Wednesday 7 August 1991

Regulated Health Professions Act, 1991, and companion legislation / Loi de 1991 sur les professions de la santé réglementées et les projets de lois qui l'accompagnent

Ontario Nurses' Association

College of Nurses of Ontario

Victorian Order of Nurses

Board of Directors of Physiotherapy of Ontario

Ministry of Health

Professional Advisory Council of the Speech Foundation of Ontario

Ontario Society of Medical Technologists

Association of Ontario Midwives

Lina Di Carlo

Edith George

Ministry of Health



Chair: Caplan, Elinor (Oriole L)

Vice-Chair: Cordiano, Joseph (Lawrence L)

Beer, Charles (York North L)

Haeck, Christel (St. Catharines-Brock NDP)

Hope, Randy R. (Chatham-Kent NDP)

Malkowski, Gary (York East NDP)

Martin, Tony (Sault Ste Marie NDP)

McLeod, Lyn (Fort William L)

Owens, Stephen (Scarborough Centre NDP)

Silipo, Tony (Dovercourt NDP)

Wilson, Jim (Simcoe West PC)

Witmer, Elizabeth (Waterloo North PC)


Callahan, Robert V. (Brampton South L) for Mrs McLeod

Coppen, Shirley (Niagara South NDP) for Mr Martin

Cunningham, Dianne E. (London North PC) for Mrs Witmer

Johnson, Paul R. (Prince Edward-Lennox-South Hastings NDP) for Mr Silipo

White, Drummond (Durham Centre NDP) for Mr Malkowski

Clerk: Mellor, Lynn

Staff: Drummond, Alison, Research Officer, Legislative Research Office

The committee met at 1003 in committee room 2.


Resuming consideration of Bill 43, the Regulated Health Professions Act, 1991, and its companion legislation, Bills 44-64.

Reprise de l'étude du projet de loi 43, Loi concernant la réglementation des professions de la santé et les projets de loi, 44 à 64, qui l'accompagnent.

The Chair: Good morning. I would like to welcome everyone to the standing committee on social development. We are examining a packet of bills known as the Regulated Health Professions Act. There is someone here from each of the caucuses, so we have a quorum and we will begin.


The Chair: Good morning. The rules of the committee are that you have been granted 20 minutes for your presentation. We would ask that you leave some time for questions from the committee members. We welcome you and ask you to begin your presentation now.

Ms Davidson: Good morning, Mrs Caplan and members of the standing committee on social development. My name is Eileen Davidson, and I am the president of the Ontario Nurses' Association. With me today are Heather Dolan, our chief operating officer; Lesley Bell, assistant director of government relations; Arlene Babad, our nursing practice officer; and Carol Helmstadter, our research officer.

I am pleased to be here to address the concerns that the practising staff nurses in this province have concerning these three pieces of legislation: the Regulated Health Professions Act, the Nursing Act and the Midwifery Act.

First, I would like to acknowledge and thank the various Health ministers and their staff for the opportunities that have been provided for nurses and all other professions to have input into this very lengthy process.

As I am sure you know, the Ontario Nurses' Association is a trade union and represents 55,000 staff nurses who form the backbone of this province's health care system. These nurses work in hospitals, nursing homes, homes for the aged, community health and in private industry.

At the outset, I must say that as nurses we were disappointed with the proposed legislation, as we had hoped and expected that the role of nurses would be expanded. Instead, we believe this legislation neglects to recognize the nurse as an autonomous member of the health care team.

The legislation puts the practising nurse in a completely untenable position and will result in even more nurses leaving the profession. We support fully the intent of this legislation to protect the public from unqualified, incompetent and unfit health care providers. However, in order to do that, the legislation must also enable nurses to practise safely and efficiently.

In our written brief we have discussed in detail our concerns, but for this presentation I have narrowed our focus to the four main issues of concern to staff nurses.

Number one, and of prime importance, is that we do not believe that licensing and controlling certain hazardous acts will protect the public. On the contrary, we believe this is not in the best interest of the public. Instead, we recommend that all professions which are to be regulated should be licensed according to their scope of practice. Without licensing, we believe that there will be a proliferation of health care workers, care will be further fragmented and the public, instead of being protected, will be left in the hands of a confusing array of both qualified and unqualified health care workers.

Nursing is being taken away from nurses and delegated to others based on the budget, not on proper patient assessment or care. The government's effort to introduce competition into the health care field is an understandable effort to reduce costs, but do we want to see competition introduced at the expense of losing quality care? The public has come to expect the best, not the cheapest, and the ONA believes this is a reasonable expectation and we will continue to try to meet it.

Currently in Canada, six provinces have adopted an exclusive licensing mechanism for the practice of nursing. That means that nurses have a right to practise within a defined scope of practice.

I refer you to our written submission, specifically reference 1, where it states: "It has been suggested that in provinces where the legislation provides only a registration mechanism, and not an exclusive right to practise nursing, the public is not sufficiently protected." The present system and the proposed legislation protects the title but does not protect nurses with the exclusive right to practise nursing. In our opinion, it therefore permits unqualified nurses to practise and is inadequate to protect the public from unsafe and unethical care.

We agree with the statement from J. J. Morris's book Canadian Nurses and the Law. Mr Morris says, "It is essential that the College of Nurses have the right to license those who practise nursing within the defined scope of practice and that these licensees have the exclusive right to practise within that defined scope." His complete article is attached to our written submission, reference 1.

The second issue I would like to address is the critical need to include within the scope of nursing practice registered nurses who are administrators, researchers and educators. The teaching of nurses, the decision of nurse administrators and the orders which they give to their employee nurses directly impact on nursing care, often to the detriment of the patient. For example, it is not uncommon to work seriously short-staffed, which is potentially dangerous to the members of the public who are our patients.

In the past, the College of Nurses of Ontario has lost appeals to the courts because the courts found that the present Health Disciplines Act only applies to practitioners who give direct, hands-on care. That is us, the staff nurses. Under the proposed legislation we can see nothing that would change this situation.


The ONA believes it is crucial that nurse educators, administrators and researchers become accountable to their governing body in order to protect the public. It is worth noting that the Canadian Nurses Association has already recognized this need by establishing its own standards for these nurses, and this position has the support of the College of Nurses of Ontario.

The third issue is the imperative need for the proposed legislation to formally recognize that many regulated professions will have dual accountability, as a professional and an employee. For staff nurses, this dual accountability means they are responsible to both the College of Nurses and their employer.

The Ontario Nurses' Association has much insight into this unique problem, as we are the only regulated profession right now in this unenviable position of dual accountability. As Florence Nightingale wrote, "Nurses must work under conditions where it is possible for them to deliver good care or they will become totally demoralized."

In our experience, with the basic conflicts between these two roles, if they are not worked out, nurses will continue to be frustrated in their efforts to deliver professional nursing care. This jeopardy situation reduces nurses to feeling compromised and insecure, and this is probably the single most important reason why qualified nurses leave nursing.

The fourth issue I wish to address is the proposed establishment of an independent college of midwives. It is our position that midwives should be nurses first, that midwifery should be regulated under and by the existing College of Nurses. While we support the right of women to choose how childbirth is conducted, the management of labour and normal delivery is a specialty of nursing, just as obstetrics is a specialty of medicine.

In closing, I would like to urge the committee members to review in depth the concerns of the Ontario staff nurses. We believe that all professions should be licensed with a defined scope of practice; that registered nurses who are administrators, educators and researchers should be included in the scope of practice and become accountable in order to protect the public; and that midwives should be nurses first. We believe our suggestions would ensure that both the public and the profession to be regulated would not only be treated fairly, but also the public would gain maximum protection.

Due to the late receipt of the government amendments, we reserve the right to forward a further written submission indicating any modifications to our current position. We would be pleased to answer any questions.

The Chair: For the record, I would like to point out that written submissions are welcome at any time through the course of these hearings, and all groups should feel welcome to communicate in writing with the committee.

Mr Owens: Ms Davidson, with respect to your comments on the necessity to have a scope of practice, with the specialization of medicine how do you see the role of the nurse being compromised? I sense that is what you are alluding to, that certain things that nurses have been doing up to this point they will no longer be able to do, or that in a situation where a practitioner, such as a respiratory therapist, is not available, or a physician, that the nurse, knowing the patient requires some medication or some form of treatment, will be torn between giving the treatment or trying to find that type of specialist. Is that what I am hearing and is that your interpretation of the bill? Is that what it will do to your profession?

Ms Bell: I will take a stab at that. I think you have brought in a number of things in your question. I will try to answer as best I can.

There are comments that nurses now function without written orders, and the legislation is not going to change that. Our comment would be that they are in fact functioning quasi-illegally in that instance now. Our hope of the legislation was that it was going to pretty well define what our role was and give us the independence to practice within that defined scope.

Our problem with not having a defined scope of practice means we have to look for orders. We have heard all kinds of comments that there are standing orders that are applicable, or policies and procedures within the institution that give us coverage. Those are only as good as the paper they are written on, and if they are not duly signed by an authorized attending physician, then we have basically stepped outside our role and gone ahead and in fact practised without proper coverage. Our concern is that this may not change how all nurses function tomorrow, but it really puts us still in jeopardy, and that was the issue we were trying to alleviate with new legislation.

Ms Davidson: I would like to expand, too, on the quasi-illegal. This is really my baby. You have no idea how many times a nurse practises because the patient expects it, the public expects it, the administration expects it and the doctors expect it. You go ahead and you do it because it is the right thing to do at the time and then you wait for the doctor to write the order to cover you. What if that doctor decides he is not going to write that order? Now we are up against a $25,000 fine. Once, only once, will I do what I think is right and that will be it.

Ms Babad: The other comment regarding a defined scope of practice and only allowing the appropriate health care provider to perform that is the concern when you have, for instance, many unregulated health facilities where people who are not qualified are doing certain activities. We are clearly familiar with the rest homes and the problems there. By restricting the practice of nursing to qualified nurses, it helps resolve that problem.

Mr Beer: Could you elaborate a bit on your concerns with respect to midwifery? As you are aware, this is a subject that over the last -- certainly since I was first elected in 1987, I have had a number of people in talking about that issue, the need for an independent college and in particular the arguments around the European and the British approach to it.

I would like to get a better sense of -- I realize there is more in here as well -- fundamentally why there should not be a college and why one, in your judgement, ought to be a nurse before being able to be a midwife, when in other jurisdictions there is certainly an historical tradition of people performing that role.

Ms Babad: There is a number of reasons we have taken that position. Certainly one is that we believe the essence of that type of practice starts out from a broad generalist base. It is fine while midwifery is only dealing with the norm, but you do not always know what is going to occur, and something abnormal could be occurring which a person who does not have that broad generalist knowledge first could miss. In other words, you are assuming that nothing is going to be wrong, and there is no way one can assume that in the world we live in. So many practitioners, if they do not have that broad generalist knowledge, could miss other things that do not necessarily touch on the aspect of birth.

The other reason, of course, is that in many remote areas it would be of benefit if the person was also a nurse and qualified as a nurse-midwife to deal not only with midwifery issues but those other nursing issues. If the person is going to be regulated under two colleges, because they need a nurse and a midwife, we can certainly see confusion resulting. We have addressed other concerns as well in our submission.

Ms Davidson: Presently, among the staff nurses we have several nurses who work in labour and delivery who are midwives from other countries and have been educated elsewhere and are practising as nurses now. All of us who have had any experience in labour and delivery have worked with nurse-midwives who are practicing as nurses with this extra education. It is really nice to have them around when you need them.


Mr Beer: Can I ask one quick follow-up? Has your association or have you had any kind of relationship with the new interim council that exists or discussions about its program or how it is operating?

Ms Davidson: Yes. We have had ongoing representation on the interim regulatory council. Our representative is Ina Casey. She is a labour and delivery nurse and has been representing us right from the beginning.

Mr Hope: During your presentation, and I may have misunderstood you, you said something like, "Standing orders are not as good as the paper they are written on."

Ms Bell: That was my response to a question, yes.

Mr Hope: I raise this question because I know in emergency rooms and other areas in the institutional settings, you have standing orders. When you commented that they are not as good as the paper they are written on, then I am starting to have questions. Why are they not?

Ms Bell: Standing orders have to be authorized by a physician once the physician becomes in attendance. The problem arises that if a physician questions what your decision was in an emergency room situation, the fact that you decided this patient was suffering from X and instituted protocol X to match it, and he determines that something went wrong and maybe he does not agree it was right, then you have actually worked without an order there.

In every hospital, certainly in my history of practice, standing orders come into vogue and out of vogue. For a long time, we had standing orders for every patient that was admitted to a specific floor, with a specific diagnosis, for surgery the next day. The problem was that then there were questions by the public: "How can you do all this when the doctor hasn't seen me and I've determined that there is something else wrong with me in the interim?" Then it is left to the nurse to say: "Okay, we won't institute any of these orders. We'll wait until the physician comes in." The physician comes in and says: "Why weren't these orders carried out? You know this." So all of a sudden, the hospital will decide: "We're not using standing orders any more. We're going to go to the situation where every order has to be written." Then you get to the problem, "We'll take verbal orders," and it just goes back and forth.

Our concern is that the nurse is left holding the bag 99% of the time if there is a dispute with regard to how those standing orders were implemented.

Mr J. Wilson: As I scan through your brief, you have a lot of concerns about almost every section. Is there anything you like in this proposed legislation?

Ms Bell: Sure. We like the fact that it is being looked at.

Ms Davidson: We like the fact that we have had input.

Mr J. Wilson: Have you had much success with the ministry with your concerns over the years? This legislation has been going on for a decade.

Ms Dolan: The best example of that is that we were here with pay equity and we are now in the courts with pay equity to prove what we said before a similar committee about pay equity. So if we have to go the court route again, we will be in court again. I do not know what we have to do to prove to people that nurses who are working at the bedside are seriously concerned about this legislation.

Ms Bell: Our concerns are certainly different from the other nursing groups that you will probably have present to you. There have been references made that both the college and the Registered Nurses' Association of Ontario are very supportive and understand the legislation. They understand the way it has been presented to them and how it applies to them. Our concern is that as practising nurses, it applies differently to us. We are the ones who are there who are left in jeopardy. We are the ones the Health Disciplines Board comes down on and so on and so forth. Our concerns have not been addressed adequately, and that is why you see a brief of this size.

Ms Babad: In addition, this piece of legislation was modelled after the Health Disciplines Act. As practising nurses we are very familiar with the problems that have occurred because of that piece of legislation, so we would have liked to see some changes made to this beyond that.

Ms Bell: I just want to throw in with regard to this. For example, you have heard from other groups or you will be hearing from other groups that there is a question as to the accountability of educators, researchers and administrators. You will be told that they are accountable under the legislation. They are accountable for incapacity and professional misconduct. Our problem is that they are the ones who assign our workload. We are the ones who have to carry out what they tell us to do, whether it is short-staffed or whatever. Because the only standards that the college has established are practice standards, it is only the practising nurses who are held accountable to those standards. So while those nurses are so-called accountable, they are not accountable in the way we need them to be, where their determination of our workload or of how our patient assignment is and of how we practise is going to make our position an area where we are the ones who are challenged and not them.

Ms Babad: This really even goes beyond that. We have disputes with the administrators about their medication administration policies, about their methods of charting, which the nurses are doing but the administrators are deciding how they will do it. If the nurses are concerned that it does not meet the patients' needs, there we have a real conflict. Certainly we have cited some of these in our brief.

Ms Davidson: One of the statements we have made before is that there is a shortage of nurses in this province. There is not a shortage of nurses, but there is a shortage of staff nurses who are willing to work under the circumstances we are being forced to work under. Those of us who stay, why do we stay? Because we want to nurse, we want to look after our patients, we care about our patients and the public, and so we stay. But when you work in an uncompromised situation where the famous floating word in every institution in this province is "cope," it is very difficult and you start looking for something else. If there was room for one more real estate salesman in Parry Sound, I would be gone.

The Chair: Thank you very much for your presentation. I know the committee will give it serious consideration.


The Chair: The next presentation is from the College of Nurses of Ontario. Come to the presentation table and identify yourselves.

Mrs Mandy: We are pleased to have this opportunity to present to the standing committee. My name is Pat Mandy. I am the president of the College of Nurses of Ontario. On my right is Linda Vanginhoven, RNA, of the executive committee. To my left is Margaret Risk, executive director of the College of Nurses, and Darwin Moore, vice-president of the College of Nurses.

I believe you have copies of our submission that were distributed today. In our submission we confirm our support for some of the issues and identify those areas where we continue to have some concerns. I would like to note that we do intend to make a second written submission relating to the draft amendments that were tabled by the minister yesterday. We need time to study these amendments in order to make an appropriate response.

The College of Nurses of Ontario is the regulatory body for nursing. The College of Nurses supports the policy intent and direction of the proposed legislation. Given the comprehensive consultation process, we have had the opportunity to suggest many changes and see them incorporated into this legislation. Therefore, our submission is brief.

We support the intent of the legislation to increase the emphasis on the identification of deficiencies in and promotion of quality care by practitioners through a quality assurance program. This is a positive enhancement to a process that at present focuses solely on responding to individual complaints.

The review team is to be commended on its review of various models of credentialing and the development of a unique scope of practice and controlled acts model. We welcome the opportunity to work with government and other regulatory bodies to implement the model and evaluate its effectiveness.

There are several areas in the proposed legislation for which we wish to acknowledge support. These include the advisory council, the openness and privacy provisions, the French-language services and mandatory reporting.

There are some areas about which we wish to express our concern and which, in our view, require some alteration.

We support the minister's proposal in the draft amendment to section 5.1 limiting the elected and public council members to a maximum of six consecutive years' service on council. We recommend that the same limitation be applied to the appointment of members of the advisory council and the Health Professions Board.


The section on minister's powers attempts to reflect a balance of independence for the governing body and its accountability to the minister. The review team had recommended that the minister may request councils to undertake activities. In the bill, the word "request" has been replaced by "require." We believe that "request" reflects more accurately the collaborative nature of self-regulation and is more appropriate to reflect the partnership between regulatory bodies and government.

The fitness-to-practise committee can impose terms, conditions and limitations on a member's certificate of competence. A breach of such conditions would be deemed professional misconduct and could result in bringing a member before a discipline committee. We would like to see an additional subsection in the legislation that would provide authority to the fitness-to-practise committee to deal with a member in breach of conditions or limitations. This would be congruent with the intent of the legislation to address health conditions differently than issues of competence and conduct.

We stated that we would support the intent of the legislation to increase the emphasis on the identification of deficiencies and promotion of quality care by practitioners through a quality assurance process. As the legislation moves forward, there are a number of issues which will need to be clarified either through legislation or complementary government policy. One fundamental concern we have with the legislation is the implication that regulatory bodies can assure quality. Regulatory bodies can assess quality, they can strive for quality improvement, but legislation which implies assurance of quality care can create expectations that cannot be met. We recommend that the terminology in the legislation be changed to "quality improvement."

