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XAVIER BECERRA Attorney General of California JANE ZACK SIMON Supervising Deputy Attorney Gerte'ral EMILY L. BRINKMAN . .

Deputy Attorney General State Bar No. 219400

455 Golden Gate Avenue, Suite 11000 San Francisco, CA 94102-7004 Telephone: (415) 510-3374 Facsimile: (415) 703-5843 E-mail: Emily.Brinkman@doj.ca.gov

Attorneys for Complainant

REDACTED

FILED STATE OF CALIFORNIA

MEDICAL BOARD OF CALIFORNIA SACRAMENTO ttlef!tj 8 20 LL BY t<v Uirn@ . ANALYST .

· BEFORETHE MEDICAL.BOARD OF CALIFORNIA

DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

11-~~~~~~~~~~~~~~~-----,

In the Matter of the Accusation Against:

Ali Hazrati, M.D. Greenstone Clinic . 300-5734 Yonge Street Toronto, Ontario M2M 4E7

·Physician's and Surgeon's Certificate No. A 112180,

Respondent.

Case No. 800-2017-038784

A.CCUSATION

/

18 Complainant alleges:

19 PARTIES

20 1. Kimberly Kirchmeyer (Complainant) brings this Accusation solely in her official

21 capacity as the Executive Director of the Medical Board of California, Department of Consumer

22 Affairs (Board).

23 2 On or about April 30, 2010, the Medical Board issued Physician's and Surgeon's

24 Certificate Numb~r A 112180 to Ali I:Iazrati, M.D. (Respondent). The Physician's and Surgeon's

25 Certificate expired on September 30, 2013, has not been renewed, and is currently delinquent.

26 JURISDICTION

27 3. This Accusation is brought before the Board, under the authority of the following

28 laws. All section references are to the Business and Professions Code unless otherwise indicated.

1

(ALI HAZRATI; M.D.) ACCUSATION NO. 800-2017-038784

1 4. Section 2227 of the Code provides that a licensee who is found gµilty under the

2 Medical Practice Act may have his or her licenst'? revoked, suspended for a period not to exceed

3 one year, placed on probation and required to pay the costs of probation monitoring, qr such other

4 action taken in relation to discipline as the Board deems proper.

5 5. Section 141 of the Code states:

6 "(a) For any licensee holding a license issued by a board under the jurisdiction of the . .

7 . department, a-disciplinary action taken by another state, by any agency of the federal government,

8 or by another country for any act substantially r~lated to the practice regulated by the Califotnia

9 license, may be a ground for disciplillary action by the respective state licensing board. A

1 o certified copy of the record of the disciplinary action taken against the licensee by another state,·

11 an agency of the federal goven:iment, ·or another country shall be conclusive evidence of the

12 events related therein.

13 "(b) Nothing in this. section shall preclude a board from applying a specific sta~tory

14 provision in the licensillg act administered by that board that provides for discipline based upon a

15 disciplinary action taken against the licensee by another state, an agency of the federal

16 government, or another country."

17 6. Section 2234 of the Code, states; in relevant part:

18 "The board shall take action against any licensee who is charged with unprofessional

19 conduct. In addition to other provisio~s of this article, unprofessional conduct includes, but is not

20 limited to, the following:

21 " "

22 '~(b) Gross negligence.

23 "( c) Repeated negligent acts. To be repeated, there must be two ~r more negligent acts or

24 omissions. An initial negligent act or omission followed by a separate and distinct departure from

25 the applicable standard of care shall constitute repeated negligent acts.

26 "(1) An initial negligent diagnosis followed QY an act or omission medically appropriate

27 for that negligent diagnosis of the patient shall constitute a single negligent act.

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2

(ALI HAZRATI, M.D.) ACCUSATION NO. 800-2017-038784

1 "(2) When the standard of care requires a change in the diagnosis, act, or omission that

2 constitutes the negligent act described in paragraph (1 ), including, but not limited to, a

3 · reevaluation of the diagnosis or a change in treatment, and the licensee's. conduct departs from the

4 applicable standard of care, each departure Constitutes a separate and distinct breach of the

5 standard of care.

6 "( d) Incompetence.

