Monday 12 August 1991

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

Association of Hearing Instrument Practitioners of Ontario

Canadian Association of Speech-Language Pathologists and Audiologists

Ontario Association of Speech-Language Pathologists and Audiologists

Stefan Fridrikkson

Arne Jensen Zabell

Paula Square

Barton Sala

Board of Regents of Chiropody

Ontario Society of Chiropodists

Ontario Podiatry Association

Vision Council of Canada

Board of Ophthalmic Dispensers

Ontario Association of Optometrists

Vision Institute of Canada



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)


Grandmaître, Bernard (Ottawa East L) for Mrs McLeod

Huget, Bob (Sarnia NDP) for Ms Haeck

Jackson, Cameron (Burlington South PC) for Mrs Witmer

Sola, John (Mississauga East L) for Mr Beer

Waters, Daniel (Muskoka-Georgian Bay NDP) for Mr Silipo

Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski

Clerk: Mellor, Lynn

Staff: Gardner, Bob, 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 de 1991 sur les professions de la santé réglementées et les projets de loi, 44 à 64, qui l'accompagnent.

The Chair: I would like to welcome everyone to the standing committee on social development. There is a member here from each of the three caucuses. I would also like to welcome the parliamentary assistant, Mr Wessenger. There are a couple of items which will be considered housekeeping, just for the information of the caucuses and particularly for the whip.

We have pretty much filled all of the available time slots for the committee hearings. We have some people waiting, some waiting lists, and I have discussed this with the clerk. As you know, last week there were some cancellations that came in on the day of the hearing and it was very difficult to contact someone and have him come in time. She will endeavour to slot in those that are waiting in any time slots that are vacated. If you know of anyone who has a time slot and is planning not to appear before the committee, it would be helpful if he gave the clerk as much notice as possible so that his time slot can be used by someone else. All those who are on the waiting list will be notified that they can submit letters or briefs or comments in writing to the committee.

I wanted to make that information available to all members of the committee just to let you know what the status is at this time.


The Chair: I see that our first group is here, the Association of Hearing Instrument Practitioners of Ontario. I want to welcome you. Please introduce yourselves. You have 20 minutes for your presentation, and we would ask that you leave some time for questions from members of the committee at the end of your presentation.

Mrs Bernath: My name is Dianne Bernath. Beside me are Joanne Sproule and Christine Helik.

The Association of Hearing Instrument Practitioners of Ontario respectfully requests the removal of prescription of hearing aids as a controlled act for audiology, Bill 44, and medicine, Bill 55. Our reasons for this request are as follows:

First, in 1987, when Alan Schwartz presented his preliminary report, there was no mention of prescription of hearing aids as a licensed act for either audiology or for medicine. After five years of careful deliberation, numerous interviews, presentations and briefs, Mr Schwartz determined that there was not significant or sufficient risk of harm in the process of acquiring a hearing aid to warrant its inclusion as a controlled act in the proposed legislation. Six months later, that decision was reversed. Why? That is a very good question. Repeated requests of ministry personnel for documented evidence to justify this change have remained unanswered.

Second, consumers and other health care providers, particularly those in nursing home administration, have clearly expressed the Ontario Advisory Council on Senior Citizen in numerous letters to ministry personnel, members of Parliament, and the advisory committee on hearing aid services, that they do not want their choices limited in accessing hearing aid services. I have with me, as exhibit 1, thousands of names of consumers and their families who are asking you not to make prescription of hearing aids a controlled act.

Third, in December 1988, in anticipation of the proposed legislation, the Ministry of Health introduced policy which reflects its interpretation of the proposed legislation. That policy allows only audiologists to become registered to provide assessment services for the purpose of selecting a hearing aid. As a result, the number of hearing instrument practitioners who have historically provided these services is deteriorating rapidly, and with that, the service locations, particularly in the rural areas of this province.

In December 1988, under the direction of the Ministry of Health, the Association of Hearing Instrument Practitioners of Ontario conducted a survey. We contacted every known hearing aid dispenser in Ontario and we asked them several questions, one of which was: "Where are you located? Where do you have suboffices? Where do you have regular scheduled clinics on a monthly basis?" We took this information and we plotted it on this map in these purple dots. As you can see, the province was very well covered at that time. Many of the very tiny rural communities that would otherwise not have services were being well provided for.

In 1990, we conducted a similar survey. We went back and we asked the same questions again, but this time we said: "What has changed? We want to know what you are doing now differently from 1988." This is the result of what we found. Each one of these little orange dots represents the removal of a clinic in the Ontario in two years. As you can see, there are certain areas that have completely had service removed and nothing has been brought back in to replace it.


So that you get a better perspective on the whole picture, we have also plotted the locations of the audiology clinics in Ontario. These are numbers of clinics, in all cases; they do not represent the number of people. As you can see, in certain areas -- for example, Haliburton, Victoria county -- there are no audiologists. In Kitchener, where there were six last year, the audiology clinic at the hospital has closed until September because its last clinical audiologist is ill, so you can see that the services in the area are decimating fairly quickly and there are not a lot of replacements.

There is a total of 259 audiologists in the province. In 1988, there were 242 audiologists. That number decreased in 1989-90 to 234. It has now increased to 259. That is a main increase of 7% over two years -- certainly not enough to offset the decrease of more than 30% in our numbers in the same period of time.

It is also interesting to note that in fiscal year 1990-91, there was a decrease of almost 10% of the hearing aids dispensed in Ontario, in a time when the numbers of senior citizens are growing rapidly.

We have proven over a 14-year period that hearing instrument practitioners can be and have been educated at the community college level to provide quality, community-based care to the consumer in a cost-effective manner. Nowhere in North America is it deemed necessary or even desirable to involve audiologists in routine assessments for the purpose of selecting hearing aids. We submit, therefore, that prescription of hearing aids as a controlled act will result in the exact opposite of what this legislation was intended to do. It will remove safe choices for the consumer. It will limit consumer options, eliminate community-based care, remove home care for the elderly and disabled, while substantially elevating the cost to our already overburdened health care system, with no evidence that there will be an improvement in the quality of care to the consumer, only restrictions.

I ask you to consider what is to become of the hundreds of thousands of hard-of-hearing seniors who have historically depended on hearing instrument practitioners in their communities, homes and nursing homes to assess their hearing, and select, dispense and maintain their hearing aids. Many of these seniors are non-ambulatory or find it difficult, if not confusing, to be transported to hospital clinics where they receive impersonalized, fragmented services. Is this really the intention of this legislation? What of someone in the workforce, or a university student, who cannot function without her hearing aid and it needs to be replaced? Why should they have to wait for months to go through a hospital clinic for a prescription when there is a safe, efficient alternative?

We further submit that the inclusion of prescription of hearing aids as a controlled act in this legislation is a bureaucratic decision that cannot be justified or withstand close scrutiny. This decision was not based on significant risk of harm -- it was just rhetoric information -- nor has it been introduced to address consumer concerns, complaints or consumer preferences. Prescription of hearing aids does not belong in this legislation. We ask that you amend the legislation accordingly.

May I answer any questions.

Mr J. Wilson: Have you seen any documented evidence, from the ministry or otherwise, indicating that there is a risk of harm in prescribing hearing aids?

Mrs Bernath: Absolutely none.

Mr J. Wilson: Your reasoning just a minute ago was that perhaps it is a bureaucratic insertion. Do you want to expand on that at all?

Mrs Bernath: What we are looking at is provincialism, in our opinion: that is, self-serving for one group. If you take a look historically at how hearing aids are fitted and worn, there are methods in the way a hearing aid is assessed. The needs of the person are assessed. Routine assessments will protect the consumer from any harm as far as the hearing aid being too strong or not being appropriate is concerned, and also the consumer will not wear a hearing aid that is not appropriate, so we are not sure where this risk of harm is coming from. We do not see any indication of it.

Mr Owens: I would like to ask the minister's staff, through the parliamentary assistant, how did the ministry come to the conclusion that the prescription of a hearing aid should become a controlled act if in fact, as the deputants have alleged, no consultation was made with their association or any of the providers?

Mr Wessenger: I will ask ministry staff to reply to that.

Ms Bohnen: The recommendation that prescribing a personal hearing aid should be a licensed or a controlled act was made by the Health Professions Legislation Review. So it was not a shift in policy made by the ministry after the Schwartz recommendations were delivered. The review determined during its consultation with provider groups, such as physicians and audiologists who you will be hearing from later this morning, that there was a sufficient risk of harm to the consumer caused by the risks to that individual of an improperly prescribed hearing aid to justify making it a controlled act, performable by both audiologists and physicians, as you have heard.

I might also point out that the controlled act itself does not prevent hearing aid dispensers from testing individuals' hearing and making recommendations about a particular type of hearing aid that would be necessary, but we are talking about a generic prescription of a hearing aid.

Mr Grandmaître: Could you briefly describe your training? How would you become a practitioner in Ontario?

Mrs Bernath: At the present time, there is no training. As of January 1989, the last graduates of Sheridan College came through. In 1974, there was a full program designed. It went over a period of 14 years. There are well over 100 practitioners in the province currently who have graduated from that program. It is a program that has been designed specifically not to produce audiologists, but to produce hearing instrument practitioners who specialize in selecting and testing and dispensing hearing aids, and we are asking for that to be reintroduced.

Mr Grandmaître: This program you are referring to, is it a two-year or three-year program, or a six-month program?

Mrs Bernath: It was a one-year program with 50 hours of clinical practicum on the side besides that, one year plus.

Mr Grandmaître: One year plus.

Mrs Bernath: Plus 50 hours of clinical practice, yes, supervised practice.

Mr Grandmaître: As far as training is concerned, when you compare the two practitioners, hearing instrument and audiologist, there is quite a difference in the training. Do you think the audiologists are better trained than you are and more capable of determining the right instrument?

Mrs Bernath: I would suggest to you that if you examine the program profile and then part of your package that we have given you, it will show you the number of hours spent on each area criteria in this brief that we have presented to you. You will see that the training audiology receives is much more involved, but is not designed with the intention of doing routine assessments for selecting hearing aids. It is not necessary to have an audiologist involved and it is a very expensive waste of good manpower, in our opinion. There is a better use for audiology, and that is to use them in the upper-echelon testing, the multihandicapped, the aural rehabilitation and the research for which they were trained.


Mr Jackson: Just on the parliamentary assistant's and staffs' response to the concept of risk for inappropriate hearing aid dispensing, were there specific cases documented by the ministry? Was there a proper complaint system, and if so, how many cases were reported? I do not want to challenge your concept; I just want to say, how does the government measure that?

Mr Wessenger: I will ask staff to comment on the specifics.

Ms Bohnen: Since the recommendation, as I said, was made by the Health Professions Legislation Review, the Ministry of Health itself did not conduct an analysis of complaints received by any particular branch of the ministry prior to that recommendation having been made by the review. The issues that were examined by the review had to do with the harm to the patient of incorrect amplification, of missing a diagnosis, the symptom of which is hearing loss, the pain to the patient caused by noises generated by an improperly prescribed hearing aid.

Since over the past few years the assistive devices program of the Ministry of Health has assumed responsibility for administration of the program and it pays for many hearing aids, it is possible that it may have some information, but its program is not really geared to focusing on this issue. So I do not know that there is available information, to answer your question.

Mrs Bernath: Madam Chair, could I just finish with one brief word?

The Chair: Yes, please.

Mrs Bernath: I am going to state once again that this is legislation based on significant risk of harm. There has been no documented evidence. This is total hearsay. We are losing affordable services in Ontario and wasting considerable dollars in doing so.

The Chair: Thank you for your presentation. I would point out to all committee members that Mr Schwartz will be appearing before the committee on September 15. I would also suggest to the caucuses that if through the course of the hearings they determine in advance specific questions that they want Mr Schwartz to address, they should give them to the clerk, who can pass them on to him in advance so he will be sure to address them in his presentation.


The Chair: The next presenter is the Canadian Association of Speech-Language Pathologists and Audiologists. Please introduce yourself. You have 20 minutes for your presentation.

Mr King: My name is Richard King and I am the executive director of the Canadian Association of Speech-Language Pathologists and Audiologists. I have only 20 minutes, so from now on it will be referred to as CASLPA. We are over 2,700 professionals throughout the country representing speech-language pathologists and audiologists in all of the provinces and territories. This includes the 16 professionals who comprise all of the speech-language pathologists and audiologists in the province of Prince Edward Island, as well as almost 1,000 members here in Ontario. CASLPA estimates that we currently have as members 75% of all of the professionals in Canada. We are also over 500 student members studying at the graduate level.

The mission of our association is to provide national leadership in human communication and its disorders. This includes the development of public and professional policies affecting individuals with communication disorders and the advancement of the professions of speech-language pathology and audiology in Canada. It is with this mission in mind that we come to speak this morning.

I am hear to speak to specific issues that we feel are important for the best service to those with communication disorders as they are to be addressed by this legislation. As an association dedicated to promoting the needs of those with speech-language and hearing disorders, as well as developing and promoting national standards for practice, we feel that we present a significant point of view.

At the outset we would stress that CASLPA supports this legislation, Bill 43 and Bill 44 specifically. The intent of the legislation, to provide the best health care for the people of Ontario in the most efficient way, is certainly what all of us want. We believe that the changes to the four areas to be presented here are but refinements to these bills, refinements that will enhance the level of health care and its efficiency. We feel these recommendations in no way run counter to either the intent of this legislation or to the common good of the people of Ontario.

There are four areas in relation to Bill 43 and Bill 44 that we would like to address at this time. Because of the time allowed, I will attempt to address only the most salient of the four issues.

The section in Bill 43 on conveyance of a diagnosis: The act as it is now written would restrict speech-language pathologists and audiologists from conveying a diagnosis to their clients. The act would limit this function solely to physicians and psychologists. Such a communication of a diagnosis would be a terribly inefficient use of a health care system and would place an important aspect of health care in the hands of the wrong people.

This is not to suggest that physicians and others do not deal with such diagnoses, but it is to suggest that when a speech-language pathologist or an audiologist arrives at a decision regarding a diagnosis, these professionals should be the ones to convey that diagnosis to the client and his or her family. The speech-language pathologist or audiologist best understands how the diagnosis has been arrived at, what it means, and is indeed the person best able to counsel about such a diagnosis. The speech-language pathologist or audiologist can also explain the long-term significance of that diagnosis and the therapeutic steps that may be taken in light of it.

To suggest that any other person would be involved in conveying a diagnosis arrived at by another professional overlays such an inefficient structure to the health care system that one can barely consider any benefit to such a move. To assume that a secondary party could bring to bear on the diagnosis all of the information and background that would be necessary is not reasonable.

Diagnosis is really inseparable from other activities of speech-language pathologists and audiologists. Diagnosis is often an ongoing part of an assessment and treatment plan and therefore must be dealt with accordingly. As patients progress, further information regarding diagnosis must be passed on. Again, to suggest that this would be done by a secondary party is not reasonable. Patients certainly have the right to discuss their assessments and the resulting diagnosis with the professional best trained and most knowledgeable in that area. The current legislation does not appear to consider this.

Diagnosis is a very significant part of our training and is included in our scopes of practice which serve as the basis of CASLPA's certification exam. Our association certifies professionals throughout Canada. This certification is based on membership in our organization as well as passing our certification exam.

We distribute a document titled Assessing and Certifying Clinical Competency, Scopes of Practice for Audiology and Speech-Language Pathology to all applicants for our exam. These scopes serve as the basis for the exam. The document was first published in 1988 and republished in 1991. I am sorry I do not have copies for all the members of the committee, as we are just about to write our exam and we have to pass them out. I do have copies for the Chair, one in each official language. The scopes in fact are a report of both our association and the institutional and professional services division, Department of National Health and Welfare. The document is published by the health services and promotion branch, Health and Welfare Canada.


In both the scopes of speech-language pathology and audiology, diagnosis is presented as a critical area of knowledge. Professionals in these areas are specifically trained to diagnose communication disorders, and the importance of diagnosis is stressed in the document. With this in mind, it is difficult to comprehend that speech-language pathologists and audiologists would not be the most appropriate people to convey such a diagnosis. This is a significant aspect of health care. It must be done efficiently, and it must be done appropriately.

Bill 44, the section on title restriction: Historically speech-language pathologists have suffered the confusion of the public because of our titles. Certainly the title "speech therapist" is a long standing designation for the profession of speech-language pathology. Therefore, this title should be protected as it continues to be recognized and sometimes used interchangeably with "speech-language pathologist." Though the latter is currently considered in North America the more accurate term for the profession, and has been adopted as appropriate by graduate schools throughout North America, we cannot deny that other titles continue to be used by the public, and therefore these other titles should be protected. This is in the best interests of the public.

The title "speech therapist" is important because of its long-standing use, and because many in our field have this title on their degrees. For example, there are many clinicians in Ontario, educated in the United Kingdom, whose degrees are those of licentiates in speech therapy. Legislation such as this should certainly be directed at protecting the public. Unregulated persons should not be allowed to use any designation that could be confusing, especially "speech therapist." To place this title outside this legislation will create a void regarding its use that will invite misuse by others, and further confuse the public.

We would suggest that the New Brunswick Act Incorporating the New Brunswick Association of Speech-Language Pathologists and Audiologists is an example of protection of title that is of benefit to the public. I enclose for you the chapter and section in appendix A at the back of my brief. This document outlines a complete list of titles to be used only by those appropriately qualified, including speech therapists and other derivatives.

I realize that what is written here may not be the particular way we want it, but it is an example of protection of title, which is of benefit.

Bill 43, the section on the use of the term "doctor": This section of Bill 43 would restrict the use of the title "doctor" to members of the colleges of chiropractors, optometrists, physicians and surgeons, psychologists and dental surgeons. This would exclude health care professionals who also have earned the title "doctor" and hold PhDs in other areas such as speech-language pathology, audiology, nursing, pharmacy -- and there could be others.

This part of the legislation would seem to run counter to the spirit and intent of the Regulated Health Professions Act. We contend it is the patients' right to know the degree status of any and all who may serve them. Not to allow the term "doctor" to be used would appear to be an active attempt to deny information to patients.

To pick out certain professions and to allow them to use the term "doctor," whether they have a PhD or MD, appears arbitrary. Nationally and internationally, a PhD is "doctor." To attempt to alter that with this legislation would seem to run counter to conventional standards of such recognition. Certainly to allow PhDs in one field to use the title "doctor" while restricting it in another seems most unjustified and unfair.

There are other concerns in our professions regarding the use of the term "doctor." Over the last two years, our association has had discussions with Employment and Immigration Canada regarding some of the difficulties our professions have had in providing a sizeable enough workforce for the population of Canada. One of the areas that has been identified as a difficulty is the small base of PhDs existing in Canada. It is obvious that if our professions are to adequately serve Canadians, we must expand the basis of those trained at the PhD level who serve as teachers and researchers.

CASLPA, with Employment and Immigration Canada, has begun to look at how we may not only train more PhDs in our fields, but also attract and maintain them. Such a move as is suggested by this legislation would certainly be detrimental to the professions and to the public.

Ontario currently has two very fine programs at the University of Western Ontario and the University of Toronto. These programs train speech-language pathologists and audiologists at the graduate level. As these universities compete with universities throughout the world for professors and researchers, one can only surmise that legislation such as this would be detrimental to both attracting and maintaining PhDs in this province. One may argue this to be a matter of symbolism, but we would suggest that does not diminish its importance at all.