In reviewing the draft legislation, the College of Nurses, with other regulatory bodies, has identified a number of legal and procedural concerns. The concerns have been discussed with the legal counsel at the Ministry of Health. Since the status of these concerns is not clear at this time, a summary is included to this submission, in appendix 1. Last week, the Minister of Health shared draft amendments that were tabled with you yesterday. After we study these proposals, as I said, we will be making a further written submission to the committee before your clause-by-clause review.

The proposed legislation does not provide for a requirement that the employer verify that the employee is registered. The Health Disciplines Act currently provides for this. We believe a statement of this nature should be included in the new legislation.

We wish to comment on two aspects of the Nursing Act: structure and title restrictions. The scope of practice and controlled acts will be discussed generally, with specific reference to nursing. Throughout the legislation review process we have supported the philosophical thrust of increased public accountability and openness and the increase in public representation on council. The proposed increase of membership to just under 50%, however, affects the principle of peer review and may be perceived as dilution of self-regulation. We have some practical concerns about the structure of the council and the statutory committees with public representation of just under 50%. The College of Nurses is unique in that it represents two categories of practitioners, registered nurses and registered nursing assistants. We have a very large registrant body, of approximately 145,000, and we have a very large council, with 33 members currently.

In the event that the higher percentage of public membership is maintained, the College of Nurses has proposed a structure, which is in appendix 2. This has already been shared with the Ministry of Health. In this structure, public membership is a little over 46% of the college council. This reduced ratio is necessary in order to have sufficient and appropriate representation of RNs and RPNs on statutory committees.

With regard to restricted titles, we recommend that "registered" be included in the title "practical nurse" wherever it appears in the legislation. It informs the public and other health care practitioners of the credentials of the practitioner.

An exemption has been made to allow a person to hold himself or herself out as a Christian Science nurse, a dental nurse or a graduate nurse. We have accepted the exemption for Christian Science nurse. We disagree, however, with the exemption for dental nurse. "Dental nurse" suggests to the public an individual who is a nurse with a speciality in dentistry. We understand that this title is no longer in use in Ontario. We therefore recommend that this exemption be removed.

We recommend that the title "graduate nurse" be protected. We have been exploring the viability of creating a roster of those individuals currently practising safely as graduate nurses in the province. The inclusion of these graduates on such a roster would allow them to continue working and still provide some monitoring to enhance public safety.

The College of Nurses supports the scope of practice statement for nursing but wishes to note the importance of health promotion as a significant practice component even though the words are not explicitly identified in the statement. We are in agreement with legislation that focuses on the practice of the professions. We recognize, however, that RNs and RPNs are accountable to the College of Nurses for nursing behaviour regardless of the capacity in which they are employed. We also acknowledge that there is a perception of immunity for members working in research, education and the administration dimensions of nursing. We have a responsibility to clarify the legislative intent to members and to inform the public of expectations for all RNs and RPNs regardless of their positions or their employment settings.

There are four controlled acts that are of specific concern to the College of Nurses. We suggest that all controlled acts be very clearly defined. The first controlled act, "communicating a conclusion," which replaces "diagnosis," has been discussed extensively and we join many other groups in expressing concern. We understand that the intent of this controlled act is to limit the determination of a medical diagnosis to qualified practitioners. The College of Nurses supports a controlled act that explicitly limits medical diagnosis to qualified medical practitioners.

The amendment to the controlled act 5, "administering a substance," which changed "on the order of a qualified person" to "on the order of a member of the College of Physicians and Surgeons of Ontario" will create problems for RNs and RPNs working with other health care professions that are authorized to prescribe; for example, dentists or midwives. We have not yet had the opportunity to discuss the rationale for this change with the ministry and we need to consult with nurse practitioners working at advanced levels to ascertain how this might impact on the service they provide. We will comment on this in our second submission.

The lack of definition of forms of energy is confusing. Nursing currently applies some forms of energy, such as bone growth stimulation and phototherapy. If these forms of energy are considered prescribed, then it is important that nursing have the application component of this controlled act within its scope of practice.

The College of Nurses has supported the inclusion of midwifery in legislation. Throughout the review process we have met numerous times with the Ontario Midwives Association and more recently with representatives of the Interim Regulatory Council on Midwifery. We recognize that in the implementation of midwifery services in Ontario there will be a learning and adjustment period as roles and role relationships evolve. This controlled act is an example of overlapping scopes of practice of nursing and midwifery. The "managing labour" component of this controlled act is not authorized for nursing in the proposed legislation but is currently practised by many RNs and RPNs and is part of the basic education program. We believe it is important to include managing labour as an authorized act for nursing, as it is essential for the safe care of the mother and foetus.

The success of the controlled acts model will depend on an informed public. Freedom of choice and flexibility for the health care consumer and education of the public will require greater collaboration between professions with regard to multidisciplinary practice. The controlled acts model requires an opportunity to be tested and evaluated and that there be opportunity for revision of the act based on evaluation and consultation with the public, the professions and the governing bodies. We look forward to working with the government and other governing bodies in implementing the Regulated Health Professions Act and would be pleased to answer any questions.


Mr White: Following from this issue, which I know you recognize as being an issue of some debate in your community, is the issue of medical diagnosis. You suggest that you are supporting an explicitly limited medical diagnosis for medical practitioners. I am wondering how communicating information, which implicitly happens in the hands-on practice you represent, might be hampered by that clause or how you would relate to that.

Mrs Mandy: Are you asking why we want it changed to "medical diagnosis"? Nurses have many independent functions which they perform and the wording in the legislation as it is would put limitations on that. The wording now is that nurses cannot communicate a disease, a disorder or a dysfunction, and there are many times when nurses do discuss those things with patients, so that is why we want that limited to medical disease.

Mr White: So you would see that as continually confining what it is that you can do.

Mrs Mandy: What we can communicate.

Mr J. Wilson: I have a general question to you, Madam Chair. There are a number of legal procedural concerns in appendix 1. Will counsel undertake to get back to us on that, or will the ministry be acting through the college?

The Chair: Procedures for the committee are that if you have questions of the ministry, you can ask directly and they can respond in writing, or we will have another opportunity this afternoon. There will be an hour from time to time and you can pose questions then, but if you pose your questions in writing, ministry staff are here, and normal procedure in the absence of either the minister or parliamentary assistant is to have the response in writing.

Mr J. Wilson: Perhaps I could ask the witnesses what kind of progress you are making with the ministry in clearing up some of these matters -- the wording of bills.

Ms Risk: Legal counsel from a number of the colleges have been with working with legal counsel at the ministry and have made significant progress in looking at a number of these, a number of which were tabled by the minister to you people yesterday. Our difficulty is that we just received them the middle of last week and we have not had an opportunity to match them up against the comments we have already made. Some of them will have been resolved and some of them perhaps will not be.

Mr J. Wilson: Will you be doing a second submission to update us on that?

Ms Risk: We will be doing a second submission. Some of our concerns are almost a matter of form and are not particularly substantive and some are a little more substantive.

Mr J. Wilson: I appreciate that.

Mr Beer: Your organization and the association that appeared just before you clearly have different approaches to this legislation. As we look at some of the points that were raised previously, I know you were here, and I am sure you have talked with people from the Ontario Nurses' Association about that. But what is the nature of the disagreement here, because I think as committee members it is important that we understand in terms of the college, the Nurses' Association and the third association, which is gone out of my head for the moment.

Mrs Mandy: There are actually four nurses' organizations in Ontario. The College of Nurses of Ontario is the regulatory body for nursing. The Ontario Nurses' Association, which just presented, is the union for registered nurses in Ontario. The Registered Nurses' Association of Ontario is the professional body for RNs, and the Ontario Association for Registered Nursing Assistants is the professional body for RNAs.

Mr Beer: Okay. Am I correct that your association and the registered nurses' association have said that in principle you support the legislation, that you have some questions, but that basically you have supported that? I guess what I was really after is, in terms of the major concerns that were expressed by the ONA, do you agree that those are concerns but simply feel that the legislation deals with them adequately, or do you not feel that those are as critical as the ONA put to us? I am trying to get some guidance because I want to get a sense of --

Mrs Mandy: I believe that we approach them from our own perspective. As the College of Nurses of Ontario, protection of the public is our mandate. The Ontario Nurses' Association is the union, and represents the RNs' interests.

Ms Risk: I think that probably the scope of practice is the area that is most fundamental in our differences. It is a new model and it has been, I think, a difficult one for all of us to grapple with during the process. It is a much more open model and actually we would disagree that it is restricting; it is rather just the opposite. It provides much more independent decision-making for nurses. So the broad scope of practice is something that we have certainly supported as something that supports consumer choice in a system that is much more multidisciplinarian and has many more grey areas between professions than there used to be. The controlled acts: I think we have supported the model in taking a try at it. We all have some concerns about whether we will have difficulties with enforcement, but it really is a very unique approach that has sparked interest right across Canada and the States. We think that we probably can make it work. It is not just our organizations that actually disagree. We all are trying to look at a new model and how it is going to work.

The Chair: Thank you very much for your presentation. The committee will look forward to receiving your written brief and any other further communication you have as the hearings go forward.



The Chair: The next presentation is from the Victorian Order of Nurses. Introduce yourself for the committee, please. You have 20 minutes for your presentation and I would ask that you leave time for questions if possible.

Ms Suttie: Yes, I will. Actually, our remarks are going to be very brief. I am Jane Suttie, the associate provincial director of VON Ontario, and this is Judith Layzell, the director of quality assurance for VON in the province. We did not hear any of the presentation that took place before us, so we will probably be unable to comment on that. Basically what we would like to do this morning is just make a couple of what we feel are important remarks in relation to Bill 178. We will be presenting a formal paper by the end of the month, which is the deadline that was given, but due to holidays and so on we were unable to gather all the people together we needed to do a formal presentation. So please bear with us.

When we reviewed the paper, one of the things that came to mind under the heading of advisory council was the fact that we would like to see some consumer representation on that council, and also that the organization of VON would be prepared to act in a consultant capacity to the advisory council should it be implemented. In essence we support the process but we would like to see a more blended group of people; for example, government representation, some professionals and consumers so that you will get a broad representation there, and participation.

Under the prohibitions there are a few comments we would like to make. It is our understanding that the concept of limiting controlled acts is applicable to acts considered to be potentially harmful to the public. We feel that this paper hopefully is for the protection of the public. I know that as an organization we are very interested in the protection of the public and would like to see this really reinforced under the legislation. However, we feel that it appears somewhat hierarchical and perhaps unnecessarily so because of the actual existence of the scope of practice for people in the various professions.

We are not sure that the recognition of the team approach has been given due consideration as well. When we speak from the community perspective, there are a lot of various professionals who go in to take care of the patients, and hopefully we are working as a team and not just as individuals in that community setting.

Section 26 gave us some difficulty. Again, we will have to clarify this at a later date when we have the appropriate people to have the input, but the act has implications for relationships between physicians and midwives, particularly when the client-directed care is exercised. If we look back at the long-term care reforms, one of the things that was being advocated was perhaps an increase in client-directed care. I think we should keep that in consideration when we are looking at the act in itself. The issues will have an impact on the VON. For example, can nurses act on the order of the midwife? Can nurses assist with the delivery after the care in the home? These issues, we felt, were not really clear in this particular act and we would like to have it looked at a little bit more closely.

Section 30: The title of "doctor" is a degree earned by many health care professionals, and we feel that any professional who earns a doctorate should have the right to use it. For example, a basic degree in psychology does not grant the title "doctor" such as optometrists and dentists, etc, have. This is really applicable to nursing. A lot of nurses -- not a great many, proportionately speaking -- do go on to get a doctorate in nursing but they are not, at this point, calling themselves doctor. We feel that should be changed and permitted. In other words, I guess what we are saying is that if we have a doctorate in nursing, do we have to go to the council to get an exemption to use that title we have earned?

The references to quality assurance and continuing competence under section 78 appear to be inconsistent. It is unclear if the function of the proposed quality assurance committee is actually quality assurance or monitoring of competency. We would like to have some clarification of that. It is the VON's position that quality assurance should be the responsibility of the funders of the system. Let me enhance that statement a little bit, because I guess what we are seeing in the community are a lot of agencies that are providing community health care. However, we feel that if some quality assurance criteria were in the legislation, then all agencies or providers that would be responsible for providing that care would have to meet those criteria.

One interesting thing that came to mind with section 91: When you talk of premises in relation to the provision of health care in the home, we feel this needs some clarification because we are in kind of a unique position. We feel the client's right to privacy must be respected, and due to the increasing utilization of charts in the home, the client's permission to access his or her chart is essential. That is where the chart will be in the future. It is, in some agencies now, and we are taking that route as a provider agency as well. It will not be at the employer's office; it will be at the patient's home. So the document will be there, and to access it we feel we should have the patient's permission.

We feel that the legislation falls a wee bit short of covering all the health and social service workers in the community. For example, we hear a lot of discussion about whether it is a multicompetent worker or whether it is a home health aide or homemaker. For these paraprofessionals we think their methods need to be defined to ensure there are good relationships between the professionals and the paraprofessionals. It is our prediction from reading the various trends in government and the community in general that there will be a significant increase of the paraprofessionals in the future and we must ensure that the protection of the public is recognized in these areas.

One final comment is that the reality of the 1990s is the control of health care costs. Diversification of staffing to include the less costly categories of staff, such as the ones mentioned a few minutes ago -- home health aides -- would be helpful. However, we recommend that the government establish some sorts of funding formulae or criteria to recognize the utilization of these paraprofessionals. This is over and above the fact that we should have some legislation covering the home health aide or multicompetent worker, whatever the individual ends up being called. Educational standards which can be appropriately monitored are equally important.

These are just really a thumbnail sketch of our comments and, as mentioned, we will be doing a full report by the end of the month. Not being a clinician, if there are any clinical questions, I may have some difficulties with those, but I will try my best to answer them.

Mr Johnson: The Victorian Order of Nurses has a reputation and a history of being the nurses of choice in supplying nursing care to people in their homes. As we try to cut costs in the province, we know there has been some conflict recently with regard to for-profit enterprises that are in competition with the Victorian Order of Nurses, and that is maybe a side issue.

The thrust of the legislation is to reduce unnecessary restrictions on who can do what and to create opportunities for more efficient use of human resources. Can you comment and give some indication on what these opportunities might be in the delivery of health services in the home?

Ms Suttie: You are talking of the paraprofessionals?

Mr Johnson: I did not want to get into conflicts between paraprofessionals with regard to who can do what. This legislation, although there has been some comment, maybe is not as comprehensive as I like to believe it is. It is supposed to reduce these unnecessary restrictions. I was just wondering if you could comment. It is supposed to create opportunities. I was wondering if you could give me some indication of what you think these opportunities might be.

Ms Suttie: I have no doubt that it does create opportunities as far as the act is concerned. Primarily what we are saying is that it needs some clarification in some specific areas. In general, we think that the prime thing as far as any legislation is concerned, particularly in this type of legislation, is protection of the public and that any providers or regulating bodies or what not will have to look at this as a primary focus for their work.

As far as opportunities go, I think there are many, although I am really not in a position to say what they would be. I do not know if Judith would like to comment on that.

Restrictions are necessary to a point, and I guess when we are talking about the introduction of -- staff diversification is one of the things we are looking very seriously at in our organization to ensure that we are providing safe, effective, quality, cost-effective care to the patients in the community. In order to do this, we also must realize that some of the people we may be introducing into the organization as staff members are covered under some sort of legislation. In other provinces, for example, the category of home health aide is currently utilized and covered. In Ontario we are unable to diversify our staff to meet that need in that category of staff because we have no legislation to cover it, and basically this is where we are coming from.

I do not see that as a restriction. I think it is an opportunity, once the legislation is changed. Am I answering your question?

Mr Johnson: Yes. We are all interested in the protection of the public. Would you agree that this legislation is a step in the direction of better protection?

Ms Suttie: Yes, I do. We very much support it in that respect.


Mr J. Wilson: You mentioned something about recognition of the team approach, and I assume you are referring to the scope of practice there. Is it not sufficiently general to capture everyone on the team? I am just not quite sure what you meant by that.

Second, quality assurance in the setting of criteria: It is my understanding from reading this -- although you are absolutely right, it is very vague in what it means, and we have not had the discussions with the ministry you have probably had and certainly other nursing groups have had about what that will mean. What is your understanding of "quality assurance criteria will be set by the advisory council," and are you invited to participate in that?

Ms Suttie: Judith may want to add a comment or two on quality assurance. Obviously, the regulating bodies will be monitoring the competence and so on of any practising professional in the province. However, when we look at the various groups that are currently providing health and social services in Ontario, there is very little to establish criteria to say I can perhaps go tomorrow and start a business and provide health care in the community. There are a lot of mom-and-pop operations which are doing very good jobs, but there should be some criteria established that if you want to provide these services, then you have to meet these criteria.

Your professionals, on the other hand, will be monitored by the regulatory bodies. So it is an added step of quality assurance in one way, I guess, although I feel it is necessary, or we feel it is necessary, to ensure that all of those who provide those services in the community or elsewhere do have some criteria they must meet in order to set up business. So that is where we are coming from.

Mr J. Wilson: And the scope of practice?

Ms Suttie: Again, this is more of a clinical issue and I am not all that well versed on it, but we were looking at it in the context of a variety of professionals going into the home to provide the service. We act under the orders of a doctor, obviously, but the team approach is critical. If the physiotherapist is given an order from the doctor and we are assisting the physiotherapy, it is within our scope of practice to do some of the activities that are related to the work that the physiotherapy would ask us to do. So it is indirectly an order from the doctor, but it is not direct. In the team approach, it could be a doctor giving an order to a physiotherapist and nurses and so on and so forth who would be going into the home to do that.

Mr J. Wilson: Have you had legal problems in that area in the past?

Ms Suttie: Not to my knowledge, no.

The Chair: You are welcome, as all groups or individuals are, to communicate with the committee in writing and present briefs. Please feel free to do that, and thank you for your presentation today.

Ms Suttie: Thank you for the opportunity, and we are, as I said, preparing an appropriate brief.


The Chair: The next presentation is from the Board of Directors of Physiotherapy. Please introduce yourselves. You have 20 minutes for your presentation and we would ask that you leave some time for questions from members at the end of your formal presentation.

Dr Avison: Thank you. I am Dr William Avison and this is Ms Gillian Firth. We are both members of the Board of Directors of Physiotherapy of Ontario. We have distributed our brief, and it does have an executive summary, so we would like to speak to some of the issues there and leave the rest for you to pursue at your leisure.

The Board of Directors of Physiotherapy of Ontario is the regulatory board for physiotherapists and physical therapists in the province. The board is appointed under the Drugless Practitioners Act and the board administers and treats through the practice of physical therapy, sets practice guidelines, receives complaints from the public regarding physiotherapists and undertakes disciplinary action when necessary. At present there are approximately 4,400 registered physical therapists in the province practising in various settings, both in institutions and in the community. The registrants are 90% female. The board's makeup is a five-member board of physiotherapists and one public, who is myself.

