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