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CAUSE FOR DISCIPLINE

(Discipline, Restriction, or Limitation Imposed by Other Jurisdiction)

On September 15, 2017, the College of Physicians and Surgeons of Ontario, Canada

11 (Ontario College) issued a Decision and Reasons (Decision) regarding Respondent's license to

12 . practice medicine. The Ontario College Decision required Respondent to appear in person to be

13 cautioned regarding obtaining and documenting informed consent. Additionally, the Ontario

14 College Decision required Respondent to complete continui_ng education related to informed·

15 consent and to provide a written summary to the Ontario College about infonned consent. A copy

16 o( the Ontario College Decision is attached as Exhibit A.

17 8. The Ontario College Decision was based on findings related to Respondent's

18 perfomiance of a rectai examination on a 15-year-old patient, probing a possible fistula tract,

. 19 conducting a proctoscopy without anesthesia, and failure to document that he had informed

20 consent from ei.ther the patient or his parents. The Decision also noted that Respondent had

21 previous cases involving informed consent before the Ontario College in 2015 and 2016.

22 . 9. Respondent's conduct and the actions of the Ontario College as set forth in

23 paragraphs 7 and 8, above, constitute unprofessional conduct within the meaning of section 2234

24 and conduct subject to discipline within the meaning of section.141 of the Code.

25 PRAYER

26 WHE~FORE, Complainant requests that a hearing be held on the matters herein alleged,

27 and that following the hearing, the Medical Board of California issue a decision:

28 \\\

3

(ALI HAZRATI, M.D.) ACCUSATION NO. 800-2017-038784

1 I. Revoking or suspending Physician's and Surgeon's Certificate Number A 112180,

2 issued to Ali Hazrati, M.D.;

3 2. Revoking, suspendl.ng or denying approval of Ali Hazrati, M.D.'s authority to

4 supervise physician assistants and advanced practice nurses;

5 3. Ordering Ali Hazrati, M.D .. , if placed on probation, to pay the Board the costs of

6 probation monitoring; and

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4. Taking such other and further action as deemed nec.essary and proper.

DATED: May 3, 2018

SF2018400721 13044770.doc

Executive Direc or Medical Board of California Department of Consumer Affairs State of California Complainant

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(ALI HAZRATI, M.D.) ACCUSATION NO. 800-2017-038784

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EXHIBIT A

. College of Physicians and Surgeons of Ontario, Canada Decision and Reasons .

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(ALI HAZRATI, M.D.) ACCUSATION NO. 800-2017-038784

-~

COMPLAINANT:

PATIENT:

CERTIFIED TRUE COPY

Staff: -1=.!L:;~~2:;:::::__~~.....::::::.

Oate: . 0 \( 3D/ l '3 . I College 01 Physicians and Surgeons of Ontario

IN QUI RI EST GOMPLAINTS AND REPORTS CGMMllTEE · (the "Committee")

DECISION AND REASONS

-• RESPONDENT:. · Dr. Ali Hazrati (CPSQ# S3925}

CPSO FILE NO.: 105030

INTRODUCTION

- sent the College a letter, received on January 10, 2017. She expressed concern about the care her 15-year-old son,.,. received from Dr. Hazrati (General Surgery .and Family . · Medicine). ·

The Surgical Panel of the Committee considered this matter at its meeting on September 15, 2017. .

ROLE OF THE COMMITIEE

-the College's complaints process provides· a route for members of the public to raise concerns . about a doctor's practice or conduct. The Committee, with the assistance of staff, conducts an investigation, then meets to review the written record of investigation and to reach a decision.

The Committee cannot award financial compensation .Of any kind. Its process is not focussed on determining liability, or on punishing doctors. The Committee evaluates the investigative information available. It then determines what action, if any, is warranted, taking into account the seriousness and context ofthe concerns raised, the physician's insight into his or her practice, capacity for remediation, and relevant College history, if any.

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the Committee's role, broadly, is to protect the public by determining whether reme.dial action is necessary and, if so, what action would best enhance the quality of medical care of the particular physician,-and the general-quality of medical-care-in Ontario,-byrei.nforcing the standards of practice.

The range of dispositions available to the Committee includes taking no further action, providing advice/recommendations, requiring a physician to atfend at the College to be cautione·d, or requiring a physician to' complete a specified continuing education or remediation program. With the Committee's approval, a physician may enter into a remedial agreement or· an undertaking with the College.