In general, the board is very supportive of the new legislation and has actively participated in the discussions and processes which have brought the act to this juncture. We believe that the original Drugless Practitioners Act has become outdated and we believe it presently limits the board's ability to fulfil its mandate to protect the public interest. We think that this new act will give us many advantages in this area and we welcome its objectives.

We are especially happy with some of the aspects that will protect the public from unqualified, unfit or incompetent health care providers and that will encourage the provision of high-quality care, especially in terms of providing guidelines for quality assurance and continuing competency. It will also give the public, we believe, freedom of choice within a range of safe health care options, and it will allow for the evolution of the roles of individual professions in order to deliver a more effective health care system.

The other point we would like to stress here is that we feel strongly that a major advantage of this new act is that it will give greater public participation in the various colleges and regulatory bodies.

Having said that, we have two concerns we would like to raise here. The first concerns subsection 15(1) of the Physiotherapy Act. That passage reads, "No person other than a member shall use the title `physiotherapist,' a variation or abbreviation or an equivalent in another language in the course of providing or offering to provide, in Ontario, health care to individuals."

As this is written, the term "physical therapist" would not be restricted. We believe strongly it is essential that both the terms "physiotherapist" and "physical therapist" should be restricted in order to protect the public. Indeed, elsewhere in the Physiotherapy Act, in clause 6(1)(c), the term "physical therapy" is also used, and this is an issue that we would like to draw to the attention of the committee concerning a possible amendment here.

The title "physical therapist" has been restricted in Ontario since amendments to the Drugless Practitioners Act in 1983. The protection was afforded in recognition of the changing nomenclature in the profession in North America. You will see in our submission that most university programs in Canada use the term "physical therapy." We also present some information in schedule B of the brief illustrating that the status of physiotherapists and physical therapists are used interchangeably.

It is our view that if this is not protected, the public itself may become very confused. Indeed, we have been talking with people from the Consumers' Association of Canada who expressed to us the fact that any distinction between physical therapist and physiotherapist will be extremely confusing for the public. For these reasons, the board requests that the committee include "physical therapist" as a protected title in the Physiotherapy Act.

The second point we wish to raise here concerns subsection 26(2) of the Regulated Health Professions Act concerning the issue of communicating to the individual or his or her personal representative a conclusion identifying a disease or disorder or dysfunction. This is the clause concerning diagnosis and assessment.

Like many professionals in the health care system, the board is extremely concerned about the impact of this decision, which appears to include not only diagnosis but also the conclusions of an assessment.

Physiotherapists routinely communicate to their clients the findings of their assessments of physical disorders or dysfunctions. It is necessary to the patient so that the patient can understand his or her condition, and it is also important if the physiotherapist is going to get informed consent to engage in further treatment. It is important that this be communicated.

We believe that the current clause is not in the best interest of the public. We feel it is only natural for the client to discuss the findings of his or her assessment with the individual who performed it, in this case a physical therapist, and we feel that this situation is contrary to the stated objectives of the legislation to give the public freedom of choice. We think it is important to balance the public's right to protection against practitioners who may communicate conclusions which are outside their scope or expertise, but we believe that it is important that physical therapists have the right to practise autonomously and to communicate their assessments to patients.

There are other issues we have raised and other points we have mentioned to reinforce our concerns about these two issues, but I think in general we would like to state that we are enthusiastic about the legislation and, except for these two issues, we heartily endorse it.


Mr J. Wilson: In your discussions with the ministry, and I assume with the review committee prior to that, why will they not give you protection for the title "physical therapist"?

Ms Firth: Their reasoning seems to be that they want to limit the titles that are restricted as much as possible, and the one they feel is most used in Ontario is "physiotherapist." We disagree.

Mr J. Wilson: Second, you said it is common practice for physiotherapists to communicate a diagnosis.

Ms Firth: It is more an assessment and the physical dysfunction. I do not know if you have had physiotherapy yourself, but people here who have can probably relate to this. You get referred to a physiotherapist or physical therapist with a diagnosis, say, of back pain. The physical therapist then has to look at that back pain and decide if it is muscular, ligamentous, joints or what it is and then discuss this with the patient before carrying on into the treatment. It is going to limit the amount of education we can give a patient and the amount of explanation we can give regarding treatment.

Mr J. Wilson: Have you put forward a suggested amendment?

Dr Avison: Yes, we have.

Ms Firth: We would like to be able to communicate within the scope of our practice, and the scope statement is in the body of the brief.

Mr Beer: I would just like to follow up on that and try to understand, because I think this issue around diagnosis and assessment is one that is going to come up with a number of groups. Could you give us an example of something you feel you could do today but that under this legislation you could not or ought not to do.

Ms Firth: Yes. As I was saying to Mr Wilson, it is really a question of how we communicate the findings of our assessment to the patient, having done the assessment. The patient will come, maybe with a disease, with a diagnosis already. They may come with a diagnosis of multiple sclerosis or a stroke or rheumatoid arthritis. The physiotherapist will then look at that person and decide that the pain may be coming from a certain joint and how to treat that pain, or the muscular dysfunction or whatever. Then we have to discuss that with the patient in order to establish a treatment plan. It is that discussion that we feel we will not be able to do with this legislation.

Mr Beer: You would not be able to discuss your assessment if you were dealing with me and say, "Look, we know people think it's something to do with the muscles, but we see a problem with the spine," or some such thing.

Ms Firth: Yes. It is likely that it would be muscle weakness or a soft tissue injury, something like that, which we would have to zero in on and explain to you. We would have to educate you as to the sorts of things you can do at home or the exercise routine you can do.

Mr Beer: Have you had a legal opinion from your people on the way this would be worded, or is worded?

Ms Firth: Yes. It says "communicating to the individual...a disease, disorder or dysfunction," which one would assume includes physical dysfunction.

Ms Haeck: I would like to follow up on that. Personally, I have not had a need to use the services of a physio at this point, but I guess my question centres around the whole process of how I would get a physiotherapist's services. I assume, and I hope you will correct me, that if I needed your service I would basically be referred by a doctor and that would hold true now as well as later.

Ms Firth: No, there has been a change in this proposed legislation.

Ms Haeck: If I have tennis elbow, I can choose to go directly to you.

Ms Firth: That is correct. Presently you cannot. With the present legislation you have to be referred by a physician.

Ms Haeck: You are concerned that if I came to you with tennis elbow, what I deemed to be tennis elbow, then after your assessment of that your assessment would have to be communicated by a doctor and that you could not, under your scope of practice, tell me that I have tennis elbow and then outline a series of exercises or treatments that might be possible.

Ms Firth: That is correct, and also, if you came on a referral from a physician the same would apply, even if you came with the diagnosis of back pain. We would not be able to tell you where that pain was coming from.

Ms Haeck: Okay. Thank you for making that absolutely clear for me.

Mr Callahan: I just want you to enlarge on the "harm" clause, why you feel that to be the case.

Ms Firth: We feel that having it in there may leave some professions that are not regulated, such as social workers, psychotherapists and clergymen, open to being prosecuted under that clause.

Mr Callahan: For what? In terms of exceeding their parameters?

Ms Firth: In terms that they would be limited by the controlled act. Therefore, they also would not be able to communicate their assessments to the people they are treating.

Mr Callahan: My colleague asked you whether you had a legal opinion on the question of communicating to the individual, etc. Would you be prepared to share that with us?

Ms Firth: I think it is basically what I explained previously, that we would be limited in our current practice.

Mr Callahan: Is that what the legal opinion says? Do not let me pressure you for it. It is your legal opinion; I do not want --

Dr Avison: That is what our legal counsel has advised, his interpretation of what the legislation would mean.

Ms Firth: We believe it was not the intent of the legislation to limit what we do, but we believe the wording that has been chosen will do that.

Mr Callahan: Does your legal counsel suggest some more appropriate wording as an alternative?

Dr Avison: No, not at this point.

Mr Owens: Just to digress for a moment, Mr Avison, you have a PhD and there have been some issues raised with respect to the use of the title "doctor" within the medical profession or the allied health professions. Do you see that this legislation would inhibit you and your use of that title, and what do you propose to the committee in terms of amendments?

Dr Avison: Let me speak as an individual and not as a member of the Board of Directors of Physiotherapy on this, because this is not an issue that has come up at the board. My PhD is in sociology. I am a medical sociologist, but I think there is a problem. I suspect the problem is that in the legislation, as it is proposed, there is a selection of which individuals may use the term "doctor." A psychologist may. A PhD in nursing obviously may not, from what we see in the legislation. A PhD in speech pathology does not appear to be able to. I think it is a somewhat arbitrary aspect of the act and, personally speaking, I am not certain how easy it would be to enforce. I think I can speak for colleagues of mine who also have PhDs; they probably do not accept this aspect of the act as being useful or particularly important, but I think the major issue is how that aspect of it can be enforced. It seems very difficult.

The Chair: Thank you very much for your presentation. If you have any additional information, documentation, briefs or legal opinions you would like to share with the committee, please feel free to table them with us at any time.

Dr Avison: Thank you.

The Chair: For the information of committee members, the clerk has received documents from ministry officials that were the basis of some of the information received yesterday. There is one copy. If it is acceptable to everyone, it will remain in the clerk's office all of this week, where any of the research staff from the caucuses can have access to it. At the end of that week we will turn it over to the research under Bob and Alison, and it will then be available through them, if that is acceptable to everyone. Agreed?

Second, I remind everyone that we will be reconvening at 1:30 for a presentation from ministry officials for approximately one hour. Thank you all for attending this morning; meeting adjourned.

The committee recessed at 1120.


The committee resumed at 1336.


The Chair: Because of a change in scheduling, the ministry presentation can continue until approximately 2:40. That leaves some time for discussion and questions. If it is the will of the committee, the procedure will be similar to yesterday's. The 2:40 presentation, the Pentecostal Assemblies of Canada, western Ontario division, has been cancelled.

Welcome back. I think we had completed section K and we were going to begin section L. All members have a copy I believe. Please begin, Ms Bohnen.

Ms Bohnen: I am going to start by talking about the issue of diagnosis. First of all, before we come to the documents in the folder, I would like to give you some background on how diagnosis or an aspect of diagnosis came to be included in the controlled acts. The review started the selection of controlled acts for the legislation by asking all the participant provider groups to list those activities their members perform which in their view were the most dangerous.

Every profession made a list of the things they considered to be dangerous, and diagnosis appeared on the list of a number of groups including, and probably most particularly, that of the medical profession. They felt that diagnosis was potentially very dangerous.

The review then embarked on an exploration of the risks associated with diagnosis and what approach the bills might take to try and contain those risks, because when most practitioners think of diagnosis, they think of the information-gathering process, the application of diagnostic tests and procedures; then they think of the cognitive process whereby they subject the information they have collected to a thought process, organize it, apply information they have learned, apply their judgement to it and then transform it into an entity which is then communicated to the patient.

The review believes that the part of the process whereby information is gathered, such as the performance of diagnostic tests, some of which may be hazardous -- all of that activity would probably be covered by other controlled acts that focus on the performance of particular activities; or other legislation covered that anyway. For example, X-ray is covered by legislation, lab testing is covered by legislation, invasive physical examinations are covered by the controlled acts.

The cognitive part of it was quite tricky. How would you go about controlling what anybody thinks? Would you really want to try to control what anybody thinks? I think the answer to that is no. You would not want to do it and if you did want to do it, you could not do it.


Ms Bohnen: I walked into that. In any event, the review concluded that it was impossible and inadvisable and silly to contemplate controlling the thought process in any way. This led them to the actual communication of the product of all of this effort, which is telling the patient what is wrong with him. When you get right down to it, that is what this is about, telling the patient what is wrong with him.

Why is that hazardous? Because if you get it wrong, patients might agree to the wrong course of treatment. They might make life decisions that are very inappropriate given what is really wrong with them. You have to be careful what you tell people when you tell them what is wrong with them. I think there was consensus among the participants; most of them said yes. The province, the government was appropriately concerned about the telling of people what is wrong with them, but when it came down to figuring out how to control it, that is where all these difficult issues arose.

First of all, some groups at one extreme of the continuum, I think, would say you do not really have to control this at all. It is a free country, an adult does not have to go to a physician at any time in his or her life. Most people choose to do so, and you are free to go to any provider you want. People should bear full responsibility for all the diagnosis they get or do not get. But that seemed to be a pretty extreme position, not one that most participants or very many governments would agree with.

On the other hand, at the other extreme of the continuum, you could say that we are never going to let anybody except a physician tell a patient what is wrong with him, no matter what that communication might consist of. That would really mean you could never go to a non-physician unless you had first gone to a physician, and the physician had said: "Okay, go to the physiotherapist, to a chiropractor, to whomever."

It would really reinforce the physician as the supreme gatekeeper for all services, both regulated and unregulated, and that did not seem to be a very sensible or enforceable position either. That is not what people want; it is not what is necessary. The cost associated with it would be rather astronomical.

So that left the review with the task of trying to differentiate between those situations or communications where you really should only go to certain practitioners to find out what is wrong with you and those where many other practitioners are quite competent to make this communication.

The words which the review proposed to achieve this were somewhat different from what finally appeared in the bills. The proposal that appeared in Striking a New Balance simply gave diagnosis as the controlled act; but then it gave a particular meaning to diagnosis. The words were "`diagnosis' means the communication to a patient, or his or her representative, of a conclusion as to the cause or identification of a disease, disorder or dysfunction." I guess the key words were "the cause or identification of a disease, disorder or dysfunction."

The review, in contradistinction to that word "diagnosis," used the word "assessment" to mean something which all regulated providers could engage in. That was something different from diagnosis, and they included that word "assessment" in the scope-of-practice statements of most of the regulated professions and they gave that word "assessment" a particular definition.

For example, in the Denturism Act that was proposed by the review, the scope of practice included the assessment of partially or fully edentulous arches. An assessment was defined by the review as the evaluation of a patient's physical or mental state in order to determine whether a treatment within the health professional scope of practice is appropriate to the patient's condition, and if so, in what manner it ought to be applied or administered. It includes the communication of evaluation to the patient and his or her representative.

By including this definition of assessment and the word "assessment" in these individual health profession acts, the review intended to signal that even if they could not perform the controlled act of diagnosis, they could nevertheless perform an assessment and communicate the results of the assessment to their patients.

This report was tabled in the Legislature and the legislative counsel was instructed to draft bills based on this recommendation. The then Minister of Health and ministry staff continued to hear representations from interested groups as to the impact they thought this would have on their practices.

The legislative counsel in particular really tried to transform what we viewed as the essence of this into language that would be clearer and would actually have some legal effect, because just sticking a definition of assessment, for example, in the individual health profession acts was not an effective way of authorizing these individual health professions to assess their patients. You cannot just stick a definition in another statute and expect it to contradict a provision which says you cannot diagnose. You cannot read bills that way.

We came up with the provisions you see in section 26 of the Regulated Health Professions Act. Because we were responsive to criticism that the definition given to diagnosis was a pretty artificial one, we did not even use the word "diagnosis" any more. Instead, we came up with the controlled act that you see in subsection 26(2).

Consideration was given to saying something such as you see here, and coupling with it a provision that might have said, "Despite this, you can do an assessment"; but we were pretty convinced that it was more appropriate to try to define what you could not do so precisely that it would be abundantly clear to all and sundry that they could do everything else.

That is one of the main reasons for this rather lengthy formulation of the controlled act. We really thought that if it was very precise, people would take comfort from it. We know now, of course, that many groups have not taken comfort from it, and I think, before we talk a little bit about the reasons why they are not taking comfort from it, it might help to flip to the first document in that tab, which is called Diagnosis: Three Perspectives. It reflects some work that a ministry intern, working at the professional relations branch, did on different approaches that different practitioners take to diagnosis.

Nearly all physicians practising today, and most regulated health professionals, see diagnosis as the process whereby they collect and analyse information to discover the cause of someone's symptoms. That is the traditional western way of diagnosing patients, and that is what physicians and most regulated health professionals mean when they give someone a diagnosis. But it is not the only understanding that people have of diagnosis.

The second way of thinking of diagnosis is labelled here as systemic. It is based on the view that there is no single cause for most illnesses or most sets of symptoms. Instead, diseases result from the interaction of individuals to their environment. It is multifaceted; there are social causes and environmental causes.

Practitioners who adopt this understanding of diagnosis have a much broader view of what it means, but they still often use the word "diagnosis," and I think the fact that they are using the word "diagnosis" to mean something different from what most health professionals mean when they use the word accounts for some of what we are hearing.

Perhaps a clear example of that is what we have heard from social workers. Social workers use the word "diagnosis" to refer to a social work diagnosis, an explanation in the terminology and the understanding that social workers have of family interaction, social interaction and so on, to explain why an individual is experiencing particular distress. But it is not the same kind of diagnosis that a physician gives when he or she says to a patient, "You are suffering from manic depression or schizophrenia." It is a different kind of diagnosis, but all these groups are using the same terminology.

There are other philosophical understandings of what diagnosis is all about, but for our purposes, I think it might be helpful to keep in mind that we are using that word "diagnosis" in this controlled act in the traditional, conventional, western medical way of thinking, which is to say that, yes, we know people exist in an environment, but the diagnostic process is a process of finding out the specific cause of a particular set of symptoms.


The next document under that tab, as you can see, includes a recommended ministry response to the concerns the ministry heard over the past year or so about the way the controlled act was expressed in the bill. I think it is worth focusing on the fact that this set of words contains four very important elements, all of which would have to be proven to sustain a prosecution, because I think some of the concerns that are expressed are based on an incomplete understanding of all of the elements of this controlled act. That may be the fault of the language, which probably can bear some improvement, but we really remember that the controlled act only focuses on communications to patients or their representatives and does not control at all communications among members of the health care team, so that nothing, for example, would stop a nurse from communicating to a physician her sense of what is wrong with this patient.

Second, the communication must be in the course of the provision of health care services to individuals. I know that some teaching groups have expressed some concern that when they talk to their students, they may inadvertently transgress this controlled act. I think the ministry's view has been that, yes, health care services is an elastic term, but it probably does not extend into the classroom when teachers are talking to their students, and it does not extend everywhere.

Third, it must be reasonably foreseeable that the patient will rely on the conclusion that is being communicated, and this is an attempt really to focus on those first communications where the news is being delivered to the patient, "This is what is wrong with you." So it would have no effect on subsequent discussion with the patient, such as many health practitioners engage in to help people manage and understand their condition.

Finally, it must be a conclusion, like a conclusive statement, that does identify a specific disease, disorder or dysfunction as the cause of the patient's symptoms. All of these elements must be present.

Mr Hope: You are talking about a direct conclusion, a disorder or a dysfunction. An alcoholic, for instance, goes and sees an AA rep who diagnoses him as being an alcoholic; he comes right out and says he is an alcoholic. Because an alcoholic is now designated under the medical terms, is, what that worker has done then against this legislation?