Bill 43, the section on the prescription of a personal hearing aid: CASLPA contends that the prescription of a hearing aid is most adequately and efficiently addressed by audiologists. Audiologists are the professionals specifically trained in this area of health care. Inappropriate assessment, or the application of an inappropriate aid, can cause physical and mental harm to patients. The master's degree is the recognized level of qualification for audiologists, and is the necessary level of qualification to adequately prescribe a hearing aid.

I again refer you to our publication, Scopes of Practice, which covers this area. CASLPA certainly recognizes that there are difficulties in the provision of this area of health care throughout Canada, but we strongly suggest that to lower any standard in relation to those who may prescribe a hearing aid would be tantamount to lowering this standard of health care.

In the limited time available here, we have attempted to stress four areas of this legislation that we feel may be refined and improved. We recommend some further attention to these areas with the intent of better delivery of quality health care as well as protection of the public. We feel that if these recommendations were to be acted upon, this legislation would be enhanced.

The Canadian Association of Speech-Language Pathologists and Audiologists appreciates this opportunity to present to you today. We are pleased to be here on behalf of our members, and in support of the Ontario Association of Speech-Language Pathologists and Audiologists. We know that other groups and individuals are competing for your attention on these matters. Differing points of view will be heard. The voices of professional associations, consumer groups and individuals should be heard. Our association, as a national voice, has been pleased to be part of this process here in Ontario. I would be pleased to answer questions.

Mr Sola: I am interested in your latest comments about the provision of inadequate hearing aids. I am wondering how often this occurs, and which of the professions, or the professionals that prescribe hearing aids is most often the culprit?

Mr King: I do not have specific information on that. The contention of our association at this time is more that the specific training at the highest level for the best health care is received by audiologists at the graduate level. It is that background and knowledge that they bring to this area of health care which is most important. I am not aware of a study that has compared the problems resulting from this between the two groups.

Mr Sola: As the parent of a child who uses hearing aids, and another child that has a hearing problem in one ear, I am interested in getting the best service available for my children. At the same time, Ontario is a huge province, and as the presentation before you made clear, there are huge areas in the province that have little or no service of any kind. I would be interested in finding out if there is any study to confirm what you have said about the inadequacy of hearing aids, because I would like to pinpoint who is responsible for that.

If I lived in the north, or one of the areas that has no service right now, any service would be better than no service, because quite often these people cannot afford to come to southern Ontario to get treatment. I am not interested in turf protection, if that is what is going on here. I am interested in getting the best service for the money, and adequate service for everybody in the province, rather than excellent service in selected areas in the province and no service whatsoever in other areas.

Mr King: One comment I would like to make is that some service versus no service, if the service provided is not appropriate, is not good service.

Mr Sola: That is why we need a study to pinpoint where the fault lies.


Mr J. Wilson: Continuing along the same line of questioning, the non-audiologists, the Association of Hearing Instrument Practitioners of Ontario, claimed that it is not necessary to have a master's degree to prescribe a hearing aid. Would you agree with that? Clearly you do not, but just to turn around the question from Mr Sola, is it really necessary, in your opinion, to have a master's degree? We will give you a chance to explain it on the record.

Mr King: Yes, I think it is necessary. It is an aspect of training at our level that is specifically designed for a high level of quality care. As I stated at the conclusion of that section, I think that to lower that is to lower the standard of health care. I know the Ontario association can present some information to you that the province is covered by services that are better than, I think, what was previously detailed.

Mr J. Wilson: That is the contention, and yet no one has been able to bring forward any evidence that there is a serious risk of harm in the work that is being done by non-audiologists. As legislators, we cannot just go on contentions and hearsay. We have to go on fact.

Mr King: I am not certain that the way the question is posed, professionals versus the others, is exactly the best way to pose it. It will have to be looked at, I agree, but the suggestion that anything less than the best service and the most adequately trained people, and that you are going to allow that service to exist, is not, I think, in the best interest of the people of Ontario. The contention is that there is a risk of harm, and the risk of harm does exist. We do know that there is a risk of harm in the prescription of the wrong hearing aid.

Mr J. Wilson: How many people are you graduating into audiology every year, and is it sufficient to cover the province?

Mr King: It is not nearly enough, but it can be demonstrated that with the growth that is predicted, there will be much greater coverage in the province by audiologists than in the past. There are shortages of speech-language pathologists and audiologists throughout Canada, but again we would suggest that another provider is not the answer. We would love to see more programs. There are only seven programs in communication disorders in all of Canada. I do not think the provision of others in the face of that is the answer.

The Chair: Thank you very much for your presentation.


The Chair: The next presenters are from the Ontario Association of Speech-Language Pathologists and Audiologists. Would you introduce yourselves, and we would ask that in the 20-minute presentation you leave some time at the end for questions.

Mr Murphy: We would like to thank each of you for the opportunity of speaking today. My name is Randy Murphy and I am a speech-language pathologist. My colleague is Barbara Kurpita and she is an audiologist. Today we were asked to speak on behalf of the Ontario Association of Speech-Language Pathologists and Audiologists to present the views and concerns of speech pathologists and audiologists around the province with respect to the impact of this legislation on speech-, hearing- and swallowing-impaired patients throughout Ontario.

We are here today to talk specifically about two areas. The first relates to support for the legislation in a generic way. Second, we will raise some of our concerns about the legislation as it is currently written, and this will be done under three main headings: diagnosis, title restriction, and prescription of a personal hearing aid.

The Chair: Could I ask you to speak up a little bit? Some of the committee members are having some difficulty.

Mr Murphy: Certainly.

Mr Grandmaître: They need a test.

Ms Kurpita: That is my job.

The Chair: The interjection is noted. Please continue.

Mr Murphy: I would like to mention that our association overwhelmingly supports the intent of this legislation in that it serves to provide a broader degree of accountability than currently exists and will provide a unifying system for consumer protection. It will also help to ensure that the high quality of care that currently exists in the province will be maintained, and will also result in a fairly cost-effective service across health care.

However, there are several areas of concern we feel we would like to discuss today. The main concern for speech therapists and audiologists around the province is what impact some of the principles contained in the legislation will have on our patients.

I should start with the topic of diagnosis. As speech-language pathologists and audiologists, primarily we would collect information on patients, maybe do testing on them, and speak with other health care professionals around things that go on with either a speech, hearing or swallowing problem. We would talk with you and your family to find out just how that is affecting broad aspects of your life. We would analyse the information and then develop a conclusion which will give us an idea of where these things are going wrong for you. From that we would discuss with you and your family what kinds of treatment plans we could develop for you and with you, and how that might improve your ability to take life on.

The process I have just described to you is perhaps best described as diagnosis. That is the way, essentially, diagnosis may be defined in the legislation itself. Ministry officials have often indicated we really do not have to worry about the way diagnosis is written, but quite frankly I do worry. Our lawyer, and certainly the lawyers for a variety of other health care groups, have indicated that one very possible interpretation of the legislation is that I cannot do what I just described. I could assess you, I could develop a treatment plan and come to conclusions about what is going on with you with respect to a speech, hearing or swallowing problem, but I could not communicate that to you. For that to happen, you would need to see someone who has an authorized act to do that, which would include physicians, psychologists and a few other groups.

We feel this will create a number of problems, at least according to my legal opinion. First, it will create an increase in the length of time you will wait. I know the length was discussed earlier. Certainly, if I cannot get on with my job and I have to send you on to somebody else who will tell you what I just did, it may be a while before you make the appointment and eventually end up back on my doorstep again.

Second, there is a real potential to have a negative effect on the relationship we develop. You come and see me and all of a sudden we do this nice job, we spend an hour or two together discussing what is going on, and all that is left is to tell you: "You have to go on and talk to somebody else now. I cannot really let you know what is going on." You are going to begin to wonder whether I really know what I am talking about and whether I can really do the job. In the end, I guess one might even suppose that all this travelling back and forth has the potential of increasing costs to OHIP.

We urge you to change this situation now. It is our belief that this issue could go to the courts. It may take a number of years to decide. It is an issue that leaves many of the health care professions, including ours, confused, and we feel that same confusion will be brought upon the public as well. We feel it can be fixed now, that perhaps the committee could provide an amendment to do just that.

Ms Kurpita: I would like to add a few points about diagnosis from an audiologist's point of view. As an audiologist, I first talk with the patient to find out what he thinks the problem is. Then I do a variety of tests to find out where his hearing loss is. I talk with that patient and his family members or other people he has brought with him to interpret my test results for them and to discuss appropriate recommendations. We have a dialogue during this time. They ask questions as I am discussing the test results. It is important that people who come to see me have enough time in my office to ask questions and that they feel comfortable, that they do not feel intimidated. In my setting, people often feel very comfortable and I am proud of the fact that they often leave my office saying: "Thank you, you have been very helpful. You have answered my questions."

If diagnosis, as it is currently written, means I cannot do what I have been doing, that I cannot talk with my patients and discuss the test results, then we strongly feel it needs to be changed.

Our recommendations are on page 7 of the brief.


Mr Murphy: The next area I would like to raise for our discussion relates to title restriction.

The legislation provides protection for the public in a couple of ways. Primarily it is through the provision of a number of authorized acts. That was bandied about earlier, that if there is the risk of harm those particular acts are governed by the legislation and are given to specific groups.

Second, it is provided through title protection. Members of professions have specific titles protected and anyone else who is not a member of the profession may not use those titles. To allow people the benefit of that aspect of the intent of the legislation, we urge you to protect the title "speech therapist." Typically, in my job as a speech pathologist or speech therapist, when I meet patients I describe myself as a speech-language pathologist. More often that not shoulders go up, eyebrows go up and they wonder whether I take bodies apart.

Essentially, when I say the words "speech therapist," a lot more calmness comes over people because it is a lot less threatening, but they do seem to understand what I do there. They have had some experience with that. In fact, when government agencies look for one of us to work for all of you, you advertise the title "speech therapist." There are some examples in the brief, in the appendices that indicate how that is done.

To eliminate the confusion on the part of consumers, the government as a consumer and other government agencies as consumers of our services, we ask that an amendment be placed forward to protect or include the title "speech therapist" along with "speech-language pathologist." We feel this will have no impact on access to service.

Essentially we do our assessments, come up with a treatment plan in terms of what might help you or your loved one best to overcome some type of communication problem, and then we would enlist your help, sometimes a volunteer's help, to actually carry all this work out.

I believe part of what gets done in therapy can be done by others, and we encourage that this be done. That is a more cost-effective way of accomplishing our goal.

We are not looking to prevent somebody who might be doing some effective therapy from doing so in the future. The idea of the legislation or its intent is to protect title. "Speech therapist" is a title to protect. We are not protecting the act of speech therapy, just that the consumer has the right to choose who is regulated by law and who is commonly known as that. Again, we would ask that this be done now before the legislation is passed.

The next issue I would like to discuss relates to use of the phrase "in health care." The recommendations initially provided by Schwartz were changed somewhat when this legislation was finally introduced. What ended up being changed was a phrase that said all groups that restrict title would be restricted, but in the course of providing health care. Perhaps on the surface that seems to make a little sense, but I think we need to look beyond that.

There are a number of areas where service providers like myself may not work for a typical health care agency; school boards, for example. Industrial audiologists is another example. There are areas where people could easily say they work beyond the confines of health care. The legislation clearly will not protect people in situations like that because of that narrow definition. The phrase "in health care" really limits public protection for a number of reasons, and I will tell you what we feel they are.

"Heath care" itself is an ill-defined term. It is one I am sure will be discussed over the next little while, but one that apparently over the last few years has been very difficult to define adequately. Second, a number of professionals work in non-health settings, not only ourselves but some of the other allied health professions from whom you will be hearing and may already have heard.

Certainly anyone could use one of the restricted titles, which is the basis for providing protection to the consumer, as wanting to do it in a setting which you can describe as non-health. In that situation, the consumer has no avenue for protection and yet this legislation's initial intent was to provide consumer protection, not in a narrow area but across your life, all of your experience across the province. This inadequacy could be rectified by the provision of an amendment at this time, and again we would suggest that the phrase in which "in health care" appears be deleted from the legislation.

The next item is the holding out clause, which is related to title restriction in a way. Holding out relates to how you could really describe what you do and who you are. Language is not strong enough in the legislation and people may be misled. The public will be confused. For example, someone could put a shingle out that says, "Audiological services." The consumer might realistically think an audiologist works there and one may not.

We are suggesting that language in our brief. You will find a suggestion that goes back to something suggested by Schwartz in the health legislation review so that the gap created by this is filled, to decrease the possibility for confusion. It is not our intent to stop people from working. It is our intent to strengthen the legislation based on the idea that you should be able to identify individuals covered by the legislation. That is what we feel this provision would do.

Ms Kurpita: I am going to talk briefly about prescription of a personal hearing aid as a controlled act. As you know, it is an act that has been given to audiologists and to physicians. I am very happy to see that it is a controlled act included in this legislation and I strongly support the fact that it remain in this legislation.

This legislation ensures that the public is protected because hearing aids can cause harm. Some hearing aids, when they are sent to us from a manufacturer, come with a warning label stating to be sure they are not set to a certain setting because they can damage the hearing of the person who is wearing it. It is important that the hearing aids be prescribed by individuals who are fully aware of the fact that hearing aids can cause damage.

There are some arguments that if this legislation is passed as is there is going to be some access problems and a cost to health care. These arguments are not true. Attached to our brief is a survey using Ministry of Health statistics that show there is not going to be an access problem.

Currently audiologists prescribe the majority of hearing aids in Ontario. We are already doing it. This legislation formalizes what is already happening so there is not going to be any change. I urge you to keep this in the legislation. It is important for the public to make sure they are not harmed. I am sure you will have some questions about this, so we will go on to the rest of our presentation and you can ask me after.

Mr Murphy: That reaches the last of our points. I would like to express our thanks again for an opportunity to speak today and to welcome any and all questions.


Mr Owens: I was not sure I heard you properly at the beginning of your presentation, but did you indicate that your association supports the legislation with the qualifiers you have listed?

Mr Murphy: That is correct. Overall, we are quite happy with the intent of the legislation. There are several refinements that we urge you to consider making.

Mr Owens: The AHIP people made their presentation earlier, and with their chart with respect to access to audiologists they painted a pretty grim picture of the reality now and what is going to happen a couple of years down the road. Do you see the legislation causing that type of grim prediction to come true? If not, what are you basing your figures on? The AHIP people seemed to feel the folks are not coming out of the programs as quickly as the need is growing. How do we balance the two needs, access and protection of your scope?

Ms Kurpita: One main argument is the fact that this is a controlled act given to audiologists and physicians. A physician can prescribe a hearing aid. We also have had a number of people grandfathered to allow them to prescribe hearing aids. A number of people who have been dispensing hearing aids can continue to prescribe them. There are also some audiologists who have been grandfathered to dispensing aids. So we have a whole generation of individuals to work through and solve the problem.

There are increasing numbers of people being graduated. The Ministry of Colleges and Universities has been very supportive in making sure that some of the programs are expanding. There are more programs and there are more spaces in the Canadian universities for people to get out and to practise. We are very confident. I urge you to read the appendix to our brief, which shows that access will not be a problem.

Mr Grandmaître: Mr Murphy, you alluded to protecting title. How come all your PhDs, not matter where they work, would like to be referred to as doctors?

Mr Murphy: I think they are probably not much different from any other segment of society where one is given an honourable title. One would like to be able to use it in situations that are appropriate. It has been something that has traditionally gone on for many years. We would in effect be putting an end to current practice. People who have worked very diligently for years towards advanced training feel this now disallows that recognition and identification.

Mr J. Wilson: It may be all very well to say that physicians under this act will be able to prescribe hearing aids, but I cannot think of any, and I know a lot of physicians, who have ever taken any courses or have really any knowledge of hearing aids other than reading the manual that comes with them. I just throw that out.

Second, you mention in your brief and in your oral submission that the non-audiologists who are currently prescribing and dispensing are grandfathered. Where is that covered in the act? I know that is the current practice, but if this act were passed, their contention is that they would be shut out from prescribing, which is the way the scope reads, the controlled act reads. How are they grandfathered if this were to pass?

Mr Murphy: Thus far, the indication we have had from ministry officials has been that this type of exemption did not need to be written. Perhaps I am mistaken, and perhaps Ms Bohnen can correct that, but it is every intent at the Ministry of Health level that this practice continue. It is not something that is contentious for us.

Mr J. Wilson: My understanding is that is not the case. I think the ministry is more worried about conflict of interest in that area and would like to narrow the prescribing or restrict the prescribing and separate it from the dispensing except in remote areas where there are exceptions made, as is current practice. I think your contention that they will be grandfathered needs clarification. Perhaps you are right. I ask, Madam Chair, that at some point this be done, that we once again clarify this point of whether or not the non-audiologists who are currently prescribing and dispensing really are grandfathered somehow in this new legislation. Certainly my reading of it does not indicate that.

The Chair: We appreciate your presentation. We may have a gap in about 10 or 15 minutes, so the ministry may be able to put that on the record today through the parliamentary assistant, if you wish.

Mr Jackson: With the point being made about challenging the contention of the cost saving to taxpayers, is it possible for the committee to get a brief explanation or a written response to the costs for prescribing, I should say, for the audiologist, the physician and/or a hearing instrument practitioner?

The Chair: We will have an opportunity to ask questions directly of the ministry when there is time. The suggestion I have in the meantime is that they are here and if you pass them a note, perhaps they could answer that for you.

Mr Jackson: But it has been communicated that I would like that information. I am serving notice to the ministry that we would like to get that.


The Chair: Our next presenter is Stefan Fridriksson. You have 10 minutes for your presentation and we would ask you to leave a few minutes for questions by the committee.

Mr Fridriksson: First of all, I would like to say I am not presenting on behalf of any association; I am presenting on behalf of myself.

Many audiologists have expressed anger and sadness that Bill 44 will be their definition as professionals. Audiologists are the primary providers of hearing health care in this province. In diagnosing hearing impairment, we use sophisticated equipment to determine the nature and degree of hearing loss. We relate our results to the patient and the referring physician and then design an appropriate treatment program. We play the central role in public and professional education regarding hearing loss and hearing loss prevention.

As audiologists, we are required to have four years of undergraduate study, another three years of graduate school and then one year of clinical training. After eight years of study, we are granted the status of a clinically competent professional. Before we are admitted, and while we are training, we must maintain an excellent grade point average. When we graduate, we must write qualifying exams that certify our skills in the assessment and diagnosis of hearing loss as well as the prescription and dispensation of hearing aids.

How is the audiologist defined in Bill 44? While the bill recognizes the assessment of hearing loss in our scope of practice, it does not allow us to form an audiological diagnosis and relate this to our patients. In contrast, all physicians are granted the right in their legislation to use our results and provide a patient with an audiological diagnosis.

While on staff at Mount Sinai Hospital, I taught some of the University of Toronto ear, nose and throat and family medicine residents. Presumably, ear specialists should be the most qualified to disseminate audiological test results. However, they received only 26 half-days of audiological training, while the family medicine residents received just two two-hour lecture/demonstrations during which they were given the absolute minimum outline of audiology. Neither the ENT nor the family practice residents are ever examined on their skills or abilities in the field of audiology, yet they are deemed to be our supervisors in most clinical settings and can pretend that they interpret our results to our patients.