In a small number of very serious cases, the Committee may refer a ·specified allegation of professional misconduct or incompetence to the College's Discipline Committee~ The Committee will do this where it believes that refe_rral to the Discipline Committee is in the public interest, and that the available information has a reasonable chance of supporting a successful prosecution.

The Committee appredates Q U bringing these concerns to the College's attention. Public engagement aids the College in protecting the.public interest and improving the quality of physidans' care throughout the province. The Committee also acknowledges Dr. Ha~rati for demonstrating professional accountability by providing a response to the complaint.

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INFORMATION BEFORE THE COMMITTEE

The Committee always has before it applicable legislation.and regulations, along with polici~s that the Coll'ege has developed, which reflect the College's professional expectations for physicians practising in Ontari~. Curr~nt versions ofthese documents are available on th~ College's website at www.cpso.on.ca, under the heading "Policies & Publications." The Committee will provide a copy of any policy it refers to in this decision. In this case, the -College's policy on Consent to Treatment (#3-15) is attached.

The Committee always has before it the physician's history with the College,, if any.

2.

Concerns Raised in the Complaint

-is concerned thatDr. Hazrati failed to provide adequate.careto her son in December 2016, in that he: · ·

• failed to obtain consent and exp.lain the procedure prior to using an "anus:expander11

[also known as a Hill Ferguson anal retractor]

• performed a fistula probe without anaesthesia

• · used force when doing the anal examination an·d abscess probe

• caused her son to have_a lot of pain and bleeding and may haye perforated the rectum.

Context for the Complaint

The background to

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On December 3, 2016; £ $family physician contacted Dr. Hazrati regarding an inguinal mass or abscess on his buttocks; Dr. Hazrati recommended-attend the Emergency Room (ER) at Scarborough General Hospital for ari assessment. - was 'initially seen in the ER by , and then by Dr. Hazr'ati in consultation. Dr. Hazrati incised, drained, and packed the abscess.

On December 7, Dr. Hazrati saw -for a follow-up appointment at the Greenestc:ine Clinic (the Clinic).· ·

• Oh December 22, Dr. Hazrati next saw - for follow-up at the Clinic. At that visit, Dr. Hazrati inserted an anal retractor and probed the abscess. According to., Dr. . . Hazrati never obtained conseQt from her or her son, and because of how Dr. Hazrati conducted the procedures, it caused pain, bleeding and additional irijury to her son.

• Dr. Hazrati referred - to a gastroenterologist at SickKids Hospital to" rule out anti-inflammatory bowel disease. ·

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Dr. Hazrati's Response

Dr. Hazrati provided information in response to the complaint; including:

Re: failed to obtain consent and explain the procedure prior to using an "anus expander"

• Anal examination does not require written consent. By bringing- to the examination room an·d positioning him in proctology position, he and his parents provided tacit consent for the examination.

Re: performed a fistula probe without anaesthesia

• Probing the fistula tract does not require anesthesia, if the probe can be easily inserted inside the fistula tract.

• - felt uncomfortable and his mother was anxious a·t watching the examination. He then terminated the examination. - ~olerated the incision and drainage of the .. abscess very well, which is a much mbre painful and bigger procedure than a rectal examin.ation.

Re: used force when doing the anal examination and abscess probe

• The size of the probe is even smaller than a Q-tip in length and diameter. He gently inserted the probe in the incision site.

Re: caused- to have a lot of pain and bleeding and may have perforated the rectum

• Ther~ was a minimal amount of blood stain on the probe and the anal retractor~ which is expected for this type of examinatiGn.

• In his-view, mg discomfort was minimal, but he did acknowledge it. - was stable and relatively comfortable after the examination.

Comments from -

After reviewing Dr. Hazrati's response, 1111 submitted further comments, and reiterated her concerns about the December 22 visit with Dr. Hazrati, including Dr. Hazrati'sfailure to obtain consent and describe the procedure. She noted that Dr. Hazrati used a 15-cm Q-tip which was much longer than that used by the CCAC nurse who saw - the day before, and measured

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abscess depth as 2 cm. She ·is concerned about the issues - experienced after the visit, including excessive discharge frpm the abscess and a staph infection. She also submitted excerpts of several medicaljournal .articles.

ANALYSIS AND CONCLUSIONS

The Committee considered the following points in reaching its decision:

• On December 22, 2016, Dr. Hazrati performed a rectal examination, probed a possible fistula tract, and did a proctoscopy on without documenting in writing that he had the informed consent of either or C?ne of his parents, and apparently without providing an explanation of the procedures being conducted.