Ms Bohnen: I think the question you ask points to the issue of, first of all, is there going to be definition of disease, disorder or dysfunction? There are many classification systems for health conditions, and one of the ones we hear a lot about is DSM3R, which is an American classification system for psychiatric conditions.

The fact that a condition is listed in one of these books as a disease or disorder or dysfunction, and somebody applies that label to a person in answer to a question or in a conversation, does not transform it into a conclusive statement telling the person that the cause of his symptoms is such and such, that he suffers from this or that. There is a distinction between the two. But to try to answer your specific question, when somebody who is an AA rep tells the person that -- I would not say that the AA rep, for starters, is providing health care services.

Mr Hope: But take away the health care services and look at the picture of an individual, one-on-one conversation. I am doing an analysis of the state of your mind right now, or whatever the state of your affairs is, and I am doing an assessment on an individual. I am putting all the pieces together and then I am coming up with a conclusion, saying: "You are an alcoholic. You need help, and we are going to put you in one of the fine institutions we have here in Ontario."

Mr White: There are a good many people who are health professionals, who are addiction counsellors, who would come up with that kind of conclusion, who are employed by the Ministry of Health. Would they be precluded from doing that?

Ms Bohnen: They are not precluded from providing assessments, and you cannot wave away the health care services context to this. In your question you started with that, leaving that aside. You cannot leave it aside. What we are trying to say is that all of the elements of the section work together. But I do not think that you want or the ministry wants or the government wants a system whereby addiction counsellors and all of these other people who are employed by the Ministry of Health and other institutions counsel people with alcoholism and other illnesses. That is not what this is intended to stop, and the challenge has been to try to come up with the exact concoction of words so that assessment and counselling activities continue without interference and without people fearing that they are going to be prosecuted for what they say, without at the same time unleashing unqualified diagnosticians on people.

Mr J. Wilson: Would it not be possible to put the definition of diagnosis and assessment that you are using in either the definitions section of Bill 43 or one of the acts?

Ms Bohnen: Sure. I do not know that you just want it as a definition. If the committee advised and if the government felt that a solution was to say something like, "despite this controlled act an assessment is possible" or "diagnosis only means this" or "an assessment means that," yes, by all means that is possible.

Mr J. Wilson: It might not be a bad idea. You have given us different versions of definitions of the word "diagnosis" and it would help a reader of the acts to know and I think it would help a court to know what the ministry or the government had in mind as a diagnosis. Or is there an accepted norm?

Ms Bohnen: In terms of what is the disease, what is the disorder, what is a dysfunction? The bills do not define those terms and I think it would be very difficult to define them. What you would expect if this were in court would be that expert evidence would be adduced by the relevant health experts as to what the condition was, so that would be taken care of best in that fashion. The other thing that is worth bringing out is that there are a series of statutory exceptions to this controlled act already contained in the bill and they are set out in section 28, so you should be aware of those. For example, treating by prayer or spiritual means, that is a religious healing exception, that can take place without fear of transgressing that controlled act -- clause 28(d) treatment within a person's own household.

In addition, there are delegations. As you heard the minister clarify, it will be very clear from the bill that any controlled act can be delegated. In many practice settings where people who are not physicians are providing diagnoses to patients today, it is because this function has been delegated to them. They are, at least nominally, being supervised by a physician, or a psychometrist is being, at least nominally, supervised by a psychologist. So there is a certain chain of command to ensure that there is quality assurance in the diagnoses that are being given out to people.

Mr J. Wilson: So what you are saying is it would be difficult to actually define the term "diagnosis" without also having to define dysfunction and disorder.

Ms Bohnen: No, I am not saying that. I do not think it is necessary to define disease, disorder, dysfunction and I think it would be very, very difficult to do so usefully. I think when it is an issue, expert evidence should be brought to the court that defines it.

Mr J. Wilson: What about diagnosis and assessment?

Ms Bohnen: The approach we have taken so far to try to define diagnosis is we have tried to be more and more precise. But the more precise we have been, it seems the more uncomfortable people have become. So I think the approach may be not to try to be more precise but perhaps to consider being more general and, as well, to consider giving some clarification about assessment and what that means. Those are the things the minister alluded to that we have been struggling to try to come up with.


Mr Callahan: It is a fairly horrendous fine for a breach of subsection 26(1). It is not more than $25,000 or imprisonment for a term of not more than six months or both. Has any thought been given in subsection 26(1) to taking that out of the vein of being what would be a strict liability offence to put in the words, "No person knowingly shall perform a controlled act"? I think it is interesting because this is going to be a lawyer's dream. Each of these cases is going to be decided. I mean my colleague over here has presented one which I thought was pretty good. There are probably a million of them out there that you have not thought of, and I cannot honestly believe that any government could ever think of all of them.

That being the case, if the person is innocently doing something, we really do not want him to be subject to up to a $25,000 fine or six months' imprisonment or both. So if you put in the words "No person knowingly shall perform," it might make it a little more difficult for whoever is prosecuting to have to prove knowledge, but at least it would eliminate the innocent person.

The other thing too is it seems to me that the harm clause becomes of some importance in light of what is being said about 26, because if you have a harm clause in there, then you have got a different criterion to apply to those people who do it but reach that harm clause. So you have got, as it were, two guidelines to prevent the public from being dealt with in a way that this bill is trying to safeguard them against.

Has any thought been given to putting the words "No person knowingly shall perform"?

Ms Bohnen: Yes.

Mr Callahan: Or wilfully, maybe?

Ms Bohnen: It was our view, as I recall when this drafting was going on, that constitutionally the word was implicit because with the application of the charter, a defence of due diligence and reasonable mistake in fact would exist anyway.

Mr Callahan: That is the middle guilty mind; that is not the big guilty mind. That is somewhere between strict liability and mens rea as it is understood under the Criminal Code. That was held in cases about careless driving because it carries a jail term with it, or any crime or any quasi-crime that carries a jail term with it. But what I am suggesting is taking it a step further, beyond the due diligence defence to one of true mens rea. What you are really looking for are people who are bad people, who are going to try to get around this act. You do not want people, I do not think anyway, to sit down and be advising someone or doing good work for the community or for people and have to worry about whether they need a Philadelphia lawyer sitting next to them as to whether or not they have gone over the limit. I do not think that can happen, if you have "knowingly" in there. Rather than just making it that middle mens rea, you make it an absolute mens rea. Then in fact you are catching the people who want to skirt the act. If they are not people who want to skirt the act, then why not give greater latitude to those people and not perhaps have to have them be treated for stress because they are worried about whether they are breaching 26(2) 1, 2, 3, 4.

That is my contribution, Madam Chairman. I will be leaving at the end of the week.

Mr Beer: The example we heard this morning from the physiotherapists -- not being a lawyer, I have been wrestling with this. I keep trying to find concrete examples of the concern they raised and I guess also the one that Ms Haeck raised around the tennis elbow. Now something says to me, common sense dictates that if a physiotherapist said to me, "Charles, you've got tennis elbow," that cannot be a big problem as an assessment. Clearly this would be something that physiotherapists would know, that indeed a lot of us know. I suppose it even goes back to Mr Hope's point about the number of people who might be able to tell one of us whether we were an alcoholic being a judgement call.

I guess what those groups are struggling with is that under the current situation they can go ahead and do that kind of thing, but now their sense is, or they are being advised: "You might be liable. Somebody could take you to court."

I think what Mr Callahan has mentioned is that maybe there is a way of wording that which re-emphasizes some of the concepts in the charter, but how do you deal with the kind of comment that the physiotherapists have made, where they seem to have some kind of legal judgement, not that you are necessarily going to be caught on this but that you might be? It is that certain area of the nebulous that has them all frightened. Is it that we really cannot legally deal with that, other than to say we think the words that are there would protect them, or do you feel there is a very clear protection for them and their concern is simply not valid?

Ms Bohnen: I would say a couple of things. The suggestion that words such as "knowingly" or "wilfully" be added, which will be considered, would not be a response to what you heard from the physios, because they quite consciously and knowingly are making statements. They wish to have the law made very clear that those statements are acceptable statements.

In the tennis elbow example that was cited, it may be that they find particular difficulty, as do a number of other groups, with the word "dysfunction" which is in the controlled act, because they want comfort that they can assess. How can they be given this comfort? I guess governments and others can say, "Don't worry, don't worry," but that does not seem to be working. They are worried. So there can be amendments that make that clearer.

I have mentioned the word "dysfunction" because a number of groups, and I think on occasion physiotherapists, have said they find particular difficulty with "dysfunction" because that is the word which most accurately describes the result of an assessment. If you were focusing on that concern, you might say, "Maybe that word `dysfunction' could go out there and it could be made clear that communicating assessments of dysfunctions is something that's okay."

Mr Beer: In that context, you made a comment earlier that instead of trying to define "diagnosis" more specifically, perhaps the key here is to look at how we define "assessment." At least that is what I thought you were leading to, that if there is some kind of amendment here that might be more helpful, it would be in looking at that term and having people more comfortable. As a layperson, you could almost use the terms "assessing" and "diagnosing" interchangeably, but I recognize that medically they have different meanings.

Is that a direction you could go, using Mr Wilson's point, go back to the earlier definitions that were used in the review and see if there is something that could be said around assessment that would not take away from the 13 controlled acts and what you were clearly trying to protect against, but would add a meaningful comfort level to those who seem to be wrestling with, "What is it I can really communicate after I have assessed somebody?"

Ms Bohnen: You also heard from the College of Nurses of Ontario this morning that it would be comfortable with something that incorporated the term "medical diagnosis." They understand that of course nurses assess their patients and come up with nursing plans as a result of those assessments, and they do not want to do medical diagnosis.

It may be that a combination of words that explains what "assessment" means and therefore what can be done, coupled with perhaps a more comforting definition of "diagnosis," would improve things for many groups.

Mr Beer: Is that something that, realistically, you within the ministry are actively looking at?

Ms Bohnen: Within the ministry we are actively looking at whatever options, frankly, are proposed by interest groups. You heard the minister say she really wants to hear from the committee, especially after consumer groups have a chance to speak, because they have spoken the least about this issue. What do consumers feel about it?


Mr Burrows: I would like to add to that. When one considers the number of bills here and the number of clauses and the number of real issues other than profession-specific issues, there are not very many. But the minister yesterday made it quite clear that this has been a real problem. Linda technically has explained how it has evolved. I think it is safe to say we are not convinced that the wording is perfect. In fact, it appears obvious from the number of different points of view on this that the likelihood of something changing here is strong.

Hopefully, the presenters who come forward during the next few weeks will bring forward not only criticisms but some suggestions as to how these issues may be resolved. Some of the options you have mentioned we definitely have considered: just saying "medical diagnosis," for example, and leaving it up to the courts; dropping a word here or there -- "dysfunction" seems to be particularly problematic. There is a range of other options we have either thought of ourselves or had brought forward, but certainly we are not in a position to make any conclusive recommendations yet on what any change might be until we have heard, and hopefully someone will come up with a balance that is even closer to perfection than this refined version we have. I know from discussions with the minister, and you heard her say yesterday, that she is hoping sincerely that some very positive input will be received in this process on this particular issue.

Mr White: I would like to explore this issue of diagnosis and assessment as well. The explication you gave in terms of the history of the phrase "diagnosis," the origin in terms of western thought -- one can follow that through literally thousands of years. It is a very troublesome issue. It is troublesome to many of the professional groups involved; it is troublesome in terms of defining or limiting what is something one profession can do that another cannot ever. The grey areas are particularly large.

You mentioned, for example, the systemic approach, which seems in the last generation perhaps, the last 20 or 30 years, to have evolved very strongly, but within the systemic approach you are really not talking about diagnosis as being a separate function but rather as being part of an ongoing process where a diagnosis or assessment, whichever you want to use to refer to it, is continually refined. A function like diagnosis is not end product -- it is not something you go to a particular professional for -- but rather it is part of a treatment process that is really quite inseparable.

As that is the case, as we are looking at more and more team approaches, more systemic approaches, the issue of what a diagnosis is and defining it and eliminating it in a certain way becomes, I would suggest, somewhat problematical.

You mentioned the assessment diagnosis of various psychiatric disorders. In my past experience, I could quite easily define a client I saw as having suffered from childhood sexual abuse, or having a range of behaviours and identify that. I could quite easily see, for example, something as simple as a reactive depression: You are out of work; you have a reactive depression. These are not very difficult nor really very medical issues. I guess the difficulty I have is that in some ways we have a systemic and a very specific, limited derivation occurring at the same time. I think that creates a confusion. Unless we were to also, in defining diagnosis, specifically limit it to what might be organic or physiological within a specific realm, it becomes very problematical for that whole range of professionals.

Ms Bohnen: One suggestion which has been made is that this should be limited to diagnosis of physical conditions. But before recommending that I am sure you would want to hear from the Ontario Psychological Association, the Ontario Medical Association and a number of other groups whose particular expertise lies in the area of mental illness, because there are differences of opinion as to what level of practitioner ought to be making diagnostic statements about psychological and psychiatric conditions. There is no easy answer to the issue you raise. Different groups have different views on the matter.

Ms Haeck: Just a quick question. It follows up on some of the things that have been discussed this afternoon. The nurses put forward a comment this morning about the holistic treatment of the patient. More and more there has been this move to not just deal with someone as the organic disease lying in the bed, but to look at the complete patient and have the history of the family and all the contributing factors as to what has brought about this disease, disorder, dysfunction and why that person may find himself in hospital.

We are all grappling with this can of worms: the question of diagnosis and how this impacts on these groups, of whether we are talking strictly in a hospital setting, and the whole definition of what health care is. I am looking to you as someone who has worked at this for four years and who has obviously heard these various questions many times and how you have come to grips with it. Each time I feel I have a handle on it, the target moves. Each group is presenting an interesting perspective and one to which I do not necessarily have an easy answer. From the ministry point of view, would you feel more comfortable if the courts defined health care?

Ms Bohnen: I do not have a difficulty with the lack of a definition of health care or health care service. It seemed fairly obvious to me that health care included all of the scopes of practice of the regulated professions and then some, and that if it ever became an issue a court would not have much difficulty figuring out what it meant in a concrete fact situation. On the other hand, it probably would not be very difficult to draft an inclusive definition in the bill that provided some guidance as to what health care services meant. That would not really be very difficult to do.

We are glad to hear you say that just when you think you have a handle on it, the target moves, because that is what it has been like for us. I guess our hope and the minister's hope is that through the course of these hearings, as you hear from groups and you ask groups if they have a proposal that would remedy the situation at least as far as they are concerned and hopefully as far as other folks are concerned too, that out of that the best approach will emerge. It may be one that will still leave some anxiety, but some public education and experience with the system will allay that.

Remember, diagnosis is something within the scope of practice of medicine now. The College of Physicians and Surgeons, in enforcing its licence to practice, has on occasion prosecuted non-physician practitioners who have been diagnosing their patients. We have not suddenly invented a new social issue here. It has been one that we have been coping with, applying common sense and experience to all these years, and we have just been having some difficulty coming up with words that will apply that experience to this new regulatory model.

Mr Hope: You made a comment earlier saying that I cannot come up with a conclusion of an individual or a patient, cannot diagnose, but if I see all the symptoms and I see what is going on and I recommend that you go see a doctor and then the doctor turns around and says, "Okay, you've got to go back and see him. This is what your problem is," the communication between -- whether it be the nurse, which seems to be the major issue in rural Ontario dealing with smaller hospitals. A nurse assesses an individual. You said the ability to communicate with a doctor is there, between medical and medical. If I pick up a phone and say, "Doc, this is what is going on with this individual. All signs are that his arm is hanging there, and naturally it is not attached, so it must be broken," the doctor says, "Okay, we'll fix it." That dialogue can happen is what you are telling me.


Ms Bohnen: Oh, absolutely.

Mr Hope: I can go to the person and say, "Okay, your arm is hanging there," but I cannot tell him the arm is broken. I am just trying to put this all in perspective.

Ms Bohnen: Telling somebody that he has a broken arm is not telling him he has a disease or a disorder.

Mr Hope: A disorder of a joint.

Mrs Cunningham: It depends on where it is broken.

Mr Hope: I am sorry. I may be nitpicking at this, but I have just got to get a better understanding, because what we are trying to say is that instead of going to the doctor and the doctor then moving it into this field of health services that are out there, so that the OHIP ticket just does not keep ringing on us, we are now saying you can go visit these people but you cannot make --

Ms Bohnen: Look, let's be very clear about this. First of all, if you have a broken arm, you have to have your fracture set. The only person you can go to to have your fracture set is a physician. If you are going to a nurse or a dentist or whomever for something that only a physician can provide the service for, then I think you are in trouble to start.

If your problem is that there are nurses who have to function with more autonomy in the rural areas, because we do not have as many physicians on site in rural areas as we do in urban areas, our health care system has accommodated that from the beginning of time and is going to continue to accommodate that. We have telephones. We have consultations. We have standing orders. We have myriad devices in place to make sure that people get the attention they need, hopefully as quickly as they need it.

I do not believe that these words that you as the government have to struggle with to define what cannot be done by certain practitioners are going to put a stop to that. But as the government, what you have to do is come up with the appropriate words so that you do not have every Tom, Dick and Harry, or Jill or Jane, telling people what is wrong with them when they do not have the foggiest notion what is wrong with them, unless of course as the government you decide that is the appropriate way to go.

Mr Hope: "Foggiest notion" as being specialized in that area. Is that what you are talking about?

Ms Bohnen: No, "foggiest notion" as knowledgeable about what causes people's symptoms.

Mr Hope: I heard a comment over there which I will ignore, but for so many years we have left this open gate. We have not cleaned the legislation up. Now we are at a point where we are trying to clean it up because some people have had more freedom to move around the health care system. Now we are closing it up a bit and we are putting rules in place.

Ms Bohnen: No, no. We are doing the opposite, Mr Hope.

Mr Hope: Well, not what we are hearing out of here, we are not.

Ms Bohnen: I guess it depends on whom you are listening to. You are going to hear from groups, like the College of Physicians and Surgeons, that are going to tell you this legislation is going to make Ontario the North American haven for quacks -- at least that is what they have been saying for the past few years -- because this is so deregulating the provision of health care that every quack is going to come here to practise. Then you are hearing from other groups which say, "We're not going to be able to do anything under this legislation because of this diagnosis controlled act."

It seems to me, when you hear both of these extremes, the truth is probably somewhere in the middle. As you heard the minister say, she acknowledges that there is probably going to have to be some fine-tuning to this provision. I think what what you are here for is to listen to a lot of community groups, including consumers, to help you figure out what kind of amendment would do the trick.

The Chair: Without a further question, would you like to proceed with the presentation.

Mr Burrows: Before Linda proceeds, I would like to apologize for the coughing. As a pharmacist, my assessment is that it is due to allergies.

The Chair: Do you need a medical diagnosis?