In reality, it is the audiologist who tells your mother whether she has a hearing loss, whether her hearing can be corrected by a hearing aid or whether she needs to be seen by an ear specialist for a possible medical or surgical solution to her hearing problems. It is the audiologist who tells the parents whether their child is permanently deaf or is simply suffering from a temporary middle-ear dysfunction. We are the ones who determine the nature and the degree of hearing loss and interpret the audiometric results to the patients.

As this legislation is now written, it does more than remove the diagnostic statement from the appropriate health professional; it puts our profession at legal risk. If I carry on as I have been doing for the past seven years, providing my patients and their referring physicians with the appropriate audiological diagnosis, I could be charged with practising medicine without a licence.

When I addressed this concern to some of the physicians in my area, many of them were compelled to write letters of support on my behalf. I have included copies of letters from 29 physicians. Each one recognizes the fact that it is the audiologist who interprets the results and provides the patient and the referring physician with an audiological diagnosis. As one physician stated in her letter, "It would be a complete waste of time for everyone and money for the taxpayer if all you did was send me the raw data without interpretation of your audiological assessment." It is apparent that a clause recognizing our skills would neither offend the medical community nor be an inappropriate assignment of skill.

The second problem: Subsection 15(1) of this bill states that no person other than a member may use the title "audiologist" in providing health care to individuals. Presently, there is a group of hearing aid dealers in Toronto which calls itself an audiology clinic. According to legal advice, this practice would be allowed to continue because they are not delivering their services in a health care setting. It is obvious that by using that name they are attempting to fool the public into believing they have completed equivalent training to an audiologist. This problem could easily be resolved by removing the word "health" from subsection 15(1).


In terms of health care providers, audiologists and optometrists are essentially identical professions serving different physical afflictions. The first university degree programs were offered to each profession in the 1930s. Both professions developed from similar roots. Optometry grew from an offshoot of the fitters of eyeglasses called the refracting opticians and the medical body known as the ocularists, while audiology grew from the collaboration of the medical specialty of otology and from a branch of speech pathology known as the auditory speech correctionists.

Present-day training programs for each profession require undergraduate work in physics, biology, chemistry, anatomy, physiology, psychology and mathematics. During our professional programs, each of us studies the physics of sound or optics, the measurement of hearing or visual impairment, and then learns the correct applicable formulae for aural or visual rehabilitation.

Some comparisons made by the Academy of Dispensing Audiologists in co-operation with the American Optometry Association point out the similarities and differences between our two professions.

Audiology typically requires the same length or one or two more years of study than optometry to receive full clinical recognition. Both audiologists and optometrists have been providing diagnostic services and prescribing and dispensing corrective devices prior to and since the birth of their professions. Both audiologists and optometrists have had periodic territorial disputes with medical professionals and paraprofessionals associated with their professions.

For two so obviously similar professions, the differences between the present legislation being offered to each is stark. Optometrists were granted full title protection, dispensing rights, diagnostic statements and a raft of definitions of territory regarding treatment, use of diagnostic tools, and assessment. Conversely, audiologists, using the equivalent tools and performing the equivalent tasks, were granted a status equivalent to a technician. We ask ourselves, how can it be fair when one profession that is so obviously of the same calibre as another is granted so much while the other is granted so little?

Is it because optometry has 870 members while audiology has only 250? That would be as unfair as granting obstetricians/gynaeocologists more status than ophthalmologists. They presently enjoy equal but different status because the only difference between them is that they apply their skills to different but equally important parts of the body.

Is it because the ears are somehow less important than the eyes? Obviously not to one of my clear-sighted hearing-impaired patients. Is it because we are under-qualified, under-examined or under-scrutinized? Both of our professions have national bodies that set national exams, standards of ethics and practice and each of us has agents of the federal and provincial governments that monitor our conduct.

Is it because audiology is dominated by females -- 82% -- while optometry is dominated by males -- 76%? I hope not. Is it because optometry was previously recognized by legislation? I thought the idea of this legislation was to seek out fairness. Is it fair that because you forgot us last time you should ignore us again?

Optometry and audiology are scientific and technical skills applied to the health care field. We both wanted fairness from this process. Only one of us got it.

I have come to the end of my presentation. After I read this to my wife, she asked: "How did it ever get this bad? After all those years of study, we owed over $35,000 in student loans. For seven years you were never home because you were always studying at the university library. Now, after all this, they tell you the only thing you know how to do is prescribe a hearing aid."

I am asking the members of this committee to change that. I am asking you not to perpetuate the privilege of the old boys' club that prevents the legitimate recognition of the contributions that the men and women of my profession make to the health care field.

Simply stated, audiologists are asking for two changes to this legislation: a diagnostic clause that allows us to relate our findings to our patients and to other health care professionals; and changes to our protection of title, in order to prevent others from using our name outside the traditional health care setting.

Mr J. Wilson: Extremely well done. Now, you are currently indicating the diagnosis to the patient.

Mr Fridriksson: Yes, I am.

Mr J. Wilson: Just for the record, why are we being asked to restrict that practice?

Mr Fridriksson: I do not understand it. I have letters from 29 physicians and I am expecting more by fax. Unfortunately, I had to leave before my fax machine got them this morning. I am expecting faxes from places up in the north and various other physicians in my area, saying I am the one who diagnoses hearing impairment. I do not understand where the process got lost.

Mr J. Wilson: In the one quote you do cite from a physician, though, that is communicating between professionals. It is our understanding from the ministry that this would not be prohibited.

Mr Fridriksson: Okay, can you read maybe in your spare time? There are about 29 letters here. Just take a glance through some of the letters. They say: "I recognize that you say this to my patients. I recognize that you are the qualified one and I am not trained in this area."

Mr J. Wilson: We have heard this from a number of witnesses, and we certainly are going to take a serious look. It is my understanding we are trying to get rid of the non-regulated quacks out there, if there are any, from communicating diagnoses, but in your case there seems to be very good evidence brought forward. If that is the current practice and people are not being harmed, and the medical profession is supporting you on that, we will certainly take a look at it.

Mr Fridriksson: Could I address some questions? People were talking about harm of hearing aids and they were also talking about prescribing. You were talking about access. One of the people cancelled --

The Chair: You are going to have to submit that in writing to the committee.

Mr Fridriksson: One of the people right after me cancelled. I was wondering if I could use a tiny bit of that time to address the question from Mr Sola.

The Chair: No, I am sorry, you cannot.

Mr J. Wilson: She cuts us off too.

The Chair: It has been noted and we will have an opportunity to have those comments addressed. Perhaps they can be discussed at committee. If you hear anything you would like to submit in writing, that would be very helpful. Thank you very much for your presentation.

Mr Fridriksson: Okay. Thank you.

The Chair: We have approximately five minutes before the next presentation. There was a question that was posed to the ministry, and I will undertake a list. Mr Jackson, you had a request. Do you want to start out first?

Mr Jackson: I think they are aware of my request. I know they cannot give me the details I am looking for verbally, so if we could get that in writing, I would appreciate it.

Ms Bohnen: Could you just restate what the request was? I think it was that you were interested to know the relative cost of a physician and audiologist or hearing aid dispenser diagnosing hearing loss? Is that how you put it?

Mr Jackson: And prescribing. I would like to see the contention from the Canadian Association of Speech-Language Pathologists and Audiologists; they challenge the notion that it would be less expensive, and I would like to see a breakdown of the fee structures and how they are paid. I would like to know the difference between those which are regulated through order in council from the assistive devices program versus those which may be a fee that is negotiated through the OMA, and other fees. I would like to know how they arrive at their fee, who controls the fee and when it is paid by those three groups. If that is the turf war we are looking at here, I would like to look at the financial breakdowns and I will draw my own conclusions about what is going to be cheaper or more expensive for taxpayers in Ontario.

The Chair: Comment or question, Mr Cordiano, and then I have Mr Owens, and we have four minutes.

Mr Cordiano: I have a question of the ministry with respect to the last brief, and it centres on the whole question of the audiologist diagnosis versus -- I would imagine what you outlined for us previously was the question of diagnosis versus assessment, and essentially the audiologist is making an assessment, in your opinion, and the way the new legislation is crafted, that would be essentially an assessment versus a diagnosis. Is that correct?

Ms Bohnen: That is correct.

Mr Cordiano: What we then have to take is that one step further and how that assessment would be relayed to the physician, who would then make a diagnosis?

Ms Bohnen: It would not necessarily go in that sequence. I think what you have heard is concern from this group and previous groups that their assessment activity, including communicating the result of the assessment to the patient or client, would be unnecessarily and wrongly interfered with by the diagnosis controlled act. The issue I think comes down to how that diagnosis controlled act should be worded, and depending on how it is worded in the end, whether such things as clarification of the right to assess and communicate the assessment is necessary, or perhaps whether other groups do perform diagnosis, however it is finally worded. That is the area we are talking about sorting.

Mr Cordiano: But certainly you are making me come to the conclusion that it was not the intention of the minister to exclude, for example, the audiologist from making his or her professional, shall we call it, diagnosis or assessment.

Ms Bohnen: There was absolutely no intention to stop audiologists or speech-language pathologists from assessing their patients or from directly communicating the outcome of the assessment to the patient. There is no requirement intended that they should have to use the physician as the intermediary.

Mr Cordiano: All right. So it is a question of clarifying that. Thank you.

The Chair: Mr Owens, one minute.

Mr Owens: I guess Mr Cordiano and Mr Jackson have both touched on the questions in terms of the different cost scenarios with respect to restricting one's ability to diagnose and prescribe and then for allowing the status quo. Has the ministry taken a look at different cost scenarios around that, and if you have, can we see those?

Ms Bohnen: These recommendations that Schwartz made and that are incorporated in the legislation do not result directly from cost scenarios but rather a risk of harm to patients and ensuring quality care. But leaving that aside, I believe it is quite possible to provide the information you are looking for, which is I think partly, with these participants in the hearing aid service area, what are the costs associated with different participant groups playing different roles.

One thing that I think complicates the analysis a little bit is the fact that during the course of Schwartz and the translation through legislation, the assistive devices program generated policies so that provincial moneys in the funding of hearing aid services would be properly spent. That changed the manner in which most hearing aid services were provided in Ontario, but it still should be possible to come up with the information you are looking for and we will do that.

The Chair: We will have to continue this discussion at another time.



The Chair: Our next presenter is Arne Zabell. Welcome to the standing committee on social development. You have 10 minutes for your presentation and we would ask that you leave some time for questions at the end.

Mr Zabell: Madam Chairperson, honourable members of the committee, my name if Arne Jensen Zabell. I am severely hearing-impaired. I wear two of the most powerful hearing aids you can get. Beside me is my wife, Pamela Zabell. She is also a hearing aid specialist. She is here to channel me when I misunderstand what you say to me, because even with hearing aids there is a tendency to misunderstand even when you can hear. Hearing and understanding are two different things.

I am a certified hearing aid specialist graduated from Sheridan College in 1980. I have a certificate from the national hearing aid society that calls me a hearing-instrument specialist. The Ontario Ministry of Health assistive devices calls me tester-authorizer and vendor. I own and operate Zabell Hearing Aids in Hamilton and Hagersville. I am the only health care professional who guarantees satisfaction or money refunded. I have told you this so you will understand I have knowledge about the subject.

I am here because I think you are making a mistake if you proceed with the bill as it is written. You have an opportunity to make the best audiology bill in North America if you will just use some of the German ideas. To do it complete justice, you should go to Germany and study their structure or invite somebody knowledgeable to testify.

Consider this. Only a very small percentage of hearing-impaired can be helped medically or by surgery. Therefore, at the entrance into the system there should be a screening procedure, such as a simple audiological test that could be done by a second-year audiologist, who could be called a hearing aid specialist. They could decide if referral to an otolaryngologist or clinical audiologist were indicated. If not, then take them directly to a hearing aid evaluation. That alone would save thousands of dollars and ping-pong trips from place to place would not happen.

To make it work, consider tiering audiology. Two-year students of audiology should learn about hearing aids, including practicum. Four-year students would be clinical audiologists but would lose hearing aid designation if they did not practise or attend updates.

It is impossible for a clinical audiologist who spends much time doing brain stem tests and such to keep up to date with the new hearing aids and it is unnecessary for a hearing aid fitter to know brain stem testing except to know when to refer. But they have a large pool of common expertise and therefore belong in the same college, both for the sake of equal progressive learning and cost benefit to the taxpayer. The common bonds between an audiologist and a hearing aid specialist can be stated more easily than the unnatural union of speech pathology and audiology. The audiologist association and the Association of Hearing Instrument Practitioners of Ontario should be forced to amalgamate. The government of the day saw nothing wrong in encouraging the Sheridan graduates' association to amalgamate with the hearing aid fitters for the betterment of the system. Now is the time to go the last step and write the legislation in such a way that there will be no more turf wars and the hearing-impaired and the taxpayer will be better served.

There will be moans and groans from both sides, but the fact is that very few clinical audiologists understand or keep up with the dozens of new hearing aids that come on the market every year, and they have tried to use an equal-loudness measure to fit air pressure hearing aids. If we get everyone into the same thorough schooling, the result will inevitably be better instrumentation, which in turn will give us better hearing aid fitting, and the audiologist in the first two years will learn all about hearing aids and ear molds and learn the use of an otoscope.

The audiologist will gain by a closer association with the hearing aid fitters, and the fitters will gain from expanded knowledge of audiology. The hearing-impaired will gain from an expanded pool of knowledge. The medical profession will undoubtedly approve, as they are already tiered into specialists of the same profession. The taxpayers will gain by only having one school to pay for, and there will be only one professional organization to go to for discipline when there is a complaint. It is totally a win-win-win situation.

As I see it, it will be a sad day if we lose this opportunity to make the best possible system for the hearing-impaired.

I have spoken to some audiologists about this idea. They say, "It isn't a bad idea, but please don't tell others I said that." I have talked to some hearing aid specialists about it, and they have agreed but said, "Don't quote me, I might be cut off from my referrals."

The past 10 years have seen an improvement in the services to the hearing-impaired. You have the opportunity to improve this bill and set an example for all of North America by improving Bill 44 by the simple method I have suggested. I thank you for the opportunity to give you my ideas, and in the right-hand side of the folder I have the papers which prove what I said.

Mr J. Wilson: A great brief. I particularly appreciate the recommendation to travel to Germany.

But on a serious note, if I understand this, the audiologist is in university for four years doing an undergraduate degree in sciences. You are recommending that the non-audiologist now -- it sounds like the corollary would be that they would have to take at least two years of equivalent, two years of university, which would be equivalent to the first two years an audiologist would go through, which would mean a cursory review of the sciences, I would think.

Mr Zabell: I have included in my explanation this McSpaden report, where everything is explained by a professor who can do it much better than I can. I included that in there to answer whatever questions you have and who knows what, where and when.

Mr J. Wilson: Okay, sorry. I did not see that. I will be sure to read that.

Mr Owens: I concur with Mr Wilson that perhaps a look at what happens in Germany is a good idea. I did not get a sense in your presentation of whether you agree with the legislation as it is proposed. Do you think it is a good idea, and have you approached the AHIP people with respect to merger?

Mr Zabell: I have spoken to them, but they say, "You know, when you hear two different stories, the truth is usually somewhere in the middle." That is what I come with in this presentation. I wanted to make this presentation because I really deeply feel -- and I am hearing-impaired myself -- I would like to see the best possible system, but as a taxpayer I certainly do not want to blow my money, because taxes are high enough as they are.

I am a member of the association, and undoubtedly a lot of different things are going to come up from my presentation, why I could have said this and why I could have said that. I tried to explain that in here.

I also have another thing in here about the jail term if I tell somebody that he has a hearing loss and he needs something. I have an explanation of that in here too. My whole object is to get the best possible for the hearing-impaired, since I am hearing-impaired, and the cheapest possible, because I am a poor taxpayer.

Mr Martin: I find your thoughts rather intriguing and interesting, to say the least, and I do hope that those who practise in the field of audiology will sit down with you and look at that. I think it will be helpful for those of us here who struggle with the final version of what this legislation will look like for you who work in this field.

The minister, when she was here last week, said that this was living legislation; it is evolving. Certainly, the whole delivery of health care in Ontario is evolving very dramatically in many ways.

I would suggest that if, in fact, the legislation goes through without those corrections in it that you suggested today and what some of the folks who presented earlier suggested, both from the audiology and the hearing instrument professions, you continue to talk and that you come up with some things within that structure which will be in place to look at the evolution of how we deliver services, that you will participate in that discussion and allow this whole field to evolve as it should, to take into account those things that you presented today, because I think you present here the beginning of a coming together of two professions that have served us well to this point, and somehow we should be looking at a way to involve everybody.

Mr Zabell: I certainly appreciate your comments.



The Chair: I would call now Paula Square. Welcome; you have 10 minutes for your presentation.

Dr Square: Madam Chair and members of the standing committee, I am Professor Paula Square, chair of the graduate department of speech pathology and director of the division of speech pathology, faculty of medicine, University of Toronto. I hold the degree of doctor of philosophy in speech pathology, and am both an academician and practitioner.

I am most appreciative of the opportunity to address the committee today to present my thoughts concerning Bill 43. The overall intent of the bill, the protection of the public with regard to health care, is laudable.

In its current form, however, several sections may in fact disadvantage the public. Those same sections would be dramatically harmful to the present practice of speech-language pathology and the future of this health care profession, which is one of several designated by the Ministry of Health as a top priority for development.

My primary concerns are two: the restriction of the use of the title "doctor" in health care settings, section 30, and communication of diagnosis of disease, disorder and dysfunction to a patient or a patient's representative, section 26.

Consideration of subsections 30(1) and 30(2) will be addressed first. The bill, as currently worded, explicitly disallows all allied health care professionals holding the doctor of philosophy degree, with the exception of psychologists, to utilize their duly earned and university-conferred academic credentials of PhD when in the health care setting.

If passed, Ontario will be distinct in North America and most probably the world in that our government will have effectively (1) infringed upon the rights of patients to know the degree status of all health care professionals from whom they receive treatment; (2) altered the historic and internationally accepted academic principles of the use of title "doctor" by individuals holding the PhD regardless of professional environment; (3) negatively influenced the ability of the universities within Ontario to recruit PhD candidates into the allied health fields in which they are most desperately needed; and (4) fostered discrimination against women in that many of the affected health care fields are female-dominated professions.

Most surely it was not the intent of the writers of this bill to promote such negative effects. Most surely it was not their intent to create further obstacles to the development of those health care professions which this ministry has designated as top priorities for development. None the less, subsections 30(1) and 30(2) do just that in their present form. I urge you to consider the above points carefully, and most humbly I offer you the following recommendation for rewording:

Any person who has earned a PhD in a discipline whose scope of practice includes the provision of health care should be allowed to use the title "doctor."

It is also my desire that this committee reconsider subsection 26(2), that section of the bill which deals with the communication of diagnosis of disease, disorder or dysfunction.

A major role traditionally assumed by practitioners of speech-language pathology is the diagnosis of speech and language pathologies. The name of our discipline, speech-language pathology, denotes this role -- the responsibility to diagnose disorders and dysfunction of speech and language, and to subsequently communicate to the patient or his/her representative all pertinent information concerning the nature, underlying causes, management recommendations and a prognosis.

