Dialogue Volume 14 Issue 2 2018 - Page 61

DISCIPLINE SUMMARIES DR. KULBIR SINGH BILLING PRACTICE LOCATION: Kitchener AREA OF PRACTICE: Anesthesiology (Chronic Pain Management) HEARING INFORMATION: Plea of No Contest, Statement of Uncontested Facts on Liability, Contested Penalty On November 21, 2016, the Discipline Committee found that Dr. Billing committed an act of profes- sional misconduct in that he failed to maintain the standard of practice of the profession. Dr. Billing, an anesthesiologist in Kitchener, has a practice primarily devoted to injection therapies for chronic pain, including nerve blocks, paravertebral blocks, epidural injections, and trigger point injec- tions. After receiving information from the Ministry of Health and Long-Term Care in 2011, the College commenced an investigation into Dr. Billing’s clini- cal practice. As part of its investigation, the College obtained independent opinions from two experts, who re- viewed dozens of patient charts and observed Dr. Billing’s care of certain patients. Dr. Billing obtained independent opinions from two other experts, who reviewed the same patient charts and observed Dr. Billing’s care of patients. Dr. Billing’s documentation in his patient charts had the following deficiencies: • Initial patient histories are not always present; • When present, the patients’ histories often lack, or record an incomplete, past medical and medication history; • Previous treatments for chronic pain are not always well-documented; • The effect or efficacy of blocks administered to patients is not always well-documented; • When recorded, changes in treatment plans or in- jection therapies are not explained in the chart; • Changes in patients’ diagnoses do not always reflect a change in treatment plans and no explanation is provided; • The correlation between physical diagnoses or findings and the treatment provided is often not documented; • Dr. Billing uses template-style reporting, or note- stamping, i.e., he “cuts and pastes” from patients’ previous clinical notes, carrying over grammatical and spelling errors; • Although Dr. Billing documents a review of the complications that may arise from nerve blocks in general, he does not document a discussion of the specific and unique complications that may arise when obtaining consent to a new kind of nerve block; • Patient consent to procedures is often poorly docu- mented; and • There is often a failure to document changes, or lack of changes, in functionality or activities of daily l iving of patients. Between 2006 and 2013, Dr. Billing submitted claims to OHIP for the maximum number of nerve blocks allowed under the Schedule of Benefits, name- ly eight blocks per patient per service date for many of his patients. From April 2010 to March 2014, Dr. Billing submitted claims to OHIP for an average of 10 to 11 injections per patient per service day. Dr. Billing’s evidence of individualized treatment plans had the following deficiencies: • The records do not always indicate an attempt to create individualized treatment plans; • Many patients receive more blocks than the maxi- mum eight paid by OHIP. The rationale for provid- ing patients with the maximum or greater than the maximum number of blocks is not always suffi- ciently documented; • Many patients are given the same or similar sets of nerve blocks and trigger point injections without a documented rationale; • Although Dr. Billing uses patient feedback to determine which blocks work best, this feedback approach is not always clearly reflected in his clini- cal notes; • It is difficult to determine the effect or benefit of any particular block, given Dr. Billing’s practice of routinely initiating multiple blocks simultaneously and his failure to record patients’ responses to vari- ISSUE 2, 2018 DIALOGUE 61