Ms Bohnen: I would like to quickly turn to the harm clause, which is tab M, because there have been some questions about that and some interest in it.

The harm clause that you see on the page before you is the version that appeared in Striking a New Balance. It in fact was the second draft of a harm clause. Unfortunately, I do not have the text of that with me. It is in the red book we gave to the clerk. I do not think you need to look at it, in any event, but suffice it to say that the original version of this clause was considered by groups like the College of Physicians and Surgeons as not being tough enough to deter unregulated practitioners. That college was of the view that the controlled acts were not of themselves sufficient to deter unqualified practitioners and to protect the public from harm from insufficiently qualified practitioners, so we had to have a kind of safety net clause, and that was the harm clause. As a result of the representations from the College of Physicians and Surgeons and some groups that the first version was not tough enough, this version that you see before you was drafted.

After Striking a New Balance was widely circulated, groups such as the Coalition of Unregulated Practitioners, social workers and other unregulated groups -- primarily those functioning in the counselling and mental health sphere -- became very concerned that this clause would so chill their activities and put them in such fear of prosecution that they would be unable to function. You will probably remember that in response to their concerns, the previous government tabled the bill without this clause, but said it was the government's intention to reinstate it after there was further consultation about what it would say. The present government has concluded that the clause is unnecessary.

The most recent public discussion of the clause makes me think that certainly the Coalition of Unregulated Practitioners and other groups that support the coalition's position feel that it would be impossible to draft a clause that would not have undue effects on their ability to practise. They have no confidence at all that it is possible to draft one that would protect the public without making it impossible for them to practice.

I suspect that you will be hearing from the College of Physicians and Surgeons and perhaps some other groups that they would like to have the clause reinstated, and a very tough clause indeed.

It certainly does appear that there is not much common ground between those two extremes of the continuum on what the content of a clause would be, in any event, but as you heard from the minister yesterday, she is yet to be persuaded that it is necessary.

Mr Beer: Is it fair to say then in relation to the harm clause, if we go back to the 13 controlled acts, when we look at that in section 26, and this sort of is the link with what we just went through with diagnosis and assessment, the problem is really around paragraph 26(2)1, the communicating?

Ms Bohnen: Yes.

Mr Beer: The others, it seems to me, are clear. When you read them, one has a sense of what they are about. In the reviews in Alan Schwartz's report, why did they feel there was a need for a harm clause? I just cannot remember. Did he look at some of the problems that have come up? Were those addressed before his working group but he still came to the conclusion that there was a need for something, or in a sense have we moved on and are dealing with different issues?


Ms Bohnen: There is some commentary in here that I think answers your question. He said:

"In commenting on the review's licence acts model, a number of participants expressed concern that licensing a series of acts identified as posing significant risk might of itself be insufficient to protect the public from harm. There are several reasons for this. The list, however carefully written, might inadvertently omit hazardous activity. The legislation might not keep pace with the development of hazardous new technologies that do not fit into one of the listed categories. Harm might be done by unscrupulous, unregulated practitioners providing care that avoids transgressing any particular licensed act. This section is aimed at preventing harm resulting from treatment or advice provided by persons who are not members of regulated health professions or who, if they are, exceed their scope of practice or licensed acts."

The rest of it is not too relevant.

This section has been revised substantially from the June 1988 proposal in response to participants' concerns. The word "significant," which modified "harm" in that proposal, has been deleted, as has the "exception for a person exercising reasonable knowledge, skill and care." An inclusive definition of "harm", as set out in paragraph 3.

The metaphor that was used by the college of physicians was that the controlled acts were like fence posts but there was not any wire or string connecting them. The harm clause was proposed as that wire on the fence. To be fair, I think there was also a strong desire to persuade the college of physicians that the new licensed act model was enforceable and was in the public interest and the hope was that this harm clause would persuade them to support the model. That really did not happen.

Alan Schwartz will be here, I am sure, later on. You may want to ask him yourself his views about this matter.

Mr Burrows: If I can just add to what Linda said too, over the change of governments we found ourselves in the position of going out for consultation on this very issue. The feedback we received -- which, by the way, is public knowledge and again is in the Ministry of Health library -- was that there was no consensus. There seemed to be a very strong criticism of (a) the need and (b) the existing wording, which led the government to its conclusion not to reinsert the clause. I am sure you are going to hear this. Those individuals or groups that still feel strongly about this, I am sure, are going to make you aware of their concerns one way or the other.

Mr Callahan: Just to carry that forward, this is really way out, and I do not mean to offend anybody by it, but let's say you had a herbalist. We have just seen a very newsworthy tragic event. Let's say someone tried to bring that under treating a person by spiritual means. Let's say they believed that treatment by herbs was something better than normal treatment. Without a harm clause in there, someone could legitimately avoid breaching section 26 by trying to bring himself within that.

Ms Bohnen: I would not combine exceptions to the controlled act with the harm clause discussion, because the herbalist, for example, might provide advice without even purporting to provide a diagnosis. You would not necessarily be into looking for exceptions to controlled acts.

If you are asking, absent a harm clause, could a herbalist who does not perform any one of the controlled acts be prosecuted under this legislation, without a harm clause, the answer is no, he could not.

Mr Callahan: That is what I am concerned about. If you do not have that harm clause in there, precisely the things, I guess, the medical profession was concerned about would be a possibility.

Ms Bohnen: Remember, first of all, that the herbalist, or whoever else, is functioning in today's environment where the regulation is based on policing the scope of practice of medicine and, as far as we know, herbalists are not being prosecuted for that. So we do not seem to be changing much of an ongoing situation.

I think the issue might be viewed in terms of when adults choose to obtain advice from a variety of practitioners, be they herbalists, physicians, registered dietitians or whatever, that they make those choices for themselves. Even if accepting the advice causes them harm, under these bills, as long as no controlled act is performed, the government accepts that risk of harm as being consistent with a model based on freedom of choice, public education and personal responsibility.

Mr Callahan: Are you saying that if someone communicated to an individual or her personal representative a conclusion identifying a disorder, and was carrying out a controlled act in that regard rather than, let's say, taking a known medication or blood, I guess, that person would escape any responsibility?

Ms Bohnen: No. I am saying if they contravened that controlled act they would be prosecuted for that, if they provided no diagnosis and no explanation whatsoever as to what the cause of the person's symptoms were but simply gave out advice not coupled with the diagnostic statement at all. I thought that is what you were asking me.

Mr Callahan: No.

Ms Bohnen: Okay, I am sorry. It does not matter what their advice is. If they perform this controlled act, they could be prosecuted.

The Chair: Linda, you have just made a statement that they could be prosecuted. Under this legislation, how would a prosecution commence?

Ms Bohnen: All right. Remember, the scheme of this legislation, like the Health Disciplines Act, first of all places the responsibility for enforcement on the colleges. Police do not lay charges; crown attorneys do not lay charges or prosecute under the existing legislation. It is a college responsibility. In fact, the experience we have with the Health Disciplines Act and other statutes demonstrates that for the most part they only act on the basis of the complaint, and the complaint is generally made when harm has been done or there is a real likelihood of harm being done. You might recall, from one of the papers you saw yesterday, that really how the system works today is that the colleges only go after and prosecute on a complaint basis instances of likelihood or real harm that happen to violate one of their exclusive scopes of practice.

We are not talking about this becoming a provincial offence, being prosecuted with the frequency of the Highway Traffic Act. That is not how it works. We do not have health police like the OPP patrolling these things and we do not want them, I do not think.

The Chair: It is almost 2:40 and we are ready for our next delegation. I have two comments, one from Mr Beer and one from Mr Owens.

Mr Beer: On these two issues, this has been very helpful both in clarifying some things and perhaps obscuring some elements as well, which is not your fault. Is it understood that you might want to come back with our two witnesses again later on?

The Chair: If that is the wish of the committee.

Mr Owens: This is exactly what my comment was to be directed to. Because of the issues around diagnosis and harm, we probably do want to have a more full discussion, before we get too far into the proceedings, so maybe early next week, if our schedule allows us to do that.

The Chair: I suggest that as we find there are changes in the schedule and cancellations -- I know both Ms Bohnen and Mr Burrows will be here. We can call on them as we have space available and will make the space available through direction to the clerk to allow for this to fill the time available. Is that the wish of the committee?

Mr Owens: The other thing we may consider doing is taking some time before or after the hearings; perhaps before would be better, say meeting at 9 o'clock for an hour, an hour and a half before we have hearings.

The Chair: The suggestion from the clerk is that we can wait until Monday to make that decision. We will have a better idea of what the schedule looks like at that time. I also point out to the committee that although the minister is going to be away, Mr Schwartz is coming in on the September 16. After having heard from everybody, we would and could have additional time then, some significant time, perhaps a day or two if you wish, to discuss these issues again. I just point out that is an option that available and perhaps we could discuss this Monday.


Ms Bohnen: I just remembered there were also some tabs dealing with title protection and a couple of other issues that I did not get to. I am sorry about that, but whenever it is convenient for you we could review those.

The Chair: We will attempt to schedule in time. We will know by Monday what is available over the next week in order to continue the ministry presentation, which we will note today is not yet complete. We have also noted the desire of members to have further discussion on the issues we discussed today. I am sure there will be other issues that will emerge from this as time goes by.

Mrs Cunningham: I have a question with regard to process. It has differed from committee to committee that I have sat on over the years. I am wondering whom the government will have with regard to clarifications and expertise on an ongoing basis. I ask the question with this in view: Many times we have witnesses come before us who are unclear or who go away with the wrong perception. Sometimes we can interject, but often we just cannot. I think it is wrong to have them leave like that. There were two this morning I could use as examples, but I choose not to at this time. They were left with the wrong impression. Sometimes we are able to clarify and sometimes we are not. Who will be the expert here? Madam Chairman, as the former minister you are very much aware that there were always people from the ministry to answer our questions and witnesses' on an ongoing basis.

The Chair: I discussed this matter with the clerk. The information I have is committee protocol. It requires either the minister or the parliamentary assistant to carry the legislation through committee. In the absence of that, in normal committee protocol, either the committee members can address questions informally to ministry staff who are here and ask for responses in writing, hopefully the same day or at the earliest opportunity, or when the minister is here ask for clarifications at that time, or when we have the discussion following the hearings or with Mr Schwartz, and so forth, we can have those clarifications put on the record.

Mrs Cunningham: Are Mr Burrows and Ms Bohnen going to be here on an ongoing basis? Is that the plan?

The Chair: It is my understanding that both Mr Burrows and Ms Bohnen will be with the committee for all the hearings. Is that correct?

Ms Bohnen: Yes, but it is also my understanding from yourself, Madam Chairman, and from the clerk that we will be here but that we are not in a position to speak during hearings.

Mrs Cunningham: Unless we ask.

The Chair: The protocol of the committee is that when groups and witnesses are appearing, the questioning is between the committee members and the witnesses. If there is a request for clarification, that is done informally with the ministry. They submit that in writing to the committee or at another time, unless the minister or parliamentary assistant are here in which case they are the ones you direct the question to. That is committee procedure as it has been explained to me by the clerk.

Mr Owens: My understanding is that there should be a parliamentary assistant on board within the next day or so who will be available for questions.

Mr Callahan: Who is it?

Mrs Cunningham: I am sure we will have all his time and his expertise. A question goes to the parliamentary assistant, and if that person cannot answer it, then it is referred to staff. That has certainly been my experience.

The Chair: That is normal procedure as well. If the parliamentary assistant is carrying the legislation, he or she can ask the staff to give an explanation.

Mr Owens: That person should be here tomorrow; if not, by next Monday at the very latest.

Mrs Cunningham: I suggest it would be better, given the presentations so far. Good for you, Steve, because you just might get stuck if it does not happen.


The Chair: We have a deputation waiting. I would like to call the Professional Advisory Council of the Speech Foundation of Ontario. Please introduce yourself. Welcome to the social development committee. You have 40 minutes for your presentation. I ask that you try to leave some time for questions from the committee, if you wish.

Mr Girolametto: Sure. I am going to be really brief. In fact, I would rather have my hair cut with a chainsaw than be here today with this weather outside. At home I have two contractors let loose in the house, a heating contractor and a building contractor, and half of me wants to be there to supervise and the other half is very grateful for the chance to be here to speak with you.

My name is Luigi Girolametto. I am a speech-language pathologist at the Hospital for Sick Children and assistant professor at the University of Toronto in the graduate department of speech pathology. I am making this presentation on behalf of the Professional Advisory Council of the Speech Foundation of Ontario. That title and address are on the cover page of your handout, which is pink.

When I saw the advertisement in the Globe and Mail inviting presentations to the standing committee, I phoned Lynn Mellor. When I got the appointment, I immediately panicked. Lynn gave me political science 101 over the phone really fast. I did not know what to expect, so I prepared a presentation and hope I will be brief and that the concerns I have chosen to present today will be accepted by the committee.

I know a lot of work has gone into this bill. By and large it is a very favourable bill. It has certainly gone through successive governments, and we have a chance at this point to make it an outstanding bill.

I will just quickly go through the handouts with you so that you know what is in your package, and then I will start from the beginning. Page 2 has a brief description of the goals of the Speech Foundation of Ontario and the aims of the professional advisory council. I will look at those with you in just a moment. It is a bit of information about the group. Page 3 is a summary of the two recommendations I want to suggest today. Pages 4 and 5 are the concerns I want to present to you, so I will go over those in quite some detail. Finally there is a lot of information in the appendix that I will be referring to. There are some sample doctorate degrees I will refer to later. There is a sample appointment letter to parents at the Hospital for Sick Children whose children are receiving a developmental evaluation. There is a members' list for the professional advisory council, of which I am the chair, and a members' list of the board of directors of the Speech Foundation of Ontario. Finally, there is a position statement of the Speech Foundation of Ontario, and that is all happy reading for you some time when you cannot sleep, I guess.

To go back to the beginning, the Speech Foundation of Ontario has as its objectives to promote a wide variety of clinical programs to deal with speech and language disorders. Also, it supports treatment, research and the training of speech-language pathologists at the master's level. It also promotes and advances public awareness.

The aim of the professional advisory council is to advise the board of directors, none of whom are speech-language pathologists, about research issues, training issues and service issues to children with speech and language disorders.

On page 3, the two recommendations I am going to make today are summarized for you. The first deals with controlled acts. I gather you have heard quite an awful lot about controlled acts today. Linda Bohnen, who just spoke, brought this up as well. As it reads now, all communications with regard to speech-language assessment and speech and language disorders would have to be made through a doctor or a psychologist. We would ask committee members to review this clause to allow speech-language pathologists to communicate the results of a speech and language assessment directly to the patient; that is, to make a speech and language diagnostic statement to the patient himself or herself.

The second recommendation deals with section 30, the restriction of the title "doctor." As it reads now, a speech-language pathologist with a PhD would not be allowed to use the title "doctor" in the provision of health care, whereas a psychologist with the same degree status would be allowed to use the title "doctor." We ask the committee members to recommend expansion of the title "doctor" to those health care professions offering doctorate programs.


I will quickly go over some information about controlled acts. In general practice today, speech-language pathologists routinely present conclusions to the patient, or to the patient's family in the case of children and stroke victims, and counsel them regarding the results of the assessment. This is routinely part of the assessment process. Speech-language pathologists are highly trained to assess, diagnose and treat a very specific group of speech and language disorders and dysfunctions, as set out in their scope of practice. They are also trained to recognize when it is appropriate to refer the patient to a physician for an assessment.

The problem we see with this section as it stands now is that the physician or psychologist does not perform the assessment and is not present during the assessment. Thus that person who communiciates the result of the assessment does not know the tests used, the behaviours the child or patient presented and how the patient presented in general. That person is not specifically trained in the assessment of all communication disorders.

As an example, 60% of the referrals that come to the Hospital for Sick Children by physicians are for articulation disorders. Of those, only about 20% are articulation disorders. In fact the rest are speech and language disorders with a primary language component. So doctors by and large are not that aware of the range of speech and language disorders that children can have.

These persons are not involved in the design of treatment programs based on assessment results, cannot make prognostic statements on behalf of patients and may not be involved in the long-term treatment of the patient's communication disorder. Therefore, as the diagnosis evolves -- this happens very frequently, that a child with a language disorder evolves into a child with an articulation disorder once the language clears up -- a further visit to a doctor would be required to clarify the diagnosis or update the diagnosis.

The gist of all this is that for the patient it means an unnecessary number of visits. First there is the assessment by the speech-language pathologist, a visit to a physician or a psychologist for the conclusion, then back to the speech-language pathologist for further treatment. Pages 2 and 3 of the appendix, which is the position statement, further clarify this, and I will just let you read that on your own. You might just want to note that pages 2 and 3 do in fact clarify this further.

There is a lot of confusion, I think, that could be generated to the patients. Specifically, there is some concern that complete information will not be shared with the patient or the patient's family from those most knowledgeable and qualified in the area of communication disorders. That can result in confusion to the patient, particularly when, as I mentioned earlier, most physicians are referring for articulation disorders and do not realize that they are in fact referring a child with a language impairment or a language delay.

Finally, there is the delay of treatment as well. Because of the issue of having to go to the physician or psychologist for communication of a diagnosis and back again, there is a potential delay of treatment. For the health care system, this all adds up to extra dollars.

We would therefore ask that committee members review this clause and allow speech-language pathologists to communicate the results of an assessment directly to the patient pertaining to speech and language.

The second issue, on page 5, deals with section 30. I am racing through this, but probably you were able to follow that part and I will be happy to answer questions at the end of the presentation. Historically, speech-language pathologists holding doctorates, ie, a doctor of philosophy -- I have three sample degrees in the appendix for you; those are degrees of persons who are on the professional advisory council currently; there are five speech-language pathologists with doctorates on the professional advisory council at present -- worked in academic and research settings. In the last 15 or 20 years, however, there has been an increasing trend for PhDs to be employed in health care settings. Their positions have combined clinical excellence in their specific area of speech and language pathology together with clinical research. The use of the title "doctor" by those who have earned this degree is common practice in health care settings in all the other Canadian provinces, in the United States, England, Australia and the rest of Europe.

Problems that arise from restricting the title "doctor" deal, first of all, with an issue of inequity. Psychologists with the same degree status, that is, doctor of philosophy, will be allowed by this act to use the title "doctor," and I ask, what makes the speech-language pathologist with that same degree status so different? Second, I think there is a potential for confusion to the patient in the sense that a patient who visits a psychologist can call that psychologist "doctor," yet when that patient subsequently visits a speech-language pathologist, he or she reverts to Mr, Ms or Mrs.

As an example, if you will flip to the appendix, there is a sample appointment letter. This is an appointment letter that is sent out by the developmental evaluation unit. If you look at Tuesday, May 28 -- by the way, this is a patient I saw in May -- at 10 o'clock, that patient had a psychology assessment with Dr Marcovitch, psychologist. She has a PhD and the patient's family was able to call Sharon Marcovitch "doctor." On Wednesday at 9:30 there was a speech and language assessment with me in the speech-language pathology department. If this act goes through, the parents of that patient would be required to call me Mr, yet I would have the same degree qualifications up on the wall. I think this inequity creates confusion, and also for the consumer, and I think consumers have the right to know the degree status of the persons whose care they are under. I think that in knowing this, it alleviates some of the confusion titles can create.