Section 26 of Bill 43, if accepted in its present form, will effectively change the nature of the profession of speech-language pathology and alter the scopes of practice of this discipline.

As the head of an outstanding graduate professional training program in speech-language pathology in North America, as the person who is ultimately responsible for the curriculum of this graduate program, and as an academic administrator in the faculty of medicine and school of graduate studies at the University of Toronto, I can state categorically that no other health care profession can communicate better to an individual with a speech and/or language disorder the nature of his speech-language pathology; no other health care professional can diagnose as accurately the disorder or dysfunction of communication; and no other health care professional can prognosticate better as to the future course of the communication disorder/dysfunction.

As an active participant in both administrative and academic matters in the faculty of medicine, I can also state categorically that while medical students are trained in a superlative manner with regard to the nature, diagnosis and treatment of diseases, they are not adequately trained to assume those scopes of practices for which speech-language pathologists are trained.

The depth and breadth of the requisite knowledge base which physicians must acquire with regard to disease processes and the diagnosis and treatment of disease precludes their becoming knowledgeable in all aspects of health care, and most certainly precludes their abilities to assume the roles of other health care practitioners.

The terms of section 26 of Bill 43 would place physicians under inordinate demands to acquire both the academic and practical knowledge required to assume the role of informant and counsellor about the nature of communication and its disorders, skills which speech-language pathologists acquire over two to three years of graduate education.

The scopes of practice for the profession of speech-language pathology includes diagnosis, communication of a diagnosis and counselling, and have been clearly defined in a publication by the Department of National Health and Welfare.

All seven Canadian graduate training programs address fully these scopes of practice in their curricula.

The current wording of Bill 43 would redefine both the professions of speech-language pathology and medicine.

I humbly again offer the following recommendation as a revision: "All regulated health care specialists may communicate to patients and their representatives information relevant to the patient's disease, disorder and dysfunction as specified by the scopes of practice of their respective disciplines."

Mr Owens: Thank you, Dr Square. I guess I can still say that without getting into trouble. One of the things that we are trying to sort out on the committee, and we heard a number of people from your profession last week who expressed the same sentiments with respect to the title "doctor," is whether there is confusion or whether there would be confusion in the mind of the consumer around exactly what specialty with standing is presenting itself to the patient. Have you, in your experience, had any difficulty with that, or any of your students?

Dr Square: I have not had that difficulty. I was at Mayo Clinic for several years and none of my patients at Mayo ever confused me for a physician. My name tag said, "Paula A. Square, PhD, speech language-pathologist." If you are concerned about the confusion, then I query why psychologists could designate themselves as doctor, if that is your query.


Mr Owens: One of the things that was suggested is that we take a look at perhaps the regulation on name tags or some level of identification indicating "Dr Square, PhD, speech pathologist." That seems to be the standard in the field, at this point anyway. Would that be acceptable to yourself and the folks you represent?

Dr Square: Most certainly. Of course "PhD" does designate the designator of "doctor" in formal communication.

Mr Cordiano: What you are recommending is that we use the title "PhD," which would be satisfactory, as opposed to the actual use of the word "doctor" in the title.

Dr Square: Yes, but in informal communication worldwide, the holder of a PhD is referred to as "doctor" in verbal communication.

Mr Cordiano: Yes.

Mr J. Wilson: Along that line, I do not see how this Legislature or any other could prohibit that.

Dr Square: That is right.

Mr J. Wilson: A PhD is a PhD. It is the highest degree earned in academia. I do not know which group of legislators along the way gave "doctor" to optometrists, but we are on a political slippery slope. We are giving the term which is held in high esteem by the public to essentially undergraduate degrees and technicians. I am certainly sympathetic to your wishes in that area. I do have one quick question, though.

The Chair: Thank you, Mr Wilson. Time is up.

Mr J. Wilson: He got my supp. I am going to ask this question now.

The Chair: But you made a speech.

Mr J. Wilson: I learned it from a particular party that was in last time.

The Chair: I am going to have to ask that you ask your question of the witness outside, as time is up.


The Chair: The next presentation is from Barton Sala. Welcome to the standing committee on social development. You have 10 minutes for your presentation.

Ms Sala: I am not here as a professional practitioner. I am here as a user and a very successful user, I think. I wanted to make a few points about my experience with speech-language pathology.

A few years ago, for many reasons -- not the least of which was a terrible cold -- I lost my voice. For all intents and purposes, I sounded as though I had laryngitis all the time; I was hoarse, I was raspy. It was particularly troublesome to me because I use my voice professionally. I make presentations often. I am on the phone a lot for my work. I attend an awful lot of meetings, public and private. I also do recordings, videotape and audiotape recordings. So it was not just annoying to have this speech difficulty; it was making my work very, very difficult.

I went to an ear-nose-throat doctor thinking that perhaps I had stress nodes, something physically wrong with me that could be easily or surgically corrected. I went to the doctor. He took a case history, ran some tests, and reached a conclusion. The conclusion was that there was nothing physically wrong. While things were not really wrong, they certainly were not right either, because nothing seemed to be working correctly. He thought that I could probably benefit from speech therapy and he sent me to a speech-language pathologist.

When I went to the speech-language pathologist, similar circumstances took place. She took a case history -- what was my health history like, what was my speaking history like. She ran a battery of tests -- different tests, but a battery of highly sophisticated tests -- and she reached, as well, a speech-language diagnosis that while certainly nothing was physically wrong, there was an awful lot that I was doing wrong.

You are probably not interested in the techniques and things, but I was not breathing properly, I was not holding my throat properly; just a battery of things that just were not going very well. She discussed that with me. She told me various ways that I might have become this way, and there are many, many reasons. You get used to talking a certain way, especially if you have a bad cold and you are forcing your voice. You might be speaking incorrectly and this then becomes habitual and difficult to stop.

She discussed it in great detail and at great length. She talked about what the therapy was actually going to be. I entered into quite a lengthy and interesting and difficult set of meetings with her where she worked as hard as I did and probably harder -- breathing exercises, speaking exercises. It was very, very thorough.

I guess if you could stand back from it, it was a fascinating experience. But in any event, after several months of this, I considered myself to be, if not perfectly well, much, much better. I am now back reading presentations and recording my voice and all that sort of thing, and I feel much better about it.

Out of all of this, I just wanted to make some points, because I really do feel it is important. I probably would not have, except that I am so delighted with what went on. When the doctor told me I should seek speech therapy, I had heard of speech therapists but I was not really familiar with speech-language pathologists. I do not think people walking down the street can think about speech-language pathology, although they often consider speech therapy.

I think it is important to make the point that those two titles are absolutely synonymous for people.

I did not say to people at work, "I am visiting a speech-language pathologist." It takes too darn long to say, and nobody knows what it is. I was seeing a speech therapist, even though she was a pathologist with all the education and training and everything that goes into that. So I wanted to let you know that I think speech therapists and speech-language pathologists are synonymous, certainly with lay people like me.

I also want to make another point, that I think it is vital that this consistency of association be province-wide. I know that if I go to a dentist anywhere in the province of Ontario, there are going to be certain qualifications; there is going to be a certain education level; that any dentist is going to give me at least the same basic treatment that I require. I have confidence in that. In fact, I went to a dentist who is not mine this morning for an emergency, with full confidence that I was going to get the kind of treatment I needed, because that person called himself a dentist. I think that is an important point.

The other point I wanted to make, possibly more important but maybe just on a different slant, is that it was extremely important that the woman who ran the tests and did the diagnosis was able to sit down and discuss it with me. It means that I began to trust her a lot more quickly than if I had had to go somewhere else for an interpretation of the tests. She ran the tests. She talked to me about what the tests were, what they meant, what the results were, what those results meant, and what the treatment was going to be.

I think that is something that absolutely cannot be taken away, that ability to communicate with me or anyone else.

I just cannot imagine what it must be like -- well, I can imagine. We have all been for X-rays, we have all been for other tests; you see five or six different people, none of whom tells you anything. Finally you get bounced back to another doctor, who sits there, looks at your tests and says: "Gee, I am not really sure what all this means."

I would like the person who does the tests and who is going to treat me to discuss them with me. I think that is very important.

That is really all I have to say. I was hoping to be very brief today. If you have any questions, I would be more than happy to answer them for you.

Mr J. Wilson: Are there many people, in your experience, holding themselves out as speech therapists who are not qualified as speech-language pathologists?

Ms Sala: My experience is limited to one person.

Mr J. Wilson: Have you heard any horror stories?

Ms Sala: No, I have not, probably because any of my peers who have sought the same kind of treatment have gone to speech-language pathologists.

Mr J. Wilson: They were aware of what they wanted and sought a speech-language pathologist.

Ms Sala: Somebody with very solid qualifications. If your voice is important to you, the treatment of that voice is important to you as well.


Mr Owens: So in terms of a practitioner, you would look for somebody using the title "doctor"? You have probably been listening to some of the discussion around the use of the term "doctor" for PhDs. Would that, in your mind, present any confusion, or would you prefer seeing a person with the title "doctor"? How do you feel as a consumer?

Ms Sala: Certainly as a consumer -- we are so trained, when we see "doctor," we see all of these --

Mr Owens: We see excellence, allegedly?

Ms Sala: We see certain qualifications. We see certain experiences and certain levels of training that lead us to believe there are certain levels, so "doctor" is always helpful. But knowing that speech-language pathologist A and speech-language pathologist B are going to have the same basic qualifications -- let's put it this way: Would I like my speech-language pathologist to be a doctor?

Mr Owens: On a scale of 10, where would you put it in terms of concerns?

Ms Sala: It is something I have never really considered.

Mr Owens: Do you really care?

Ms Sala: I think, for other people who do not take the time to investigate, perhaps "doctor" would help. "Speech-language pathologist" says to me an awful lot of medical knowledge. Perhaps "doctor" would round that off, I am really not sure.

Mr Hope: When you see the title, not necessarily the word "doctor," but "speech-language pathologist," you know there is an academic level or degree of education involved. That is all you are concerned about. You do not want the title and then two different academic levels involved. You do not want one having a higher level of education than the other?

Ms Sala: The doctor and the speech-language pathologist?

Mr Hope: No, get rid of the "doctor." Now look at the speech-language pathologist. What you want to do is make sure that the level of education is the same for all. You referred to dentists; speech-language pathologist would be at the same level. You do not want two levels of education involved, where one down the street would have a higher education than the one across the street.

Ms Sala: That does not bother me, as long as the lower level of education meets the standards for that particular profession.

The Chair: Thank you very much for your presentation.

Ms Sala: Thank you very much.

The Chair: The committee has seven minutes available till we adjourn at noon. Mr Owens, you had some questions of the parliamentary assistant. We cut you off last time. Did you want to continue that live discussion now?

Mr Owens: My questions were essentially around the cost comparisons between restriction and status quo; the ministry staff indicated that it is possible to provide them.

A further question on a totally different topic: I wonder if there is available an explanation or a rationale why the title "doctor" was restricted to the groups that are now currently within the legislation. I do not understand why all of a sudden it has changed. We have restricted it to certain groups, and we have other groups out there that are clearly able to use it and have earned the title through academic study.

Mr Wessenger: I think I will refer that to the ministry staff. I would assume that it is based on the traditional use of the term.

Ms Bohnen: The review inherited a landscape in which physicians, dentists and optometrists were permitted to use the title "doctor" in the course of providing health care, optometrists having acquired that right with the Health Disciplines Act in 1974. Prior to that, only physicians and dentists could use the title "doctor" in the delivery of health care.

As the review developed, the criterion to determine which additional profession, if any, should be granted the statutory right to use the title "doctor" during the provision of health care was primarily whether a degree or diploma that said "doctor" was the entry-level academic requirement for practice of the profession. The two additional professions which met that criterion were psychologists and chiropractors.

To register in Ontario to practise psychology, you must have a PhD. To register in Ontario to practise as a speech-language pathologist in the future, once the legislation is enacted, in all likelihood the basic entry-level requirement will be a master's level of preparation. Some practitioners do have PhDs, but the entry-level requirement which all practitioners must have is not the PhD.

A PhD is the requirement for psychologists, and a diploma with "doctor" in it is the requirement for chiropractors. Coupled with that, I think, was the issue of common usage attached to these professionals in the course of providing health care.

Does that help you?

Mr Owens: Looking at speech-language pathologists in particular, I am just wondering how it would upset precedent if the committee recommended that speech-language pathologists, as an example, were allowed to use the title "doctor" if they had reached the PhD level.

Ms Bohnen: You may recall the review also recommended there be an exception permitting anyone who worked in a regulated setting like a hospital, or university, I suppose, to use the title "doctor" if they had it. They felt that the management of those institutions would ensure there was no patient confusion.

Currently, from what we heard this morning, a speech-language pathologist with a PhD works in a hospital or wherever; the name badge says "Linda Bohnen, PhD, speech-language pathology." That will not stop. The new legislation does not restrict in any way the use of the letters "PhD."

In informal communication, some patients might say "Dr Bohnen," and others would say "Miss" or "Mrs" or whatever they chose. It is hard to imagine much enforcement should they use the wrong prefix to my name.

Mr Cordiano: I think it is a question of where we are drawing the line. In the case of speech-language pathologists, there are those who do not have PhDs who are practising as speech-language pathologists. To have two levels of practitioners, which would be viewed as two different professional designations, is a bit of a quandary, if you will, for people who would then perceive one to have a PhD degree and another who might have a master's. You are going to create two tiers. Is that what the concern is?

Mrs Bohnen: That is one concern. But the concern that primarily motivated the review to limit the use of "doctor" was that most Ontarians still think "doctor", unless they are in a dentist's office, means "physician." The consumer whom we just heard from said she went to her doctor. Her doctor referred her to a speech-language pathologist.

The review's primary concern was that people think "doctor" means "physician." If we let other practitioners, especially those practising privately outside settings where there is responsible management necessarily in place, they will think they are being seen by a physician when they are not.

Mr Cordiano: We are making it worse. I think I am going to throw a wrench into all of this and say that we should have restricted the terms to medical doctors. That would have simplified everything. It is too late now because we have come along that slippery slope. There have been many, many years of usage of those terms by dentists, by optometrists, and it is now very confusing.

As for concern for the consumer, we do have a confusing situation on our hands, so I think we have to draw the line with a view to the use of the term "PhD," which is what I would recommend, and that is not restrictive. You still have a real mess on your hands as far I am concerned.

The Chair: The committee now stands adjourned until 2 o'clock this afternoon.

The committee recessed at 1200.


The committee resumed at 1400.

The Chair: Good afternoon. The standing committee on social development is now in session. We have agreement from the Progressive Conservative caucus to begin promptly at 2 o'clock. The parliamentary assistant is here.

I understand there is going to be a joint presentation, or one following the other. The Board of Regents of Chiropody will be followed by the Ontario Society of Chiropodists. I understand you have a video presentation. Would you introduce yourselves for Hansard. I understand there is an agreement with the Ontario Society of Chiropodists that you will have a total of 25 minutes in your presentation and it will have 15 following. In total, there will be a 40-minute presentation with questions and answers at the end of the two presentations. Is that agreed?

Mr Springer: Actually, after my verbal presentation we would prefer to separate the questioning. We will show the video in our part of the session, I will make a verbal presentation and we can respond to questions.

The Chair: In that case, as the agenda shows, there will be 20 minutes for each association and we ask you to leave time during your 20 minutes for questions.

Mr Springer: The society has agreed to give up five minutes of its presentation because of the length of the video.

The Chair: In that case, you will have 25 minutes and they will have 15 minutes.


Mr Springer: My name is Andrew Springer. I am here to make a submission to the committee on behalf of the Board of Regents of Chiropody, the regulatory body of chiropody and podiatry. Accompanying me are Neil Naftolin, a member of the board, and Peter Wilson, who is the chief of the Ontario chiropody program. Unfortunately, our chairman, Dr Diana Schatz, is unable to attend due to the unfortunate passing of her father, Roland Michener, last week.

During the preparation for this presentation, and very commonly in years past, I have continually encountered misconceptions regarding the function and the role of chiropodists in the health care system. It has become increasingly evident that there is a lack of understanding about what it is that chiropodists do. This state of affairs is not surprising. Most people will not have encountered a chiropodist and many have never heard of the profession.

In 1984 the board registered 150 practitioners, 34 of whom were chiropodists. In 1991 there are 319 practitioners registered with the board, 218 of whom are chiropodists. Compared to other professions which will be making submissions here, this represents a very small group. Many of you will not have had any direct contact or experience with chiropodists. To that end, our presentation is designed not only to allow for suggestions that we have to make regarding the Chiropody Act, but also to elevate chiropody from the conceptual level closer to a concrete reality, therefore providing you with another frame of reference for discussion.

With your indulgence, I will display a brief video which the Ontario Society of Chiropodists has agreed to include as part of its presentation. They are sacrificing, as you know, some of their time to allow for the showing of the video. The primary function of the video actually is for the recruitment of potential students, but I believe it will provide you with a broader understanding of what the profession of chiropody has evolved into.

Following the brief video, I will make my comments about our position on the act.

[Video presentation]


Mr Springer: Thank you very much for your indulgence. I hope that was informative for you. The board is very pleased that the Regulated Health Professions Act and its companion acts have reached this point in the legislative process. Certainly, in many ways, Bill 43 and Bill 45, the Chiropody Act, represent a significant improvement over the existing Chiropody Act, which, except for regulations, remains unchanged from its original form in 1944.

We strongly endorse Bill 45 with one single suggestion for change. We believe the communication of a conclusion identifying a disease, dysfunction or disorder of the foot is an essential authorized act for chiropodists. We believe the nature of the authorized acts that chiropodists will perform -- that is, cutting into the subcutaneous tissues of the foot, administering substances by injection into feet and prescribing drugs -- requires such communication.

Every patient is entitled to informed consent to understand the nature and cause of their condition, the treatment of choice and the alternatives. Without the right to communicate this information, the patients will not be fully informed. There has been some question as to the ability of chiropodists to actually provide this information. The education and training of chiropodists is designed to develop their powers of deductive reasoning, to allow them to come as close as possible to the cause of a problem and then to provide the appropriate care.

This training, of necessity, has developed partially in response to public need and also in response to existing legislation and regulations which require presently that chiropodists furnish a diagnosis as part of each patient record. Included in our written submission is a list of chiropody-specific diseases and general systemic diseases which manifest themselves in the lower limbs. These are commonly seen in the practice of chiropody and are taught as part of the chiropody educational program.

Chiropodists now provide approximately 250,000 patient visits per year in publicly funded clinical settings. This represents a very real saving in tax dollars because of the number of seniors particularly who are kept ambulatory as a result of their treatments. There is an impact on their physical and emotional wellbeing. Their ability to move around freely allows many to maintain a measure of independence and self-esteem that most of us do not value until it is threatened.

Being unable to diagnose will change the nature of the practice of chiropody. Recognizing the right of patients to full disclosure of information regarding their condition and treatment, chiropodists would have to refer patients back to their physicians to have the doctor relay information already discerned by the chiropodists and then send the patient back to the chiropodists for treatment. If this procedure is projected over 250,000 visits, with allowances for the continual growth of chiropody in Ontario, this translates into millions of dollars spent at no increased benefit to the consumer.