· • As noted in the College policy on Consent to Treatment: -

o In order for consent to be valid, it must be related to the treatment, informed, given voluntarily, and hot obtained through misrepresentation or fraud. If any of these requirements are not m~t, the consent may not b_e valid ..

o When obtaining consent the College requires physicians to engage in a dialogue with the patient or substitute decision-maker, regardless of whether or not

. physicians use supporting documents, including consent forms.

o ... The College requires physicians to document information regarding consent to treatment in certain circumstances, and recommends thatthis b_~ done in all other cir'cumstances.

o Im plied consent is inferred from the words or behaviour of the patient, or . surrounding circumstances, such that a reasonable person would believe that consent has been given; although no direct, 'explicit, and unequivocal words of agreement have been given.

o Although the Health Care ConsentAct (HCCA) states that consent to treatment may be express or implied, the College·strorigly advises physicians to 9btain express c;onsent, particularly when the treatment is likely to be more than mildly pai.nful, carries appreciable risk, will result in ablat,ion of a bodily function, is a surgical p

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rocedure or an invasive investigative procedure, or will lead t? · significant changes in consciousness. [Emphasis add~d]

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o A legible, understandable and contemporaneous note in the patient's record regarding consent to treatment is-the bestevidence ~physician-has to

·demonstrate that the requirements of the HCCA have been satisfied.

o When a-treatment is likely to be. more than mildly painful, carries appreciable risk, will result in ablation of a bodily function, is a surgical procedure or an invasive investigative procedure, or will lead to significant changes in _ · consciousness, the importance of documentation increases. As such, in these circumstances, the College requires physicians to document in the patient's record information regarding consent to treatment.

• Dr. Hazrati's response to tl;ie College indicates that he believes that the mere fact that --was in the examination room ·in proctology position implies tacit consent for the procedure. While the Committee agrees that formal written consent is not required for a rectal examination, verbal consent is certainly required. ft is unclear whether Dr. Hazrati obtained this from either-or his mother, or what if anxthing Dr. Hazrati

·communicated to them regarding the" examination, given in his response suggests that he assumed he had consent based on - position. Even if we assume Dr. Hazrati had consent to complete the rectal examination, he should have obtained and . documented consent prior to conducting a proctos~opy and/or. fistula probing.

• The Committee also noted that Dr. Hazrati conducted the proctoscopy and the prol?ing of the possible fistula site without anesthetic. Proctoscopy and probing of a fistura can· be uncomfortable, and particularly so.when the patient is an adolescent, as was the case here. Most rhysidans complete these procedures with an anesthetic, an_d if one i's not. going to use an anesthetic, a physician must obtain consent and explain the procedures will be more painful if no anesthetic is used. In the Committee's view, Dr. Hazrati should have offered the option to complete the procedures with an anesthetic, explaining the risks and benefits to proceeding without one, and documented the consent discussion in the record. The Committe.e also observes that probing a fistula· may take time, and often. requires other modalities, such as injection of methelyene blue dye into the tract first. All of this should have been explained to and his family and documented in the record.

• The Committe·e is unable to know if Dr. Hazrati used excessive force, perforated the · rectum, and/or otherwise caused excessive bleeding in this case. Some bleeding is a kn·own risk of the procedures. The Committee's main concern is that Dr. Hazrati failed to document that he obtained informed consent for these invasive investigative

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procedures or that he explained the risks and benefits of them, including that the procedures may be done with anestheti~. ;

• ·Dr. Hazrati has a histdry of College investigations and/or complaints, whkh raised similar issues with communications and/or consent as the case before us. In F~bruary 2016, the Committee advised Dr. Hazrati on the importance of ensuring good communication with_ a patient and/or their family regarding discharge from hospital. In April 2015, th~ Committee advised Dr. Hazrati respecting full consent discussion, full documentation of consent and of OR (operating room) procedure, and full communication with patients post-operatively.

• Dr. Hazrati's response to the College, in which he state.d tacitconsent was sufficient, suggests to the Committee that.Dr. Hazrati lacks insight into the deficiencies in communications and the consent process that arose in this case. Dr. Haz~ati's history of· similar complaints further elevated our concern, such that the Committee wish.ed to meet with Dr. Hazrati in person to impress upon him the importance of obtaining and documenting fully informed consent when conductingfovasive investigative-procedures .. The Committee also felt Dr. Hazrati could.benefit from education to improve his practice in these areas.

