Thursday 8 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

Ontario Chief Psychologists Association

Ontario College of Pharmacists

Ministry of Health

Ontario Dietetic Association

Beverly Campbell

Toronto Hospital Speech and Swallowing Laboratory

James H. P. Main

Robert Kroll

David G. Scroggie

Deanna Mulvihill

Mary Anne Witzel

Centre for Independent Living in Toronto Inc

Stuttering Association of Toronto

H. Ayala Manolson



Chair: Caplan, Elinor (Oriole L)

Vice-Chair: Cordiano, Joseph (Lawrence L)

Beer, Charles (York North L)

Haeck, Christel (St. Catharines-Brock NDP)

Hope, Randy R. (Chatham-Kent NDP)

Malkowski, Gary (York East NDP)

Martin, Tony (Sault Ste Marie NDP)

McLeod, Lyn (Fort William L)

Owens, Stephen (Scarborough Centre NDP)

Silipo, Tony (Dovercourt NDP)

Wilson, Jim (Simcoe West PC)

Witmer, Elizabeth (Waterloo North PC)


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

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

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

Jordan, Leo (Lanark-Renfrew PC) for Mrs Witmer

White, Drummond (Durham Centre NDP) for Mr Malkowski

Clerk: Mellor, Lynn

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

The committee met at 1003 in committee room 2.


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

Reprise de l'étude du projet de loi 43, Loi de 1991 sur les professions de la santé réglementées et les projets de loi, 44 à 64, qui l'accompagnent.


The Chair: Good morning. Welcome to the standing committee on social development.

We are going to begin this morning with a presentation from the Ontario Chief Psychologists Association, Patricia DeFeudis. The procedures for the committee are that you have 20 minutes for your presentation, and we ask that you leave some time so that we can ask some questions, if there are any questions from members of the committee. While this is a formal meeting, please relax, do not be nervous, and welcome. If you will sit down and speak into the microphone so Hansard can pick up the names, that would be helpful.

Dr DeFeudis: Fine. My colleague Dr Ferguson will make the presentation, and we will be glad to answer and discuss with you the issues. Thank you.

Dr Ferguson: The whole process of being involved in legislation is not our business and it is brand-new to us. It has certainly given us an appreciation of the difficulty in drafting good legislation, perhaps particularly when that legislation has goals both of broadening and restraining or controlling things people do.

In general we applaud the legislation, its goals and its nature. The Ontario Chief Psychologists Association, as you might imagine, is dedicated to improving health care and access to health care. We are particularly interested in those aspects of the legislation aimed at facilitating greater flexibility of roles for health care providers, as we believe that psychology and psychologists, as well as other professions, are capable and deserving of greater scope than sometimes may have been awarded in the past in our health care system. Because of that we look forward to the passage of this legislation into law and moving on to the review of the Public Hospitals Act.

I am going to be brief and bring to you the concerns we have; not the broader concerns of the profession of psychology, but the concerns the legislation brings to us as we practise within the hospital system in Ontario. There are mainly two.

The first one I want to touch on relates to the issue of diagnosis as a controlled act. It is our understanding that some professions have raised questions about the need for retaining diagnosis as a controlled act. Diagnosis is one of the core functions psychologists carry out in hospitals. We are very frequently called upon by our colleagues to make diagnoses. We realize diagnosis is a very important function, and it is also one which is, to perhaps use a word that is risky, a dangerous one. In psychology over the last 20 or 30 years we have learned painfully the difficulties labelling can cause the people we work for. None the less, it is simply because the dangers of labelling are so pronounced that it is clear to us that diagnosis needs to be a controlled act.

It is our view that psychologists are well prepared, both through their education and their inside training, to carry out the process of diagnosis as it has been defined in the scope of practice in the proposed legislation. Not only that, but there are some areas where in fact psychology is clearly the very best profession to make diagnoses, and examples of those areas would be in diagnosing personality disorders and mental disorders and in diagnosing learning disorders with children.

While we feel diagnosis should be retained as a controlled act, and that it should be retained as a controlled act for psychology as it is described in the legislation, we are also mindful of the needs of others of our colleagues to assess and communicate their findings with regard to treatment within their scopes of practice. We urge you in this committee to give some thought to making the distinction between assessment and diagnosis and allowing many of our colleagues clearly the right to communicate the results of their assessments.

The second area where we have concerns relates to title protection. As you have undoubtedly already heard, the new Psychology Act would change title protection for psychologists. The broader issues for professional psychology will be addressed enthusiastically and in detail by our regulatory body, the Ontario Board of Examiners in Psychology, and our professional association, the Ontario Psychological Association, so I want only to look at one area that relates to us in hospitals.

In our hospital practices, many of our staff members are frequently involved in assessment and feedback and treatment and planning in areas relating to education; psycho-educational assessments of children and the follow-up of those assessments, and forensic assessments for the court.

As we understand the current legislation and the definition of health care that might ensue from that legislation -- and we have not obtained an independent legal opinion on this; we are relying on the legal opinions obtained by our regulatory body and by our professional association -- we are concerned that we would have staff members who would be practising in the educational and forensic areas within the hospital who would not be regulated while they carry out those particular jobs. We are concerned because for us in the past all the things our staff have done have been clearly regulated.


We are also concerned because these two particular areas are often contentious and sometimes involve litigation. Since what psychologists do in those areas are not controlled acts, we feel that quality assurance in those areas then rests on having the services provided by regulated practitioners. We do not have a clear proposal for how to iron out that difficulty. One possibility would be to move to a definition of health care which would clearly include those areas of psycho-educational practice and forensic practice that our hospital staff members had been involved in for many years. I think that is the core of what I want to say. If you have questions, Dr DeFeudis and I would be glad to try and answer them.

Mr White: As chief psychologists, you would be chief psychologists in hospitals?

Dr Ferguson: That is correct.

Mr White: So you are not referring to what would be, say, a chief psychologist of a board of education or whatever, but entirely within the medical field.

Dr Ferguson: Entirely within the public hospitals of Ontario.

Mr White: I think you were absolutely accurate with regard to learning disabilities, etc. I recall in the past a colleague, a psychologist, just doing an incredible job in assessing learning disabilities. I was just amazed at the accuracy of the assessment or the diagnosis, depending on your phraseology, and the treatment and recommendations, which were extremely specific and helpful for the treatment staff. In the hospital setting you would usually have a multi-team comprising social workers, psychologists, psychiatrists, etc.

Dr Ferguson: Most often, not always.

Mr White: And I am sure as well that the psychology department in some areas is staffed alone with psychologists and perhaps some psychometrists underneath them. Within the mental health clinic, the multidisciplinary clinic, what would be the approximate proportion of those staff?

Dr Ferguson: What proportion are psychologists?

Mr White: Yes, or psychology staff. I guess that is a very accurate phrase. First off, what proportion would be psychologists? What proportion would be psychological in the mental health clinic? Do you have any idea?

Dr Ferguson: As an association, every two or three years we do a survey of our member hospitals in Ontario. In our hospitals the majority of psychology department staff are psychologists. We have only one hospital where it is not the majority and I believe that is my own, and we only have one other hospital where the ratio approaches 50-50. So in the majority of hospitals, most of the psychology department staff members are psychologists, not psychometrists.

Mr White: And the psychometrists would be people with their MAs in psychology.

Dr Ferguson: Yes.

Mr White: And upon the multidisciplinary teams, the mental health clinics, etc, do you have any idea what the breakdown would be by profession?

Dr Ferguson: If they were mental health clinics designated as such, I believe psychologists likely would make up between 25% and half of the staff. That probably varies from clinic to clinic. Within my own hospital all of the services are multidisciplinary. The proportion of the service that is psychology staff depends on the nature of the service. For instance, in the forensic service there is proportionately more psychology staff and neurologically oriented service.

Mr White: You mention here the distinction between assessment and diagnosis. We had a lengthy discussion of that issue yesterday and I am sure it is not as yet resolved to everyone's satisfaction. How do you think that distinction could be made to meet the needs and practices of your colleagues in the mental health or other health professions? I am speaking here, of course, of mental health.

Dr DeFeudis: We made a suggestion in our brief that we presented today for a generic "notwithstanding" clause which would read something like the controlled acts regarding communicating the results of an assessment. Professionals registered by their respective colleges are exempted from this restriction in so far as the communication relates to the results of assessments performed within their scope of practice. In other words, one can communicate what one has accomplished through an assessment, and that is not the diagnosis. But one should not be restricted in doing that and we certainly feel very strongly that all professions should be allowed to do that.

Mr Beer: Thank you for your submission and also for your suggestion about what an exemption might look like. I think, and you have noted it, that one of the issues we have to wrestle with is not only how we read this definition of diagnosis and assessment, but recognize that if there is to be a change that seems to fit one group, what are the implications of that for another. This whole thing is such a balancing act that one is concerned about how those all fit together.

I just wanted to go back, because one of the things for us as laypeople is in understanding what it is you do today and what this act, were it to pass unamended, would mean so we have a clearer sense of what might limit you today in your practice within the hospital. Is there an example you could give us of a kind of activity or case you would deal with today in a hospital setting where, if this were to go through, you would feel you could not do it, or there would be some limitations, just to give us a more practical sense from the day-to-day experience.

Dr Ferguson: I would like to try that. As directors of psychology working in Ontario public hospitals, we fall not only under Ontario law, but our hospitals are accredited nationally, so there is a Canadian Council on Health Facilities Accreditation. For our institutions to be accredited, one of the things we are charged with is the assurance of good quality psychological services within the hospital. One could argue that we are stretching a point, but the way the new legislation is set up, as we understand it, a hospital -- not all hospitals have psychology departments -- or a health facility could set up psychological services. Because the words "psychological" and "psychology" would no longer be protected they could set up a psychological services division which would not of necessity have to be supervised by a registered psychologist. That cannot happen now.

On the other hand, I cannot look at you in good faith and say the way the legislation is set up will prevent me or Pat or any of our staff from delivering service to people. However, the business of controlling the quality of the service is the thing she, I and our colleagues are more concerned about. That is the aspect of the title protection that we are concerned about.

Mr Beer: That is very helpful for us in trying to understand what is the essence of the problem and how the present legislation regulation compares with what would be coming, because we are going to be continuing to talk to people in the ministry and also to Alan Schwartz around some of these issues.

Dr DeFeudis: Another concern would be the definition of health care. Again, it depends on how wide the net is cast. Psychologists tend to go in and out of -- if the definition is very narrow, our functioning may go beyond the definition. However, if it is a fairly broad definition, for example, consulting in a child and family service, one is frequently also making contact with the school. If that contact with the school around treatment for a child is considered health care, what is done would be controlled. If it is not considered health care, then what is done would not be controlled. It would be that kind of a very grey -- we understand -- situation. It may be that a definition of health care can fit this -- for example, a definition of health care that encompasses all the controlled acts, an operational definition that brings in the concept of all the controlled acts, so therefore health care may be adequate.


Mr J. Wilson: You have heard my questions before. Thanks for the presentation.

I am still grappling with the terms "assessment" versus "diagnosis." The way I read this -- a cursory reading anyway -- is, at the PhD level, those psychologists are able to offer diagnosis within the hospital setting and the "notwithstanding" clause you would like to put in is to cover the masters.

Dr Ferguson: It also would cover other professions who have not been offered diagnosis as a controlled act. Academics have had discussions for years about the difference between diagnosis and assessment and the way the legislation approaches it now has to do with attribution of causality. While we do not think that is perfect, that is something we feel we can live with within our institutions, and it does encompass at least a good part of what we feel is important about diagnosis and what separates it from assessment.

For instance, an occupational therapy colleague of mine will assess a child's functioning in the motor sphere and maybe a little bit even in the visual sphere. If they are going to develop a program to improve a child's fine motor co-ordination, then I think it is fair that they be able to sit down and communicate the results of their assessments so they can explain why they are going to do what they are going to do, and how in fact they are going to judge whether it is working, so the parent and the child can understand the whole reason for doing something. They ought to feel that is comfortably within what they are allowed to do.

The Chair: Thank you very much for your presentation. The committee has decided to allot 20 minutes, and if we take more time for one, it means less for someone else. We appreciate very much your coming before the committee this morning.

Dr Ferguson: Thank you very much for the opportunity and good luck.


The Chair: The next presentation is from the Ontario College of Pharmacists. I would remind all members when questioning that we are trying to ensure that all of those who want to ask questions have time, so if you could just be aware of that, it would be helpful.

Welcome to the standing committee on social development. As you know, we are hearing representations on the Regulated Health Professions Act. You are from the Ontario College of Pharmacists and you have 20 minutes for your presentation. We would ask that you leave some time for questions at the end if that is possible.

Mr Truong: My name is Nghia Truong. I am a practising pharmacist from the Ottawa area. I am presently the president of the college. I have here with me the registrar of the college, Mr Jim Dunsdon, and in the gallery we have our solicitors, Mr Phil Isbister and Mr Gordon Meiklejohn.

The Chair: They are welcome to join you at the table, if you would like. We can get additional chairs.

Mr Truong: The Ontario College of Pharmacists is pleased to have this opportunity to make this presentation respecting bills pertaining to certain health professions. Our comments are confined to two bills: the Regulated Health Professions Act, 1991, and the Pharmacy Act, 1991.

Let me give you a brief history of the college. The Ontario College of Pharmacists has been the licensing and regulatory body for pharmacists in Ontario since 1871. Its responsibilities also include the accreditation of pharmacy premises and the regulation of the sale of drugs to the public of Ontario. There are currently some 7,700 licensed pharmacists on the college register and 2,000 accredited pharmacies. This college is governed by an elected council of 16 pharmacists, the dean of the faculty of pharmacy and six public members appointed by the Lieutenant Governor in Council.

The council is the overall policy and planning body, under the chairmanship of the president. An administrative staff of 32 persons, including 17 pharmacists, works under the direction of the registrar and the deputy registrar, and the college departments include drug information, education, field services, investigation, licensing and registration.

The college has worked closely with the Ministry of Health with respect to the discharge of its statutory responsibilities as well as proposing statutory changes and the making of regulations, subject to approval by the Lieutenant Governor in Council and with prior review by the minister.