The right to confer a degree is vested in institutions of higher learning. Excluding PhDs from using the title "doctor" infringes on the role of universities as well as the individual rights of the degree holder. Again, I emphasize that this does go against standard practice in North America and Europe.

Finally we would ask the committee members to recommend expansion of the use of the title "doctor" to those health care professions offering doctorate programs. This involves nursing, occupational therapy, physical therapy and audiology as well as speech-language pathology.

That is it. I have kept it short and I am very happy to answer any questions you have.

Mr Beer: I want to address my question to the last point you raised around title. It is for purposes of clarification, but I think is important. We have been visited by a number of your colleagues, broadly speaking, on this issue, but the point is not that everyone who is a speech pathologist can refer to himself or herself as "doctor," but only those who have fulfilled the requirements of a doctoral program at a university.

Mr Girolametto: Exactly.

Mr Beer: Those people are in the same boat as somebody who did it in history or philosophy or whatever; they have a right to use that term "doctor" and should continue to have that right. I take from that, first of all, there is the principle about it. I think there was a gentleman this morning who wondered whether, even if the province sought to deny you the right to use that, in point of fact that would stand up in a court of law in any event. But it would seem to me there is a point of principle there that we have to look at, and frankly I had not been aware of that particular part of the problem.

I have also been told that in a hospital setting, if you are going around with your coat on, it would say Dr So-and-so and then underneath it says what you do. So in terms of confusing patients, it is quite clear that you are a speech pathologist or whatever.

Then I guess the other point that has been made is that there are a number of people within the greater Metropolitan Toronto area -- one example given to me, I believe, is the person who is the head of the Hugh MacMillan Medical Centre, who is Dr So-and-so but whose degree is in engineering, albeit, as he has gone through his career, he has applied the engineering to helping those with disability problems and so on.

That is, as I understand it, the nature of the problem.

I think for me, and what I have said to people who have come in, I want to explore both with ministry staff and whoever else out there thinks you should not be allowed to do that what the reason or reasons are, because on the face of it, it is a hard one to accept when it would appear that other jurisdictions allow somebody who legitimately has a doctorate to call himself doctor. That is where I am with that one. It seems to me you have raised a legitimate point. On the face of it, it would seem perhaps we are moving into an area that we really do not need to move into, subject to somebody explaining to me that there is some compelling reason why we have to ensure that you cannot call yourself "doctor," at least not in a hospital.

Mr Girolametto: I think too that speech-language pathologists and audiologists will have a college which will ensure that this title is used appropriately by those persons possessing the degree status. I think too that the legislation does promote some inequity. A psychologist, as I pointed out, will be allowed to use that title, and I think it is either all or nothing with respect to health care providers.


Mr White: Further on with what Mr Beer was mentioning, it strikes me that with that exclusion as it is written into the bill, you could still refer to yourself as a doctor. Most likely you would not be called to account. You probably would not be charged under the act. Most of those things would not happen.

On the other hand, within the institution where you work, although your patients would not be confused about what your role would be, that institution would not recognize your doctorate. As you suggested, this patient would have an appointment with Mr Luigi but it would not say "doctor." The institution would not recognize it.

Mr Girolametto: That is right.

Mr White: Following Mr Beer's point, if one has a doctorate in the area of his specialty, whether it is social work, speech pathology or whatever, that does not seem to be problematic unless one is, say, working as a speech-language pathologist and has a doctorate in --

Mr Girolametto: Engineering, math, history.

Mr White: Right. In that sense it would be misleading, but I cannot see otherwise that it would be.

Mrs Cunningham: This is one of those instances where I thought we had asked this question yesterday of the staff and had been assured that in fact his title, PhD, could be used and people could be referred to as positions. If it is appropriate, Madam Chairman, I think that should be reiterated.

The Chair: We will make note of that and at the appropriate time -- a comment?

Mr Cordiano: I think there is a distinction to be made. It is not just the title PhD; I think it is the title "doctor" that we were talking about, the actual word "doctor" being used in front of someone's name.

The Chair: There will be an opportunity for further discussion of many of these issues at the appropriate time during the hearings, and we heard there is likely going to be a PA appointed in the next little bit of time.

Mr Cordiano: Okay, but I just wanted to make that distinction as far as I was concerned, that there is quite a distinction between what you have just said, Mrs Cunningham, and what I think the deputant is saying about the title "doctor," that it is something vastly different.

Mr Girolametto: Yes. The D in PhD stands for "doctor," but the restriction of the use as presented by the bill restricts us from using that specific word.

Mrs Cunningham: My point was that when I asked the question yesterday, the response I got was that the word "doctor" could be used. I would suggest, sitting here as a person who has been involved with the medical community, that anybody who has a PhD who wants to be called doctor, unless some institution says otherwise -- if that were me and I had your degree, I would not work for them. It is that simple.


The Chair: The next group appearing before the committee is the Ontario Society of Medical Technologists. Would you please come forward. You have 20 minutes for your presentation. Please introduce yourselves to the committee. We would ask that you try and leave some time for questions at the end of your presentation.

I would ask all members to give you their attention and ask you to introduce yourselves and make your presentation.

Mr Morrow: My name is Des Morrow. I am pleased to be here as president of the Ontario Society of Medical Technologists and to have the opportunity to speak today in support of the Regulated Health Professions Act.

The medical laboratory technologists of Ontario have long pursued the goal of self-regulation and inclusion in the Health Disciplines Act. Over the past 10 years considerable changes have taken place in technology, the technologists and the laboratory environment. Public awareness has increased and enhanced the need for legislation to protect the public interest.

The Ontario Society of Medical Technologists has been an active participant throughout the Health Professions Legislation Review, monitoring and commenting on the respective stages. This dialogue with the review team and later with the professional relations branch of the Ministry of Health has resulted in legislation which meets the need to provide protection for the public and which represents the profession appropriately.

The OSMT represents some 8,000 medical laboratory technologists working in the province, who in turn constitute the third-largest group of health care professionals in the province. The practice of medical technology includes the main disciplines of clinical chemistry, clinical microbiology, haematology, immunohaematology, transfusion medicine, histotechnology, diagnostic cytology and the disciplines of virology, parasitology, immunology, cytogenetics and electronic microscopy; quite a mouthful.

Mr Beer: Is there going to be a test at the end?

Mr Morrow: That is why I have them written down. I cannot remember them.

In clinical chemistry, technologists analyse blood specimens to measure a wide variety of constituents, ranging from a simple blood sugar level in a comatose diabetic to the complex analysis of drugs and hormones. Examples of this might be the identification of the causative drugs in an overdose patient or the investigation of the causes of infertility. This is often accomplished using highly sophisticated and computerized equipment. In haematology, the blood cells and plasma are studied in search of anaemias, leukemias and clotting disorders such as haemophilia. Clinical microbiology encompasses the isolation, identification and antibiotic susceptibility of bacterial, fungal and parasitic infections. In more simple terms, it perhaps might be the identification of a bacteria causing an infected throat and indicating which antibiotic would be effective in treatment.

The importance of compatibility testing for units of blood to be transfused during surgery or following blood loss and the cytological assessment of pap smears for the early detection of cancer is self-evident.

Medical laboratory technology therefore plays a vital role in the diagnosis, treatment and prevention of disease, and as such it is imperative that the consumer is protected from incompetence and has a say in the performance and future development of professional practice. Quality assurance of laboratory testing was part of our daily professional life long before the concept was generally accepted and we support the professional quality assurance aspect of this legislation. We are pleased that the college council will set clear standards for entry to practice and that the act embodies the concept of professional equality.

I would like to pass the floor to my colleague Sheila Woodcock, who has chaired the OSMT legislation steering committee, to comment on the history of the OSMT involvement and more specifically on Bill 53, regulating the profession of medical laboratory technology.


Mrs Woodcock: The Medical Laboratory Technology Act will establish a College of Medical Laboratory Technologists of Ontario, which in turn will set standards for entry to and ongoing practice in medical laboratory technology.

Even prior to the initiation of the Health Professions Legislation Review the OSMT had been actively pursuing legislation for the regulation of our profession. The Laboratory and Specimen Collection Centre Licensing Act exists to regulate the operation of medical laboratories, but reference to the technologists is limited to a broad definition of who may work as a technologist. It does, however, define the role of the laboratory technologist as one who performs tasks which require the exercise of independent judgement. This is distinct from the technician, who works under direct supervision and performs only tests which require limited technical skill.

Changing technology has simplified the performance of some of the more frequently performed tests, such as blood glucose. Many diabetic patients use glucometers to monitor their glucose level and adjust the insulin dosage if required. Within the hospital setting, the use of glucometers has proliferated. The apparent simplicity of this instrumentation may lead to the misconception that checks and balances used in laboratory testing are not required. This is not the case. In fact, quality control of the procedure is vitally important and there have been at least two tragic outcomes from the inappropriate use of glucometers.

An extensive study of current practices has been undertaken and recommendations developed for standardized implementation within the hospital under the jurisdiction of the laboratory. This has subsequently been endorsed by the Canadian Council for Health Care Facilities Accreditation.

The public needs to understand what happens in that mystical place, the laboratory, and the importance of the accuracy of the results produced. The Regulated Health Professions Act will not only create an increased awareness of the profession but also a means of investigating and obtaining information on individual practitioners. A member of the public will be able to approach the College of Medical Laboratory Technologists to verify the qualifications of an individual or to lay a complaint should that be necessary.

The days of the bubbling flasks, the big syringes and most manual techniques are long gone. The laboratory today is filled with sophisticated computerized equipment requiring the vigilant judgement of the medical technologist. Similarly the old images of the past are replaced by highly skilled modern medical laboratory technologists, vital members of the health care team.

The minister, in her proposed amendments tabled yesterday, has recommended a change in the wording of the statement describing the scope of practice of medical laboratory technology. It now reads: "The practice of medical laboratory technology is the performance of laboratory investigations on the human body or on specimens and the evaluation of the technical sufficiency of the investigations and their results."

Changing technology and the consequent need for change in the role of the technologist are reflected in the revision of the former wording, "on specimens taken from the human body." Some tests can now be performed using non-invasive techniques at the patient's bedside.

The medical laboratory technologist should be involved in near-patient testing to avoid pitfalls encountered previously with the indiscriminate use of new technology. The change in the scope statement does not limit the role of the technologist as the evolution progresses. This in turn should reassure the public of the appropriate skills being available no matter where the testing is performed.

Another change to the scope statement qualifies and clarifies the phrase "the evaluation of the technical sufficiency" with the addition of the words "of the investigations and their results."

The minister's proposed amendments also recommended inclusion of a controlled act permitting the medical laboratory technologist to obtain the blood samples required for testing. The minister has proposed the addition of a section 3.1 to Bill 53: "In the course of engaging in the practice of medical laboratory technology a member is authorized, subject to restrictions on his/her certificate of registration, to take blood samples from veins or by skin pricking." As technologists we would recognize "skin pricking" as being capillary puncturing.

The public image of the laboratory technologist is often limited to the person taking the blood sample. As a profession, we have striven for years to overcome or at least broaden this limited perception. It is important, however, to recognize the potential hazards associated with the collection of blood and to put in place a mechanism for quality assurance of the procedure. With the inclusion of this controlled act in Bill 53, the College of Medical Laboratory Technologists will be responsible for setting and maintaining standards for blood collection.

Once this legislation has received third reading and royal assent, a transitional Council for Medical Laboratory Technology will be appointed. This council will have the task of writing the regulations to define the entry-to-practice requirements. We understand that grandfathering will be a concern to some of our profession and we propose to work with the transitional council on this issue, but in the course of the hearings it is entirely possible that this issue may be raised by other technologists.

We want to say that we support the minister's proposed amendments to the legislation.

Mr Morrow: We will be glad to answer any questions we can.

Mr Owens: It is funny you should raise the issue of grandfathering. This is a concern that has been raised to me by a number of my former colleagues down the street at the Toronto General Hospital. I wonder if you could briefly explain to the committee what is meant by grandfathering and why some people find that problematic.

Mrs Woodcock: What is meant by grandfathering is that when you bring in new legislation that encompasses a profession there is sort of an underlying assumption that -- the transitional council will have the task of defining what the entry-to-practice standards are, and there probably will be one standard defined. We know that standard within our profession would be certification by the Canadian Society of Laboratory Technologists, which is held by 90% of the practitioners in the province. There are, however, a small number of people who hold other qualifications, and the challenge facing the council will be to decide what are appropriate qualifications and whether or not those people will be accepted with their existing qualifications or whether they will be required to undertake further examinations, training, whatever.

As a society we had discussion on this and we will be in dialogue with the transitional council, but at this stage we feel it is not appropriate for it to be addressed, but we know there are concerns out there, yes.

Mr Callahan: That is just a little bit more than grandfathering. That is really retroactively possibly changing someone from fish to fowl.

Mrs Woodcock: That is one interpretation, that is true, yes.

Mr Callahan: You are saying it is about 5% of the present profession who would be affected by that.

Mrs Woodcock: Roughly; 5 to 10 per cent.

Mr Callahan: These would be people who would be at the point where they might be close to retirement.

Mr Morrow: These are probably people who are British or American qualified and presently can work under some complementary legislation, the laboratory licensing act, which defines who can practise medical technology in the province.

Mr Callahan: I speak only personally. I recognize the reasons for this legislation -- very ambitious and also needed and very good -- but I do have some concern about the fact that it is more than grandfathering. Grandfathering is, in some respects, where you put a time frame on legislation to have it disappear or not take effect or to take effect at some later date, but it does not, as far as I know, ever interfere with a person's right or ability to continue in the profession he has chosen.

That does concern me. I do not know whether the rest of the committee would want to know, but I would certainly want to have some idea if I were voting on this, which I will not be because I am only a sub, but I would want to know what hurdles these people might have to overcome to continue in the chosen field that they have. I do not know whether that can be done or not.

Mrs Woodcock: We cannot answer that question until the transitional council defines the entry-to-practice standards and makes the decision on what it will do with these people. They may very well decide to accept everybody who is currently practising as a technologist for registration within the college.

Mr Callahan: You are saying then that they have not given any consideration to that at this point and would not have something at least in mind before this legislation was passed.

Mrs Woodcock: As a society we have recommended that the qualification held by the majority of technologists be recognized as the entry-to-practice standard, but we have no way of knowing that this will be the only qualification accepted.

Mr Callahan: All right.

Mrs Woodcock: So it is very difficult to argue this whole issue until later on in the process.

The Chair: I would like to thank you for your presentation to the committee. I am sorry, we are out of time.



The Chair: Our next presenter is the Association of Ontario Midwives.

Mr Callahan: These people get a badge for the most effective lobby that has ever existed in this province, and I want to be the first one to congratulate them. There probably were more petitions presented in the Legislature on this one issue than in the history of this country.

The Chair: Welcome to the standing committee on social development. You have 20 minutes for your presentation. We would ask that you leave a few minutes for questions.

Ms Kilpatrick: I think we will have lots of time. I saw in the agenda that I had 10 minutes, the one I saw earlier.

The Chair: Are you representing the Association of Ontario Midwives?

Ms Kilpatrick: Yes. Maybe my math is bad.

The Chair: Actually the agenda looks like 10 minutes, but the association should have 20 minutes. If you can do it in a shorter time, that will be fine.

Ms Kilpatrick: My plans were shorter, so hopefully we will get through it.

I am going to start by making some general comments about our association and our association's involvement with this process and general comments about the legislation. We have only a couple of specific comments to make specifically on Bill 56, the Midwifery Act.

Our association has participated in this legislative review since the review team was appointed in 1983. The lengthy consultative process has provided the opportunity for discussion among many professions regarding general health care and governance issues. We believe the resulting legislation will have a positive impact on the health care system, benefiting not only the public but the professions as well.

This legislation moves us towards a more responsive and accountable health care system. Open public hearings will help to ensure accountability of the professions to the public, and public protection will be enhanced by the increased number of public members participating on councils. The Health Professions Regulatory Advisory Council also provides for greater public input to health care policy decisions.

We also fully support the concept of providing health care consumers with a wider range of choices of practitioners. We believe the controlled acts model which controls those acts that are potentially harmful instead of licensing a profession, thus giving that profession a monopoly over all acts interpreted to be part of that profession, offers a balance of increased consumer choice and public protection. This framework acknowledges the important contributions of a variety of health care providers to the system.

Our association supports the Health Professions Regulatory Advisory Council also as a mechanism to keep the legislation and in turn the health care system responsive and to keep the act relevant.

We would like to make one comment on the procedural code and our other comments, as I stated, will be specific to Bill 56, the Midwifery Act. With respect to quality assurance programs in section 80 of Bill 43, confidentiality is addressed as it relates to the member. We believe it would also be appropriate to address client confidentiality when discussing quality assurance programs.

Midwives will be providing primary care to their clients during pregnancy, labour and the post-partum period, according to the proposed scope of practice. In addition to the draft amendments submitted by the Minister of Health to this committee, we would like to ask the committee to consider the following issues:

There are three other acts which we believe should be included to enable midwives to provide continuity of care within the proposed scope of practice and according to the international definition of a midwife adopted by the Interim Regulatory Council on Midwifery.

The first is pre-natal blood screening. This is performed on all women and we believe midwives should be permitted to draw blood in this instance. In addition, if the mother is Rh negative, a post-natal blood screening is also routine. The change that would be required is that midwives would be permitted to perform venipuncture for the purpose of routine blood screening. Another method of obtaining a blood sample is by skin pricking or, as we just heard, capillary puncturing. This is currently used by some midwives to obtain a haemoglobin assessment by use of a haemoglobinometer.

The second is that in the course of a normal labour it may be necessary to rehydrate a woman by use of intravenous fluids. This is an instance where a midwife would be continuing to provide primary care. In the interest of continuity, as well as in recognition of the midwife's role as primary care giver, we believe midwives should be able to insert an intravenous catheter for the purposes of rehydration.

The last is that with the recent draft amendment proposed to this committee we understand the suggestion is that midwives be able to prescribe as well as administer certain drugs as specified in regulation. We believe midwives need access to a limited list of drugs in a limited number of situations, and in each of these situations it is within the course of complete primary midwifery care and enhances continuity of care, as well as client safety.

Our concern relates exclusively to post-partum care when a midwife may need to leave a medication with a woman to take in the midwife's absence. Rural midwives are particularly concerned about this, as their clients may not be able to fill a prescription for several hours. It is our position that the inclusion of dispensing for specific medications in specific post-partum situations allows midwives to practise fully within their scope of practice and according to the definition adopted by the Interim Regulatory Council on Midwifery.

That is all and I am ready to answer questions.