Based on all of the above., the Committee has determined that a two-fold disposition is ·appropriate in this case.

First, the Committee requires Dr. Hazrati to attend at the College to be cautioned. in person with respect to obtaining and documenting informed consent. A caution in person arises when the Committee is concerned about an aspect of a physician's practice, and believes that the physician would benefit from direction provided iii person about the issues raised. It is also intended to protect the public interest, and a summary of the decision will appear on the College's public register. At Dr. Hazrati's attendance at the College, Committee members will provide directfon to him about steps the Com.mittee believes he must take in order to avoid future difficulties.

Second, the Committee has the power.ur:1der section 26(3) of the Code to require a physician to complete a specified continuing education or remediation program and it has determined that it is appropriate .to do so in this case in light of the deficiencies identified in Dr. Hazrati's practice. The Committee therefore requires Dr:Hazrati to undergo a specified continuing education or remediation program (the .Program). The Program is inte'nded to address the Committee's concerns and to protect the public interest and a summary of the decision will appear on the College's public register.

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The College will monitor the Program set out below.

A. Courses/Programs

Note: If a course mentioned is no longer available, Dr. Hazrati shall successfully complete a suitable alternative, acceptable to the College. ·

AND-

1. Group Courses

Dr. Hazrati shall attend and successfully complete the ·next available e-l earning module on Informed Consent, offered by the Ca1"1adian Medical Protective Association, or an alternate course provider indicated by the College. The member is to provide pro-of of successful completion ofth.e Gourse.

B. Self-Directed Learning

1. Dr. Hazrati shall review the College policy on Consent to Treatment. The member is to submit a written summary, up to 2000 words in length, to the College within 3 months of receiving this decision to ensure completeness of the review. The summary should reference current standards of practice (where applicable) with. respect to obtaining appropriate consent and alleviating discomfort in performing peri-anal procedures, how the policy is applicable to Dr. Hazrati's situation as well as how Dr. Hazrati has made, or plans to make, changesto his practice.

C. Other

1. The Committee also notes the following regarding the Program:

a. All costs associated with the Program are Dr. Hazrati's sole responsibility b. Any failure on Dr. Hazrati's part to comply with the Program requirements

will be reported to the Registrar and/or the Committee.

A Compliance Monitor from the College will contact Dr. Hazrati to assist in implementing the requirements of the. program.

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DISPOSITION .

The Committee ~equires Dr. Hazrati to attend atthe C?llege to .be cautioned in-this-matter.

Any failure on the part of Dr. Hazrati to attend for this caution may res.ult in further . consideration and action by the College. . .

-AND-

Dr. Hazrati is required to complete the specified continuing education or remediation program, as o.utlined in this decision.

PANEL MEMBERS: September 15, 2017

D. MERCER, Mb- Chair, icR Committee

. A. HAMILTON, MD R. HOLLENBERG, MD E. MARGOLIN, MD H. ERLICHMAN - Public Member

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January 31, 2018

Ms. ?ara Pasion Staff Services Analyst Discipline Coordination Unit Medical Board of California 2oos-Evergreen Street; Sujte 1200 ·· Sacramento CA 95815-3831 United States

Dear Ms: Pasion: .

THE

COllJEGJE OF

.JPJillYfilCIANS AND

SlURGJEONS OF

ONTARIO

We are in receipt of your request of December4, 2017, for documents from the College of Physicians and Surgeons of Ontario (CPSO) pertaining to recent CPSO matters regarding the following physician:

Dr. Ali Hazrati CPSO Reg. No.: 83925 Date of birth:' Current Ontario Practice Address: Suite 300, 5734 Yonge Street, Toronto ON M2M 4E7

Enclo_sed are certified copies of the following (third-party names redacted):

1. Certified copy of the Decision and Reasons of the CPSO's Inquiries, Complaints and Reports Committee, dated September 15, 2017.

Please let me know if you have any questions.

Sincerely,

Caitlin Hase Administrator Membership Services, Corporations & · Physician Register Department

Enclosure

QUALITY PROFESSIONALS/ HEALTHY SYSTEM / PUBLIC TRUST

80 College Stre,et, Toronto, Ontario MSG 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 9Gi-3330