The college supports the proposed legislation which has taken many years of consultation to develop. We have been actively involved both with the Health Professions Legislation Review and the Ministry of Health in its development over many years and are pleased that this important legislation is now being brought forward. We do, however, have a few concerns which we wish to identify with you today.

1. Membership of governing council: The Ontario College of Pharmacists strongly supports the recommendation of the Health Professions Legislation Review concerning lay representation on councils.

The requirement for one third of the membership to be composed of lay people ensures an effective public presence, while preserving the principle of self-governance. It will preserve the climate of meaningful and effective dialogue at the council table as well as keeping the size of council at a workable level. The inclusion of lay members on the council, established under the Health Disciplines Act, has worked well in our experience and is endorsed.

We are, however, concerned that the proposal to increase this membership to just under half will impair the effectiveness of policy deliberations and seriously erode the principle of self-regulation. The HPLR came to its conclusion on this matter after years of study and its recommendations concerning council and committee composition should be accepted.

2. Use of title "doctor": The proposed legislation would prevent pharmacists who have earned the academic degree of doctor, either by obtaining a doctor of philosophy or a doctor of pharmacy degree, from using this title as a vocational designation. It is our submission that provision should be made to permit such pharmacists to use this title in the same fashion as certain other health professionals.

I would ask now the registrar to continue.

Mr Dunsdon: We have five other items we would like to very briefly highlight and then we would be very happy to entertain any questions you might have.

3. Discretion of the discipline committee: The proposed legislation compels a discipline committee to make a finding of professional misconduct even for a technical breach of the statute. The present Health Disciplines Act, under which we operate, provides for discretion in making such a finding, and we believe that this discretion should be retained. Resorting to a lesser penalty to exercise compassionate discretion is not, in our opinion, a satisfactory approach and removes an element of discretion currently available in the courts, where partial or complete discharges are ordered in appropriate cases.

4. Pharmaceutical services in hospitals: The provision of drugs to patients in hospitals, that is, the distribution of drugs to those patients and other health or custodial institutions, is exempted by these proposals, as it is under the current Health Disciplines Act. We agree with this exemption; however, it is our position that the pharmacy service itself be directed by a pharmacist who is registered and accountable to the college for his or her professional activities. Cases such as hospitals in remote areas, which are unable to secure such services, would be exempted by regulation.


5. Communicating information on investigations: We think it is important that the legislation enable persons making investigations under the act to share appropriate information with such agencies as the police, with inspectors appointed by the bureau of dangerous drugs and with investigators of other colleges.

6. Deputy registrar: We feel it is essential that the legislation should recognize the appointment of a deputy registrar, as is the case in the present Health Disciplines Act, so that such a person, if he or she is appointed, has the powers of the registrar in the absence of the registrar.

Finally, a matter we have just added to our submission, term limitation for elected members: Last week draft government motions to amend the Regulated Health Professions Act, 1991, and certain other companion bills were released.

These motions were described as technical and in the main they were, but there were a number of matters involving policy-making by our council, including most significantly a legislative amendment to limit elected members of the council to serve for not more than six consecutive years. Ontario pharmacists have had the democratic right to stand for election to council and to elect candidates of their choice to council since the establishment of the college about 120 years ago, and these rights are fundamental.

There has really been insufficient time for us to give proper consideration to this important issue and we would like to reserve further comment at this time. We will, however, put forward our position to the committee on this matter as soon as we have had an opportunity to discuss it, and I expect that opportunity will arise within the next two or three weeks.

We thank you very much and appreciate the opportunity to come.

The Chair: Thank you very much, and of course your organization as well as individuals can continue through the course of these hearings to communicate in writing at any time with the committee. We will be pleased to have written presentations from anyone interested in this legislation.

Mr Owens: I would like to ask a question around your comments in point 1 regarding the increase of laypersons on the committee. Could you explain a little more fully how you feel that will dilute the principle of self-regulation and hinder your effectiveness in policy discussions?

Mr Truong: Right now on our college council we have six public people and 16 pharmacists elected, and the dean. With that quota of public people versus elected people we have a good rapport. We can work closely because we consider the public people as part of the council membership. If we start thinking having half, the membership would be so great, the council will be so big that we would have very difficulty in having any significant debate or deliberation.

Mr Dunsdon: We feel the 23-member council is an appropriate number to properly discuss matters and deliberate on policy. Under this particular proposal, and assuming that our electoral districts did not change -- indeed we would like actually to increase them by one because of the population increase of pharmacists over the years -- we would be faced with well over 30 people on our council. I think that is the essential problem we have in terms of effectiveness, that we would have 34 people on the council. We have a concern that that would create problems of effective deliberation because of the large numbers.

The principle of self-regulation, we feel, was appropriately dealt with and addressed by the HPLR. At present we are at about a quarter. A third would have appropriately addressed the public concerns in that regard and at the same time preserved the principle of self-regulation.

Mr Beer: With respect to investigations, you mention here that you would like the legislation to enable persons to share appropriate information. What is the status right now? How is that done?

Mr Isbister: As matters now stand, you cannot share information from college to college, for instance. This means that when there is an investigation by our inspectors and they see something not right on the part of the doctors -- which can happen, because they are the ones who issue the prescriptions and give the orders -- under the present confidentiality section we cannot tell the College of Physicians and Surgeons, and we think this is wrong.

Mr Beer: When you say "the present" do you mean the existing legislation or this new legislation?

Mr Isbister: My understanding is that that position is being maintained.

With respect to the police and the bureau of dangerous drugs, we are in the same position technically. If we find somebody pushing narcotics out the back door, we cannot tell them. They can tell us if they find something, but we cannot tell them. We think it is appropriate and very much in the public interest that this information be shared.

Mr J. Wilson: In the use of the title "doctor," the language of the act is to restrict it to "in the course of providing and offering to provide health care to individuals." Do pharmacists come under that definition of providing health care to individuals, as far as you understand?

Mr Dunsdon: Yes.

Mr Truong: Pharmacists working in a community pharmacy or in hospital, like myself, cannot use the title "doctor" although we provide a service to the public.

Mr J. Wilson: This might be a dumb question but is dispensing drugs considered in this act, as far as you are concerned, an actual health care hands-on service?

Mr Dunsdon: Yes. We consider that a service. The practice of pharmacy involves both the dispensing, the nuts and bolts aspect, as well as what we like to call clinical pharmacy or patient-oriented practice. This legislation would prevent people who have an earned degree from saying they have an earned degree as a vocational designation. The numbers of doctor of pharmacy people is not huge in comparison with the 7,700 members, but it is an increasing phenomenon. It is not uncommon in teaching positions in hospitals, and it is becoming not that uncommon in community practice as well, Dr Truong being an example. There presently is no discretion in the legislation for someone like Dr Truong to call himself Dr Truong when he is practising in community pharmacy as a pharmacist.

Mr Callahan: What is your doctorate in?

Mr Truong: Doctor in pharmacy.

Mr Callahan: I thought you had suggested that a person who has a PhD should also be able to use the term "doctor." Surely this legislation is for consumer protection and information, and to have somebody dispensing drugs or, for that matter, conducting any type of health service with a doctorate in something other than that particular field is not helping the consumer understand what is going on.

Mr Truong: I could elaborate on that. There is a PhD in pharmacy and there is a pharmacy doctorate, which are two different degrees. The PhD in pharmacy is more involved in pharmacology, specializing in pharmacology, but a pharmacy doctorate is just specializing in pharmacy and is a short diversion.

Mr Callahan: I thought I heard you suggest that a person who has a doctorate in philosophy --

Mr Dunsdon: They both have earned academic degrees; a PhD or a PharmD are both earned academic degrees.


Ms Haeck: I would like to refer to your last item, term limitation for elected members. I realize you really have not had a chance to examine all of this, but what is the longest elected membership within your college that you are aware of?

Mr Dunsdon: At the present time?

Ms Haeck: Yes.

Mr Dunsdon: I believe one member has been on council for 10 years at present.

Ms Haeck: As far as a concept of having a sunset provision for members goes, bringing in new blood but then possibly allowing people to stand again, I think there is no limitation here as far as somebody being able to stand again after being off of the board for a while. Do you see that as being problematic?

Mr Dunsdon: I am not sure, because we have not had a chance to talk about it. I think that is one aspect we want to look at. The six consecutive, as you say -- it could be a George Wallace of Alabama type of approach. We would want to look at all aspects of this before we comment further.

The Chair: Thank you very much for your presentation. We appreciate hearing from you today and look forward to your written submission when it is ready.


The Chair: The Society of Independent Community Pharmacists is not here now, so we will ask the ministry to continue its presentation at this time. We have until 11:10 available. Mr Cordiano said he had a question to lead off. I will make a list.

Mr Cordiano: I want to zero in on the title question again, the use of the term "doctor" that you just heard pharmacists talk about. I think we need to establish some consistency, and until I am convinced that we are being consistent -- wherever you choose to draw the line is fine with me as long as we are perceived to be in continuity with everything else and there are logical reasons for having done what we did.

Let us use the pharmacists and compare them to, say, a medical doctor. The pharmacists have a four-year program, I believe.

Ms Bohnen: I believe so.

Mr Cordiano: After which they are granted a degree.

Ms Bohnen: Yes.

Mr Cordiano: Which is what? What is their degree?

Mr Burrows: Bachelor of science in pharmacy in Ontario, but there are also many pharmacists who have the degree of PharmD, doctor of pharmacy, which is a five-year degree. In addition to the academic requirement, there is a practice requirement of one year in Ontario. So it is five years, a combination of education and practical experience.

Mr Cordiano: How does that compare to a medical doctor?

Ms Bohnen: To try to answer that and to address your concern about consistency, the answer would be that in Ontario the basic degree which entitles a pharmacist to registration with the college is not a doctor degree.

Mr Cordiano: It is not a doctorate.

Ms Bohnen: The degree does not say "doctor," whereas for the physicians, the psychologists, the dentists, the optometrists, the chiropractors, their basic, entry-level academic qualification for registration with their college is a degree or, in the case of chiropractors, a diploma earned in Ontario that says "doctor."

Mr Cordiano: That is a technicality, though, in my opinion. It is the college's or the institution's or the government's decision to grant that degree with the title "doctor" included in it. For example, a chiropractor would be granted a degree or a diploma which says "doctor of chiropractic." Correct?

Ms Bohnen: The charter that established the Canadian Memorial Chiropractic College entitles them to issue credentials that are diplomas but use the title "doctor."

Mr Cordiano: Really it is a technicality stemming from what the charter provisions were at the time they were granted.

Ms Bohnen: I do not know whether I would call it a technicality or not. That is just the factual information I can provide you with.

Mr Cordiano: But what I am trying to say is it is the use of terminology and more a semantic question. I am Mr Consumer out there thinking, "What kind of qualification" -- I think you have to equate the two -- "or what assurance of qualification is there when someone calls himself or herself `doctor'?" I think it is all a question of arbitrary determination in that case, stemming from a granting of a charter which in the beginning says, "This degree shall have the use of the term `doctor' in it."

Ms Bohnen: I guess the other aspect of it is that I do not think most Ontarians associate the title "doctor" with pharmacists. As we have heard, there is a small number, a growing number of pharmacists who have a doctorate. Presumably most of them are in pharmacology or pharmacy -- some may not be; I would not know -- whereas people associate all physicians as Dr Whoever.

Mr Cordiano: I am having difficulty because in my mind a pharmacist is part and parcel of the health care system. Shall we say he works almost exclusively within the health field.

Ms Bohnen: Yes.

Mr Cordiano: I do not think you can find an example where a pharmacist is working outside the health care field. My concern is to be consistent and have a sense of continuity where we draw that arbitrary line. I am having difficulty with this example. I am still not convinced at this point that we have done the right thing in terms of drawing that line with respect to the pharmacists.

Mr Burrows: I think, as you heard Linda say yesterday, that there is really a double-edged issue here. One is, what is an appropriate set of criteria for title protection? The other issue is the one of trying to ensure there is not confusion in the public mind.

Mr Cordiano: That is exactly it.

Mr Burrows: To reiterate what Linda said yesterday, it comes down in some aspects to a judgement call. It was suggested in some of the discussions that we had as an aside yesterday that the one group that really has not been heard strongly on this issue is consumers. Are they or are they not confused and what would help them in that regard? It would seem to me that one of the things you might want to elicit from consumers who appear here is a response to that question.

Mr Cordiano: What was your information respecting that question, with the response from consumers? As an intended course of action before we came up with this list, did you sample the consumer to find out whether we are headed in the right direction?

Mr Burrows: Consumers were certainly involved at the association level in the review and we certainly had a lot of correspondence and dialogue since, not only with groups but with individual consumers. I think it is safe to say that this issue, in those discussions, has not been a focus of a large amount of discussion. The focus of discussion with consumers has been more on the broader issues, the complaints and discipline processes and so forth. So this may well be something the committee wants to go into in greater detail in this part of the process.

Mr Callahan: I just want to specifically ask why the government has moved an amendment to strike section 20 of Bill 61. Is that because pharmacists cannot delegate the delivery of drugs?

Ms Bohnen: No. With the clarification that any controlled act could be delegated, that is an amendment to the Health Professions Procedural Code. The regulation-making authority in each college was taken out of the individual health profession act and moved to subsection 91(1) of the procedural code, paragraph 14.1.


Mr Callahan: So that will be struck out of all the bills that deal with it.

Ms Bohnen: Yes, it was just shifted to the code. It was a little bit inconsistent in how it appeared in each health profession act.

Mr Callahan: If I could just quickly address my colleague's comment, if "doctor" could be used in a pharmacy where the consumer's major concern is to receive proper drug prescription preparation, would that not add to the impetus for various druggists to hire a doctor because it might be a marketing feature, and thereby add to the cost to the consumer? Maybe I should not ask you that. That is really a policy question.

The Chair: There will be an opportunity to ask those kinds of questions to the parliamentary assistant or to the minister when they are here.

Mr Callahan: I do not think it is a fair question.

Ms Bohnen: Could I just throw in one comment? As the registrar of the college pointed out, the scope of practice of pharmacy deals not just with the dispensing of drugs, but also the provision of information related to drug use. It may be that in the provision of information about drug use there is greater opportunity for a risk of confusion if the person is using the title "doctor" than there is in just the technical dispensing functioning per se.