Mr Johnson: Midwives are, in quotations, "a new profession," but they are not really; they have been around for a long time. At one time they were an accepted and welcome part of the community, I have no doubt. As you have given your brief today, you have asked for some things and you certainly have gone into some detail, but I was wondering how easily the kind of care that is advocated by midwives, client-centred and continuity of care, will mesh with our modern hospital routines. That is not to suggest that what midwives are doing is something ancient or something that is not new, but how will it mesh with routines in the hospital?

Ms Kilpatrick: Currently there are midwives who do not work within the hospital as a recognized part of the team. But there are clients who seek midwives who still want to have their birth take place within the hospital. So I think the system has begun to see how midwives practise and what people want from midwives. Those of us who have worked with our clients within the system have begun to give it a try. I am not quite sure whether you want to know where we fit in relation to nurses and physicians, if that is the specific question you are asking.

Mr Johnson: Certainly you will have a relationship with them.

Ms Kilpatrick: Right.

Mr Johnson: I was wondering what kind of relationship you will have in working with nurses and doctors. What kind of relationship do you expect?

Ms Kilpatrick: Think of the midwife as the practitioner providing primary care, not just client-centred or continuity of care. We also have submissions at this point in time in the review of the Public Hospitals Act that midwives should have admitting and discharge privileges within the hospital system. So midwives would work with their client going into the hospital and providing primary care within the hospital system. We would interact with nurses, as nurses are providing the ongoing care within the hospital when the midwife is not with her client, if the labour is over, for instance, and the woman remains in hospital overnight. The midwife would not remain throughout the night, so the nursing staff would then be providing the ongoing care. The relationship we envision with physicians would be most commonly a consultative relationship in situations outside a midwife's scope of practice.


Mr J. Wilson: To play devil's advocate, the Ontario Nurses' Association suggested today that perhaps midwives should be qualified nurses first. Do you want to comment on that?

Ms Kilpatrick: Yes, we have been commenting on that since we made our first submission to the Health Professions Legislation Review. One of the arguments we made at that point in time is that in fact the profession of midwifery is a longer-established profession than the profession of nursing. Midwifery is an identifiable profession with a very defined scope of practice, much more clearly defined than many others possibly, and the tradition of nurses first and midwives second is a very recent North American phenomenon.

In fact, when the Task Force on the Implementation of Midwifery in Ontario did its investigations worldwide, it found there actually were a lot of different countries with well-established professions of midwifery that identified it as a separate profession from nursing, not a specialty of nursing, as the ONA would describe it. That essentially was our position, that it is a separate profession traditionally, and it is a very recent phenomenon that we have this understanding that it is a specialty of nursing. It is primarily in North America that we have this understanding.

Mr J. Wilson: In a hospital setting, following on Mr Johnson's question, how do you figure you would get along with nurses, who seem to have their concerns? It seems like a bit of a turf battle, to tell you the honest-to-God truth.

Ms Kilpatrick: I think the only way we can find out how we will get along is by working alongside the professions that are in the health care system now. As Mr Johnson said, we are a new profession in Ontario and we will be establishing relationships with a number of professionals who have been working in the system as long as they can remember. It will be, I think, a slow integration process.

The task force on the implementation of midwifery asked hospitals and services to make presentations if they were interested in midwives working in their particular hospital. I think one of the ways will be midwives' services or midwifery services being offered by institutions or by centres that are interested in having midwives working there. So the beginning of establishing relationships with other professionals working in the system, primarily nurses and physicians, will first be with those who want to work with midwives. Then the rest of the system will become exposed to midwives working in those particular services of whatever sort: an exposure kind of process and a working out of the roles that midwives will play. How that will affect the roles of the other professionals will then be worked out basically in the working relationships.

Mr Owens: What types of medications would you be looking at prescribing?

Ms Kilpatrick: We have talked about this on the Interim Regulatory Council for Midwifery. They are just beginning to look at regulations. They would be very limited, mostly post-partum, possibly just analgesics for post-partum pain. There is an injection of an oxytocic drug that stops the woman from bleeding post-partum. There is another time that may be necessary: in a labour, the same kind of agent, an oxytocic agent, that would stimulate the labour. We have not made the recommendation that midwives would directly prescribe that, but post-partum you may need to give a woman an injection of an oxytocic drug to stop bleeding.

That is administering more. The prescribing was to cover, I believe, working within the hospital as well, so that you have the power to write an order and leave an order behind with a nurse.

Mr Owens: Basically, you are looking at a Tylenol 3 or something like that. We are not talking about any type of narcotic agents.

Ms Kilpatrick: Well, Tylenol 3 is considered a narcotic agent. Analgesics basically for pain relief post-partum are one of the main. There are very few actually. It is a very limited list of medications that midwives would need access to and would be using within a normal practice, within a low-risk pregnancy.

Mr J. Wilson: How many midwives are there currently in Ontario?

Ms Kilpatrick: Our association has a roster of practising midwives and then we have a membership for non-practising midwives. The practising midwife membership in our association is around 60. Our non-practising midwife membership is fairly low, around 25. There are probably thousands of trained midwives from numerous other countries.

The College of Nurses did a survey, around the same time that the task force on the implementation of midwifery was trying to sort out how many trained midwives there are from other countries, as well as the practising midwives, and the College of Nurses found out how many college registrants were also midwives. But there are a number of midwives, particularly from the Philippines and other European countries like Holland, who are direct-entry midwives, that is, they are not nursing. Therefore, right now they are probably not registered with any other health profession, college or association. There is really no way of assessing those numbers.

Mr Callahan: I have two questions. The first one is, apart from these people who have come from other countries, where does one become educated in midwifery?

Ms Kilpatrick: Currently?

Mr Callahan: Yes.

Ms Kilpatrick: In our association, our membership, the majority of practising midwives are apprentice-trained midwives. They learn from other midwives, usually here in Canada, many of them in Ontario. About one quarter of our membership are midwives who have formal midwifery education from another jurisdiction.

Mr Callahan: Is it proposed that this would be a course that one could take at one of the community colleges or a university?

Ms Kilpatrick: The decision has not been made where the midwifery educational program will be mounted from. There is no decision, as far as I am aware, of where the midwifery education program will be located.

Mr Callahan: Does your association resist, as was suggested by the nurses this morning, the additional qualification that they be either RNs or RNAs?

Ms Kilpatrick: Yes.

Mr Callahan: Not to want to advance one turf over the other, recently in British Columbia there are two midwives who are being criminally prosecuted for having practised what the crown is alleging to have been criminal, in a negligent way. I also notice that the scope of your service is "conducting of spontaneous normal vaginal deliveries."

Not that I want to give the medical profession a black eye, but I am sure we have all heard of cases where a patient has been under the care of a doctor and he happens to be occupied elsewhere, be it outside the hospital -- I will not go into what activities -- and the nurse in attendance very often becomes the perhaps unwilling subject of having to conduct a spontaneous normal vaginal delivery. Would you not think that in a case like that the additional qualifications of either an RN or an RNA would be of some importance, or if complications arose in, let's say, a delivery of that type and you were not in a hospital setting? I had a lot of questions there.


Ms Kilpatrick: Yes. Addressing the conducting of normal spontaneous vaginal delivery, the scope of practice, the educational program will prepare midwives to conduct a normal vaginal delivery. But the bulk of the midwifery educational programs that we have investigated and that we support the Ontario program to somehow reflect is that one of the main tools you have to be sure that you are attending a normal vaginal birth is that you assess throughout the pregnancy and you know how to detect an abnormal condition and you refer then to someone who is qualified to deal with an abnormal condition.

The Chair: Thank you very much for your presentation.


The Chair: We are now going to hear from Lina Di Carlo. Welcome to the social development committee. You have 10 minutes for your presentation. We would ask, if you could, that you leave a few minutes for some questions from the committee members.

Ms Di Carlo: I am not very good at this, so you will have to bear with me.

The Chair: Do not be nervous. While it is a formal committee hearing, we ask you to be quite informal and comfortable as you address the committee. We are here to listen to what you have to say.

Ms Di Carlo: In reading the answers to the House after the second reading of Bill 43, I was disturbed by two things: (1) that 22 bills were discussed at the same time; and (2) that the word "patient" kept recurring throughout the document.

In the first case, this means to me that the concerns of the disabled community are not important enough to be discussed as a bill which affects us so drastically and should have been discussed separately from the others.

Second, this bill says to me that the politicians consider individuals who use mobility aids as "patients." We are not patients. We are not sick. The health professionals rehabilitated us when we were sick so that we could live independently. So now, let us.

In this paper you speak of an exemption. This exemption regulates the care giver. It does nothing for the individual receiving the care. We do not need to be taken care of. We want the right to direct our own care and our own lives.

Also, Bill 43 is very patronizing. It says that, as we are sick, we need qualified health professionals to take care of us. Having health professionals does not equal good care.

I quote you an incident of a woman, a quadriplegic, who was a resident at an extended health care hospital, which shall remain nameless. She was given six months to live. She was in a hospital where she should have been able to receive the best care. That was not the case. In fact, it was just the opposite. Her strong desire to live gave her enough strength, with the help of some friends, to move into her own apartment with attendant care. That was over a decade ago. Now this bill would place hundreds of people's lives in jeopardy where up to now they have enjoyed an independent life.

It is ironic that the government would make $7 million available for its disabled employees for such things as attendant care in the workplace, and also while travelling, and yet it denies the very service which gets us into the labour force in the first place: attendant care at home.

Perhaps you do not understand what this bill implies to disabled individuals. This bill would make it illegal for me to clean my husband's ears with a Q'Tip or for someone to help a women with the insertion of a tampon or help someone with toiletting. Under this law, we would be criminals. Going to the bathroom is not a medical procedure and health professionals have no business in our bathrooms.

The disabled community has been fighting for attendant care for 20 years, and now in one vote you would bring them back to the Dark Ages. The government should not waste taxpayers' money in training health professionals to perform a job which is already being done. Rather, they should put more money in the attendant care services area already in existence so that the attendants are recognized for their vital contribution to our lives.

Therefore, in conclusion, I request that this bill be withdrawn or eliminate the attendant care portion from it. The fact that this bill has been around since 1982 and has never passed should tell you that it is not a good bill. Thank you.

The Chair: Thank you very much. Mr Beer has a question.

Mr Beer: You have raised a number of specific points that I am not sure are really so much dealt with by this bill, and in fairness, this bill is really quite new. People have been discussing it for 8 or 9 years, but the legislation is really within the last year or so.

But the points that you raise, I would not have thought that this bill is moving against those, but rather that both the previous government's initiative around long-term care and the present government, which is continuing that, particularly in speaking around issues of attendant care, attendant care in the workplace and a whole series of things that I think both the former government and the present government have been working on with many of the major organizations that represent the disabled -- indeed there is an awful lot of activity going on and I think some quite exciting things that are going to happen.

I am struck by the comments you make, because I would not have thought that this legislation, which is directed more specifically at regulating the professions, in fact would limit you in terms of these other things that I think we all want around providing greater attendant care. I certainly want to look at this from a different perspective, but I think I would also want to say to you that I do not think, frankly, that would be the intention of any of the political parties to want to do that and that in fact there are some encouraging signs that a lot of other things are going on or are going to be taking place which will enhance independence, your independence and that of anyone else who has a particular disability.

I guess that is more by way of a comment in a sense, but certainly I think that would not be the intent of any of us with any of the bills that are before us. We would want to look at that, but I would urge you as well to look at some of the other things that are going on where I think we really are as a society trying to enhance the independence of those who are disabled.

Mr Callahan: Just to follow up on what Mr Beer said, and relying on the three instances you discussed in your presentation, section 26 says, "No person shall perform a controlled act set out in subsection (2) in the course of providing health care services." So those three examples you have given would really not be health care services; they would be assisting a person in performing functions that he or she might have performed himself had he not been disabled. If you have thoughts beyond that which would get into the definition of health care services, I think that is something we would want to look at to see if that is required, but if it is just the three things you are suggesting, then I would suggest they are not prevented by this act.

Ms Di Carlo: The bill does not address the needs of the individual. The exemption is for the care giver. It is for the professional. It is not for me to be able to direct my own care.

Mr Callahan: Yes, but the act itself is not making it illegal for you, it is making it illegal for someone who is carrying out health care services. So it does not affect you one way or the other.

Ms Di Carlo: But it does. Yes, it would affect me. If this person feels that it is illegal for him to perform a certain duty, he will not do it. Thus, my care is going to go down the drain because I will not have the care.

Mr Callahan: Well, as I say, if your examples are beyond the three you gave us, then that might be something of concern, but the three you gave us are really --

Ms Di Carlo: Which three are you referring to? I said a lot of things.

Mr Callahan: You suggested the insertion of a tampon or the -- I cannot remember what the others were, but they certainly were not --

Ms Di Carlo: Well, there is a lot more that I -- I do not need attendant care, but I am sure that there will be other people who will be able to be much more graphic in the details, if that is what you are looking for.


Mr Johnson: I concur with Mr Beer and Mr Callahan. I think the intent of the legislation was to provide further protection for the public. Although I think there has been a misunderstanding, if I may say that, I think the intent is clear: that there is further and greater protection for the public. I get the impression you do not agree. I would like to hear you say it. Do you disagree?

Ms Di Carlo: Yes, I disagree.

The Chair: Perhaps this would be helpful. The time for this presentation is up. This is the first individual presentation we have had. We have been told there will be a parliamentary assistant. If it is the committee's wish, we could ask ministry officials to clarify for this individual at this time. Is that the will of the committee?

Mr Callahan: Good idea, yes.

The Chair: Linda, would you come to the microphone please to answer Ms Di Carlo's questions?

Ms Bohnen: The services provided by personal care attendants have several different aspects. I think this legislation would either have no effect whatsoever on some aspects, or propose exceptions to deal with some others. As several of you have pointed out, the legislation focuses on activities done in the course of providing health care services. Many routines of daily living such as tampon insertion are not health services, they are just that, routines of daily living.

Second, there is already an exception in section 27 dealing with functions performed within the household among members of the family. Many disabled people, we have been told, do receive assistance from members of their family, and that exception would cover other aspects of it.

However, both the previous Minister of Health and the current government's Health ministers have said that they do favour an exception to be created by regulation for procedures which are really on the cusp between routines of daily living and health care procedures. Those are the more invasive and hazardous things like suctioning, ventilator care, things that have a health care stamp on them, to ensure that people who are living in the community continue to do so.

All the Health ministers who have addressed it said they hoped to create this exception by regulation so that disabled consumers and interest groups would have an opportunity to participate in the crafting of the regulation so that it really does meet their needs.

Finally, for those activities which are really health care activities and do need some ongoing supervision or at least direction by health practitioners, there is still the device of delegation. Nurses can delegate controlled acts within their statutes; so can respiratory therapists and so forth. So for the most hazardous procedures, or hazardous procedures performed on the most vulnerable disabled people, those who are least capable of directing their own care, the delegation mechanism may be the best way of ensuring that the service is provided but that the quality of care is also safeguarded.

I think there has been recognition by the previous government and this government that consideration must be given to ensuring that services continue to be provided to disabled people living in the community, and there is a variety of ways in which this is going to be done.

The Chair: Thank you very much for the clarification.


The Chair: Next is Edith George. You have 10 minutes to make your presentation -- please do not be nervous, we are very friendly -- and we hope you will leave some time for questions.

Mrs George: I am a private citizen. I belong to a consumer group but I am speaking today as a private citizen.

Bill 43 as it relates to doctors is not against anybody but is for patients; I want to make that point right off the top. I have seven points here.

1. The new Bill 43 is a very much improved bill in the composition of complaints and disciplines, but I still feel an independent tribunal would be far better, or committees with equal representation; that is to say, two doctors and two patient advocates.

Here we have an example of a lay gentleman who is one of four on the disciplines committee under the existing Health Disciplines Act, and of course he is outvoted four to one. Under the new act, it is two to one in disciplines, but whether it is four to one or two to one, the layperson must always be outvoted. I think there should be a little bit more thought given to protection of patients. It is only 15%, or perhaps a little more, of doctors who do not work error-free; nevertheless that percentage causes havoc.

2. A suggestion was made in 1990 by some members of the task force on complaints that the Ontario Medical Association should help with complaints. If that is suggested to the committee, may I respectfully suggest no.

3. It is to be hoped that the increased openness of the process means: (a) no longer must a complainant sit outside a disciplines hearing while the doctor and his lawyer sit inside; and (b) as in subsection 41(1), if the defendant is allowed 10 days to peruse the case against him, the complainant should also see the case of the defence laywer.

4. In addition to decisions of discipline and incapacity hearings being on the register, which is of the college, clause 22(1)(e), I think all admonishments should also be on the register, because these are warnings given to physicians when they are not working up to par. I think you could phone the register and they would say, "No, he has never been disciplined," but he might have had 10 admonishments. I think a little bell should start ringing in the college's head when that happens.

5. The Attorney General is proposing no limitation period for sexual abuse by doctors. I think we are starting to categorize patients here and to put them into little pigeonholes: This is sexual abuse, this is battery, this is negligence.

I do not think this is going to develop very well at all. I think all patients should be treated equally under the law no matter what has gone wrong between a doctor and a patient.

The one-year statute of limitations does not allow patients with considerable injuries to get a case together, because they are very traumatized. In addition, they do not have the money, they do not have the advantages of physicians, they do not have the insurers.

I am sure, Madam Chair, you will know all about the Advisory Committee on Liability and Compensation in Health Care, chaired by Robert Prichard, the president of the University of Toronto. He has suggested that not less than six years would be acceptable for a statute of limitations, from the time when it was known there had been negligence. But subsection 85(1) of the bill says one year.

I would please ask the committee to change that. I believe the Attorney General is trying to do something about it, but whether that is just going to be for sexual abuse or whether it is going to include all maltreated patients, I do not know.

6. Physicians should be mandated to report abuse and incompetence. Consumer groups have advocated this for years. A discussion paper of the Progressive Conservative Party, December 1986, has advocated this. In fact, they ask if it is really a self-regulating profession, why do their colleagues not bring forward complaints when they suspect one of their members may be a danger to their patients? If we are going to have self-regulation, then there really should be self-regulation from the grass roots up.

The recent task force on sexual abuse also recommends that doctors be mandated, but the OMA feels it would deny its members protection from slander and libel by other physicians wishing to hurt a colleague's reputation. Not a word that it might protect patients, just that it would possibly lead to some slander and libel. I do not believe doctors go around slandering and libelling one another. I do not know any doctor who does it. Nurses are mandated and they do not slander and libel one another, nor do lawyers.

7. The last point is, please add a clause to this bill for regular monitoring of the complaints system so that when the bill becomes law, it does not sit there for 17 years with nothing done. If you monitor it, you can see if it is working and if the college is working. If it is not, why is it not working?