You may ask why chiropodists, above other professions who are seeking the same change in their acts, should be allowed to diagnose. Chiropodists are primary care practitioners. This means they commonly see patients without a physician's referral. It is reasonable to assume that when a physician refers a patient to another health practitioner who is not primary care, a communication has already been made regarding the nature of the patient's condition. This permits the patient to make an informed decision about his or her treatment. This assumption cannot be made about a patient who attends a chiropodist.

By including this controlled act in the Chiropody Act, you will be ensuring that patients are fully and accurately informed by trained personnel, thus facilitating informed consent.

In summary, the Board of Regents of Chiropody strongly urges you to seriously consider augmenting the list of authorized acts accorded to chiropodists in Bill 45 to include the communication of a conclusion identifying a disease, dysfunction or disorder of the foot. We feel that this is justified because the public has a right to informed consent; because this is not an expansion of the scope of chiropody practice but accurately reflects the training and practice of chiropody as it has existed in Ontario for quite some time; because there is a foreseeable increase in the cost of what is now a very cost-effective service to the province's population; and because there is a legislative precedent in existence -- specifically, the regulations of the present Chiropody Act, 1944.

I thank the committee for its attention and hope that you will give our arguments every consideration. We will be glad to answer any questions you may have.


Mr Owens: That was an excellent presentation, Mr Springer. I have a question around your requested amendment, in that the video we saw was basically Toronto centred. Have any morbidity and mortality studies been done in areas where chiropodists are available versus areas where they are not, with patients who have have circulatory problems as a result of diabetes or any of the other illnesses that would affect the feet?

Mr Springer: I believe there have been some preliminary studies. Mr Wilson might be able to respond to that.

Mr P. Wilson: To my knowledge, there have been no such studies specific to chiropody. However, I understand there have been studies conducted which would lead one to the conclusion that if chiropody were introduced to that particular geographical region, there would certainly be an impact and a need for that type of service and it would in fact enhance the health of the local community.

Mr Owens: What happens now in some of the more remote areas where a chiropodist may be available but a physician is not available? Is the assessment and diagnosis made and passed on to the patient? Would this legislation be a change to current practice?

Mr P. Wilson: First of all, with regard to current practice, since the introduction of chiropodists into the province in 1982, physicians have not been involved in the referral of patients to chiropodists, nor have they been involved in the diagnosis of conditions of patients received by the chiropodists. The role of the physician has been that wherever there has been a designated physician in a particular hospital who would take an interest in chiropody, his or her responsibility has been to represent the chiropody department at the medical affairs level of the institution. It has been purely administrative.

Also, to help smooth the introduction of this essentially new profession or health discipline into the hospital, a physician has usually been identified but not in all cases. The relationship is not one where the chiropodist cannot operate independently.

Mr Cordiano: My question is probably directed at the ministry, but I would also like to direct my question to our presenters with respect to the point they make on the degree of sophistication of service they provide in the controlled act. Your suggestion is that because you provide that sophisticated treatment, that you are authorized to perform those acts, you would be able to evolve into a profession which would be probably able to fill the gap which will be created when a cap comes into play in 1993 as suggested by this legislation for podiatrists. Correct?

Mr Springer: I think that like any other profession, there is room for evolution. The original ministry position, I believe, felt that there was not really a gap in existence -- above the level of scope of chiropody, that is -- but that there was a lack of practitioners present.

Our presentation is not based on the contention that we want to evolve into that scope, but simply that to provide the present scope as listed in authorized acts we would have to be able to communicate this information to the patients.

Mr Cordiano: I understand that. Perhaps I could direct my question to the ministry.

The Chair: I have a question from Mr Wilson first and there will be some time with the second presenter who will be discussing this.

Mr J. Wilson: I appreciate the answer to Mr Cordiano's question, because it is a good one. As I understand it, you are currently communicating your assessment to your patients.

Mr Springer: We are.

Mr J. Wilson: Do you know why you are being asked to restrict that function now?

Mr Springer: I would have difficulty giving a full answer to that. My understanding is that there is an impact on other professions, and that has been a concern. Our response to that is that many of the professions that have been presenting or will be presenting on this issue may not be primary care. We can assume, if they are referred by a physician to that particular profession, that communication of that information has been passed on.

I think it is an issue of professional pride as well for many people. Here we feel there is a very practical and real problem in restricting our present practice.

Mr Cordiano: To the ministry, then, I would simply put this: Will there, in your opinion, be a gap created between the two professions at the time we are phasing out podiatrists? There is not really anyone who is going to be filling that void other than physicians. Is that what is envisaged by the ministry to take place?

Mr Wessenger: I will have ministry staff reply to that one.

Ms Bohnen: Specifically in terms of bone surgery?

Mr Cordiano: That is what podiatrists are essentially practising in Ontario. That is the scope of their practice, if I understood correctly.

Ms Bohnen: Podiatrists are not currently permitted by law to perform bone surgery. However, the review recognized that there would be demand for that service and evidence that podiatrists could competently perform limited bone surgery, surgery that is in the bones of the toes and the forefoot, and so concluded that they should be permitted by law to do so.

However, coupled with that was the decision that since Ontario in 1980 had decided to opt for a chiropody model, the number of podiatrists would be capped. As to whether there will be a gap in the accessibility of service, it was anticipated that those patients who require surgery and nothing but surgery will be able to obtain that service from the existing group of podiatrists when they are not available from orthopaedic surgeons. Other patients will be managed more conservatively, using non-surgical techniques.

Mr Cordiano: I am to understand, then, that orthopaedic surgeons would perform the exact same function, or do that now, as a matter of course. What we are allowing in this legislation is for podiatrists to perform a minimal type surgery?

Ms Bohnen: "Minimal" in the sense that it is only certain parts of the foot and certain kinds of surgery.

Mr Cordiano: That is what I mean.

Ms Bohnen: Yes, that is correct. Orthopaedic surgeons, of course, also do surgery on the foot.

Mr Cordiano: What impact would that have on orthopaedic surgeons with respect to their practice at the present time? Podiatrists are not providing that service now, so orthopaedic surgeons are currently doing what is required with respect to surgery on the foot.

Ms Bohnen: You may wish to ask this of the podiatrists whom you will be hearing from shortly, but it is my understanding that in a sense they have been functioning in a kind of limbo. A number of them were performing this kind of surgery. One particular podiatrist was taken to court by the College of Physicians and Surgeons of Ontario. This highlighted the fact that the kind of bone surgery being done was not lawfully provided by podiatrists at this time and put the board of regents in the position of having to police a prohibition which perhaps previously had not been well enforced. I think you should ask the podiatrists to what extent, prior to announcement of this new legislation, their members had nevertheless been doing surgery which under current Ontario law is restricted to physicians.

The Chair: We are going to have an opportunity this afternoon. We will be hearing from two more groups, the Ontario Society of Chiropody and also the Ontario Podiatrists Association. That should afford you an opportunity to pursue the line of questioning further.

Thank you for your presentation.



The Chair: I will call now on the Ontario Society of Chiropodists. Welcome to the standing committee on social development. You have 15 minutes for your presentation. We would ask that you please leave some time for questioning from members of the committee. Please begin your presentation by introducing yourself.

Mr Kerbl: My name is David Kerbl. I am a practising chiropodist. I am also the president of the Ontario Society of Chiropodists. Our society represents 107 practising chiropodists throughout Ontario. In addition, our position on the proposed Chiropody Act, the position I am about to present, is supported by 78 chiropodists who are not members of the society, which represents about 88% of practising chiropodists. They have shown their support through letters written to the executive, copies of which I will be happy to share with you.

With me are Peter Guy, who has worked in institutional and private practice and is now clinical instructor at the Ontario chiropody program, and Olga Laland, who practises now at Victoria Hospital in London but previously practised in clinics in northern Ontario in underserviced areas.

Chiropodists are foot care specialists, and the development of chiropody in Ontario is a function of government policy. I thought it would be useful if I explain for a moment how that came about.

In 1970 an Ontario government task force forecast that the foot care needs of Ontarians, particularly seniors, would increase beyond the capacity of the established medical profession and other existing health care professions, including podiatry, to meet them. The task force recommended a model oriented specifically to foot care. This thrust is consistent with trends in other jurisdictions -- the US, the UK and Australia -- where chiropody or podiatry flourish by filling a gap in the health care spectrum.

In 1981 a decision was made by the government in power that Ontario would accommodate the accelerating demand for foot care through the so-called UK chiropody model. This meant that a chiropody school was set up in Ontario, with the clinical parts of the curriculum being delivered at Toronto General Hospital and the didactic portions being delivered at George Brown College and increasingly at what is now called the Michener Institute. While awaiting graduation of Ontario-trained chiropodists to meet the demand, UK-trained chiropodists were imported to fill the gap.

Chiropody care is delivered through institutions such as hospitals and clinics. I should emphasize, because it is important background for what I am going to say later on, that an increasing number of chiropodists practise in community-based clinics and provide chiropody services to nursing homes where there is little or no medical supervision over the treatment the chiropodist provides. I, for example, practise in Ottawa in a group practice with two podiatrists.

What distinguishes chiropody -- and podiatry, by the way -- from other modes of foot care delivery is that our treatment modalities focus on the foot, and the approach to foot care revolves around the presumption that improper foot function, or "mechanics," is the root of many foot problems. When confronted with a foot ailment, we address function as well as the actual symptoms. We believe this is what makes chiropody as a discipline a highly successful model.

An unfortunate side-effect of the way in which chiropody has been developed in Ontario is that the interests of chiropody and podiatry have been placed in conflict. Many in our profession, the Ministry of Health and our regulatory board see the continued existence of podiatry as a threat to our profession.

We in the OSC know that chiropody alone, at least in its current configuration, cannot meet the demand for quality foot care in Ontario. With current demographic and other trends, in particular what is known as the greying of Ontario, this situation will only get worse. However, we also know that as long as US-trained podiatrists are allowed to enter and practise in Ontario, chiropody will be stultified. It will never be able to grow and develop, as chiropody has elsewhere, in response to the legitimate and actual health care demands.

It is unfortunate that the interests of one health care profession have been juxtaposed against another, especially when today, demand for quality, professional, full-scope foot care far outstrips supply. But this is a function of a public policy decision made by a government over 10 years ago and confirmed by every subsequent government.

What those professionals whom I represent want, therefore, is a recognition by policymakers that chiropody must be allowed to evolve and grow in order to satisfy the foot care requirements of Ontarians. This was what the Health Professions Legislation Review process was all about: establishing, on one hand, an effective regulatory framework, while on the other hand making the framework flexible enough to respond and adapt to the legitimate and natural evolution of each profession. That evolution occurs because of constant developments in training and procedures and in response to patient demand.

Chiropody has benefited greatly in Ontario by being a creature of government. In crude terms, were it not for a government decision made a decade ago, the chiropody model would not exist in Ontario. The burden of foot care would be delivered by podiatry -- the profession chiropody has been designed to supplant -- and by other health care professionals.

Being a creature of government also has its disadvantages, the major one being the extent to which government fiscal and policy objectives, rather than patient demand, dictate the evolution of our profession. We recognize that fiscal constraints impact to some degree on every health care professional group. In our case, fiscal constraints have meant that insufficient resources are available to many hospitals and institutions for chiropodists to practise full-scope chiropody. While our training has generally evolved to keep pace with chiropody elsewhere, particularly in the UK, public policy constraints have kept us from practising full-scope chiropody as practised in most other jurisdictions. In practical terms, our scope of practice for chiropody -- and I am talking about what most of us do in institutions, as opposed to what we are trained or legally qualified to do -- now lags behind the UK model we were supposed to emulate.

I must convey to you the deep sense of frustration many chiropodists feel in being unable, because of policy constraints, to deliver the type of foot care we have been trained to provide. We have in our profession a revolution of rising expectations that are not being met. This unmet revolution of rising expectations has caused a significant decline in the number of chiropody students enrolling in, or graduating from, the chiropody program. It has caused a small number of chiropodists to move into private clinics on a full- or part-time basis. A few chiropodists have left the profession; a few have gone to the US to train as podiatrists and hope to return to practise as podiatrists in the "podiatric scope" defined by the proposed legislation.

We would like, however, to thank the government and previous governments for bringing forward the Regulated Health Professions Act and the proposed Chiropody Act. Madam Chairman, if I might, I would like to acknowledge in particular the role you played as Minister of Health and the role you continue to play. The proposed legislation will remove many anomalies and some uncertainties relating to our profession and will begin to bring our scope of practice up to speed with our training, existing technology, and patient and practitioner expectations. This brings me to two specific issues I would like to address.

First, while our podiatry colleagues have the right to diagnose under the proposed Chiropody Act, chiropodists do not. We feel this is an unwarranted anomaly for four reasons:

1. Under the existing Chiropody Act, we have to date exercised the right to diagnose. To the best of my knowledge, there have been no issues or problems raised as a consequence of chiropodists exercising that statutory power, and I see no reason for it to be removed. Our regulatory board is of the same view, as are our podiatric colleagues.

2. In our clinical and didactic training, we are trained to diagnose. We can document and explain this further if you wish. Perhaps this is something Peter Guy, who teaches at the school, can respond to.

3. Without the power to diagnose, chiropodists cannot be primary contact practitioners. The practice of chiropody will be restricted to institutions, under the supervision of a medical practitioner. Such a restriction means that chiropody can never become a decentralized, community-based system in response either to patient demand or to the legitimate aspirations of chiropodists.

It also means that practitioners such as Olga, who practised for a time in an outlying area and spent most of her time outside the hospital setting, will not be able to deliver the service they now provide. Without the ability to diagnose, chiropody will be restricted, as a practical matter, to large institutions in the larger urban centres.

4. Without the ability to diagnose, our patients cannot make an informed consent to the treatment being offered by a chiropodist.

The other issue I would like to raise relates to the so-called podiatric cap, the provision whereby no podiatrist may be licensed in Ontario after July 1993. For the reasons I have set out in my introductory remarks, I want to make it clear that the Ontario Society of Chiropodists does not support the podiatric cap. It will impose a glass ceiling on our profession, an arbitrary restriction on the natural evolution of chiropody.

The professionals I represent expect that some day Ontario-trained chiropodists will be able to perform the licensed acts now limited to podiatrists under the proposed Chiropody Act. Without that potential, our profession will stultify and grow stagnant. I have already mentioned that chiropody in other countries is surpassing the Ontario model. In the UK, for example, on which our program is supposed to be modelled, chiropodists are being trained in post-graduate courses to perform bone surgery, and chiropodists routinely perform bone surgery in some National Health Service areas. In Ontario, bone surgery is reserved for podiatrists in the proposed act. As written, Ontario chiropodists will never be allowed to perform bone surgery.

I emphasize the point that the podiatry cap not only limits podiatrists; it also limits chiropodists. For that reason we oppose the cap and would support any amendment that allows chiropodists, some day and with the requisite training and in response to a demonstrated need, to perform the licensed acts now reserved for podiatrists.

Our solution is simple. The wording of subsection 3(2) need only be amended to apply to US or any other foreign-trained graduates of podiatric medicine, leaving it open to qualified Ontario- or Canadian-trained chiropodists to practise in the so-called podiatric scope. This will accommodate the revolution of rising expectations that I mentioned earlier and will, ultimately, be in the best interests of the public.

That concludes my remarks, and I will be happy to respond to questions.

Mr Owens: Thank you for your presentation, Mr Kerbl. Looking at the act under section 4, which to us is the chiropodists, and then looking at the section that addresses podiatrists, can you tell me why you are allowed to do an assessment and then treatment but not to tell me why you are doing what you are doing to me? Is there a rationale? Am I missing something in this language?

Mr Kerbl: This is our concern as well, in that we are currently communicating these conclusions to our patients. The current "assessment" versus "diagnosis" wording is very confusing. To our understanding, we require the ability to communicate this conclusion to our patients in order to continue to treat patients the way we have over the last eight or so years since the program was developed.

Mr Owens: Madam Chair, can I put this question on the list of supplementary questions that we will speak to the ministry about?

The Chair: Yes.

Mr Cordiano: I asked the question in the previous set of presentations, and I think you have answered most of it for me in your brief, with respect to where you would like to see chiropodists evolve into a practice that would include, some day, the act of surgery being performed by your profession, I suppose. I think the question that I asked of the ministry earlier was, would the set of circumstances we are going to be imposing with the new act not create something of a gap down the road when, at some point, all of the podiatrists, by natural forces or otherwise, are no longer with us? What would happen to that niche in the health care market? If it is not going to be served by you, it would be served by, presumably, orthopaedic surgeons. How would you respond to that?

Mr Kerbl: I totally agree, because there is a difference currently between -- in the new act -- what chiropodists and podiatrists would be willing to do. In fact, podiatry is phased out; there will be a segment that will no longer be delivered. Presumably that could be delivered by orthopaedic surgeons, and my response is that there is no reason they could not be providing that at the moment.

Mr Cordiano: And they do not? I do not know; I am asking. Anybody can answer that.

Mr Kerbl: I cannot speak on behalf of orthopaedic surgeons, but if those services were being provided, then there would be no reason for podiatrists at the moment to be providing them. We know that chiropody and podiatry exist because there is a lack in other professions and we do fill a niche.

The Chair: Thank you very much for your presentation.



The Chair: I call now on the Ontario Podiatry Association. Welcome to the standing committee on social development. Would you begin by introducing yourselves. You have 20 minutes for your presentation, and we would ask that you leave some time at the end for questions from committee members.

Mr Zamojc: Thank you. My name is Tony Zamojc. I am a doctor of podiatric medicine and I am the president of the Ontario Podiatry Association. With me is Neil Koven, the vice-president of the association. Neil is a doctor of podiatric medicine as well; he practises in Mississauga.

The Ontario Podiatry Association represents the majority of podiatrists in Ontario and is part of the Canadian Podiatry Association. In Ontario, podiatrists are licensed and regulated by the Board of Regents of Chiropody under the Chiropody Act of 1944.

Since there is no podiatry school in Canada, podiatrists earn their doctorate in podiatric medicine after a four-year program in one of the seven US colleges of podiatric medicine. Entry to any of these colleges requires an undergraduate science degree. All applicants must also take the Medical College Admissions Test, also known as MCAT, and competition for entry is very intense. After graduation and before being licensed, many podiatrists serve a hospital internship or residency, and this can range between one and four years.

Before moving to the specifics of the proposed legislation, I want to preface my remarks by stating that the proposed Chiropody Act is supported by my membership. Although both podiatry and chiropody are dedicated to foot care, the bill recognizes the distinctions between the two professions, which spring essentially from the differences in our current levels of training.

The Ontario Podiatry Association views chiropody and podiatry as complementary professions, sharing the same health care sector but focusing on different parts of the spectrum by virtue of our respective training, scopes of practice and delivery modes. For example, the unique and enhanced training associated with podiatry -- generally, four years of post-graduate education for podiatry as opposed to three years of post-secondary training for chiropody -- means that certain procedures are more appropriately attended to by one of the professions as opposed to the other. I point to section 5 of the proposed act, which draws a clear distinction between podiatric and chiropody scopes of practice. Under section 5, podiatrists are granted the authority to, first, diagnose, and second, to perform bone surgery.