Mr Callahan: I withdraw the other question. That really should not be put to you.

Mr White: I want to thank you for your explication as to why several fields were left alone in terms of the word "doctor" -- doctor of psychology, doctor of medicine, doctor of chiropractic. That makes a good deal of sense. It is the entry level.

However, what I am concerned about is that within the health care disciplines, we have many very dedicated professionals who, though the entry level for their profession may be a bachelor's or a master's degree, are so dedicated that they are going back for further education. I think at an increasing level, if we allow only those people for whom the present entry level is a doctorate to refer to themselves in that way, in a sense we are preserving the status quo at a time when that status quo is moving. There is Dr Truong in pharmacy. I know many people who have doctorates in nursing or social work or whatever. They would not be able to refer to themselves by that name, even though they had earned those credentials.

I am wondering if you have any thoughts about perhaps limiting that phraseology and ensuring that people do not refer to themselves as doctors in medicine or doctors in psychology when they are clearly social workers, speech pathologists, whatever, as opposed to limiting the term entirely as an entry level.

Ms Bohnen: The options available to you, should the government wish to amend this provision of the bill, would be to consider provisions which permit the use of "doctor" together with a requirement that the nature of the degree or the nature of the qualification be provided to the patient. You might consider that a rule like that is necessary for regulated, and perhaps a different rule, perhaps a different kind of prohibition concerned unregulated practitioners who may also have various kinds of doctorates, but who do not have a college to keep them to adhere to a particular set of rules.

I guess in the end you have to balance the desire to encourage professionals to advance their education against the public's need not to be confused about the practitioners they are dealing with.

Mr White: I think your suggestion makes a great deal of sense, but I think it will also, in terms of the public interest -- if I were in need of mental health services and I had a choice between going to a social worker who had a bachelor's, a social worker with a master's and a social worker with a doctorate in social work, there is a slight change in terms of whether it is BSW, MSW or DSW. I probably would prefer the DSW. So in a sense there is a public interest there.

Ms Bohnen: There is a public interest. There is also the public interest in not encouraging credentialism that has an adverse impact on access to services. For example, if the general trend were to be that the entry level to practice -- I will not name a profession -- as whatever was advanced from a bachelor's to a master's or from a master's to a doctorate, you would have fewer practitioners available to the public. You have to be concerned about that. There could also be a negative impact on women, on immigrants, on rural Ontarians, on people who have difficulty accessing higher education.

Mr White: That is if the entry level were changed?

Ms Bohnen: Yes.

Mr Hope: I like the comment that was put forward earlier, that we are listening to the professional groups about this "doctor." I am looking forward to hearing the public and talking with them on this whole issue of "doctor." When I go to a doctor, the doctor -- this is my own terminology -- is one who will do an assessment on me and give me a diagnosis of what I have. We always say, "Well, how are things going, doc?"

The doctor I have in mind is going to be able to treat me. A doctor of pharmacy and stuff like that, I guess there is where the general public -- the public, by the identification of "doctor," has to be assured that something hopefully will help their illness. I listened to the professionals express their point of view, but I think there is a group out there we have to keep in the back of our heads, the general public on their viewpoint on "doctor."

I just wanted to air that out, because I think you brought up a good point, listening to the public. What do they perceive as a doctor? What do they expect out of the word "doctor?" I think that is maybe where we should be going.

Mr Burrows: I think this is a perfect example of the validity of the title of the review's final report, Striking a New Balance. In its recommendations, it is our understanding in the ministry that this is what the review really tried to do on this issue, to expand the title protection slightly to incorporate a couple of groups that were not previously protected but who widely used the title, but to draw the line there without broadening it so much as to make the title protection meaningless.

Certainly the option Linda mentioned is an option, but one of the downsides of that is that in those jurisdictions I think that may have such a model, where do you draw the line? It can become meaningless. There are diploma mills in existence where you can buy a degree of doctor of herbology, for example, that probably offers no protection whatsoever to the consumer. I could not agree more with your last statement, which is that if it comes down to a social call, certainly the people who need a voice here are the people who would access these services.

Mr Beer: Just briefly on your last point, I think the editorial this morning in the Globe and Mail would be useful, if people have not seen it. It speaks directly to herbalism and the case that has been before the courts, which is of interest.

The Chair: I have asked the research staff to circulate it to all members of the committee.

Mr Beer: I realize sometimes we get you back here and we are sort of bouncing back to different testimony, but I was concerned yesterday at the concerns raised by the disabled woman, I think in large part because that is not the way I have read the act here and also because I believe there are other things that are happening which provide protections or more meaningful programs for individuals.

To the best of your knowledge, did Mr Schwartz consult with the various disabled groups? Did the Ontario Advisory Council for Disabled Persons comment on this legislation? Are there a couple of real issues which may be presented to us later, but none the less which we should be trying to wrestle with in terms of Bill 43 or any of the others and the disabled community? That is the first thing.

Ms Bohnen: I do not recall that there was a great deal of consultation with the disabled community during the review, although the review was aware of the need to provide an exception for health services which might nevertheless be assistance with routines of daily living, and felt that there was sufficient flexibility in the system, with the exemption-granting power and so forth, to accommodate that. Subsequently there have been ongoing consultations between the Ministry of Health and the Ministry of Community and Social Services with groups such as Advocacy Resource Centre for the Handicapped and other government representatives concerned with these issues to discuss the nature of the exemption that would be helpful to them. Those discussions are continuing and are most recently involving the College of Nurses of Ontario and the Ontario Medical Association for their perspective.


I guess the more difficult social policy issue that arises from this is whether there is a need to have different rules or different kinds of exemptions for individuals capable of directing their own attendant care and for those who are more vulnerable because of their mental or physical state who are not capable of self-directing; and second, whether there has to be detail that addresses an exemption for the more hazardous routines of daily living, things to do with ventilator care. It is largely because of the complexity of these issues that it has been the preference of successive Health minister to iron out the details in a regulation rather than in the act.

Mr Beer: Thank you for that. Could I just note also for the record that it might be useful that we make contact with the Ontario advisory council and at some later date perhaps have the chairperson or others come. I recall very vividly, as Minister of Community and Social Services, this whole issue around the independence of the disabled community and how it is able to access these kinds of services. You have outlined it exactly and it is complex, but I would like to feel a greater comfort level around myself in terms of how we are approaching it. It may well be that the regulatory route is the way to go but frankly, I think there is a difference here over the last five years in terms of how we view those issues and how we are trying to deal with them. If I could just make a note that we would perhaps have them back later and if other groups come forward, this is something we might come back to.

The Chair: Is that a specific request, Mr Beer, for the group to be invited to the committee?

Mr Beer: One of the things I asked was whether they have put together any particular documentation, but if we did not get requests from the disabled community -- I know there are some individuals, but I am just concerned that there is an issue here which --

The Chair: The clerk informs me there are two groups she is trying to schedule here.

Mr Hope: Just to reaffirm what the ministry staff are saying about the disabled communities and attendant care, I know there is constant dialogue taking place around this whole issue and around the health professions regulations, making sure that the individuals out there wanting to live an independent life are able to live an independent life. I know, talking with the ministry people just yesterday, when the lady came and raised some concerns yesterday I got on the phone immediately to make sure this was happening. So there is dialogue going on and we are making sure the independence is still there.

Mr Beer: I quite realize that. I am not making this as a political point at all. As I said yesterday, I think this is something everybody has been moving towards. My concern was that here an individual came forward with concerns around the act which I thought were for the most part trying to be met in other ways, so I am concerned there may be some other issues out there among the disabled community and I think it is important that those get expressed here somehow.

Mr Martin: I just want to confirm Mr Beer's concern around that. I was not here yesterday to hear that. I wish I had been. It raised a red flag for me and if nothing else, certainly I would like at least a further briefing on it so I can get my head around it, know how to participate in the discussion more fully and support whatever we can do to make that happen.

The Chair: I have heard the request and there seems to be some agreement. I am sure Mr Wilson may want to make some comment on this but, at some point when we have some time with the ministry officials, you might like some discussion on the impact of this legislation on the disabled individuals, what consultations have taken place and how, through regulation, you intend to ensure that the goals which have been expressed by all three caucuses are met. Can you spend some time or prepare some briefings for the committee on that?

Ms Bohnen: Sure, but it might be particularly useful to the committee to invite staff from the Ministry of Community and Social Services, since they administer attendant care programs. We have been working closely with them and involving them in discussions with community groups, so they are very knowledgeable about the impact. I can suggest to the clerk individuals who might be helpful.

The Chair: We can discuss the technicalities and how to do that but there seems to be a desire to have that happen at the committee. All agreed? The next speaker is Mr Wilson. I am going to hold supplementaries on issues to just one question, if it is a request that is really on the speakers' list.

Mr J. Wilson: I was wondering whether we could go back to the Ontario Chief Psychologists Association, where they recommend the amendment adding a "notwithstanding" clause. It was very close before I was cut off on the time limit. Could you comment on what they were trying to get at here?

Ms Bohnen: It is an option that has been considered together with other options in the ministry. I think they mean that the controlled act dealing with diagnosis would stay more or less as it is. Perhaps it could be easily improved upon but that would stay. Coupled with it would be an additional clause with words to the effect of, "Even though diagnosis is a controlled act, nevertheless a regulated health professional may assess his or her patient within his or her scope of practice and communicate the assessment to his or her patient." A number of regulated groups have recently proposed that as responding to their concerns. It just might be a little more difficult to apply that to unregulated groups that do not have any officially recognized scope of practice that their assessments could refer to, but it might be a solution for the regulated groups. I think that is what they meant.

Mr J. Wilson: I am glad you made the distinction between regulated and unregulated because I was thinking exactly that. When they come before us, this is not a remedy for their concerns.

Ms Bohnen: I think they may propose to you variations of that which they would see as a remedy for them.

Mr White: With the mental health clinics and hospitals there are some 4,000 social workers employed who are not regulated. I believe the total membership in the OPA is only around 700 or so. That kind of clause would not include the majority of the staff in mental health clinics who are social workers, so it would still limit that function, which I am sure is one of the major groups the psychologists were referring to.

Ms Bohnen: Yes, and social workers, although they are not currently regulated by statute, have a more definable scope of practice than some of the other practitioner groups whom I think you will hear from who practise more outside. They do not practise so much in regulated settings like mental health centres, clinics and so on. I think you are correct in saying that solution would not do for them. It may be that variance of that solution would do for them, though.


Ms Haeck: I have met with my local psychological group. One of the things they raised, which is sort of following up on some things that both Mr Wilson and Mr White have raised, was a concern that as a result of this act -- I will use the figure "half" -- half of their membership would no longer qualify to be part of their college.

Ms Bohnen: I had heard that very recently, however. I do not have the correspondence with me but it could probably be obtained. Their board of examiners in psychology wrote a letter of clarification to a member of the minister's staff saying that was not correct. I have forgotten the percentage they quoted but, according to the board, a very high proportion of psychologists do practise in what they regard as health care psychology.

Ms Haeck: Excuse me for interrupting. What would happen to those people who are in education?

Ms Bohnen: I would like to address that. The scope of practice of psychology is not restricted to hospital or medical clinic settings. It refers, for example, to the diagnosis of neuropsychological disorders and dysfunctions. It has always been our understanding that this scope of practice, which was negotiated with the review by this profession, included things like psycho-educational assessments, which is why diagnosing a child as having a particular learning disability would be within the controlled act of diagnosis. Our view has been that if the function refers to something within the scope of practice, there is not an issue here of regulation by the college. There are a smaller number of practitioners who practise industrial psychology, which is very far removed from health psychology. It has to do with things like industrial design, the design of driver licensing tests and things of that nature which are not, probably by any stretch as a term, health psychology.

Some of those practitioners are concerned that they would lose the benefit of the title protection. Nothing whatsoever would stop them from continuing to be registered with the college as psychologists. But since it is not held, by any stretch of the imagination -- it is really not referred to in the scope of practice. This was the scope of practice agreed to by the profession. Their board now says the overwhelming majority of their registrants practise health psychology, so I think that issue has really narrowed in its significance.

Ms Haeck: I appreciate your comments.

Mr Callahan: I can raise my question the next time we have a break. It was to do with the investigation powers. I am just interested, if we can talk about that the next time.

The Chair: Any members of committee are free to pose questions informally at any time of the ministry staff, which they can respond to.

Mr Callahan: I think it is important to have on the record.


The Chair: The next presentation is by the Ontario Dietetic Association. Please come forward. Welcome. I ask you to introduce yourselves. You have 20 minutes for your presentation. We ask also that you leave some time for questions if possible.

Mrs Poduch: Absolutely. Good morning. My name is Carol Poduch and I am president of the Ontario Dietetic Association. With me today are Mary Ann Rangam, who is the executive director for the Ontario Dietetic Association, and Phyllis Tanaka, who chairs our health professions legislation committee. There are two or three other delegates and interested listeners in the audience who are representing dietitians here today.

Dietitians are leaders in providing nutritional information to the public. The need for good nutrition information is common to each and every member of our population from infancy to old age. We are a profession with one foot firmly planted in the arena of disease prevention and health promotion while the other foot is firmly planted in the arena of disease intervention. You will find dietitians working in public health units, private practice, research, industry, school, throughout health care institutions and in many community settings. In fact, there are close to 2,000 dietitians practising in Ontario. It is well recognized that nutrition is a major component in the prevention of diseases and disorders. Some examples would include heart disease, cancer, diabetes and osteoporosis.

Members of the dietetic profession applaud this proposed legislation. The Ontario Dietetic Association strongly supports the legislation for its promotion of a health care system that provides protection to the public yet is innovative, cost-effective and safe.

The Regulated Health Professions Act respects the right to self-determination for both consumers and health professionals. The public will have the freedom to choose health care providers. Health professionals will be given the opportunity to improve the quality of the services they offer. These features should provide mutual benefit and facilitate the best outcome for all concerned.

In our view, the act can and should go further to protect the public interest. We have prepared five points for your consideration this morning. These points represent position statements of the Ontario Dietetic Association.

With respect to our first point dealing with controlled acts, we believe diagnosis should remain a controlled act. It is our belief, as is obviously held by many members of the committee, that there is a difference between diagnosis and assessment, and we too have grappled with what the definitions of "diagnosis" and "assessment" really are.

