Doctor's disagreement with policy disruptive to safe operation of new renal care program
The Ontario Superior Court of Justice has affirmed the suspension of the privileges of a physician who refused to comply with a hospital’s new model of care for renal patients.
In Kadri v. Windsor Regional Hospital, 2022 ONSC 4016, a new approach to the treatment of patients preparing for dialysis was developed and implemented by Windsor Regional Hospital (WRH) in Windsor, ON. Dr. Albert Kadri, a physician specializing in nephrology and a member of WRH’s professional staff, was unhappy with the changes so he actively resisted complying with the hospital’s new model of care.
The Medical Advisory Committee at WRH determined that Dr. Kadri’s hospital privileges should be revoked, which would prevent him from practicing at a hospital or admitting patients. Under the Public Hospitals Act, physicians who are granted privileges remain accountable to the hospital for compliance with its quality-of-care requirements, by-laws, policies, and rules of conduct.
New model of care
WRH’s new model of care required patients who were admitted to the WRH dialysis program to be seen by a WRH multidisciplinary clinic team. Dr. Kadri operated a renal care clinic separate from the one at WRH, providing treatment to patients transitioning to dialysis. He expressed concern over WRH’s new model which directed all pre-dialysis care to the program at WRH. Dr. Kadri insisted that he would attend personally on “his” patients, contrary to the new model of care.
Dr. Kadri requested a hearing before the Health Professions Appeal and Review Board pursuant to the Public Hospitals Act. He argued that WRH had implemented the new model of care in bad faith. However, on the day the hearing was set to commence, he notified the board that he no longer wished to proceed. The appeal court noted that in doing so, Dr. Kadri withdrew from a proceeding that would have allowed him to question the implementation of the model of care, including his allegation that it had been implemented in bad faith. Consequently, the court was of the view that Dr. Kadri had accepted the new model of care as the properly established policy of WRH.
Suspension of privileges
In the days following the implementation of the new model, Dr. Kadri refused to act within its terms. He continued rounds and made orders for dialysis for patients he considered as his own patients. Under WRH’s by-laws, a doctor’s privileges may be suspended if their behaviour “exposes or is reasonably likely to expose patients or employees or other persons to harm or injury, either within or outside of the health care facilities.”
A panel of the hospital’s board of directors found that Dr. Kadri had “consistently resisted, undermined, and disrupted” the implementation and operation of the renal program at WRH under the new model of care. The panel further found that Dr. Kadri used tactics of intimidation and bullying to threaten other physicians and the hospital’s administration. As a result of Dr. Kadri’s resistance to comply with WRH’s new model of care, the hospital decided to suspend his privileges.
No likelihood of future compliance
Dr. Kadri opposed the decision of the hospital to suspend his privilege. He appealed to the Health Professions Appeal and Review Board. However, the board affirmed the hospital’s decision and noted that if Dr. Kadri’s privileges were reinstated, “there is no likelihood that he would comply with the model of care for the renal program.”
The appeal court likewise affirmed the board’s decision. The court found that Dr. Kadri’s conduct was disruptive and contrary to the policy and approach of WRH. The court said, “no health care system could run on the basis that were a doctor does not agree with hospital policy, he or she is free to act on his or her own view, ethical or otherwise, of how things should be done.”
The court further noted that none of the other nephrologists at WRH objected to the new model of care. In the court’s opinion, if Dr. Kadri could not work within the boundaries set by WRH, his option was to go elsewhere and not to force his views on others and undermine the efforts of WRH.
No bad faith
Dr. Kadri argued that the review board misapprehended the evidence of bad faith on the part of WRH. The court noted that this argument was based on the idea that the new model of care was directed, not to improving treatment, but to undermining Dr. Kadri’s practice. The court pointed out that if there were concerns with the substance of the new model of care, the remedy was to appeal before the Health Professions Review and Appeal Board. However, Dr. Kadri ultimately withdrew his request for a hearing before the board.
Breach of by-law
Dr. Kadri further contended that there was no evidence of any specific harm to any specific patient. The court said Dr. Kadri failed to acknowledge that his behaviour could have and did have an impact on other patients that were the responsibility of the hospital. He also failed to consider the impact his conduct had on other members of the staff that could have and did affect their ability to serve other patients.
As the review board found, Dr. Kadri provided orders in an inconsistent manner and these orders were disruptive to the safe operation of WRH’s renal program. He also threatened and bullied other physicians and staff of WRH. The board further found that Dr. Kadri systematically sabotaged efforts to collaborate and follow the guidelines under the new model of care. Based on these findings, the appeal court determined that Dr. Kadri’s conduct was indeed detrimental to the implementation of the new model of care and to the patients. The court found that Dr. Kadri acted in a way that was inconsistent and contrary to WRH’s by-law, which justified the revocation of his privileges.
In dismissing Dr. Kadri’s appeal, the court concluded, “if a doctor is unable or unwilling to work within and respect the policies and programs properly approved and implemented by the hospital, the choice is not to undermine the service being offered. It is to find another way or place to practice.”