I can tell the committee that the podiatric profession is pleased that the proposed act provides the legislative confirmation of a podiatric scope of practice commensurate with our training, abilities and patient demand. For that reason alone podiatrists support this bill, and we acknowledge, with thanks, the role that the current and previous ministers of health -- in particular you, Madam Chair -- have played.

Unfortunately, I cannot restrict myself to simply highlighting the benefits of the proposed legislation. I must also address, in the time allotted, our outstanding concerns relating to two issues.

The first relates to a mistaken perception that the interests of chiropody and podiatry are at odds or in conflict with each other; that somehow the development of foot care in Ontario has been a zero-sum game: a gain by one profession was a loss to the other. As a result, one might conclude that podiatrists would be opposed to chiropodists having the diagnosis function. I would like to state unequivocally that the podiatry profession has no objection to the diagnosis function being accorded to chiropodists. By the diagnosis function, I mean the power to communicate a conclusion. In fact, it would be logical in our view that since chiropodists are to perform surgical procedures, they must be allowed to diagnose. Since we are not involved in any way in the chiropody training program, we have no basis on which to judge whether chiropodists are, indeed, trained to diagnose. The board of regents, however, is, and we note that the board supports authorizing chiropodists to diagnose.

In short, if the legislation is amended to allow chiropodists to diagnose as one of their licensed acts, you will get no argument from podiatry.

Our second and only other concern deals exclusively with podiatry. The Ontario Podiatry Association regrets that the proposed act would legislatively implement a plan on behalf of the ministry to eventually consolidate foot care in this province under one profession: chiropody. The ministry's intention is accomplished by establishing July 1993 as the cutoff point, after which no new podiatrists can be licensed to practise in Ontario.

We find this regrettable and inconsistent. On the one hand, the ministry and act have recognized the unique training and role that podiatry plays in foot care. On the other, however, it is prohibiting the entire foot care profession from evolving and growing in response to patient demand and natural professional evolution.

There are two subsidiary issues here. First, the understanding we had with the Schwartz committee and the ministry was that the effective date of the cap would be three years after the date on which the legislation was tabled. That, then, is July 1994. By moving the date to 1994, all Ontario residents currently in podiatry programs in the United States would have the opportunity to return to practise in Ontario. We strongly urge the committee to make this very simple and valid amendment in the spirit of our original agreement with those responsible for the Health Professions Legislation Review.

The second concern is more substantive. Although frankly we do not agree with the rationale, we understand the public policy reasons for putting a cap on US-trained podiatrists practising in Ontario. What we do not understand is why any government would want to prohibit Ontario-trained or even Canadian-trained podiatrists from practising in Ontario at some date in the future.

The podiatry scope represents the natural evolution of the chiropody profession. We can document a persistent and growing demand for podiatric services. With the greying of Ontario, that demand will increase. As the number of podiatrists declines, who will fill that need? Experience shows that orthopaedic surgeons and general medical practitioners cannot.

The logical and natural successors to podiatrists in Ontario are chiropodists, trained to perform what is now called the podiatric scope of practice. The Schwartz committee recognized this, we recognize it and our colleagues in the Ontario Society of Chiropodists look forward to it.

The podiatric cap militates against the natural evolution of the chiropody profession and will leave Ontario, some day, without enough qualified practitioners to respond to patient demand. We propose keeping to the podiatric cap -- extended, of course, to 1994 -- but applying only to foreign-trained doctors of podiatric medicine. This proposal is in harmony with the intent of the legislation, that being to create a flexible framework that accommodates the natural and legitimate evolution of the regulated health care professions. To retain the cap is to place an arbitrary and artificial cap on chiropody and engage in an exercise of swimming against the tide.

That concludes my remarks. I think you will agree that our proposals are in the public interest, and we would be happy to entertain questions at this time.

Mr J. Wilson: I am trying to get a better understanding of the cap on podiatrists in 1993. Is it your understanding that it is the ministry's intention to expand the scope of practice of chiropodists at that time? We are not just putting podiatrists out of business; we are, I understand, putting them into one profession called chiropody.

Mr Zamojc: Yes, the legislation for the act is in basically a two-tiered system. One will include the additional portion as bone surgery for podiatrists in the province, and then the soft-tissue surgical procedures, ingrown toenails, warts and things like that, as well as injections and prescriptions, are extended to everybody. So there is that additional section that makes the podiatric portion of the act slightly different.

Mr J. Wilson: I understand that, but what about after July 1993?

Mr Zamojc: In July 1993 -- or, what we are hoping for, 1994 -- basically any podiatrists who graduate in the United States, regardless of whether they are Canadian -- for example, practising out in British Columbia -- if they wish to come back to Ontario after that date, would be allowed to practise under only the chiropody side of the profession. They would not come in under the podiatric scope after 1993 or 1994. That is the end of that podiatric scope for anybody coming in at that time.

Mr J. Wilson: So after July 1993 or 1994, chiropodists are limited to the scope of practice that we are being asked to pass. If this passes, podiatrists would then be limited to the same scope and neither will be doing bone surgery, which podiatrists are still doing.

Mr Zamojc: But American-trained podiatrists would not be allowed into Ontario to practise under the podiatric scope. Actually, there is one error in that.

Mr J. Wilson: I am just trying to get a feel for the state of affairs after July 1993.

Mr Zamojc: There is one error in that. The practising podiatrists in British Columbia, if they are licensed before the 1994 date, can enter Ontario and practise at the full podiatric scope.

The Chair: For clarification, I have had a request from the parliamentary assistant to clarify. Is that acceptable? It will probably use up your remaining time.

Mr Wessenger: I would like the ministry to clarify this point.

Ms Bohnen: The scope of practice of podiatry will not narrow on that date in 1993. What will happen is that no further additional podiatric registrants will become registered with the college, so that there will be a limitation on the group of practitioners entitled to practise the expanded scope. That is the significance of that date.

Mr J. Wilson: What happens eventually when your podiatrists die off? Who does bone surgery?

Ms Bohnen: There are two answers to that. One answer is that orthopaedic surgeons do the bone surgery, which is what they do today. The second answer is that, should there be a need in the future identified for further practitioners of bone surgery and, second, should the educational program for chiropodists in this country be expanded to teach bone surgery, then at that point I think we would expect to see a proposal for an amendment to the act which would be circulated and placed before the advisory council.

Mr Waters: What kind of cost difference are you talking on these types of things? It is to serve the public. You are saying that as podiatrists die out, I guess, it will all be picked up by someone else. Is that an increased cost?

Mr Burrows: I would like to suggest that question be best directed to the members of the profession in terms of comparative incomes and so forth. However, I would like to point out that the chiropody model, as a matter of ministry policy, has existed since the early 1980s and has not changed under three successive governments. The need, in the ministry's opinion, has been for a much broader access but limited scope of practice because the need in such groups as senior citizens for some sort of low-risk but preventive and supplementary care is what has led to the formation of that policy.

But, as Linda pointed out, should circumstances change in the future, the notion under this legislation is that it is living legislation and should that need be there and the need for additional practitioners present itself, there is a fairly ready way of amending things so that could occur. But that would require a policy change and a decision at that time.


Mr Cordiano: So in that sense, the ministry has virtually identified a lack of need for this type of specialized foot care. At some point in the future when podiatrists are no longer with us, that void would naturally be filled by orthopaedic surgeons who are currently providing the same surgical treatment.

Ms Bohnen: Yes. In respect of surgical treatment in the forefoot, yes, what you said is quite correct.

Mr Cordiano: So orthopaedic surgeons are, as a matter of course, doing this regularly at the present time?

Ms Bohnen: I believe so.

Mr Cordiano: I should ask the former minister.

Mr Hope: Just for clarity, you are saying "foreign-trained" and they are saying "US- or foreign-trained." I would like to know what the difference is.

Mr Zamojc: We are basically stating that if there is a podiatrist produced in this country and working in British Columbia, because British Columbia also has a podiatry group, and Quebec is in the process of producing a podiatrist model with additional training out of New York colleges of podiatric medicine -- the eventual evolution of a school of podiatric medicine in this country, which is conceivable either in Quebec or in British Columbia in the future -- we want to make sure there is still an opening for those trained people to enter Ontario, rather than limiting it to just the American-trained. We can see the point of the Americans, but when it is our own citizens of anywhere in the country who do not have that free movement to practise, we basically say "foreign-trained." That would be anybody outside of Canada.

Mr Jackson: I am trying to get a sense of the concepts of deinstitutionalization and access here. I am getting nervous about the phase-out of podiatrists coupled with the loss of diagnostic abilities for chiropodists. Essentially, the outcome of that would be the need for more physicians to examine foot ailments and do referrals to orthopaedic surgeons. I have had bad experiences with orthopaedic surgeons and really good ones with podiatrists and chiropodists; it has probably saved OHIP thousands of dollars. I am now nervous that both groups have referenced institutional settings and yet the model for care for the elderly in this province will be in a deinstitutionalized vein. I am really nervous about this because it will be more costly. It might be a Rolls-Royce health care system that we can fast-track them all to orthopaedic surgeons, but by the same token, there is a whole lot of preventive areas involved with foot care that might be limited here. Would you like to comment on my concern?

Mr Zamojc: One problem in the legislation, especially with the cutoff date being so finite, is that there is no room for the evolution chiropodists have mentioned, as well as us, into what Ontario can have as a full scope of chiropody. There is one, then we die off and then there is something else with this space in between. There is no evolving process going on with an interrelationship between the two. That is a weakness I see in the thing as well. That is possibly one of the reasons for the attempt at making the 1994 date, which is still a finite date, but allows all the Canadians down in American schools to come back, as well as providing the other side of it to provide Canadian-trained podiatrists. There will be more of bridging that gap between the two, and the free movement of that level country-wide will provide that. In that respect, I feel this is going to help that gap we referred to earlier as well. That is really my only comment.

The one thing I would like to note is with regard to the orthopaedic surgeons and us doing surgery or foot care as well, there are differences and similarities between the two, versus ambulatory foot surgery and the use of orthopaedic supports and devices and that kind of thing. There is a sort of continuum with the orthopaedic surgeons as well, so I feel we are all going towards the same goal providing a service at a multistaged sort of level.

The Chair: Mr Owens, I have a note that you had a question on this matter of the ministry. Did you want to ask the parliamentary assistant at this time to get it on the record, or has it been answered in the discussions?

Mr Owens: I think it has been answered.

The Chair: A question from Mr Jackson to the parliamentary assistant to be answered at a later time?

Mr Jackson: Yes, that has to do with long-term care reform. I would like to know to what extent foot care matters are being considered in that discussion paper as it relates to the issues I am concerned about with respect to access and deinstitutionalization. I would like to know to what extent there is a dialogue or thinking going on between this piece of legislation and the long-term care agenda.

The Chair: Thank you very much for your presentation. We appreciate hearing from you.



The Chair: The next presenters, Vision Council of Canada, please come forward. We ask that you begin your presentation by introducing yourselves. You have 20 minutes, and please leave some time at the end for questions from committee members.

Mr McArthur: Madam Chair, members of the committee, good afternoon. My name is John McArthur. I am pleased to be here to present this brief on Bill 59, An Act respecting the regulation of the Profession of Opticianry, in my capacity as president of the Vision Council of Canada. I am joined today by Ross King, who is a member of the board of the vision council.

First, I would like to give you a bit of background about the Vision Council of Canada. The VCC is a nationwide, non-profit organization which was incorporated in early 1989. In Ontario its members represent a significant number of retail optical outlets. VCC members and supporters employ over 1,000 people, including more than 25% of the province's licensed opticians. Our mandate is to ensure that the highest quality of eye care products and services are available to the public at a reasonable cost.

The VCC fully supports the goals of this package of legislation. We believe that the system of patchwork acts which currently regulates the various professions has often led to inconsistent policies and has made it extremely difficult to address emerging problems. The RHPA and the 21 acts governing the individual professions will ensure that the public will be accorded the same rights and remedies regardless of the professional providing the treatment or advice.

As it relates to the vision council and our presentation before your committee today, we believe the legislation governing the profession of opticianry falls short in one very important and fundamental respect: the absence of a precise definition of the act of dispensing eye wear, both in the opticianry scope of practice and the authorized act.

The vision council believes that the lack of such a definition will or could result in unnecessary and costly commercial restrictions on the practice of opticianry. The Vision Council of Canada believes the following definition of "dispensing" should be added to the Opticianry Act. I will quote:

"The final verification of an ophthalmic appliance for conformity and suitability to a prescription issued by a prescriber and the final fitting and delivery of the ophthalmic appliance to the designated person."

For purposes of consistency, we would respectfully suggest that this definition also be included in Bill 60, An Act respecting the regulation of the Profession of Optometry. We believe this definition, in conjunction with the controlled act, appropriately identifies and controls the limited risk involved in the dispensing of eye wear. At the same time it preserves the role of the optician in this process.

Without a definition of dispensing, there is no certainty as to what the government intends to be a controlled act limited to the profession of opticianry. Conversely, there is no certainty about what is permitted to be done by their unlicensed and unregulated assistants or staff. At the same time, an overly broad definition of dispensing, such as the one under which opticians are currently regulated, neither increases accountability, and thereby the quality of our product, nor improves access. In fact, it potentially impedes access. Without a specific definition of dispensing or with one which is too broad, an optician could be required to be present throughout the entire process of obtaining a pair of eyeglasses.

What does this mean in practical terms? It means that in the majority of optical retail stores, the optician must shut down his store to go to lunch. It means that in the existing legislative framework and potentially under the legislation we are discussing, should his assistant help a client choose a frame, the optician can be charged by the Board of Ophthalmic Dispensers and/or its successor college with a violation of the act. It means that access to quality eye care is more difficult and more expensive. This is also the result of the broad definition of dispensing included in the legislation currently regulating opticianry.

We believe that in introducing the RHPA and its companion pieces of legislation, the government made a conscious decision to depart from the present system. We hope that it will carry its decision through and include a focused definition of dispensing in Bill 59.

At this point it is important to note that what we are suggesting would in no way create a greater risk of harm for the public. In a letter to the Board of Ophthalmic Dispensers, Dr B. J. MacInnis, chairman, professional affairs, section on ophthalmology of the Ontario Medical Association, wrote as follows, "An incorrectly dispensed prescription for a visually mature adult may blur vision, cause diplopia" -- which in lay terms means double vision -- "induce an heterophoria" -- meaning causes problems with regard to focusing on an object -- "cause asthenopia" -- which is eyestrain -- "or induce headaches." Most significantly, Dr MacInnis added, "No permanent harm ensues."

The section on ophthalmology does believe that contact lenses have a very definite potential for permanent harm and should be dispensed only by regulated professionals. We agree. They state as well that an incorrectly dispensed prescription for a child under the age of visual maturity, which 99% of the time is under nine years old, carries the potential for harm in the form of amblyopia, which is a dimness of sight. Again we would agree.

The vision council believes that these two potential areas of harm should be specifically controlled, either directly in the legislation or in ensuing regulations. We wish, however, to emphasize again the limited risk of harm overall that is associated with the dispensing of eyeglasses.

As you deliberate this issue, we hope that you will consider the following: A staff study by a US government agency looking at issues similar to those reviewed in this process found that, "commercial practice restrictions...actually decrease the quality of care in the market by decreasing the frequency with which consumers obtain eye care." In fact, there are many North American jurisdictions which do not regulate opticians to the degree Ontario does, without any adverse consequences to the public.

In her comments during second reading of the legislation, former Health minister Evelyn Gigantes commented, "It is important for us to acknowledge that there is such a thing as overmedicalization." While Ms Gigantes was not directly referring to opticianry, we believe that the concept is applicable here. We are asking you not to overmedicalize the provision of eyeglasses.

Again, we support the intent and the direction of this legislation and heartily endorse one of its primary objectives, the protection of the public from risk of harm in health care. We ask, however, that you not use it for a purpose for which it was not intended. We ask that you not use it to protect the profession's self-interest. We do ask that you use it to protect the public and to ensure a high-quality, cost-effective health care. Thank you very much. We would welcome your questions.

Mr J. Wilson: Thank you for the presentation. I have yet today to hear any reason why your proposal concerning the definition of dispensing is not workable, but if we did not include it in the act as an amendment, just on the employment side, which is certainly not addressed -- you have, I would imagine, among your members and in their shops a great many technicians -- do you have any idea how many people might be affected? You would still need them to do some of the work, but if they are not actually doing the dispensing --

Mr McArthur: You are talking about non-opticians?

Mr J. Wilson: Non-opticians.

Mr McArthur: I actually could not give you a number of individuals who would be affected. It would be a considerable number of that thousand that I referred to with respect to our specific membership. It would be significantly larger than that, considering all of the optical retail community.

Mr J. Wilson: I ask because I have a couple of good friends who I think work for you.

Mr McArthur: I am sure their jobs are secure. I think the absence of a definition, first, leaves in great question what exactly is the role of an optician and what can or cannot someone who is not an optician do. There are many today working with that uncertainty over their heads and they do not know what in fact they are allowed to do and not to do. That is why we believe that specifically defining what the act of dispensing is, and we believe, as we have suggested, that the definition ought to be restricted to those areas where there truly is a risk of harm, will protect the public and provide the most cost-effective and accessible health care.

Mr J. Wilson: Would your amendment need another sentence added to do exactly that, restrict it to those areas where there is indeed severe risk of harm? You give a suggested definition on page 2, and then you do mention the two exceptions of children and contact lenses.

Mr McArthur: I think in any event both of those conditions would be protected by the definition that we have proposed, in that nobody would be leaving an optical outlet without having had an optician check the ophthalmic appliance and verifying that it is correct according to the prescription and that it has been fitted correctly to the patient's or customer's face or eyes.

Mr J. Wilson: And the liability would still be with the optician, clearly?

Mr McArthur: Absolutely.

Mr Owens: If we were to agree to the proposal of the amendment, and you are suggesting this would lead to increased consumer protection, would it also help in terms of the cost of glasses and prescription lenses and things like that to some extent? How would it do that?

Mr McArthur: The fact is that currently, with the uncertainty that revolves around what someone who is not an optician can do, it can lead to someone who has been trained for a two- to four-year period of time doing a task you do not require that amount of training to do.

A for instance is deciding on what set of frames you want, forgetting about the lenses that go inside them. That is to a great extent a fashion issue. It is also to a certain extent a comfort and fit issue. You do not require to be educated for that period of time.

Having been educated, that accreditation carries with it a salary that is higher than would otherwise be the case, without necessarily providing any increased service to the public, and certainly not eliminating any degree of risk upon them.

Mr J. Wilson: Just as a follow-up, we will have the OMA speaking before the committee at some point. Have you had discussions with them to see if they are comfortable with your definition at this point?

Mr McArthur: We have not been able to meet with the OMA. We have requested that meeting. We were not able to arrange it.

The Chair: Thank you very much for your presentation. We appreciate the opportunity to hear your point of view.

Mr McArthur: We appreciate it as well. Thank you.



The Chair: The next presenters, the Board of Ophthalmic Dispensers, please come forward. Welcome to the standing committee on social development. We would ask that you begin by introducing yourselves. You have 20 minutes for your presentation and we ask that you leave some time for questions from members of the committee at the conclusion.