The conclusion we have come up with, with respect to assessment and diagnosis, is that health care providers contribute information gained from their assessment to the diagnostic process. While all regulated health care professionals can assess within their scope of practice, we feel that a limited number have the thorough knowledge base to assimilate all information and form a proper diagnosis and treatment plan. Because it requires extensive knowledge, skill and practical experience to gather appropriate data and reach a conclusion regarding a patient's disease or disorder, this activity should be restricted to those health care providers thoroughly trained in the diagnostic process.

Consequently, our recommendation to the committee would be, first, that diagnosis remain a controlled act and, second, to clarify some of the semantics, that there be a definition of "diagnosis" included in the legislation.

Our second point deals with the harm clause. The harm clause, while possibly imperfect, we feel is necessary to protect the public from current and future risks that have not been anticipated by the Health Professions Procedural Code and the list of controlled acts. We feel the public deserves protection in two areas: first, from self-regulated health professionals who practise out of their scope of practice and, second, from unregulated health practitioners who provide treatments, some of which may not have been proven to be both safe and effective. It is our belief that the benefits in terms of public safety outweigh the risks associated with the potential for unintended use of this clause. Consequently, our recommendation would be to reintroduce the harm clause into the legislation.

The third point I would like to address this morning has to do with the scope-of-practice model. The ODA wants to use this time available to us to once again strongly support the basic premise of this legislation. The proposed scope-of-practice model encourages a working together of health care providers. This open and flexible system will foster professional growth and the creation of a comprehensive approach to patient care. We believe the outcome for consumers of health care services cannot help but be improved in terms of the development of innovative care programs that will have the benefit of input from a wide range of professional expertise. Our recommendation is essentially to maintain the scope-of-practice model. We feel it is a primary strength of the proposed legislation.

The fourth point I would like to raise this morning has to do with public membership on college councils. You are not going to believe this: We did not confer with the pharmacists prior to preparing our points this morning, but they are virtually identical. In the consultative process of developing the legislation, it was the general consensus that a one-third/two-thirds ratio struck a balance that allowed public protection under the self-regulatory model. Public members on the council will not have the knowledge of the profession to make informed decisions. Our perception is that the newly suggested ratio is out of balance, and our recommendation is to maintain lay membership at one third, as originally agreed upon.


Our fifth and final point for the morning has to do with professional titles. One of the identified needs, after introduction of the Regulated Health Professions Act, has been for public education. Our feeling is that this is going to be no small task. To fully realize freedom of choice, we believe that consumers should be able to easily recognize health care providers that are regulated. Our members work in a variety of settings, yet have common educational and training backgrounds that entitle them to call themselves dietitians. Job titles include both the term dietitian and/or nutritionist. We require protection of the professional designation "RD" and its French equivalent "DT." This is so that members of the public can easily identify members of the College of Dietitians of Ontario. Indeed, it is our feeling that title protection is the cornerstone of informed consent for the public.

Additionally, we feel that the holding-out section should be amended to protect the public from unscrupulous practitioners who may add descriptors to their titles in order to pass themselves off as regulated professionals. Consequently, our recommendations with respect to professional titles would be, first, to protect the professional designation "RD" and its equivalent "DT," and that the restricted-title section and holding-out section of the legislation should be amended to read "services in Ontario" and not just "health care services."

This concludes our formal presentation this morning, and I would like now to invite your questions.

Mr Owens: We have had some discussions around how consumers perceive various professionals. Coming from a hospital in my former life I know there was often confusion between the dietitian and the food service supervisor. What would your association propose doing with respect to promotion of the difference between your organization as a self-regulating body versus the food service supervisor who after two years of community college could come out and do her thing in the kitchen?

Mrs Poduch: Our association represents dietitians only. There is a different training background defined for dieticians versus food service supervisors. Dietitians hold a four-year baccalaureate degree in food and nutrition and subsequently complete an internship in dietetics. Our mission or our job as the ODA is really to represent dietitians. Presently, food service supervisors operate under a separate association in Ontario, so at this point in time it would not be our job to represent their interest.

Mr Owens: My question is more on how you would educate the public with respect to your role as dietitians so that confusion is eliminated.

Mrs Poduch: That is an issue we have not addressed in detail within our association. I can answer as it occurs to me at the moment, and that would be to represent ourselves with the training we have to the public, through the various media and outlets that will be available to us. It is important to dietitians to maintain our status as a part of the health care team, and that is probably where we would start, with direct consumers of our services, patients with the disorders I described -- cancer, diabetes, osteoporosis. That would be our first step.

Mr J. Wilson: I was wondering about public membership on college councils. A few groups, as you know, have mentioned that now. Do you have any idea how the new rule came into effect or was suggested, that we have lay membership composed of just under 50%? Were you consulted on that at all?

Ms Tanaka: No, that decision for increasing the public participants was not part of the consultative process. That was determined with the introduction of the bill under the new government.

Mr J. Wilson: If the minister's new suggestion were adopted by the committee, would that place any type of burden on you? I am just trying to get a feel for the concern.

Ms Tanaka: With our profession we will be a small college, so our governing council will not be a large governing council. For us, it will not necessarily place a burden in terms of numbers, making it too large a body. But as Carol mentioned, the public participating on the council provides a perspective in guiding policy development in health care but they do not necessarily have the knowledge base of the profession. We see that as the problem more than the actual numbers in our particular college.

Mr J. Wilson: I am glad to hear you say that, because my belief behind the new number is that it was basically a political decision. It sounds good to have almost half public on these. Having formerly been an executive assistant to our federal Minister of National Health and Welfare and trying to find some 2,700 people a year to fill appointments across Canada, I have no idea where the government is going to get all these qualified people.

Ms Tanaka: That is one of our concerns as well, the logistics of getting the public participants, having access to them, having public participants who can give up that amount of time and educating them in the process.

Mr J. Wilson: It does raise the cost. If the government moves ahead with just under 50% representation, as you understand it now, your college would have to absorb the cost of bringing these people up to speed. Would you be able to bear that cost? You would probably prefer not to, I would think.

Mrs Poduch: We are newly regulated, so it is very difficult for us to answer that. We have some sense of fear in anticipating trying to do that; concern with the logistics of effectively self-regulating and taking on that task as well.

Mr J. Wilson: My experience, too, with these is that unless you pay them a handsome per diem you have tremendous turnover on these councils. Certainly across Canada we were constantly replacing people and trying to bring them up to speed. I just throw that out so the government may consider that.

Mr Callahan: Perhaps I am opening up a can of worms, I do not know. I gather that dietitians do not cover the waterfront of things such as weight control, but I suspect that you may very well see the effects of some programs -- I certainly would not want to zero in on any specific program -- out there in the public domain that create a nutritional problem. Would that be a fair comment? Do you run into that?

Mrs Poduch: Create a nutritional problem?

Mr Callahan: You see all sorts of glitzy ads: "We'll take off 40 pounds in a day." I am sure none of that is healthy to the human body, but do you find any of that in your profession in terms of fitting into your mandate of nutrition, because they have gone to those who perhaps are not accurately describing what they can do for them?

Mrs Poduch: It is an issue we have dealt with over the years and it is a contentious issue for our association. There is no question about that. Our hope is that this legislation will help to protect the title "dietitian," and then we will be able to use that title to let the public know who we are and what we can do and that we have been recognized by the government of Ontario as having an expertise that is useful to them. In terms of protecting the public, that is an issue that needs to be dealt with. There is big business in weight loss. There is no question about that.

Mr Callahan: I am glad to hear you say that. That is something that down the road is perhaps another protection for consumers. Perhaps it is more appropriately dealt with through consumer legislation. I was curious as to whether you encountered that. As a professional dietitian that must create some problem.

Mrs Poduch: It is a problem. We would be happy to work with the government in that undertaking. We have very strong feelings about protecting the public in terms of fraudulent claims for weight loss as providing health care, and the 40-pounds-a-day example is classic. That does not provide adequate health care and does open up some risk in the long term.

Mr White: I have just a couple of very brief questions about your association. You referred to the difficulty you are faced with now, being a newly regulated profession. How large is your association?

Mrs Poduch: We have roughly 1,700 members of the ODA, and there are some members who will probably want to become members of the college who practice outside of the dietetic association, so that in total there are approximately 2,000 dietitians in Ontario.


Mr White: So that is actually a fairly large association in terms of the parameters of the groups that we are looking at.

Mrs Poduch: Is it? I would not know.

Mr White: I would think so. What kind of problems do you anticipate in forming a college, a regulated, legally sanctioned institution?

Mrs Poduch: I think some of the concern we have is that it is all new to us and we have a learning curve to go through, and there is an anticipation of a major learning curve. Maybe some of our fears are unfounded, but it is this big, looming job to be done that we do not yet understand fully.

Mr White: I am sure you will have the resources.

Mr Hope: Dealing with the public membership of the council, I have heard the other viewpoint and then I hear the comments dealing with the public awareness of your job. Would it not make more sense, then, to have more of the professional group? You are talking about having more of the professional group on the council. Would it not be better to have more of the public involved in this council so that you are not hearing it from the professional or from the organization itself, but you are also hearing it from the public?

You are saying that you will not have the expertise around. Well, we all learn on a day-to-day basis, but I think it would be more important for you to have more public perception inside the decision-making process, which then communicates your message, not just as a professional but as a public going out there and communicating that information.

Mrs Poduch: One of the points I wanted to raise earlier and was not able to was that we want to reiterate that we applaud the balance that was originally described and we are not interested in excluding the public from our activities. That is absolutely not what we want.

Our concern has more to do with the balance and the logistics of running the college. So let me reiterate clearly: We welcome input from the public. That has never been a question for us. It really has to do with logistics in working. That is a concern and perhaps a fear that we have.

Ms Haeck: I have just a very brief question and you are going to be expanding my learning curve by answering it. At the present time, how would you see getting the public representatives on to your college? Is that going to be done by your actually seeking them or are they all appointed by the province?

Ms Tanaka: My understanding at this point is that is going to be a government --

Ms Haeck: Each and every one will be a government appointee?

Ms Tanaka: I believe, from a briefing I attended last week that Minister Lankin conducted, they are in the process of developing a bureau of public participants. My understanding at this stage is that is where the public participants will be drawn from.

Ms Haeck: I know from my personal experience as being someone who was elected in September and then having a new process for public appointments, that my office has received a great many CVs of people who are interested in standing for government-appointed positions on a vast array of bodies. I really feel, unlike Mr Wilson, that in fact we are probably going to have a sea of faces from which to pick and people are very anxious to be part and parcel of the process. I think you are going to find that there are a lot of people who are interested in health care and want to participate.

The Chair: Thank you for your presentation.

Mr Callahan: Can I send you a couple of CVs?

Ms Haeck: Sure.

The Chair: We appreciate the representations that you have made to the committee and would advise you that if you have any further comments as the process unfolds, please feel free to communicate with us in writing at any time.

Mrs Poduch: Thank you very much. Good luck with your deliberations.


The Chair: The next presenter is Bev Campbell. Welcome to the standing committee on social development. You have 10 minutes for your presentation. While this is a formal committee, please feel quite comfortable in addressing it, and we would ask also that you leave a few minutes so that the committee can ask you some questions.

Ms Campbell: Thank you, Madam Chair and members of the committee. My name is Bev Campbell. I am a management consultant with a practice in downtown Toronto, and while I provide general management advisory services, my main interest these days is in employment equity. By training and experience I am a certified general accountant and a former professor of accounting and finance at George Brown College.

I am also a former member of the council of the College of Physicians and Surgeons of Ontario. I was appointed by order in council in April 1989 and served for two years until forced by the time demands of the position to resign two months ago. It is primarily the circumstances leading to that resignation, and their implications for public representation in the governance of health professions, that bring me here today.

As a secondary matter, I wish to raise for your consideration an issue which I believe is not adequately addressed in either the existing or the proposed new legislation, but is of concern to the young people of the province, as well as to people who are immigrating to Canada, and to Ontario in particular, with training acquired in other parts of the world. I refer to careers as health professionals, and in particular to the well-recognized and well-paid professions, such as medicine and dentistry.

With respect to public representation, my first issue, I would like to say that I support fully the proposals to increase substantially the numbers of lay members on councils. At the same time, I support the notion of self-regulation for responsible health professionals and therefore believe that the elected professional members of all councils should constitute the majority.

Speaking solely from my experience with the College of Physicians and Surgeons, I believe that increased lay membership is needed to:

(a) strengthen the public voice at council -- and again from my own experience I can tell you that it is very difficult to stand and speak out in opposition to a quite overwhelming majority of professional members;

(b) to spread the committee work demands over more people, thus lightening the load for each, although in the proposed committee memberships for the CPSO in particular, there is increased public representation required;

(c) to provide greater diversity in the public perspective that is being brought to any issue.

This last need is one that concerns me and one which I fear will not be fulfilled unless the intertwined issues of exorbitant time demands and inequitable compensation are addressed.

As an example, in the 1990-91 year, I personally devoted 92 days to CPSO work. In addition, my fiduciary responsibilities and liabilities as a director were equal in all respects to those of a professional member of council. My compensation, by way of a per diem, was less than one fifth of the per diem compensation paid to a professional member. My experience, I believe, was typical of the demands on all public members of the CPSO council. I have attached to my presentation notes of a couple of documents, one of which is my own letter of resignation which sets out in some detail the time demands in my experience and in the experience of one or two others, for your information.

Combining the substantial time demand with an inequitable compensation provision means that the pool of public members from which to draw will be restricted to those with considerable time available, such people as those who are retired or those who might be otherwise unemployed, as well as to those who are financially independent. While all of those views are important, I think the need for diverse perspectives representing the needs and concerns of us all will not be satisfied unless that situation is corrected.


I urge you to take the opportunity provided by this legislative reform to provide accordingly. The contributions of business and professional people will be lost otherwise.

My comments with respect to access will be limited to the profession of medicine and the provisions of the code and Bill 55. I agree wholeheartedly that the consuming public must be able to rely on the profession to ensure that practitioners are properly qualified and remain up to date. Accordingly, the college is mandated to develop, establish and maintain standards of qualifications and of continuing competence.