Also, you can find out where most negligence occurs and why. Is it partly the fault of the facility? There are facilities -- I certainly know one -- where they always stress meeting the budget, but when I go to hospital, I really do not care whether they have met their budget. I want doctors and nurses and proper health care. I think the prime aim should always be quality care. Meeting the budget is good and fine, but it has got to come further down on the list of priorities.


The Chair: Thank you for your presentation. Mr Callahan?

Mr Callahan: I want to address a couple of items. One, the limitation period, as you probably know, is under review -- and it should well be under review -- to give a commonality to limitation periods, because they are very disconcerting, particularly to lawyers who do not have a tickler system, and they cost the lawyer and the law society a lot of money. More importantly, the cause of a legitimate complainant can be lost as a result of it.

On the question about the makeup of the discipline committee, I agree with you: It says three members of the council, and it seems to be five to two, because two of those members are appointed by the cabinet, that is who the Lieutenant Governor in Council is. If you carry the process forward, if you look at the composition of council, at least seven and no more than 10 persons, of whom at least four and no more than six are appointed by the Lieutenant Governor in Council, they do not even have to be members of the particular body in question.

Mrs George: The college.

Mr Callahan: They are in fact the people who appoint, under section 15 of the act I am looking at, the Chiropody Act -- and it is probably similar in all the acts -- the members of the committees mentioned in the various sections. That includes the discipline committee, so really the primary responsibility belongs to the council. It is made up of independent people, in addition to people who are members of the council. You are relying on them to appoint appropriate people for the discipline committee, and if they are not happy with what they are doing, then they should be removing them and putting somebody else in their place.

Quite apart from that, as was witnessed in the recent case against some prominent lawyers in this city, the courts are, in fact, coming around, as is the law society, at least to the view that you have to squeal on your partners and anybody else who is involved in acts that are detrimental to the public. I for one -- and I am only a substitute on this committee -- think it is a matter of public policy that the government should be looking at the question of requiring this -- similar to the way we require doctors to report child abuse, subject to penalties if they do not.

A similar type of reporting procedure should be required under law for all professional bodies to ensure that the public does not get -- I was going to use a word that probably would not show up in Hansard -- scuppered by the closing of ranks of people who belong to various professions. I happen to belong to the Law Society of Upper Canada, I would not want to see that. Nor would I think responsible doctors, dentists, or anybody in various professions would want to see that happen either.

I agree with you in that regard. I do not think it is something you will see in this act, but I would certainly urge those government members here that it is a good matter of public policy that should be brought up by your government: making it mandatory that they in fact do report their colleagues. The days of the old boys' club are gone.

Mrs George: Not quite.

Mr Callahan: The major concern should be that of the consumer and the people who pay big bucks to get those services.

Mrs George: Here we are, Mr Callahan: "Lawyer disciplined for not reporting his son." This is by the Law Society of Upper Canada. Can you imagine that ever happening at the College of Physicians and Surgeons?

Mr Callahan: That is the height of nepotism. I agree, I think that has got to change.

Mr Johnson: In number 7, your very last comment, you said: "While meeting the budget is important to health care facilities, it ought not to be the prime aim. The prime aim must always be quality care." There is a direction relationship there. Meeting the budget produces quality care. You get quality care as a result of closely scrutinizing your budget.

I am a little confused about something. Maybe I have misunderstood the point you are trying to make there. Could you elaborate on that?

Mrs George: There are facilities where they give quality care, but they do not meet the budget because they are giving quality care. To some extent, they are taking corrective work from other facilities which have not given quality care. All that corrective work is very heavy on the OHIP bill, but there is a great deal of corrective work going on when there are -- shall I use the word "bungles"? I do not quite know what word to use best. Perhaps just negligence, complete, unintentional negligence.

Mr Johnson: To what particular kind of health care facilities were you referring?

Mrs George: Let me put it this way: I do not use my local hospital at all. They always meet their budget, but I will not go there. I go right downtown here to a very good hospital. I am sure they are not meeting their budget, but they really give good care. It just depends on what you want from a hospital.

I heard a nurse talking the other day about where administration in some places is top-heavy. They are cutting out nurses and they are cutting out doctors but you have got everybody at the top. As a patient, I am not terribly interested in who is sitting in an office; I want the doctor. You cannot totally blame doctors in a lot of cases. They are so stretched out, they are trying to do so many things. You go to any emergency ward and sometimes it is a wonder there are not more errors than there are. I believe it was Mr Callahan who mentioned responsibility. Everybody understands that no human institution is infallible, but surely they should be accountable when mistakes are made.

Responsibility and accountability, not perfection, because none of us is perfect, but when you have a complaint and nothing gets done and you fight for year after year -- we have a woman in Toronto, 11 years. That should not have to happen. Why should I have to complain if something goes wrong? Should the doctor who sees what went wrong not complain? Should he not complain if this is self-regulation? The doctor should complain. He should go and help his peer or his colleague and say, "Look, let me show you what is going wrong here," give him a helping hand.

When I suggested this one time, I was told, "Professionals don't do that." They certainly do, because I have just shown in here what the law society does. So professionals do, and professionals should do it. Patients should be safe when they go into a facility. Otherwise put a great big notice up there letting them know.

As I say, this is just 15% probably. I say "just 15%," but 15% represents a lot of trauma, a lot of heartache and a lot of pain. I really thank you for listening to me.

The Chair: We appreciate your presentation. Thank you for addressing us.

The committee has just heard the last presentation for today. We believe there may be an opening tomorrow for a half-hour discussion with ministry staff. It looks like we may have a cancellation at that time.

Mr Beer: This is just a suggestion to the other whips. I am wondering whether we might deal with some of the points that were mentioned, that you wanted to raise anew and had not had an opportunity. I think titles was one of them.

The Chair: Is it the committee's wish to adjourn now or to adjourn at 4:30?

Mr Owens: I would not mind spending some time. Yes, 4:30.

The Chair: All right, we will ask the ministry representatives to continue the presentation now until 4:30 and then we are hopeful that there will be additional time tomorrow to continue that discussion. The committee is in session. We will continue discussion with the representatives from the ministry. I believe that everyone has the documents before them. We were at tab Mc.



Ms Bohnen: Just before you turn to tab Mc, I would like to remind you that under tab I there is a little document that shows how the review summarizes some of the concerns that were expressed by interest groups about title provisions. Those are the review proposals that have been contested by professions which are motivated in part by status concerns and attempt to create or maintain an economic monopoly and the desire to do indirectly what has been directly prohibited. Status concerns are that some titles connote more status than other titles. It is as simple as that. It is not necessarily a bad thing, but it is a fact of life. For example, "technologist" is a higher-status title than "technician."

With regard to the other two points, monopoly and doing things indirectly that you cannot do directly, you may observe the fact that the professions which are most concerned about the title protection and how it is expressed in the bills are those which have no or few controlled acts. One could analyse their situation as the profession in competition with unregulated groups because there are not controlled acts restricting the service to the regulated group. If you cannot control your competition by a law that says the other group cannot do it, another way of trying to secure an advantage is by restricting a title and trying to steer the public, by use of that title, to your group or yourself instead of to your competition. That is not to say there are not public interest aspects to the debate, but titles are also another way of achieving economic advantage.

Mr Burrows: Just to add, there is a large body of academic literature widely available to support what Linda has said.

Mr Johnson: From a public perspective, it would appear to me that this might be just semantics in title. The family practitioner is a doctor. If somebody said, "I am going to see my family practitioner," I would make the assumption that he is going to see the doctor and I do not think any less of him because a layperson has called him a family practitioner. I guess it is the organizations themselves that have the greater interest in what their title ultimately is because, as you have already indicated, it may mean more money, it may mean more work is directed their way.

I do not see it as being as controversial, or maybe I do not see it as being the sort of thing we would want to interfere with. If a particular organization did not conflict with another organization with regard to title, then would not the title that it wanted be the best title for it? We would not get into any adversarial situations then.

Ms Bohnen: There are adversarial situations, though, because some titles are claimed by more than one group or words derived from the title are claimed by more than one group. You heard from physiotherapists today that they would like protection of the title "physical therapist." It is the case that some other professions, such as chiropractors, believe they also provide physical therapy. I think you may hear from them that they would be concerned if restricting the title "physical therapist" to physiotherapist meant that they, as chiropractors, could not describe some of what they do as physical therapy.

There are several different kinds of title issues. You have already heard the "doctor" title issue. It might be helpful to clarify that a little bit.

The Chair: I have Mr Cordiano and Mr Beer and both have questions relating to the doctor issue. Is that correct?

Mr Cordiano: Can I just say something at this point before we get into that? I think the way I would try to configure this so that I could understand it would be to attach some sort of value to a title on the basis by which that profession claims to have that title. So if that profession wants to be called doctors, is it in relation to the kind of training, the kind of value added to the profession that we would then, as a group, as a committee, say, "Yes, this is justifiable"?

Ms Bohnen: Why do we not start by seeing what the bill actually says in terms of the restriction on the use of the title "doctor," because doctor is an issue. Section 30 of the RHPA says (1) "Except as allowed in the regulations under this act, no person shall use the title `doctor,' a variation or abbreviation or an equivalent in another language in the course of providing or offering to provide, in Ontario, health care to individuals."

The only restriction on doctor applies to providing or offering to provide health care to individuals. Some academics, some people with PhDs in unrelated fields initially thought that meant they could not use the title "doctor" in a classroom, in administration, at a cocktail party. That is clearly not the case. We are only focusing on the use in health care settings and providing health care to individuals.

Mr Owens: Just in line with the speech pathologist who was here, who would be involved in the provision of health care as we understand it, and the physiotherapist providing health care as we understand it, would they not then be restricted?

Ms Bohnen: I am trying to work through this systematically. First of all, we do not have a problem with our non-health-care academics. They can call themselves doctor. Then we have our people who are health professionals providing patient care who do not belong to one of the five professions authorized to use the title "doctor." You are quite right. You heard from a speech-language pathologist and a physiotherapist in that situation. This is when you come down to government's decision-making.

Mr Owens: Politics.

Mr Cordiano: You asked the question.

Ms Bohnen: I would not say it is politics. I think governments have viewed this as a difficult social question.

Mr Owens: Scary, is it not?

Ms Bohnen: Governments have decided, so far, that most Ontarians think that when they hear the word "doctor," they are dealing with a medical doctor or a dentist or a chiropractor or a psychologist. Remember, those professions all have something in common. The basic educational qualification for entry to the profession is a degree or a diploma that says "doctor" on it. You cannot practise medicine, psychology, dentistry or chiropractic without a doctor's degree. But you can practise speech-language pathology, etc, without that degree. Some of their members have those degrees. In fact, a minority have doctorates; most of them do not. Most of them are prepared at the bachelor's or master's level.

Mr Owens: My understanding, if one wants to get really technical about this, is that a person who graduates from medical school simply has an undergraduate degree and that it is only when one enters a specialty through the Royal College of Physicians and Surgeons of Canada that one is actually entitled to use that post-graduate --

Ms Bohnen: No, that is not correct. The degree granted in Canadian and American medical schools is doctor of medicine. That is their entry-level academic qualification. It is the same thing for dentists and the other professions I mentioned.

You have heard and you will hear from groups which say: "No, Ontarians don't think that way any more. They are able to discriminate among every health care provider and they are not misled by the use of the title `doctor.'" All I can say to you is that the government, in these bills, decided that doctor should be restricted to the professions authorized to use the title "doctor," the interest being in not confusing people about the qualifications of the person they are obtaining care from.

I guess there are two levels to the issue. One is before you. Should use of the title "doctor" be extended to other regulated professions? Beyond that, you may hear from some groups which also have PhDs but are not regulated as to whether they should be able to use the title "doctor." It is not a complicated issue; it is just an important social issue that you are going to deliberate on.

Mr J. Wilson: Essentially you are telling us that this continues the current practice.

Ms Bohnen: It modifies the current practice in so far as it legalizes the use of doctor by chiropractors and clarifies that psychologists who customarily use it are entitled to do so, say, PhDs. For the other professions, medicine, dentistry, optometry, it is current practice.

Mr J. Wilson: Okay. It was also suggested yesterday that perhaps you may not have any real grounds to prosecute someone who decided he would continue, because he had a PhD like our speech pathologist, using the term "doctor" in front of his name in a hospital.

Ms Bohnen: Arguably, today they are violating a section of the Health Disciplines Act. The Health Disciplines Act restricts these titles.


Mr J. Wilson: That is what I was wondering: Has anybody bothered to prosecute anybody for this?

Ms Bohnen: Time was when the College of Physicians and Surgeons warned chiropractors most particularly and complained to their governing body. But I am not aware that they have gone after a speech-language pathologist or groups like that. I cannot conceive that they would now consider that necessary, remembering that many speech-language pathologists practise in institutional settings where there are safeguards against confusing patients. It may be that this is the sphere across which the regulation, making an exception to this prohibition, would apply.

Mr Beer: I appreciate the points you have made about this and I think you are quite right to underline that it is not in a real sense a technical problem. It is a governmental or political decision in the best sense of that terminology regardless of who the government is, because we are reflecting or trying to reflect what we think the norms are. I guess what strikes me is that as we look at it, can we find some principles here that can guide us? One of the questions, and you may have the answer to this, was that in Europe and in the United States if somebody has a doctorate he may use the term "doctor." In point of fact some do and some do not, but there is not a prohibition.

It is as if we are using a sledgehammer on the proverbial fly instead of a fly-swatter. I think that is something as a committee we are going to have to wrestle with. I know there are going to be other presenters but I think it is a valid issue, in that on the one hand you are saying to somebody, "You went through a course of study, you received a doctorate as did somebody in history or somebody in philosophy, but we are saying that you can use that title in certain places but not in others and there is a rationale for that."

The issue for us is, is that any longer an acceptable rationale? Does that affect the public interest or does that affect in some way potential harm that might befall someone? Those are all very legitimate questions which we have to answer. My sense, though, is that the overall thrust of this legislation has been to open. This, while it clarifies it, also closes and I do not know if that is the direction we want to go in. I am not sure what my own answer is yet and I want to hear more on it. This is helpful but I just sense that we are legislating in some areas that perhaps do not need legislation.

Mr Cordiano: I would just reiterate what has been said already. My concern is that if someone has a doctorate, if he is not in one of these groups that have been exempted, he may be like our speech pathologist who has a doctorate and not everyone is required to have a doctorate in speech pathology to practise -- correct? That is where our difficulty lies: trying to draw the line here. We on the one hand will sacrifice those who have a doctorate who somehow deserve, in my opinion, to be called doctors, whether it is in health or in some other field of practice.

It happens to be that they chose health for their field of practice and their profession. I think it is a tough decision to make to call and draw the line at that point and say that they are not going to be allowed to use that title when I think it is rather important for them to be able to use that title. If you create that kind of distinction, as you tried to point out earlier, it creates a monopoly -- it certainly does for the groups that have been included here -- and I think the same kind of logic could be extended to those who have a doctorate and who are not included here and have fallen in the cracks, if you will. I would like to see that addressed and I think we should pursue this.

Ms Haeck: I do have a question for the ministry staff. In discussing this issue various people have remarked on the fact that in dealing with medical practitioners in a hospital setting frequently the badges identify the specialty of the attending specialist. So seeing a person in a white coat who happens to be called "doctor" does not necessarily mean that he is a physician. You could read that as part of the identifying name tag the person is wearing.

Is this consistent practice or is this something that one institution or two institutions across the province happened to initiate? Thereby we are faced, as you so rightly pointed out, with people being faced with this array of people standing before them in white lab coats and trying to figure out who really is the physician and who is the speech pathologist, but they are all called "doctor." I am just wondering if there is some way of making sure that there is clarity in a simple identifier.

Ms Bohnen: The health professions review suggested that there be a statutory exception for individuals practising in hospitals, nursing homes and other regulated settings where, as you suggested, the administration can be expected to have some rules about what the name tags say. It was legislative counsel's view and I think the ministry's view that this kind of exception may well be very appropriate, but it is better done by regulation and there is regulation-making authority in the act to do that by regulation. It may address part of the problem sectors in which there is less likelihood of individuals being misled. Again, as I suggested, there is probably less likelihood of people being misled by regulated practitioners whose colleges will discipline them presumably if they mislead their patients. It is harder to get a handle on it for unregulated people.

I would just like to remind you, though, that this is not a new prohibition. The Health Disciplines Act prohibits anybody other than a dentist, physician or optometrist from using the title "doctor" as an occupational designation relating to the treatment of human ailments or physical defects. These bills have updated that rather outdated language but it is not a new prohibition. It has been expanded to cover chiropractors and psychologists because of common usage and the nature of their educational qualifications.

Mr J. Wilson: It seems to me that society does place a fairly large emphasis on status. We saw from our speech pathologist, for instance, that if he were allowed to call himself "doctor," he felt that he was of the same status as the medical doctor who is on the same page, same itinerary. It seems to me what society forgot, and one of the reasons that Canada has this problem with the titles, is if you go to a graduation ceremony at any university the PhDs in philosophy are given out first. They are the highest degrees attainable in academia, and actually a medical doctor's degree or a chiropractic degree is an undergraduate degree and of little significance compared to a PhD.

I have always felt sorry for the PhDs and their inability to use it in everyday usage because actually in academic circles and in the hierarchy of things they have higher degrees and yet they are not able to get the recognition I feel they deserve. They spend many more years in school, for instance. I have a brother who spent 15 years getting his PhD in zoology and he teaches medical students but cannot use the term "doctor" because he is confused with a medical doctor.

We cannot change society and I have really no intention of changing the act the way it is proposed but I did want to put that on the record because I am going to mail it to my brother.

The Chair: Mr Hope, the committee has agreed to adjourn at 4:30. You have one minute.

Mr Hope: There is just one comment I would like to make. You mentioned that they were not supposed to use the title "doctor" but they did, and I notice you moved your little red book there --

Ms Bohnen: Sorry, I wanted to read from the existing section.

Mr Hope: Oh, okay. But we have people using the title "doctor" in the medical fields, health providers. They were not supposed to but they did. Why did somebody not do something to make sure that we were not into the problem we are in today?

Ms Bohnen: There was a time when the College of Physicians and Surgeons of Ontario, which polices the title "doctor," did try to warn off some other practitioners from using the title, but faced with, I guess, hundreds of other practitioners and increasing public acceptance that they could use the title "doctor" -- you would have to ask the college. It may be they decided that this kind of enforcement activity was not worth the expense and the poor public relations involved in doing it. They also probably felt that these bills would sort out the situation.

Some groups, because they have had their diplomas or degrees that say "doctor," have felt that they had a colour of right to use the title. Other groups have not. Remember, we heard from speech language pathologists, nurses. We are talking about very small numbers of practitioners in those fields with doctorates, unlike every chiropractor, who has a "doctor" diploma. So the numbers are quite different.

Mr Hope: So that would move pretty well into the comments of the lady who just did a presentation to us about some of the accountability issues.

The Chair: The meeting is formally adjourned. We will reconvene tomorrow morning at 10 o'clock. It has been an interesting day.

The committee adjourned at 1633.