Mr Buckstein: My name is Murray Buckstein. I am a public member on the Board of Ophthalmic Dispensers, and with me is Mrs Barbara Skinner, who is a professional member on the Board of Ophthalmic Dispensers.

The Board of Ophthalmic Dispensers, established by the Ophthalmic Dispensers Act of 1961 and consolidated regulations under the act, is charged with the responsibility of administering and enforcing the act and its regulations. As the governing body for the profession of opticianry, the board ensures that citizens of Ontario receive the highest standards of care and service in all areas of ophthalmic dispensing, provided by opticians who under the act must be registered with and deemed competent by the board in order to practise in this province. Currently in Ontario, student opticians must undergo community college training. The professional dispensing service they provide, once registered by the board, involves the design and provision of eyeglasses, contact lenses and devices for subnormal vision, based on the interpretation of a prescription provided by an optometrist or a physician.

Under the proposed Regulated Health Professions Act, 1991, and the Opticianry Act, 1991, the board will continue to function as the College of Opticians, charged with the responsibility of regulating the profession of opticianry and ensuring that the public interest remains paramount in the provision of all professional ophthalmic dispensing services. Both acts also specify certain procedures and powers with which the college and the courts may regulate those services, and they establish very specific penalties for breaches of various provisions.

In the view of the board, however, there is a very serious omission in the proposed act, the failure to provide, as does the present Ophthalmic Dispensers Act, a specific, clear definition of the word "dispensing," the very activity in which professional opticians engage. Accordingly, the Board of Ophthalmic Dispensers respectfully submits this concern to the committee and hopes the committee will take it into consideration when making recommendations prior to third reading of the proposed acts.

It is our firm belief that the inclusion of a definition of dispensing is mandatory. Without one, it will be left to the interpretation of individual opticians and/or the various corporations which employ a very large percentage of those practising in this province, some of which may, for economic self-interest or other reasons, define dispensing in terms other than those understood by the college to be in the public interest. This will make a determination of illegal and unprofessional activity virtually impossible in cases in which charges involve the dispensing of ophthalmic services and products, necessitating, in turn, the time, expense and involvement of the courts, all of which could be avoided by defining this most important term in the proposed Opticianry Act, that is, Bill 59.

After very careful consideration of the intent of the Regulated Health Professions Act and the Opticianry Act, and ever-mindful of the college's obligation to protect the interests of the public, the Board of Ophthalmic Dispensers, in consultation with the two professional associations to which opticians in Ontario belong, that is, the Ontario Association of Dispensing Opticians and the Ontario Contact Lens Association, has established a definition which ensures the provision of professional services by trained, qualified persons only and which protects the public interest to the fullest. This addition, which we propose to be included in section 1 of Bill 59, that is, the section relating to definitions, would define the words "to dispense," which now appear in section 4, line 5, as follows,

"`To dispense' will mean: (a) interpreting a prescription for; (b) evaluating or advising a person in respect of, or: (c) preparing, providing, verifying, adapting, fitting or duplicating a device for subnormal vision, a contact lens or eyeglasses."

The unique environment of optical dispensing necessarily involves considerable judgement and interpretation on the part of the optician in order to formulate the best vision aid for his or her patient, based not only on the prescription presented, but also on the personal needs and vocation of that patient. Most ophthalmic dispensing takes place in what is generally considered to be a retail environment. It is not performed under the same scrutiny or constraint as provided by hospitals, clinics, or other institutions regulated by the Public Hospitals Act, or by pharmaceutical dispensaries regulated by the Pharmacy Act.

Because of this, the board is of the unanimous opinion, expressed by public and professional members alike, that standards of quality already established and enforced to protect the people of Ontario can only be maintained by including a clear, precise definition of dispensing in the Opticianry Act. With the defintion we are recommending, all regulated functions of professional dispensing will be clearly defined and easily understood both by practitioners and the public whom they serve. It provides the clarity and detail that is required to ensure the continuation of a professional dispensing service and will therefore be in the best interests of the public.

To assist the standing committee in understanding the functions of a professional optician, we have attached a chart on the following page to graphically illustrate those functions. I might add that you will note, in glancing at that chart, that some of the functions that may have been previously described to you as being regulated, such as fashion counselling and selection of frames, etc, are not currently regulated, nor are they proposed to be regulated by the board. That, Madam Chairman, is our formal presentation and we would answer any questions that the committee may wish to ask.

Mr Grandmaître: I would like to ask the ministry to define the word "dispense." Do they agree with what is before us? What were their initial thoughts on the word "dispense"?

Mr Wessenger: I will ask the ministry staff to indicate what the word means.

Ms Bohnen: I do not think I can define the word for you at this moment, but I can tell you that the Health Professions Legislation Review came to the conclusion that it was best not to define the word in the statute. The word "dispense" has a number of meanings in health professions acts. It has a meaning in the context of pharmacies dispensing drugs. It has a meaning in the context of dispensing personal hearing aids. The review is of the opinion that a statutory definition would not be helpful, that fundamentally the standards of practice required of a regulated health professional were the key to ensuring the public receives an adequate quality of professional service and that within each industry a definition comes to be worked out over time as business is conducted. I guess the key point is that the regulated professional is responsible for adhering to the standards of practice of his or her profession.

Mrs Skinner: If I could just help in that a little bit. Sometimes the word "dispense" as applicable in our industry is very difficult for the consumer to understand. Many of you here today are wearing eyeglasses. We basically agree with our predecessors here today that a definition should be in place. The only difference we are talking about, I believe, in looking at the two proposals you have before you, is that the first proposal says you may pick up your eyeglasses from an optician and have them adjusted. However, you may not see the optician up until the point of final delivery to the consumer. That is not as it has been in Ontario for the last 30 years.

What it leaves out is the interpretation of the medical prescription prior to the manufacture of the eyeglasses. This means that when you come into an optician's and you give him or her that paper with the numbers on it, those numbers are not always the numbers you get in your lenses. It is very simple and easy to understand. There is a judgement that is made by the optician prior to the manufacture of the client's eyeglasses or contact lenses. We have to use the training and experience we have on the vocation or avocation of the person. Do they want to read at 14 inches, which is on the prescription, or do they work at a computer all day, in which case that prescription will be useless for them? We have to make a judgement and that is what we are trained to do.

We are hoping this second definition, as we are proposing, would include that members of the public would see the optician prior to the manufacture of the eyeglasses so that the design could be worked out with the intent of the prescription of the medical practitioner and, at the final verification of that design, would be concluded. That is what we are hoping to do here. We are certainly not trying to restrict fashion consulting or, as we also have listed here, acts not requiring registration: the product information, which could be generic lens designs to the consumer. We are hoping, after that fashion consulting is done, that the optician would be seeing the consumer even for a short moment to make sure of decisions such as, "The lovely red frames look beautiful, Mrs Jones, but your prescription won't go into it." We want to make sure those previous decisions on fashion are going to complement the intent of the appliance and be wearable for the patient.

Mr J. Wilson: Is it possible that the Vision Council of Canada and your group could get together and bring back one definition or have you been hammering this out for 30 years?

Mrs Skinner: We have met previously to this and presented our reasons. Their feelings were that final verification was all that was necessary. It is a regressive step in Ontario. Opticians have been licensed to provide this eye care since 1961 with a definition that includes the interpretation of prescription. Without the word "interpretation" in our act, our board is assuming the public will be protected with the inclusion of interpretation under the definition of "dispensing."

Mr J. Wilson: If you end up in court, for instance, the judge is going to ask the same thing.

Mrs Skinner: Exactly. We are different from some regulated professions, where you may not take someone to court for pretending to be a doctor or doing those acts, but they do take people to court for illegal dispensing. We have a definition under the current legislation that is much lengthier than the proposed one which covers it in detail. We have had a recent decision from the Court of Appeal for Ontario and it does hold up the present definition of "dispensing" under the Opthalmic Dispensers Act. So without a definition in there you are right; it would be a lengthy court case, probably, with the Court of Appeal left to decide what the intent was. We are hoping that can be eliminated by including a definition in this act.

Mr J. Wilson: Where legislators are normally confronted with conflicting and not quite consistent definitions from two different parties, probably that is what the review panel found and decided not to put a definition in at all.

Mrs Skinner: I hope you give some consideration to the source of the two definitions you have before you. One is from the regulatory board, which is ourselves, setting the quality assurance standards and the standards of practice. One is from membership of corporate entities who, I agree, are employers that often have an economic interest, which we do not at the present time.

Mr J. Wilson: They are employers and they are providing a service to people. It could boil down to a question of access and efficiencies.

Mr Buckstein: I think too, Mr Wilson, having sat on the disciplinary committee for some three or four years and listened to some of the cases that have come before us, and some of the charges of unprofessional conduct, if the intent of the Regulated Health Professions Act is to ensure that the public receives public health care in all areas, it would be very difficult to do without the definition we described in the detail that we described. Again, I think they are being very realistic. There is an economic self-interest that is involved in the case of some employers, some corporations, and we see that before us when these charges are raised all the time. As the regulatory body charged with the responsibility of ensuring that the public receives professional eye care service, we feel that this definition we propose covers all the bases.



The Chair: The Ontario Association of Optometrists, we are five minutes early, but if you are prepared and ready to go we could begin now. Please come forward. We ask that you begin your presentation by introducing yourselves to the committee and leave a few minutes at the end of your presentation for questions from committee members. You have 20 minutes for your presentation.

Dr Trinaistich: I would like to introduce myself first. I am Dr Mary Trinaistich, president of the Ontario Association of Optometrists. With me are Dr Lynn Carter, chairman of our legislative committee, Dr Marvin Langer, a member of the legislative committee, and Dr Mira Acs, vice-president of the Ontario Association of Optometrists.

Members of the legislation committee of the Ontario Association of Optometrists and our board of directors thank you for this opportunity to appear before you. Our brief submission today on Bill 60, An Act respecting the regulation of the Profession of Optometry, focuses on the effects Bill 60 will have on the delivery of eye and vision care services and programs.

Let me begin our dialogue with a short description of the profession of optometry in Ontario. We are an independent, primary health care profession that has been self-regulated since the passage of the optometry act in 1919. Optometry is one of the five health professions currently regulated under the Health Disciplines Act.

We, the Ontario Association of Optometrists, incorporated in 1909, are a voluntary professional association. The regulatory and licensing body is the College of Optometrists of Ontario, which replaced the Board of Examiners in 1960. Its published standards of practice, which are continuously reviewed and updated, have been in place for more than 20 years. These standards have been upheld by the Health Services Appeal Board and the courts.

The school of optometry, in the faculty of science at the University of Waterloo, has provided since 1969 the academic and clinical training of optometrists. Upon completion of a four-year professional university program, the entry into which requires the prior successful completion of a minimum of one year of a university science program, a doctor of optometry degree is awarded.

Optometrists then are self-regulating, provincially licensed, professionally educated and clinically trained to assess, to diagnose, to treat and to prevent conditions, ie, diseases, disorders and dysfunctions, of the eye and visual system. In so doing, optometrists are required to provide this care to their patients in accordance with the standards of practice published by the College of Optometrists.

Currently there are approximately 850 licensed optometrists in Ontario practising in 80% of the communities with a population of 1,500 or more. In 75% of these communities, optometrists are the only source of eye and vision care. In fact, outside of the larger urban centres, optometrists are for the most part the only specialized eye care professionals available. Changes to the practice of optometry are therefore sure to have a very significant effect on the eye and vision care services in many localities. The geographical impact of these effects can be seen in attachment (a).

The two sections of Bill 60 we would like to address specifically are section 3, scope of practice statement, and section 4, authorized acts.

Scope of practice, section 3: "The practice of optometry is the assessment of the eye and vision system and the diagnosis, treatment and prevention of vision and oculomotor dysfunctions of the eye."

Authorized acts, section 4: "In the course of engaging in the practice of optometry, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to perform the following:

"1. Communicating a conclusion identifying a vision or oculomotor dysfunction of the eye as the cause of a person's symptoms.

"2. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses."

In an overview of impacts of Bill 60, at the outset let us state that if the intent of the legislation is that the practice of optometry in Ontario should continue as it is under part V of the Health Disciplines Act, then amendments must be made to sections 3 and 4 of Bill 60. We understand that in her briefing on August 6, Linda Bohnen stated that in the opinion of Alan Schwartz's team, optometry got the status quo. Respectfully, this is not so.

The considerations which we will raise with you now are not, as it may be suggested, motivated either by economic considerations or by the desire to maintain or obtain exclusivity over the area of practice. Plainly put, we are interested in being able to continue to provide the same level of health care services to our patients and, in so doing, provide them services in an efficient and cost-effective way.

In the executive summary of Striking a New Balance: A Blueprint for the Regulation of Ontario's Health Professions, Mr Schwartz described one purpose of a scope of practice statement. He wrote, "It will describe for consumers, members of the profession, employers, and the courts the proper range of the profession's scope of practice."


With respect, we point out that the scope of practice statement and authorized acts in Bill 60 will place severe constraints on the range of services optometrists may legally provide. The current proposals will restrict the historical pattern of optometric practice. These restrictions have potentially grave consequences for the effective delivery of eye and vision care services in Ontario. These would include negative impacts on health service expenditures, limitations on access to and availability of services and the disruption of existing public health care programs.

These restrictions on or limitations to optometric practice will arise because of the omission in the scope of practice statement and in the first authorized act of conditions described as "diseases" and "disorders." Optometrists have always diagnosed, treated -- including monitoring -- and prevented diseases and disorders of the eye. The result of these omissions will be that patients can no longer receive the services they have come to expect from their optometrists.

All of the organized bodies of optometry in the province believe this proposed redefinition of optometry will move the practice of optometry to a more limited position than it has ever occupied in Ontario. This will severely restrict the provision of eye and vision care services.

When we first received the Health Professions Legislation Review proposals in 1989, and after consultation with our colleagues, we sought the opinion of three legal counsel on the impact these proposals would have on optometric practice. We have provided their opinions for your review in attachment (b).

Briefly, these opinions all state that the definition now before you in Bill 60, coupled with the authorized acts, will narrow the profession of optometry from its current scope of practice. They all agree that optometrists will not legally be able to continue to provide all of the services they currently provide, as they will be prohibited from communicating the diagnosis and identification of diseases and disorders of the eye and visual system to their patients.

If this happens, the OAO will be forced to advise its members that in order to maintain their professional liability coverage, they must now refer patients for whom they have previously provided care and who currently, under the Health Disciplines Act, do not require referral. Let me take a minute now to give you two examples from my daily practice that will demonstrate just how these limitations will disrupt our services and care to our patients.

In the case of a patient with cataract, in current practice I make a diagnosis of a cataract, monitor its development, provide for changes in the patient's visual needs and consult with my patient. I would refer this patient for surgery for the cataract when it reached the stage where surgical intervention was appropriate. In future practice under Bill 60, I would have to immediately refer this patient, because I would be prohibited from communicating my diagnosis and effectively monitoring this patient.

In the case of a patient with blepharitis, in current practice I make a diagnosis of blepharitis -- a disease condition of the eyelid whose appearance is red, flaky lids -- in my patient and I recommend the appropriate treatment for it. If it is a severe case, I refer this patient to a medical practitioner. In future practice under Bill 60, I would have to immediately refer this patient to a medical practitioner, because I would be prohibited from communicating my diagnosis of this disease, recommending treatment and monitoring the efficacy for this patient.

Turning now to the financial consequences, we believe that unless Bill 60 is amended, the cost of eye care services will dramatically increase. The increase will arise as a result of unnecessary referrals to physicians to have optometric findings confirmed.

In 1980, Dr W. Harding le Riche authored a study documenting the eye and vision care services provided by optometrists to a representative sample of patients in Ontario. The study found that optometrists diagnosed disease for 42% of their patients and subsequently had cause to refer about 13%. Under the provision of Bill 60, the almost 30% of patients in this study who did not require referral at that stage, if at all, would now be referred, at considerable cost. For example, according to OHIP statistics, optometrists provided services to 1.7 million patients in 1988-89. Applying the results of the le Riche study, there would be over 500,000 extra referrals to other health care practitioners, at a conservatively estimated cost of over $20 million with no benefit to the patients. It would be imprudent, we believe, to increase eye and vision care delivery costs without any expansion of services simply because of a poorly worded definition.

In addition to increasing the cost of eye and vision care delivery, these legislative proposals will ensure that many patients will suffer unnecessary delays in obtaining treatment and will have to travel outside of their communities at personal and/or public expense to receive treatment.

Optometrists are the most accessible and available eye and vision care professionals in Ontario. Optometrists practise in all Ontario counties, districts, regional municipalities and in more than 80% of Ontario's communities with a population of over 1,500. As a result, patients of optometrists have consistently reported waits of two weeks or less for appointments. If optometrists must now unnecessarily refer more than 500,000 patients yearly to ophthalmologists, it will increase the waiting time of non-emergency eye care. Where no ophthalmologists are available locally, patients will have to travel, often at great distances and at considerable cost.

The magnitude of this potential problem is difficult to assess. However, we have identified 15 counties/districts with an estimated 1991 population of 681,000 with no ophthalmologists. These same areas have 68 full-time practising optometrists.

The Ministry of Health has an assistive devices program which provides financial assistance to visually impaired residents for the purpose of obtaining specified low-vision aids. The ADP recognizes optometrists as authorizers, with physicians, of low-vision devices. In their role as authorizers, the optometrists must provide "primary diagnosis (eg, achromotopsia) including level of functional visual disability...secondary diagnosis if any, eg, cataract, cerebral palsy." We believe that with the current legislative proposals, optometrists will be prevented from continuing to practise in the Ministry of Health's ADP.

The federal Minister of Finance amended the Income Tax Act and the disability reporting certificate for the 1988 taxation year to allow optometrists to certify severe and prolonged sight impairments. Optometrists as well as physicians must provide a "diagnosis of the disabling condition and any other associated conditions causing the marked restriction in ability to perform basic activities of daily living." Again, it appears that with the proposed legislative changes optometrists will be forced to discontinue providing this service for their patients.

The government stated, when introducing this package of legislation, that it provides for uniformity in the regulatory framework; enhancement of public protection; protection of the right of consumers to receive health services that are competently performed to suit both their needs and desires; protection of the right of health professionals to work in an equitable system that recognizes their autonomy and respects their contributions; and establishment of a system that reflects the reality of the health care system and facilitates evolution within it.

We support these intentions. Indeed, we have been willing supporters and participants in this lengthy review process. It is no secret, however, that we have been less than happy with the outcome. We do not believe that these goals have been achieved for our profession and optometric patients.

We are pleased that the Minister of Health views this as "living legislation." If the status quo had been achieved with Bill 60, we would be far more willing to adopt a wait-and-see attitude, to monitor the impact of the legislation and see what evolves. However, it has not been achieved and we cannot, indeed we must not, abdicate our professional responsibility to our patients, to our communities and, yes, to ourselves as well-trained professionals in a scientific health discipline to try to amend this legislation.

We offer the following suggestions for amendments in that spirit. We believe they are in keeping with the stated intent of this health legislation. We propose for a scope of practice statement to consider the services currently performed by optometrists, "The practice of optometry is the assessment, diagnosis, treatment and prevention of diseases, disorders and dysfunctions of the eye and visual system."


We further request that section 4 be amended to the following:

"1. Communicating a conclusion identifying a disease, disorder or dysfunction of the eye and visual system as the cause of a person's symptoms.