The college's registration committee is mandated to rule on any application not meeting prescribed criteria for qualification, that is, from those applicants whose education and training were not acquired through recognized Canadian or US academic and internship programs; for example, obtained in Japan or Germany or Australia.

I believe that much more needs to be done to investigate and assess training programs around the world, in order to facilitate the entry of foreign-trained physicians, in particular, to practise in Ontario and throughout Canada. To this end I believe that there should be a stronger public voice on the registration committee than is currently proposed, which is two of seven members.

In summary, the issues of time demands and inequity in compensation for public members must be addressed to ensure broad public representation. Second, I urge you to address the issue of opening access to careers in the health care professions, in particular medicine.

I wish to commend the minister and her predecessors for their foresight and tenacity in bringing forth health-care legislation that I believe is a model for other jurisdictions to emulate.

I thank you for hearing my views. I would be quite happy to respond to questions.

Mr Hope: I have one in particular, dealing with the public representation on this, and I am glad you brought it out because I think a lot of us felt that way when we sat on boards, agencies or commissions.

In your own personal view, you commented that you had a hard time communicating, in getting the point of view across, of the public. Would increasing the size from the existing one third, which is the amendment, to just under half be more adequate in serving the needs and making sure the communication level of the public is brought into the professional group?

Ms Campbell: In my view, yes. Take the circumstances of the College of Physicians and Surgeons, for example, which currently has a membership of 27, and that would likely change with the changes in the numbers of public members. There are currently six public members. You have to expect that there will be some diversity in the views and positions of the public members themselves. Hence, if all six members are in agreement on an issue, then probably six people acting together can help to convince 21 members, who are the rest of them, that this view ought to be respected. However, if only two or even one of those six holds a view strongly enough to pursue it, it is kind of difficult to get that through. I think increased numbers would add to the odds of there being more people of the public membership on side on a particular issue, and would add weight and support to communicating that concern to the rest of council.

Mr Hope: The issue you brought forward dealing with the per diem -- and quite honestly, volunteer work is, as you know, getting costly. You talk about the differential between the professionals and the public sector. Where does that differential start? Who enforces the law and who brings in the per diem aspect of it? Is it the council itself, or is it --

Ms Campbell: With the public members, the rates are determined by the government through the regulations, I believe. The professional members' rates are determined by the colleges themselves. The determinations and the sources of payment are two different places. None the less, where they meet, the responsibilities and demands are equal, and that gives rise to a problem.

If I may go a step further, I recognize that public representation role is a volunteer role essentially, and no one would be expecting to spend full time doing that. Therefore the issue of compensation is not substantial, provided that the time demand is constrained such that it is an appropriate percentage of one's normal time, and the kind of time that one could devote to volunteer activities.

The issue in this case is that the demands on the time, combined with the rate, make it very difficult. Nobody can devote 35% to 40% of their annual working time on a volunteer basis unless they are financially independent.

Mr Hope: Just to follow up on that point, I noticed you used 92 days of reference in a year's period. Say, for instance, there was a time period of allocated meetings scheduled, and if it went beyond that then you would be up for more per diems maybe, because you have been allocated a certain amount of time. You are saying that as issues arise in the public, or as issues arise in the council itself, it requires more meetings, so there should be a compensation. Say, for instance, there were fewer than 92 days; it was not a whole lot of financial hardship on yourself, it would not have been a problem. You probably would have stayed, but because it went beyond that point, it has now become harder for you financially.

Ms Campbell: That is exactly right, yes.

The Chair: Thank you very much for your presentation. We appreciate hearing from you. I know some of the members have signalled that they have questions. The amount of time for individuals was 10 minutes, and I am sure some of the members will want to have a chat with you following the meeting. The committee will reconvene at 2 pm.

The committee recessed at 1147.


The committee resumed at 1404.


The Vice-Chair: Order. Our first witness is from the Toronto Hospital speech and swallowing laboratory. Ruth Martin, come forward, please. Welcome to the committee, and you have 20 minutes for your presentation. I think it would be good to allow for some questions after your presentation, if that is your wish. Please proceed.

Dr R. Martin: I will not take the whole 20 minutes. I wish to thank the Chair and members of the committee for giving me the opportunity to address Bill 43 today. My name is Ruth Martin, and I am representing the Toronto Hospital speech and swallowing laboratory. This lab is operated by myself and Dr Scott Adams. Both of us hold PhDs; that is, doctoral degrees in speech pathology and speech science. Our group also includes three affiliate members, all faculty within the graduate department of speech pathology at the University of Toronto. These individuals also hold doctorates in speech pathology.

We work closely with a number of medical specialties, in particular, neurology, gastroenterology, and otolaryngology. Our mandate is threefold: We conduct research into the speech and swallowing disorders that often result from neurological damage, such as stroke and Parkinson's disease, we diagnose these speech and swallowing disorders, and we provide treatment to patients suffering from them. These three aspects of our work go hand in hand. That is, whenever we diagnose a patient's speech or swallowing function, we conduct a research study in parallel.

In our case, then, provision of health care goes beyond the traditional definition in that it includes both research and clinical practice. As such, Bill 43 could have far-reaching effects on both our direct patient care and our clinical research.

We wish to address the committee with regard to section 30 of Bill 43. This section of the legislation would restrict use of the title "doctor" to members of five colleges, the colleges of physicians and surgeons, dental surgeons, chiropractors, optometrists and psychologists. In effect, section 30 would prohibit individuals like ourselves, who hold earned doctorates in speech pathology, from using the title "doctor," and possibly the abbreviation "PhD," while providing health care in Ontario.

The members of our lab are very concerned with section 30 for the following reasons: First, after consulting with our national and provincial associations, we find no evidence that use of the title "doctor" by individuals holding PhDs in speech pathology has created confusion for patients in the past. In fact, we believe it is the patient's right to know the degree status of any individual providing health care.

In our case, a member of our lab, Dr Adams, by virtue of his PhD training, has specialized expertise in the speech disorders associated with Parkinson's disease. It was because of this training that the Toronto Hospital hired him to establish the lab. By using the title "doctor" and the abbreviation "PhD," the public is made aware that this individual has specialized skills gained through several years of advanced training. The title "doctor" allows the patient to identify Dr Adams as a speech pathologist with specialized training.

Second, we believe section 30 will result in a situation that is fundamentally unfair and inconsistent. For example, under section 30, psychologists who hold PhDs will be referred to as "doctor," while speech pathologists with equivalent degrees will be restricted from using the title. This inconsistency is confusing and lacks justification.

Throughout the world and across Canada, persons with the degree of doctor of philosophy are referred to as doctor and PhD, and have been for many years. These titles are not reserved for PhDs within specific disciplines. To allow some, but not all PhD holders to use the title "doctor" will only create confusion for patients and the public. Thus, we suggest that section 30 is not consistent with the intent of Bill 43, which is to protect the health care consumer.

Finally section 30 will make it more difficult for us to establish our credibility with other members of the health care system. This is very important, because the future development of our lab hinges on our having the strong endorsement of our hospital administration, and strong collaborative ties with other health care providers, particularly those in medicine, dentistry, psychology and biomedical engineering. It will be very difficult for our profession to establish its credibility if our right to use the title "doctor" is removed.

For these reasons, we urge the committee to consider the many ramifications of section 30, both on the patient and the health care provider. It is our hope that the legislation can be modified such that health care professionals who hold doctorates will retain the right to identify themselves using the title "doctor."


Ms Haeck: I had the opportunity to meet with someone at lunch regarding speech language pathology, and this issue was raised. I posed a question to that person, and I am also going to pose it to you at this time. The scenario this lady presented was that in her relations as part of the health care team and assessing someone who had a stroke, a neurologist would probably be involved, and she would be dealing with the manifestation, the speech problems as a result of that stroke. She felt her position would therefore be much more equal, because the neurologist would be referred to as Dr. So-and-so and she would be also referred to as Dr So-and-so by that patient, and therefore whatever her assessment or diagnosis of the patient and prescribed treatment would be dealt with in a very equitable manner.

My question to her then arose: What happens to all those people in this field who are part of the health care team in a hospital setting and who do not happen to have the doctor title, who are not PhDs? Do you feel that by virtue of not being a doctoral candidate they do not achieve the same credibility within the health care team?

Dr R. Martin: I think the two groups fulfil different roles. Any speech pathologist who has graduated from an accredited university program has fulfilled the requirements to practise speech pathology within the health care system. I practised speech pathology for several years with a master's degree before I went back and did my PhD.

A person who has gone back to school and done a PhD has spent four or five years training specifically to conduct research, and typically clinical research, then has specialized training in some field. In tertiary care facilities like the Toronto Hospital, it is very important that individuals with this specialized training are present so that if someone comes in, in our case, with Parkinson's disease and can benefit from the extended training of someone who has spent five years studying the speech manifestations of Parkinson's disease, then we can provide that service. There is a role in providing specialized service. There is a role for us in providing research skills that the person who has a master's degree in speech pathology may not have.

Ms Haeck: I have a master's degree myself, and if I went for the doctorate in library science, yes, I would definitely like to have the PhD after my name, but I am not sure that every day of the week I would like to be Dr Haeck. Somehow it has a different air to it. Christel works just fine most of the time. But I am concerned in light of the fact that there is a certain standard for entering the profession and that the professional standard for librarians and speech-language pathologists happens to be the master's degree. Are we setting up a criteria in this process that in fact is going to be exclusionary to the bulk of your membership?

Dr R. Martin: I do not think so for the reasons I mentioned a moment ago. I think there are different roles for both speech pathologists who have master's degrees and speech pathologists who have PhD training. The PhD is fundamentally a research degree. The reason it is important to have PhDs in the health care system today is that more and more the issue of quality assurance is coming up. It is not good enough to provide a health service, but it is necessary to determine if the service you are providing is making any difference. The only way to do that is to do some controlled research. With a PhD you have been trained to do that controlled research, and that is exactly what we do at the Toronto Hospital. We do it hand in hand with patient care. Whenever we diagnose a patient, that is diagnose the speech problem not his neurological problem, whenever we treat a patient, we do it within the context of a research study.

On the other hand, there is certainly room within the system, vast room and a need for speech pathologists to provide sound clinical service, diagnosis and treatment that is not necessarily within the scope of a full-scale research study of every patient.

Mr Beer: Thank you very much for your presentation. This question is one that has come up in our hearings this week on several occasions. One of the suggestions that may have been made by the review or by somebody, and I forget exactly but I think it may have been in the actual review, was that by way of regulation, for certain groups that are practising within a hospital and perhaps certain other institutions that could be defined, one way to deal with this specific problem would be that there would be a regulation that would say that where a speech pathologist is working in a hospital, for example, he or she may use the term "doctor" if in fact he or she has the doctorate.

Have you or your organization looked at some of that? I suppose one of the distinctions is that if you went out into private practice, you would not be covered. I am assuming that probably the largest number of speech pathologists are in hospitals or working in institutions.

Dr R. Martin: I believe the largest number of speech pathologists in Ontario are actually working within the schools.

Mr Beer: With school boards; sorry.

Dr R. Martin: A large number of speech pathologists work within the health care system and many speech pathologists do private practice. It seems to me that the argument we have made for the person with PhD training being referred to as doctor and PhD holds not only if you are in a hospital, but if you are doing private practice, because presumably you are providing the same quality of care. You still have the doctoral training once you leave the hospital, and you should be recognized as such.

It is equally important for the public to be able to identify who has doctoral training and who does not outside the hospital as within the hospital, and maybe even more important. There are many signals to patients within the hospital as to who is a speech pathologist and who is an MD. At the Toronto Hospital my name badge would say "Ruth Martin, PhD" and underneath it "Speech Scientist, Speech Pathologist." It would have my picture, and it is colour-coded. MDs have a green badge; I have a red badge; nurses have a different colour of badge. So there are many indications as to who I am and who I am not.

Mr Beer: You are colour-coded.

Dr R. Martin: We are colour-coded, exactly.

Mr Beer: At the present time you are identified by PhD.

Dr R. Martin: On my name badge.

Mr Beer: Right, and in effect your area of specialization.

Dr R. Martin: Yes, as are the MDs, for example.

Mr Beer: Right.

Dr R. Martin: They would say, "John Smith, MD, Gastroenterology."

Mr Beer: What you are saying is that there is protection there. If a member of the public comes up to you, he knows what it is you do.

Dr R. Martin: That is right. At the same time, presently another individual, for example, an MD, would introduce me, as they typically do: "This is Dr Martin. She is a speech pathologist. She is going to do this."

Mr J. Wilson: In the case of Dr Adams, the current practice is that he would call himself on his name tag if it was the policy of the hospital, for instance, "Dr Adams," leave the PhD off, "Speech Pathologist," or whatever the actual title is underneath. Is that allowed in the current legislation, do you know? Do you know what the legislative status is of titles right now?

Dr R. Martin: I do not know if it is allowed. I know it is not allowed at the Toronto Hospital.

Mr J. Wilson: We have had evidence before the committee that it is happening and it is my understanding, and I stand to be corrected by counsel, that it is currently within the Health Disciplines Act as really not permitted now either.

Dr R. Martin: I am not aware of the details of the present legislation. As I say, that is not the case at our hospital. I have spoken to people from various other hospitals in the city and I know the emphasis is always on making sure the patient knows who is who. For example, I spoke with people at Hugh MacMillan Rehabilitation Centre, and they have a similar name badge situation, the person's name, the degree status and specialty, not Dr So-and-so.

Mr J. Wilson: It is helpful the way the Toronto Hospital has it. That is the way I think the committee might consider standardizing for the rest of the province, because you do not use "Dr"; you are using the degree specification after the name, which I am sure is very helpful.

Dr R. Martin: That is, I guess, an issue somewhat separate from the issue of being able to identify yourself as "doctor."

Mr J. Wilson: In oral communication, for instance. Okay.


The Vice-Chair: I have Mr Owens next.

Mr Owens: Thank you, Mr Chair --

The Vice-Chair: Mr Owens has some more questions. Doctor.

Dr R. Martin: Oh, okay. I am sorry.

The Vice-Chair: You have about three minutes left for those who would like to ask questions.

Mr Owens: I am a friendly person.

Dr R. Martin: I am sorry.

