturesor
services,includingthereasonforthedisruption,theanticipatedduration,anda
descriptionofanyalternateservices.
Providetrainingtoallemployeesandanyoneelsewhodealswithmembersofthepublic
orthirdparties(i.e.,anyoneoutsideofapractitionersorganization),orparticipatesin
thedevelopmentofpolicies,practicesandproceduresregardingaccessiblecustomer
service,whichmustincludethefollowing:
o ReviewofpurposesoftheActandrequirementsofCustomerServicestandard;
o Howtointeractwithpersonswithdisabilitieswhouseassistivedevices,usea
serviceanimal,orareassistedbyasupportperson;
o Howtouseavailableaccessibilityequipmentanddevicesonpremisesorthatare
otherwiseprovidedtothepublic;and
o Whattodoifsomeonewithaparticulartypeofdisabilityishavingdifficulty
accessingtheprovidersgoodsorservices.
Establishaprocessforreceivingandrespondingtofeedbackaboutaccessibilityand
makeinformationabouttheprocessreadilyavailabletothepublic,
o Peoplemustbepermittedtoprovidefeedbackinperson,bytelephone,in
writing,orelectronically,and

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o Processmustspecifyactionsthatwillbetakenifcomplaintisreceived.

Fororganizationswith20ormoreemployees,thereareadditionalrequirementsincluding
puttingitspolicies,practicesandproceduresinwritingandmakingthemavailableupon
request,filingpublicallyavailableaccessibilityreports,andkeepingrecordsofthetrainingthat
hasbeenprovided.

InformationandCommunicationStandard

TheInformationandCommunicationStandardrequiresorganizationstoensurethat
informationavailabletothepublicandtheorganizationscommunicationswiththepublicare
accessible,orcanbemadeaccessible.Thisincludesmakinganyfeedbacksystemaccessible
uponrequest,ensuringthatanyemergencyorpublicsafetyinformationthatisavailabletothe
publicismadeaccessibleuponrequest,andprovidingaccessibleinformationformatsand
communicationsupportsuponrequest.

Thisstandardmayrequirepractitionerswithatleastoneemployeetoprovideintakeforms,
charts,andotherhealthinformationinanaccessibleformat(e.g.,largeprint,audio,orBraille).
Itmayalsorequirepractitionerstoprovideapersonwithsignlanguageinterpretation.The
practitionermustconsultwiththepersonmakingtherequestregardingtheformofaccessible
formatorcommunicationsupport.Thepractitionermustprovidearequestedaccessibleformat
orcommunicationsupportinatimelymanner,andmaychargenomorethantheregularcost
thatischargedtootherpersons.

Fororganizationswith50ormoreemployees,additionalstepswillberequired,including
ensuringthatwebsitesarecompliantwithwebaccessibilitystandards,andfilingaccessibility
reports.

Thisstandardwillbephasedinandwillapplytoorganizationswithfewerthan50employeesin
2017.

EmploymentStandard

Theemploymentstandardrequiresemployerstoprovideanaccessibleworkplace.Thisincludes
thefollowing:
Providingpublicnoticeregardingaccessibilitypracticesinhiringemployees;
Providingaccessibleworkplaceinformation;and
Providing,onrequest,anyindividualizedemergencyresponseinformationto
employeeswhorequirethisindividualizedinformationbecauseofadisability.

Fororganizationswithfewerthan50employees,theemploymentstandardwillgenerallycome
intoforceonJanuary1,2017.Theexceptionisthatthedeadlineforprovidingindividualized
workplaceemergencyresponseinformationisJanuary1,2012.

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BuiltEnvironmentStandard

Thestandardonbuiltenvironmenthasnotyetbeendeveloped.However,itwillapplytothe
constructionofnewbuildingsandtomajorrenovations.

AODAScenario

X,asolepractitionerhasanofficewithoneemployeewhoprovidesadministrative
support.Xmustcreateanaccessibilityplanforprovidingaccessiblecustomerserviceand
accessibleinformationandcommunications.Xisnotrequiredtoputitspolicies,
practicesandproceduresinwriting,butmustensurethattheyarefollowed,includingby
hisemployee.Xisalsoresponsibleforensuringthattrainingisprovidedtotheemployee
regardingtheaccessibilitystandards(e.g.,thatsupportpersons,animalsordevicesare
allowedonthepremises).Xshouldalsobeawareofhowtheinformationand
communicationsandemploymentstandardswillapplytohisorherpractice.

vii. Municipallicensing

InadditiontobeingregisteredwiththeCollege,practitionersmayrequireamunicipallicence.A
municipallicence,suchasabusinesslicence,isgrantedandregulatedbythemunicipality,and
notbytheprovincialgovernment.Amunicipallicencedoesnotgiveapractitionertherightto
beregisteredwiththeCollege.However,apractitionermayberegisteredwiththeCollegeand
alsoholdamunicipallicence.

Generallyspeaking,thepurposeofmunicipallicensingistosetconditionsforapractitioners
premisesinwhichapractitioneroperates,aswellaspublichealthmatterssuchassanitation.
Forexample,amunicipalinspectormayinspectapractitionersofficeandensurethatprotocols
areinplacetoavoidthespreadofdisease.Amunicipallicensingbodyisgenerallynotfocused
onprofessionalqualificationsorprofessionalconduct.

IftheCollegerequiresahigherstandardordifferentstandardthanthemunicipalitydoes,the
Collegesstandardmustalwaysbefollowed.TheRegulatedHealthProfessionsActisa
provincialstatute;ittakespriorityoveramunicipalbylaw.

Municipallicensingscenario

Y,apractitioner,hasamunicipallicencetopracticeinhercityandpaysafeeeveryyear
torenewherlicence.ThemunicipalauthorityrecentlyinspectedYspracticeandfound
noviolations.YnowwishestoregisterwiththeCollege.Ymustmeetallregistration
requirementsoftheCollegeinordertobecomeamember.Whilethemunicipallicensing
authoritydidnotrequireYtomaintainaccurateclinicalrecords,anddidnotlookatYs

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recordsduringitsinspection,theCollegedoesrequirethis.Ymustunderstandandabide
bytheCollegesrecordkeepingexpectations.

Conclusion

Ifalegalissuearises,practitionersareencouragedtodiscussthemwithcolleaguesandones
professionalassociationandtocheckwiththeCollegeastoitsexpectations.TheCollegecannot
providelegaladvice(neithercanonescolleaguesorprofessionalassociation).Thusonmany
issuesapractitionermayneedtoconsultwithhisorherownlawyer.