"2. Performing a procedure on tissue in or below the surface of the cornea.

"3. Applying or ordering the application of a prescribed form of energy.

"4. Prescribing a drug.

"5. Prescribing or dispensing subnormal vision devices, contact lenses or eyeglasses.

"6. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.

"7. Prescribing or ordering orthoptic and/or vision therapy."

In summary, the scope of practice statement in Bill 60, the Optometry Act, 1991, will substantially alter optometric practice, increase costs and reduce accessibility in the delivery of eye and vision care services in Ontario.

We are unreservedly opposed to the proposed restrictions of optometric practice that this legislation will necessitate.

We believe the Ministry of Health and members of the committee will understand that the changes to the eye and vision care system that are consequent to these legislative proposals are not in the best interest of the people of Ontario and will take the appropriate action to amend this legislation.

Thank you for this opportunity to make our concerns known to the committee. We would be pleased to make available any other information or points of clarification which you require.

Mr Owens: If we were to pass the scope of practice as is proposed currently, where would it put you in comparison to other practitioners in other jurisdictions in Canada and the United States? If we were to accept your amendments, where would you draw the line between yourselves and ophthalmologists?

Dr Trinaistich: I would like to pass that question on to Dr Carter. He will answer that.

Dr Carter: There is not another jurisdiction that we are aware of in North America that would restrict optometry as much as this proposal is going to do. We are not aware of any jurisdiction which prohibits optometrists from communicating to the patient, for example, that he has a cataract. I guess the example that needs to be elaborated is in that the United States, in those jurisdictions there has been a bit of a trend recently, in the past 10 years' time, to not only allow optometrists to continue to diagnose and discuss that diagnosis or treatment or the pathology with the patient, but indeed to actually treat it. In 1981 there was not a single state south of the border that allowed, for example, optometrists to prescribe therapeutic drugs. Now there are 27 or 28 of them. So while we are going in one direction in this proposal, other jurisdictions are going actually counter to that.

Mr J. Wilson: So what you are saying here is that the proposed scope of practice in the proposed act is really narrowing your current practice. Again, I have asked other groups this: Do you have any idea why we are being asked to do that? Were there complaints? Are optometrists currently causing severe harm to patients?

Dr Carter: That is a very good question. We frankly do not know why the ministry or the review has come up with the decision it has come up with. Certainly there has been some ongoing communication with ophthalmology and we believe that ophthalmology has promoted ophthalmologists' interests.

Mr J. Wilson: We will have a chance to talk to the ophthalmologists.

Mr Carter: It has been somewhat difficult over the years. We attempted on one occasion and as an association did sit down. We did not really accomplish a great deal. Just recently our college has had an opportunity to sit down, and again there really was not an awful lot of consensus that could be drawn.

The problem in respect to ophthalmology is that at some point the policymakers with the Ministry of Health are going to have to come to the conclusion that you are not going to keep both groups happy. I really do not think you can keep both groups happy. The system we have in place as far as optometry is concerned has evolved over a matter of the last 20 years' time with the HDA. Optometrists are filling the role that was left open to them under the HDA and that role is going to be restricted under the new act.

Mr Waters: Where would the line be drawn between yourselves and the ophthalmologists, is it, the other group?

Dr Carter: The line would be drawn in the fact that optometrists do not treat pathology such as glaucoma, optometrists do not treat pathology such as cataract. It is not the intent of our submission today to ask for that, and it is not the intent of our proposals to the ministry to ask for that. If it was the intent of optometrists to do those procedures, then we would be asking for surgery, for example, and we have not requested a licence to act for surgery.

About the only thing that is contentious in our mind, when it comes to our proposals, is prescribing drugs. The prescribing drugs is in there for two purposes.

The first purpose is that we wanted to ensure that optometrists did not lose the capacity to utilize over-the-counter pharmaceuticals which are currently part of optometric practice. Indeed, there are 19 drugs that occur on the scheduled drug benefits that are currently used in optometric practice. We wanted to ensure that a not favourable interpretation by the courts would not eliminate the use of those over-the-counter medications.

The other function that we wanted to establish by prescribing drugs is the one that Alan Schwartz said in the first place. The legislative model was supposed to facilitate an evolution. We firmly believe that if the Ministry of Health looks very closely at our profession, down the road it will come to the same conclusion that optometrists can be better utilized by prescribing therapeutic drugs in this province.

The Chair: Thank you very much for your presentation. We appreciate your coming before the committee this afternoon.



The Chair: The next presenters, Vision Institute of Canada, come forward now, introduce yourselves, and you have 20 minutes for your presentation. We would ask that you leave some time for questions by committee members at the end of your presentation.

Dr Acs: My name is Dr Mira Acs. I am the past president of Vision Institute of Canada. Our current president, Jim Passmore, could not be here. With me is Dr Mitchell Samek, who is the executive director of the Vision Institute of Canada.

The Vision Institute of Canada is a non-profit charitable organization established in August of 1981. The institute is overseen by a voluntary board of directors. The institute is entirely funded through donations from individuals and corporations, service delivery programs, corporate and foundation grants. The institute does not receive any government funding in support of its programs.

Our mandate is to improve the quality of vision care services in the community. Our objectives that help us attempt to achieve this mandate are the support of a clinic providing high-quality vision care services, the sponsorship of high-quality educational programs and the support of scientifically based clinical research.

Some background on the clinical services that we provide: The vision institute operates a clinical facility in Toronto staffed by optometrists. Our clinical staff provide over 4,000 diagnostic services annually in the following service categories: primary vision care, low vision care, contact lens care, binocular vision care, pediatric vision care, electro-diagnostic services, community outreach programs including geriatric services.

I will elaborate on one or two of these presently in order to provide you with some understanding of the scope of these services and their relationship to the proposed legislation.

Clinical education services first: In order to achieve dissemination of information relevant to the delivery of high-quality vision care, the vision institute sponsors continuing education programs for optometrists. These programs are attended by professionals from across Canada. The purpose is to enhance knowledge, skills and techniques of practitioners through lecture and workshop programs. These programs are accepted by the College of Optometrists of Ontario for renewal of licences.

We also provide education programs for other health professions including nursing, chiropractic, pharmacy and medicine.

In keeping with our commitment to the community, we freely provide public education presentations to various lay groups such as seniors organizations and parent-teacher groups.

In terms of our clinical research services, although the institute engages in various research projects, we are limited by our resources to projects wholly funded through corporate grants or foundation support. Some of our projects have included evaluation of new materials in contact lens solutions, evaluation of new instrumentation and the epidemiology of diseases, disorders and dysfunctions of the eye and visual system.

The current legislation defines optometry as those services optometrists provide within their level of knowledge, skill and training. That is under the HDA. Thus, diagnosis and treatment or referral of a wide array of diseases, disorders and dysfunctions are managed by our clinical staff on a regular basis. The following will highlight for you some specific areas in terms of primary care.

Primary care: To dispel a misconception that glaucoma is simply high intraocular pressure, it should be noted that a large percentage of glaucoma falls into a diagnostic category of low-tension glaucoma. Additionally, several other categories of glaucoma of lesser or greater severity exist. The differential diagnosis is critical in the appropriate management of the disease.

Glaucoma work-ups include visual field testing, pressure measurements and extensive evaluation of the optic nerve heads and an extensive evaluation of the retina. Although not all-inclusive of full testing, these procedures are performed routinely by our staff. Patients are counselled accordingly and referrals or monitoring are made based upon professional judgement related to the test results. Irrespective of the fact that optometrists in Canada do not treat glaucoma, they must be able to diagnose the disease in order to manage the patient appropriately.

Low vision services: These provide opportunity for our staff to treat through optical and non-optical means a number of conditions which are non-medically or surgically treatable or beyond further medical and/or surgical care.

For example, macular degeneration is a common degenerative condition found principally among the elderly. It results in death of the vision fibres affecting central vision only, thus reading vision is impaired most profoundly. Over 99% of macular degenerations are not treatable medically or surgically. Significant improvement of function can be achieved through optical means, however.

Other causes of low vision include inherited conditions such as retinitis pigmentosa or the consequences of a cerebral vascular accident, a stroke.

The assistive devices program of the Ministry of Health currently has optometrists authorizing patients to enter this program through a completion of certification which includes the diagnosis of the cause of the low vision. The vision institute staff currently provide in excess of 300 complete low vision assessments annually. It is anticipated that this service will grow in excess of 25% annually for the next several years. In 1990 dollars, each of these patients is subsidized by the institute to the level of about $60.

Let me give you some examples of electro-diagnostic services. This service includes the measurement of eye and brain wave recordings generated by a visual stimulus such as a flashing coloured light. Certain conditions which can be diagnosed with these tests include optic neuritis, which may be associated with multiple sclerosis; retinitis pigmentosa, an inherited degenerative condition resulting in night blindness and tunnel vision; and possible pituitary tumours.

Patient referrals for these diagnostic tests are received from neurologists, ophthalmologists, optometrists and community agencies and facilities including Toronto Sick Children's Hospital.

Let me now finally talk about the impact of RHPA proposals. The limited scope of practice currently proposed by the RHPA will significantly impair our traditional role in the delivery of high-quality, efficient, accepted health care. It will prevent us from communicating with patients the diagnosis of the disease or disorder causing their visual symptoms such as cataract. This effectively interferes with the traditional patient-practitioner relationship.

The effect of such a limited view of optometrists' capabilities will necessitate over-referral of patients, with incumbent increases in the cost to the public. The increased costs will not only affect the OHIP payment system, but also affect the patient through the necessity to attend another practitioner's office with associated loss of income for the patient.

The current proposed scope of practice for optometry specifically denies the policy objective of promoting evolution in the roles played by individual professions and flexibility in how individual professionals can be utilized so that health services are delivered with maximum efficiency.

The proposed scope of practice fails to recognize the extensive level of professional education and clinical training undertaken by optometrists. The University of Waterloo program involves four years of education only after a minimum of one to two years general science at the university level.

Let me talk about a solution. The current legal accountability and professional responsibilities must be recognized. The scope of practice must include the diagnosis and treatment of diseases and disorders of the eye and vision system, and the controlled act should recognize this change. It should be noted that this proposed change in scope of practice is neither status-seeking nor an attempt to obtain financial gain, but merely reflects the current practice of optometry in this province.

In summary, the vision institute has provided high-quality vision care to the community for the past nine years: services to the elderly, the multiply handicapped, the institutionalized, to those with strokes, infants, children and to patients of all racial and ethnic origins. Patients have sought our counsel with respect to the diagnosis, treatment and management of their various eye and visual system problems. Irrespective of the ultimate management, including referral as necessary, we have openly communicated our diagnoses and management options with them. On behalf of our patients and their families, we ask that you amend the proposed legislation and grant optometrists the right to continue to serve the public in the same professional manner they have for decades.

The Chair: Thank you very much for your presentation.

Mr Waters: Maybe I am slow on the uptake or something, but I seem to be getting the opinion here that there is going to be a major change. I represent a very rural riding. I am somewhat concerned. From what you are saying and what other people have said, what is going to happen to the people in my riding? Let's say a small rural town in Muskoka or up in the Collingwood area, these small rural communities, are they going to have to go to a place like Barrie to have their eyes checked? Under this new thing, is this what is going to be a standard practice?

Dr Acs: Yes. For some situations, for certain types of patients, yes, they are going to be going someplace else -- after they see you, because they are still going to go see the optometrist.

Mr Waters: But you are saying that they have been safely treated at the optometrist --

Dr Acs: At the optometrist's office. Yes, I am saying that.

Mr Waters: And a proper diagnosis has been made, and now you are not even allowed to tell about the diagnosis. You have to --

Dr Acs: We have been sort of told that what you could tell them, couched in the language, is that you could say perhaps, "I think you may perhaps have -- "

Mr Waters: Okay. Can I have a supplementary to that to the ministry? Could they respond to that answer?

The Chair: Mr Wessenger.

Mr Wessenger: I will turn this over to the staff, because I think it does require some clarification.

Ms Bohnen: First of all, in case there has been confusion about the diagnosis issue vis-à-vis optometry, then from some of the other professions that you have heard concern about, I would like to remind you that the scope of practice of optometry recommended by the review does include diagnosis of vision and oculomotor dysfunctions of the eye. What you have heard from optometrists is that they believe that they diagnose, in addition to vision and oculomotor dysfunctions of the eye, diseases and disorders of the eye and vision systems. So, first of all, that is what the issue is about. It is about the extent of the ability to diagnose.

The review came to the conclusion that optometrists do not diagnose all diseases, all disorders, all dysfunctions of the eye, which is what ophthalmologists do, but rather that they do something more confined than that, and that is, as I just spouted to you, the diagnosis of vision and oculomotor dysfunctions of the eye.

Now, of course, in addition to conclusively diagnosing those dysfunctions, it is well recognized that optometrists assess the eye and vision system and are quite capable of identifying the symptoms of cataract, the anomalies of pressure that indicate glaucoma, of monitoring patients with those conditions and of referring them to ophthalmologists for treatment at the appropriate time.

That being the case, it was not the review's belief or intention nor has it been the government's belief or intention that this would alter current practice by optometrists. So that no, patients who had been going to their local optometrist would not find themselves in a position of having to drive 60 miles to the closest city with an an ophthalmologist.


Mr Waters: Especially when they cannot see.

Ms Bohnen: Especially when they cannot see.

Finally, just because you heard about it, the scope of practice of optometry in the Health Disciplines Act says, "The practice of optometry means the services usually performed by an optometrist, including the measurement and assessment of vision other than by the use of drugs, except such drugs for such purposes as are described by the regulations, the prescribing and dispensing of ophthalmic appliances and the prescribing and providing of orthoptics" -- and it goes on a bit. But I guess the salient part is, "The practice of optometry means the services usually performed by an optometrist, including the measurement and assessment of vision." The review concluded that the services usually performed by an optometrist are what you see proposed in the Optometry Act.

The Chair: I have a further comment from the deputation, and then a question by Mr Wilson.

Dr Acs: I would like to respectfully disagree with what was just said, and what was said was that optometrists are quite capable of identifying X and then are capable of monitoring it. With all due respect, unless you are able to communicate what it is that you are identifying to the patient, you cannot expect the patient to keep coming back to you for monitoring if the patient does not know why he is coming back for monitoring. They are going to travel to somebody else who will tell them, "You're coming back for the monitoring of cataracts."

The Chair: A clarification.

Ms Bohnen: I am sorry. I should have gone on to say that of course the outcome of an assessment can be communicated to a patient. That is the same for optometry as for all of the other professions you have heard from who are justifiably concerned that they can tell patients the outcome of an assessment.

Mr J. Wilson: This is really a question to the ministry. Do we have any independent legal opinions to back up the ministry's belief that you have not changed the status quo, for instance, in the practice of optometry?

Mr Wessenger: I will refer that to ministry staff, but the legislation has, in effect, been drafted in accordance with the intent of the --

Mr J. Wilson: I trust in our legal department, but I was just wondering if we had any independent opinions on this.

Mr Wessenger: To be fair, there seems to be a confusion among various groups about the difference between assessment and diagnosis. There was never any intention, as I understand it --

Mr J. Wilson: It is not just among groups; it is among legislators, I assure you.

Mr Wessenger: There is certainly no intention to limit the assessment of problems and the communication with respect to that assessment, and I think that should be made clear to the committee as well.

Mr J. Wilson: I gather the government would not bring this forward unless it was comfortable with it. We have had group after group saying they are not comfortable with it. We have some legal opinions in appendages to briefs. I am wondering if the government itself has any independent legal opinions backing up the fact that we should be comfortable with the legislation it puts before us.

Mr Wessenger: Perhaps I will just let ministry staff add to what has been said.

Ms Bohnen: As you have heard, different groups are uncomfortable with different aspects of the diagnosis-assessment issue. Most of the groups you have heard from, prior to the optometry groups, are uncomfortable because they have not been given the authority to diagnose at all, and therefore all they can do is assess. In various ways I think they have told you that they need some comfort that they can continue to assess their patients and communicate the results of those assessments. I think you have heard the minister, when she came to the committee, say that she anticipates the need for some amendment in this area and was hopeful to hear the advice of the committee, but that is quite a different issue from the issue of whether a group that has been authorized to diagnose has been authorized to diagnose the correct subset of health conditions, and that is the issue that optometrists are uncomfortable with.

I think the issue was stated correctly to you, that optometrists believe that they diagnose all diseases, disorders and dysfunctions of the eye and vision system. The review did not agree with that. The review looked at what optometrists do and said, "We agree on what you do; we disagree on the characterization of what you do." I do not think the ministry considered a further legal opinion about that issue as being really helpful to the point.

Mr Cordiano: To carry on with this: In a sense, the scope of practice, as defined by the review, essentially is unchanged. It is a status quo situation that we are bringing forward in the legislation, and it more clearly defines what optometrists do.

Ms Bohnen: The Health Disciplines Act uses those rather indistinct words, "the services usually performed by an optometrist." The review looked at what optometrists actually do, and said, "We describe that as diagnosis of dysfunction and assessment of other health conditions." The review said, "Look, that's how we write down the status quo." What you are hearing from optometry is that, "No, the right words to describe what we do are diagnosis of all of these health conditions." That is what the argument is about, I think.

Mr Cordiano: Let me quickly ask the optometrist: With respect to diagnosis, currently you are, in your opinion, diagnosing, say, a disease as it comes up. Is that what you think you are currently doing?

Dr Acs: Yes.

Mr Cordiano: And the legislation would now prohibit you from doing that, correct?

Ms Bohnen: The legislation would say, "You can diagnose dysfunctions. You may not diagnose diseases. However, you can assess patients and tell them the results of the assessments," and where that assessment includes a sign or symptom of a disease, certainly that could be communicated to a patient.

The Chair: Thank you very much for the clarification. I know that in the course of these hearings there will be an opportunity to pursue this and other similar matters on other occasions. I want to thank you for your presentation.

For the information of all committee members, the video that was presented by chiropody is available in the clerk's office and will be available to any member of the committee or anyone who is subbing on the committee; for that matter, any interested member of the Legislature who would like to view it, until such time as the committee has completed its deliberations. Actually the clerk has informed me that they can make a copy of it so that it will be available indefinitely.

The second item of business before we adjourn is a report of the subcommittee, which met briefly the other day and agreed to meet on September 16, which is a Monday, and on September 19, which is a Thursday, not to have witnesses and public hearings but to have ministry-specific presentations. On the 16th and 19th Mr Schwartz is coming. We had considered the other dates during that week but they are the high holiday dates, and so the determination should be the 16th and the 19th.

Mr Martin: Again, with all due respect, the 16th and the 19th, for people who travel from the north, makes for a big problem if we want to spend any time back in our constituencies before we go into the House. I just want to put that on the record.

The Chair: I understand the problem was that the ministry staff were not available on the 17th, and with the holiday period out of consideration the committee determined that if it was necessary we would meet on the 19th. Excuse me just one moment.

For the information of the committee and the subcommittee, we will discuss it further. It may be possible, provided we adjourn not too late on the 17th, to actually meet the 16th and the 17th until approximately 3 o'clock to help with that problem of out-of-town participation. The subcommittee will consider the matter further, and I will report back to the committee at another time. Thank you.

The committee adjourned at 1620