Mr Owens: You must know that I used to work at the Toronto Hospital, so you are running. Anyway, my question is along the same lines we have already heard. Do you find there is much confusion from patients with respect to the doctor identity? Do you find yourself having to explain the difference?

Dr R. Martin: I do not find I have to explain the difference, I assume because by 1991 speech pathologists have been a part of the health care system for some time now and people usually understand, generally, what it is that a speech pathologist does. When someone comes into our lab, it is very obvious that we are dealing only with the speech system, from the equipment they see around them, from the procedures we carry out, from what we talk about. We talk only about speech and language and issues related to that. Quite honestly, it is not a problem for us.

Also, can I just add that when a patient is seen at the Toronto Hospital, for example a patient with Parkinson's disease, he is seen by many different subspecialties, let us say, or specialties. I think it is fairly clear to the patient that he is going from specialty to specialty, and that these are, to a certain extent, different and marked differently.

Mr Owens: In your opinion, then, consumer confusion would not be an issue if we agreed with your suggested amendment, and the amendment suggestions from other groups as well, that the title of "doctor" be more widely applied?

Dr R. Martin: In my experience, it has not been confusing in the past, and so I do not see why it would be confusing in the future.

Mr White: Does your regulatory body have standards in terms of the training for people who aspire to become speech pathologists?

Dr R. Martin: Yes. In order to be registered by the Ontario Association of Speech-Language Pathologists and Audiologists, one must have gone through certain training, but we do not have a college as of yet under this legislation.

Mr White: But you would anticipate having standards, in terms of what universities or faculties would be accredited to issue degrees in speech-language pathology.

Dr R. Martin: Yes, that is right.

Mr White: We have had the example before of, you know, Dr Cronkin Copps College of something or other, crobology or whatever, being able to issue degrees or whatever, but you would have standards in terms of accreditation.

Dr R. Martin: Definitely. At the present time, in order to become a registered member of the Ontario association, you have to have gone through a program in speech pathology at an accredited school, and have done a certain number of clinical hours in several different subspecialties like children's language, adult neurogenic communication disorders, stuttering, hearing impairment, oral rehab and so on.

Mr White: You would have the same in terms of the doctoral degree?

Dr R. Martin: That is right. In order to earn a doctoral degree, you have to meet the standards of an accredited university, and that is established and maintained within the university system. So it is the university that grants me the degree, or that does not.

The Vice-Chair: Thank you very much for your presentation.


The Vice-Chair: Moving right along, Dr James Main is next. Would you like to please come forward? It is Dr?

Dr Main: Yes.

The Vice-Chair: We have to keep our titles straight, especially in the context of the discussions around here. I think I should check my Bill 43 before we use that title. Welcome to the committee. You have a 10-minute presentation and you may wish to leave some time for questions. Please carry on.

Dr Main: I am here to speak on behalf of the faculty of dentistry of the University of Toronto. I am James Main, professor, and head of the department of oral pathology in the faculty of dentistry, professor of pathology in the faculty of medicine, and head of the dental department at Sunnybrook Health Science Centre.

The faculty wishes to comment on Bill 50, the act relating to denturists, and in particular to comment on the fact that this bill will permit denturists to make dentures for patients who have not been examined by a dentist. We believe this will result in cases of serious diseases of the mouth not being diagnosed until too late, with, in some cases anyway, serious health consequences for the patients.

When a patient is seen by a dentist, for any reason, the dentist will carry out a complete clinical examination of the mouth, jaws, jaw joints, salivary glands and face, and the dentist will take a medical history. He will then make a diagnoses, which is based on the findings of this examination, the medical history, and on the dentist's extensive knowledge of pathology, which is the science of diseases and disease processes.

There are very many diseases that can affect the mouth and the surrounding tissues, and to be able to diagnose these diseases requires a lot of study, a lot of reading and a great deal of clinical education. Dental students study pathology for three years, in the second, third and fourth years of the dental curriculum.

This provides them with a memory bank of knowledge of oral diseases, and also clinical experience in their diagnosis of these diseases, which is even more important in diagnosing early disease. This is the important time for diagnosis to be made from the point of view of the patient being able to be treated easily and effectively, and in terms of the serious diseases like cancer, curatively. In other words, with regard to the serious diseases, this is a matter of life or death. Cancer diagnosed early in the mouth, and treated at that time, is cured in the great majority of cases. Cancer diagnosed late is not cured. The patient dies.

Some of you may have seen the article in today's Globe and Mail, written by a patient who had a cancer of the bowl diagnosed by a physician at a routine checkup before he had any symptoms. This is a common situation also in the mouth, when cancers are diagnosed by dentists before the patients are aware they have them.

To illustrate this, I would like to show you four photographs. They are not gruesome, I hope, and are to illustrate the difficulty of early diagnoses of cancer and HIV infection.

This is the photograph of a patient's tongue with a huge cancer on it. Now this requires no diagnostic skill at all to recognize. Most lay people would recognize that as cancer, and to diagnose cancer at that stage is valueless. This patient is dead, as a result of that tumour. There is no virtue in it whatsoever.

This is also cancer, and that is just as deadly, but that is an early case. This is a lady in her mid-40s who has cancer in the middle of her upper lip. To most people, I am sure to the great majority of us, perhaps all, this would be looked on as a canker sore, or something relatively trivial, and not worth further investigation or even a great deal of thought.

This is cancer on the side of the tongue in a 26-year-old lady. Again, both this case and the previous case, were essentially asymptomatic. They had not troubled the patients in any way at all. They had not come to see their dentists about these lesions. They were picked up during routine examinations. In both these cases, the patients were referred to me at Sunnybrook to arrange for treatment.

The point I want to make is that unless you have a data bank in your brain of the diseases you are liable to see, you are not going to pay any attention to these. It is not only in regard to cancer that this argument applies. To illustrate another one, a gentleman who has the unequivocal signs of AIDS in his mouth was unaware of being HIV-infected, and he had no other symptoms whatsoever, but to trained persons who know what they are looking for, that is AIDS; it is not just an HIV infection. Once again, it was asymptomatic. It was not there because of this. To the great majority of people it would be passed over as a whitish tongue.

I could go on all afternoon showing you pictures of early disease of the mouth, all of which have been diagnosed, picked up by dentists and referred to me for further investigation or treatment, proving that they have been diagnosed and proving that they are in fact serious diseases, but I do not think there would be much point or perhaps even interest for you in such a thing.

As you know, denturists have no knowledge or training in pathology. Patients of the type I have shown would not be diagnosed by them and their diseases would progress unchecked. In some cases the delay would be fatal. The faculty has therefore asked me to express to you its opinion that the legislation should be amended so that before a denturist is allowed to construct dentures of any type, the patients should have been examined by a dentist. Thank you for your attention.


Mr Beer: Thank you very much, Dr Main. I do not dispute anything you have shown us, but as we are obviously a group of laypeople without the specialty, a question comes to my mind on the ability of the denturist to figure out what the problem was in those cases where the person is going to the denturist for a plate or a denture. Why should the denturist necessarily have to know that? It is not as though he or she is making that diagnosis. The denturist is dealing with a person who needs a denture. I am just trying to find a relationship between other things he or she may know or which it perhaps would be helpful to know but --

Dr Main: The point is that when a patient goes to have his mouth examined, that person should have it examined by people who can recognize disease; otherwise the diseases are not going to be recognized. Making dentures is something that is done to replace lost tissues and so on. It has no direct relationship with diagnosis of disease.

There are occasions when denturists see patients and make dentures for them because the patients have been complaining about the dentures, and the complaint is in fact due to a disease process. For instance, the only personal experience I have of a denturist making an error of this sort is when I had a patient a number of years ago who had dentures made by a denturist because the previous denture had been uncomfortable, and so he said, "We'll make you new ones." He had done this, and the new ones were uncomfortable. The patient then went to the family physician, who referred him to me. The problem in this case was not a malignancy but a cyst. There was a cyst under the denture. It was pressure from the cyst that was causing the denture to give rise to the symptoms, and making the new denture had not only not alleviated the symptoms, but had allowed the cyst to grow larger. A cyst is not a malignancy; it is not going to shorten the patient's life, but it is not a pleasant thing to have either and it could have been removed several months earlier when it was considerably smaller, had a proper diagnosis been made at that time.

Mr Beer: At the present time, not under this legislation but under what exists right now, a denturist can do a partial plate, a partial denture, is that right? But that has to be done at the direction of a dentist, or can that be done independently?

Dr Main: I am not terribly well informed on the legislation, to be honest, Mr Beer, but I know that under the new legislation they are not required to have the patients examined by anybody. They can just go ahead and treat them. We feel this government would be very ill advised to allow this to happen. They should be examined by somebody competent before dentures are made.


The Vice-Chair: We will move on to our next presenter, Robert Kroll, if you would like to come forward. Welcome to the committee. I remind you that you have 10 minutes.

Dr Kroll: I am going to bring you back to the PhD issue and in many ways my remarks echo those of Dr Martin's before me, so for those who still had some questions that were left unanswered, perhaps you could have a chance to talk about them now.

Thank you for allowing me this opportunity to discuss with you today my concerns about section 30 of Bill 43. By way of introduction, my name is Robert Kroll and I am head of the department of speech pathology at the Clarke Institute of Psychiatry, a position I have held for the past 17 years. I have a doctor of philosophy degree in speech pathology and have a cross-appointment to the University of Toronto.

When I first learned of this impending legislation through discussions with my colleagues and members of my professional association, I was very hard pressed to understand the reasoning and rationale behind it. I kept hearing that the purpose of the legislation, specifically the restriction on the use of the title "doctor," was meant to reduce confusion among the consumers of the health care system. To this day, I cannot comprehend how this would reduce confusion. As I understand it, the impending legislation would allow such professionals as physicians, psychologists, chiropractors, dentists and optometrists to use the title "doctor," while disallowing members of other clinical disciplines, such as speech-language pathology, pharmacy, nursing, audiology and so on to use similar titles. I feel this would result in legislated confusion rather than clarification of roles to the public. I also feel that the individual consumer's right to know the professional qualifications and degree status of the individual providing the service has been infringed upon if this legislation is approved.

The wording of this legislation implies to me that there are certain holders of doctorate degrees who appear to be more valuable or recognized than others. Is, for instance, a PhD in psychology more credible and more worthy of the title than a PhD in speech-language pathology? These are two clinical disciplines that have very similar academic tracks and holders of doctorate degrees within these two disciplines are constantly involved in independently assessing, diagnosing and prescribing methods of treatment for the various problems and disorders they see. Why does it seem fair or justified to allow the holder of a doctor of philosophy in psychology to call himself or herself "doctor," while disallowing the holder of a doctorate in speech-language pathology to call himself or herself by a similar title, when in fact training, education and clinical practice are very similar within these two disciplines?

I would like to describe for a moment my own workplace and the reason for my employer's decision to hire a PhD to lead the department of speech pathology. I work in concert with three other speech-language pathologists who hold masters' degrees. We provide specialized programming for people who have a variety of communication disorders and I guess we are noted for our treatment programs for children and adults who stutter.

I was hired specifically for my expertise in treatment outcome, research and in program development. Over the last 15 years we have been able to develop our programs, which we feel have ultimately been able to serve the needs of the community in a far more efficient way. I feel that this is in large part due to the decision made to hire a PhD to lead the department. From a consumer's point of view, the holder of this title also adds some credibility and comfort to the patients being served. The speech-language pathologists working in my department always have ready access to consult with me regarding difficult decisions around planning treatment programs for the various individuals they see.


Furthermore, the patients themselves will have access to the department head, who currently holds the title "doctor," reflecting several years of advanced study in a specialty area. I do not hold the view that suddenly disallowing this individual to use his earned degree title will in any way benefit the consumer of our services. In the 17 years I have worked at the Clarke, I have never encountered any difficulty regarding titles or perceived patient confusion about the qualifications of the individuals working in my department.

I would also like to add that this legislation, if it is passed, will in fact infringe upon the right of academic institutions to define their standards of education and to grant the right to individuals to use the titles of their degrees. The PhD is the highest level of academic training that one can obtain. This legislation in Ontario would certainly prove to be a major disincentive for individuals accepting employment here. This is an extremely unfortunate situation since, as many of you may know or probably know, there is a sad shortage of qualified speech-language pathologists and services available to people with communication problems.

When highly trained specialists in speech-language pathology and audiology learn of these restrictions, it is unlikely that many would want to accept positions in Ontario. These additional shortages would create serious problems for health care delivery in speech-language pathology. We would end up seeing a dearth of clinical research. No longer would we have individuals working on program evaluation and treatment outcome studies, and it is my contention that this service to the public would be seriously affected since our clinicians would no longer have access to the research findings of the specialty workers. This situation would surely run contrary to the emphasis that has been placed on hospital quality assurance programs.

The PhD is a degree that is noted internationally and throughout the world holders of this degree are allowed to use the title "doctor," or the abbreviation "PhD" behind their names. I would urge the members of this standing committee to consider seriously the effects this intended legislation would have on the consumer, as well as on the practitioners within the affected fields. Ontario, as I have always known it, has been a forward-looking and socially aware province. I feel, though, that this intended legislation is a step in the backward direction and I hope we can look upon section 30 of Bill 43 as something that needs further study and major revision.

I would like to close my comments by illustrating the rather ambiguous and confusing nature of the impending legislation. As I mentioned at the beginning, I teach students both at the university and in the clinical teaching facility in which I work. Would I now be advised to counsel these students to refrain from calling me Dr Kroll as soon as they enter the Clarke Institute? Personally I think it is foolish to spend one's time dealing with these matters. As far as I am concerned, the issue of title usage, as it is presented in section 30, does not reflect the intended spirit of protection of the consumer of health care services in Ontario. I would therefore recommend expansion of the use of the title "doctor" to those health care professions offering doctorate programs. Thank you for you time and consideration.

The Vice-Chair: Thank you. We have but two minutes remaining and I call on Mr Martin, who was first on the list.

Mr Martin: Thank you for your presentation. Certainly the issue you raise is becoming one of some contention re this legislation and one that I think we certainly need to explore a little bit further.

We are getting differing opinions, depending on who is speaking, re the issue. The bottom line for me is that first of all I am led to believe that some of the rationale behind what is being done here is to try to lessen the level of in many instances somebody presenting themselves as a doctor is raising the expectation of the consumer that they are in fact getting a level of service that is of a quality. In some instances, that level of service is not being delivered and so there is some protection factor there.

There is also the issue of confusing the public. I am of the opinion that the public sometimes are not given enough credit for figuring some of these things out by themselves. But the question I have -- and there are two parts to it -- is, will the dropping of the use of the term "doctor" for some of the groups here in fact lessen the type of service that will be delivered or can be delivered, and will the effort by the Ministry of Health to try to develop a team approach to delivery of services be positively or negatively affected by some people being doctors and others not?

Dr Kroll: Those of us who work here and continue to work here certainly abide by an ethical code and a standard of practice, and regardless of what the legislation ends up being, it certainly will not lessen any of the quality of service that we provide. Absolutely not.

But as I mentioned in my presentation, I think that the legislation may have far-reaching effects because it is so unique and so disheartening to up-and-coming researchers and specialists who may want to look to Ontario to continue or to develop their research and expertise. I think the effects would be long-term rather than immediate.

The Vice-Chair: I am sorry, we have run out of time. Thank you very much for your presentation.


The Vice-Chair: I would like to move on to our next presenter, David Scroggie. Please come forward and welcome to the committee. You have a total of 10 minutes. It is quite rushed, and if you would allow for some questions at the end of the presentation, if that is your wish.

Dr Scroggie: Thank you for allowing me to address you. I would like just to elaborate slightly on my qualifications. I graduated in medicine in 1964 and spent five years in general practice and then did my specialty training in psychiatry. Since then, for the past 15 years, I have worked half-time in a community mental health centre, first in the south Parkdale area and now up in the Lawrence-Dufferin area.

Since the blue book was published on the health review legislation, I have been involved with it concerning particularly the front-line workers and their ability to be able to continue their practice as I have seen them work, and I have great concerns that now under subsection 26(2) in the first controlled act that their ability to continue work without undue legal jeopardy would be quite compromised. So I would like to address that.

Diagnosis in physical medicine can be a well-defined and effective act, as it is based primarily on scientific evidence. It needs to be, as it is now, regulated in some way so as to protect the public from charlatans. However, diagnosis in the realm of mental health is a much less certain procedure. Medical practitioners have developed a diagnostic system but, as well, many professionals outside the physical medical field have developed a significant body of etiologic theory and effective practice. Both have contributed to and enhanced each other's knowledge, but many of the latter would be unregulated under the RHPA, and to protect their continued ability to practice without undue legal jeopardy, I strongly recommend that the following subsection, proposed by the Coalition of Unregulated Practitioners, be substituted for subsection 26(2):

Restrict unregulated and regulated in different ways: (1) retain the prohibition of practising medicine without a licence in relation to all the unregulated; (2) modify this prohibition in relation to the non-medical regulated professions by saying that it only applies if they perform a medically authorized controlled act for which they are not authorized; and (3) delete the first controlled act relying on the current prohibition of practising medicine without a licence in case of the unregulated, and introducing a new clause for all the regulated permitting them to communicate assessment within their scope of practice.

In addition, the advisory council should screen all prosecutions under the RHPA, except those initiated by a college in relation to its own members, setting aside those which do not pertain to the protection of the public.

To go on a little further and explain: In physical medicine, the scientific method has proven to be a potent tool in elucidating the nature of many diseases and allowing therefore for some powerful interventions producing cures or better control of the disease process. However, the proof of these methods has rested on demonstrated pathological changes in the normal basic cellular structure.

Unfortunately, for mental diseases, though researchers may be moving closer to this type of proof, with few exceptions this kind of hard scientific evidence is lacking. Consequently diagnosis is based on the clustering of similar observable signs and symptoms. The etiology or reasons for these remain in the realm of educated guesses or theories, of which many exist, and consequently so do proposed treatments.

However, there are physical medical conditions which do have psychic symptoms. The alert, honest non-medical practitioner must somehow be aware of these so the underlying medical condition can be properly attended to. Education, both for the practitioner and the client, is probably the best preventive. Unfortunately, these situations can slip by the awareness of even the best-trained medical personnel.

On the other hand, there are clearly mental health issues which are never going to have a demonstrated physical cause. Most marital/family conflicts do not. Sexual abuse, while it is a physical act, has devastating psychological effects but no physical brain pathology. Indeed, most of the experts in these two fields are not physicians but unregulated social workers and family therapists. Are they going to be prevented from naming the dysfunction or disorder which they perceive from their extensive training to be the cause of a family's stress, or a sexual abuse victim's emotional problems?

Certainly in the realm of mental health, psychiatrists and registered psychologists do not have the corner on the diagnostic truth market. All disciplines interpenetrate and enrich each other.

Briefly, I have tried to demonstrate the impossibility of keeping the diagnosis in the mental health field strictly a medical act and therefore controlled as it is presently proposed. I believe that the way through this dilemma and to protect adequately both the public and the unregulated practitioner is by adopting the solution as outlined in the above summary.


Mr White: I find the examples interesting. I have had a fairly extensive background myself as a family and child therapist, and in terms of the area of sexual abuse have worked extensively with adults who were molested as children, primarily women. It certainly has devastating psychological effects some of which have physiological ramifications, high levels of anxiety, depression, etc.

I think you are quite accurate on this point, but with this legislation, without being able to make that kind of assessment we would essentially be colluding with the continued suppression of that kind of abuse, at least within the clinical realm.

Dr Scroggie: That is a possibility, but it seems to me it does not make sense because -- I am not sure of your background -- my awareness is that most of the front-line workers dealing in that area say, "I am not a psychiatrist or a registered psychologist," so that if they could not make the assessment and give their opinion, then the health services would be overloaded. They are overloaded now and I do not know how the health system would continue to function, frankly, unless somehow you get around this dilemma of allowing assessments to be made by non-regulated professionals.

Mr White: Or professions which are presently non-regulated, such as family therapists and social workers that you specify.

Dr Scroggie: I think the whole system would -- I know the intent of the legislation is not that, but I think the effect would be and certainly people in the field feel it would be. This is my great concern.

Mr Beer: You have suggested that we look at what the Coalition of Unregulated Practitioners has put forward. I know we are going to hear from them and they have submitted some written material.

In terms of that in relation to the old harm clause, what is your sense of the way of dealing with the problem, which I think I understand as you set it out? Do you think there should be a harm clause as set out before? Is that another way of trying to deal with this same issue?

One of the issues that has been raised with us would be the third part on page 2, where it talks about permitting each profession to communicate assessments within its scope of practice, which is clearly one of the problems that people see. On the balance, can the problems that have been raised here be dealt with by some new harm clause, or do you feel it needs to be this specific with regard to the way it has been worded?

Dr Scroggie: It is a very difficult issue. My initial concern and involvement was over the harm clause, which I felt was even more draconian than perhaps this is. I think it would really even be a wetter blanket than this would be in terms of preventing people from engaging in legitimate practice.

Take your sexual abuse situation: As you get involved in dealing with these people, you take off a layer and another layer and it gets very concerning because more and more memories come up and you have no idea what might occur in terms of their feelings and reactions to those feelings. You certainly do not want to cause harm, but on the other hand, in dealing with them that might be a consequence of doing effective therapy -- not intentionally, but there is certainly a possibility. I think this kind of situation needs to be protected.

I know the original committee on this certainly was against continuing the clause about the practice of medicine. At least you are dealing with something that is fairly specific, and once you move off that you get into a very non-specific area. I guess my feeling was that by retaining that at least you would have something harder to deal with, and if further research develops harder criteria in the psychological area, then you can sort of add on when you know there are more clear facts and details involved.

The Chair: Thank you for your presentation.

Dr Scroggie: Thank you for the opportunity.


The Chair: Deanna Mulvihill. Welcome. You have 10 minutes for your presentation and we would ask, if you can, to leave some time at the end for questions from members of the committee.

Ms Mulvihill: I thank the Chairman and the members of the committee for hearing me. By way of introduction, my name is Deanna Mulvihill. I am speaking here as an individual nurse. I am presently employed as the director of nursing practice at the Hospital for Sick Children, and in that position I have a joint appointment at the University of Toronto.

In reviewing the act, I actually like many aspects and approve of many aspects in the act and welcome its introduction as a participatory collaborative practice to delivery of health care, but I did have some concerns and I have listed them for you.

Under clause 8(b) in relationship to the membership of the advisory council, you are exempting people who are or have been members of their council or college. Although I can see that there may be a conflict of interest if someone is presently a member of their own college. I come with 25 years' or more experience in the health care field, and if I had been a member of my college 10 years ago I could only see that would add to me as a member of the advisory council at some later date. So to me, that did not quite make sense.

The other issues I have heard already spoken about today, so I will not spend a length of time on them. The first one has to do with communicating to the individual his or her personal representative a conclusion identifying from disease. You have heard several presentations, but I would like to speak to the issue in relationship to nursing diagnosis.


Nursing, as many people are not aware, is a distinct discipline from medicine, and we have a distinct scope of practice in that nursing as a scope of practice helps individuals cope with their handling of the disease process. So many factors deal with the prevention, coping and lifestyle assessment.

I have attached the characteristics of nursing diagnosis and I have also attached some ways nurses have of classifying their diagnosis. So you can see that in no way would we want to be sharing the medical diagnosis with the person but looking at how this impacts on their lifestyle, their relationships and how they are coping with the disease.

In relationship to your comment, Mr Beer, to our last speaker, I think one of the things that would help nurses in using nursing diagnosis is that we could begin to do some research on which interventions helped. Nursing is a very soft science and we have not had a long history of doing research. We are struggling with trying to do that now, but when we get into not analysing or labelling our problems in a consistent fashion, that does not give us a good background of research in which we can move our profession forward. That was one area I wanted to address.

The next one is, of course, the title of "doctor," and I really will not belabour that point because I have heard a number of speakers there. I really feel that perhaps the intent was to help the public with confusion. I am presenting myself as a nurse. In no way does restricting the title of "doctor" to certain people eliminate the confusion between who is a doctor and who is a physician, and there is no way, if I would present myself as a doctor, I would want to be presenting myself as a physician.

Schedule 2, which is my next point on the paper, is that there is information that you are saying the college or the councils would give out on people. There have been problems in the past where the college -- and presently the college does give out nurses' home addresses and telephone numbers. This, particularly for some nurses who work in high-risk areas, has presented them and put them many times in a personal risk situation. There is no way anyone other than I should be giving out my home telephone and address, and there have been many risk issues.

Section 85, under schedule 2, is the limitation period of one year. I do not feel this is appropriate in many cases, and the college needs to be aware of all areas of negligence and malpractice and not restrict it to one year. Each case then has to be validated or assessed on its individual basis; what relevance it has to the practice of the practitioner at that point in time.

My last note has to do with procedures and methods regarding the investigation, hearing and evaluation of sexual abuse and sexual impropriety and the need to have their own unique process, separate and different from other malpractice things. I have made some suggestions: that there be a period of preliminary investigation prior to the notification of the physician; seizure of appropriate medical records at the same moment of physician identification; that the physician be allowed to retain a copy in order to prepare his or her defence; that there be early notification and involvement of the police in a joint investigation; the removal of the physician from patient care during the investigation procedure; protection of the identity of the patients by closed-court system and media blackout; and that the time period from the initial complaint to the discipline hearing not exceed six months.

I also suggest the Limitations Act be amended immediately, in keeping with the March 1991 report of the Limitations Act consulting group, so that there be no limitation period whatsoever on sexual assault occurring in or as a result of a relationship of authority, trust or dependency, and that the offence of aggravated sexual assault in the Criminal Code be amended to include "by a person in a position of trust or authority."

Mr Owens: Ms Mulvihill, that was an excellent presentation and I think you will find sympathy among the committee members for the issues you raise, especially the last issue with respect to sexual abuse. The issues you have raised notwithstanding, do you find this piece of legislation will follow the intent of the government, which is clearly to provide consumers with a wider choice of health care services, but also adding that extra level of protection consumers need and want?

Ms Mulvihill: Yes, I do. Not only does it offer many things for the consumer, but it also offers a more collaborative practice for the variety of disciplines and I welcome the recognition of those other disciplines into a joint presentation. I think it paves the pathway for eventually a more collaborative health care service than I feel we have been in, which is a more heavily medical service and illness-oriented service.

The Chair: Thank you very much for your presentation.


The Chair: Mary Anne Witzel, welcome to the standing committee on social development. You have 10 minutes for your presentation and we would like to leave some time for questions.

Dr Witzel: Thank you, Madam Chair and members of the standing committee on social development, for giving me the opportunity to speak to you. I am the director of the department of Speech-Language Pathology at the Hospital for Sick Children and hold appointments in the faculty of medicine, faculty of dentistry and school of graduate studies at the University of Toronto. I have a PhD in speech pathology and I specialize in assessment, diagnosis and treatment of patients with cleft palate and facial deformity. I am here today as a member of the Alliance for Equal Entitlement in Health Care and also as a member of the Ontario Association of Speech-Language Pathologists and Audiologists to again voice concerns about section 30 of Bill 43.

Section 30 restricts the use of the title "doctor," a variation or abbreviation, which to me means the letters PhD, or an equivalent in another language, in the course of providing or offering to provide in Ontario health care to individuals to members of the colleges of chiropractors, optometrists, physicians and surgeons, psychologists and dental surgeons.

Ladies and gentlemen, we are proposing that you support and recommend changes to section 30 that would continue to allow health care professionals such as speech-language pathologists trained at the doctorate level to use the title "doctor." As it currently stands, section 30 is unfair and unjust to both the public and health care professionals for the following reasons: It legislates confusion for the public; it removes the public's right to know the qualifications of some health care professionals; it legislates and reinforces gender biases in the health care system; it is a disincentive to excellence in health care in Ontario.

With regard to my first point, it legislates confusion for patients and the public. Ms Lindberg, assistant deputy minister, consumer health and planning, stated in a letter to my MPP, Mr Marchese, July 15 that the "purpose of the proposed restrictions is solely to assist consumers to distinguish among health providers." But how is the public to know which professional with a PhD they may call doctor and which ones they may not?

Picture this common scenario at the Hospital for Sick Children: A PhD psychologist and a PhD speech-language pathologist working in a teaching hospital are meeting jointly with the parents of a child with psychological and speech and language problems to discuss test findings and treatment. In attendance, because it is a teaching hospital, is a student in speech-language pathology and a medical resident from the University of Toronto. The student and medical resident would address both professionals with the title "doctor," because they are not giving them health care, yet the parents would have to be instructed that they can only use the title "doctor" when addressing the psychologist, but not the speech pathologist. Would it not be natural for the parent to react with confusion, to have more trust and credence in the psychologist's opinions? Would the student and medical resident not also experience confusion? One minute the speech-language pathologist is a doctor and the next minute she is not.


2. It removes the public's right to know the qualifications of all of their health care providers. Patients have this right. I want it as a patient. It enables them to make more informed decisions about their own health care. The patient's right to know is supported in the codes of ethics of the Ontario and Canadian associations of speech-language pathology and audiology, which state that "members must not misrepresent their training or competence" to the public. If we are unable to use the title "doctor," a variation or abbreviation, how are we truthfully to represent our training and competence to the public? Are we to remove our diplomas from the walls of our offices? Are we to drop our PhD credentials from our name badges, from our letterhead? Speech-language pathologists and audiologists who have sought training at the doctorate level often provide health care in a very specialized area; for example, Dr Kroll in stuttering and Dr Martin in swallowing problems and myself in cleft palate and craniofacial deformities. These are difficult and complex disorders and to our patients the PhD and its title "doctor" is often a further assurance of quality of care.

3. It legislates and reinforces gender biases in the health care system. Frances Lankin, Minister of Health, in her opening statement on August 6 regarding the Regulated Health Professions Act stated, "This legislation brings women closer to achieving equality in a health care system that has been dominated by men." However, with the exception of psychology, whose membership is approximately 50% female, the professions which will be allowed to use the title "doctor" under section 30 are male-dominated professions. Those that will be precluded, such as speech-language pathology, audiology, nursing, physiotherapy, are female-dominated professions.

Unchanged, section 30 will result in a further entrenchment of the gender biases which presently exist in the health care system. This differential treatment of female- and male-dominated health professions calls to question the most basic tenets of equality and sends a clear message that the government of Ontario does not really support equality in the health care system, but rather gender bias. Therefore I submit to you that section 30 does not bring women closer to achieving equality in the health care system; rather, it moves them farther away.

Section 39 of the act states that, "Subject to the approval of the Lieutenant Governor in Council, the minister may make regulations allowing the use of the title `doctor.'" But why, ladies and gentlemen, must we with doctorates in the female-dominated health professions be required to apply for use of our rightful title through the back door?

It is a disincentive to excellence and leadership in health care in Ontario. Unchanged, section 30 will cause Ontario to be the only province in Canada, the only place in the world, where an individual with a PhD in health professions other than psychology cannot rightfully use the title "doctor" in providing health care. This legislation will discourage the health care professionals of tomorrow from seeking advanced training in professions such as speech-language pathology and audiology. It will discourage these individuals from providing health care in Ontario, from offering specialty knowledge in the more complex areas of communication and hearing problems to the people of Ontario and from providing leadership, teaching and research in the profession.

Ontario has a right to be proud of the contribution its PhD members of the professions of speech-language pathology and audiology have made to the diagnosis and treatment of communication and hearing problems. Many have brought international recognition to this province in the practice of speech-language pathology and audiology. The province should be supportive of these individuals and not treat them as second-class health care professionals.

In closing, I urge you on behalf of my PhD colleagues to amend section 30, for it does not assist consumers to distinguish among health providers, but rather, it legislates confusion for the public. It removes the public's right to know the qualifications of all of their health care providers. It legislates and reinforces gender biases between health care providers and discourages excellence in the health care system of Ontario. We ask that section 30 be amended to expand the use of the title "doctor" to those health care professions offering doctoral programs. Thank you.

The Chair: Thank you very much for your presentation.

Mr J. Wilson: Can we ask a question?

The Chair: We have used all the time.


The Chair: We are now going to hear from Mr Victor R. Willi, who is representing the Centre for Independent Living in Toronto Inc. Welcome, Mr Willi. You have 20 minutes for your presentation, and I would alert members to the fact that you also have a video which is available from the clerk's office if any member wishes to view it. We would ask that you leave some time so that members can ask questions at the end of your presentation, but it is your decision as to whether you wish to do that.

Mr Willi: My purpose in appearing before this committee is to explain why the inclusion of attendant services in Bill 43 will destroy 30 years of struggle by people with disabilities for the right to live in the community.

I speak to you today as a member of the independent living movement, which is really part of a social movement spreading across the world. It consists of people with disabilities taking responsibility for their own lives. We have been called the last civil rights movement. Years after black people have forgotten what it was like to ride at the back of the bus, we are fighting to get on the bus; and while the women's movement pushes for equal representation in the boardrooms, we struggle to find work.

Although there is archaeological evidence indicating that people with disabilities were fully integrated in prehistoric times, throughout most of recorded history we were institutionalized and taken care of by others. The two most popular methods of service delivery to us in the western world today are still based on either the welfare or the medical model of disability. In the former, others decide who deserves the service; in the latter, others decide what is best for the individual.

Both these methods have their place, but people striving to live independently in the community are neither in need of charity nor sick. They require individual responsibility for directing their own services and their own lives. That includes having the dignity of risk taken for granted by the rest of society.

It was out of this need that -- and I am giving you a little background to show you why the inclusion of attendant services in that bill is of critical importance to us -- in the early 1960s, people with disabilities first formulated the principles of independent living in general, and attendant services in particular. These have worked so well for us that they are almost sacred. After hundreds of years of well-intentioned institutionalization and segregation, we have found something that works for us. I will attempt to explain why.

Attendant services are almost universally misunderstood. My own family has a very hard time understanding that I am not taken care of. Even the term "attendant care" is a misnomer. The attendant's job is not to care. The responsibility for directing and training attendants rests squarely with the consumer of the service. The locus of control is with the consumer. This is a unique relationship. I do not think anything exactly like it exists anywhere, and that is why it is difficult for the average lay person to be familiar with it. But it is critical to understand that it is a real alternative to the dependency-inducing medical and professional models where experts take all the responsibility.

The consumer -- myself -- is the expert because all of us are experts in our own needs and wants. I am not talking about fancy lifestyles here. This is about how and when people go to the washroom. It is about how something like what you are wearing today is important for you, and why it was important you chose that particular tie or skirt or whatever. It is how people look after their most basic routines, which can include eating, cleaning your own ears, and for women, inserting a tampon.

The controlled acts set out in section 26 would medicalize, and in some cases, make illegal, what most of us consider a normal daily routine. So what, if we really have to ask others to assist us in the community and to help us with our daily routine? Is that not what society is all about? People helping other people so that we can contribute to society?

Yet section 26 -- and I am speaking for people with disabilities who use attendant services -- would make most of our daily ways of coping with disability an illegal, dangerous, or at best, a controlled act.


What I am trying to say here is that people with disabilities themselves have come up with what is really a low-tech solution to an incredible institution, in other words, the health services system. I must tell you, this is a grass-roots sort of thing. Many of the arguments that are used against giving people with disabilities a chance to control their own services, to run their own lives, protecting us from risk and making decisions, are the very same arguments that were used earlier against minorities and, not too long ago, against women, in not allowing them access to the levers of control and decision-making in society. It is not that long ago that women were not allowed to vote and do many things.

We draw very much from the civil rights movement. There are many parallels. That is why I am trying to familiarize you with it in a way that you can understand.

The offer of a special regulation is well-intentioned but potentially harmful and somewhat patronizing. It is mistakingly aimed at the attendant, completely ignoring the responsibility and control of the consumer. Also, a future minister could do away with it at the stroke of a pen.

This is a matter where the public interest is at stake. I am sure the intention in writing this act was to do no harm; in fact, it was to remove harm from receivers of health care. But this very fact is what could happen if attendant services are allowed to remain in this act.

At this moment there are about 2,000 people with disabilities in Ontario directing some 3,000 attendants. I have lived independently for the past 16 years using attendant services and I have lived with a disability for 25 years. I work full-time and I pay an obscene amount of taxes, but I am proud to be able to this.

The attendant services I receive are, I feel, among the best in the western world. The cost per diem is extremely low considering we are talking in Ontario right now about daily services to a population bigger than the entire patient population of Toronto General Hospital; and I am sure many of you here are familiar with the annual budget of Toronto General Hospital. At the very most, we are talking about a cost per diem per individual which is less than 10% of the cost of someone being in the hospital.

It also appears that there will be a dramatic increase in the number of people living in the community in need of these daily support services. I am alluding to the policy statements of this government and the previous two governments regarding the idea of helping people get out in the community, get out of institutions, and become useful contributing citizens.

There really is and has been and continues to be an irrational resistance to the understanding of this concept and the embracing of it as it should be. I do not understand why. We feel, after trying to sell this concept to the government and to social services for the past 15 years, a tremendous resistance, especially on the part of the health professions. Now, I do not know if this is a turf struggle, or is perceived as a turf struggle or as a threat to control, but somehow this act has cast a huge net over all of us with disabilities, when we have just had our first 15 years of progress.

The first sort of niche we made was in 1975 when we convinced the Ministry of Consumer and Social Services to fund a project, as I understand it, that people themselves had set up and were supporting with their WCB cheques or UIC cheques and their FBA disability benefits. It is still running to this day.

Before this legislation proceeds any further, I request you to help us correct a serious mistake in an otherwise laudable piece of legislation. Make an exception for attendant services in the act itself and recognize it as a unique and empowering option of service delivery for people who can direct their own services.

We propose an exception under clause 28(e) reading something like "working as an attendant providing physical assistance to a person with a physical disability, under the direction of such person and the act is a controlled act set out in paragraph 5 or 6 of subsection 26(2)."

Tomorrow my colleagues and I will be meeting with the Ontario Medical Association and quite possibly the Ontario Nurses' Association and their lawyers to try to work out the precise wording acceptable to both of us -- the consumer and professional groups -- for insertion into the act. This will be presented to you on August 28 by Ian Parker of the Attendant Care Action Coalition, better known as ACAC.

I have included background information in the form of a paper and a video on attendant services. The video is really an updated version of one that was aired last year following a conference we had on attendant services. At one part in the video one of the honourable members of the committee is featured. If you choose to look at the video, there are some blank spots which will be filled in by commercials prior to its airing on CBC. It is an updated version of how we are doing in this fight.

In the coming weeks you will be hearing from other people with disabilities regarding Bill 43. You may be surprised at the depth of feeling and anger occasionally displayed, but I want you to consider this: After 20 years of explaining ourselves, explaining why it is important we live in the community, why we should use public transit or enter public buildings, explaining why we want to have children, get married, we find ourselves at this juncture in 1991 explaining why it is important that we control how and why and when we go to the washroom.

I urge this committee to give us serious consideration and I thank each one of you for hearing me out. I would be glad to answer any questions you may have.

Mr Hope: It is good to see you again, Victor. I know you are concentrating on certain sections but, dealing with the disabled community in finding adequate service providers or finding service treatment, as we start to identify the criteria of certain legislative body groups, that service may not be so difficult because you talked about how you have moved yourself up, and you have probably met some people who were providing non-adequate service. Did you find that the legislation has, outside of the issue you are talking about -- which means it would be looked into more deeply -- outside of that issue, would it not be easier and maybe better for the disabled community in identifying --

Mr Willi: What I am trying to say is that this attendant service is completely outside the sphere of medical health services per se, although it usually ends up in a ministry that deals with these other issues. Including the attendant services in there would drive it back into that again. We are completely outside that.

People receiving attendant care train their own attendants. You cannot get an attendant. When attendants from agencies occasionally have to be called if the regular attendant does not show up, people just simply do not go to bed until they leave. You develop a very personal, unique relationship with the attendant and there is a sort of interplay back and forth. The person with the disability trains the individual in the routine and then directs what is needed at a particular time.

We access the health care system as much as or maybe more than anybody else. These people are outside that and we would like to be exempted in the same way. These are our homes, these are things that happen in our homes. Just as the care givers in the home were exempted, we would like that same sort of exemption.

Mr Hope: What you are saying is that the Victorian Order of Nurses who supply home services may be going that same route, looking for exemption because they provide care in a home setting?

Mr Willi: Well, VON helps sick people. They give needles to people who are diabetic and who cannot give their own needles, they do medical procedures. We are not dealing with medical procedures. Going to the washroom is not a medical procedure. I have been doing that for 25 years with the help of other people with no problems whatsoever. I think there is the implication that some of these acts are dangerous.

I should make it clear that I am talking about people who have the ability to direct their own services. The onus is always on you when you are disabled to prove you are not incompetent, and it is the other way around if you are not. That just goes with the territory. That is something else we have to fight.

We see the implication in here, that when disabled people, regardless of their cognitive level, direct their own services and direct people to do this, somehow you say, "It'll be a little dangerous, you know." I hope I am answering your question.

Mr Hope: Oh, you are.


Mr Beer: Nice to see you again as well.

Mr Willi: Good to be here.

Mr Beer: In the description of the prohibitions under 26, they talk about, "No person shall perform a controlled act set out in subsection (2) in the course of providing health care services." I agree completely with the premise that in terms of you dealing with the individual who is attending you, that direction comes from you and you set it out. I think most of us would say those are what I would describe as daily sorts of services or functions.

I am really interested in the fact you are sitting down with the OMA, and I think the committee would be very much interested in the sorts of things you come up with there. But is there a way, and I guess I throw this out as a possible suggestion as you are meeting with people from the OMA, of defining the attendant care services or the meaning here of health care services so that, clearly, what is being done under the attendant care program, however you want to describe it, is not health care? Or is your feeling that, because we are getting more and more sophisticated with providing those services, while perhaps 90% of them could not in any way be described as health care, eventually indeed some things may be able to be done, just because of the advance of technology or whatever, or when we get into things like perhaps certain kinds of drugs that may be being provided to that individual.

I guess it is just where a blanket dispensation, saying anyone who is doing attendant care, needs some kind of definition, because I think, as Randy Hope was saying, if we do it here, then do you start people saying: "Well, look, we're not all that much different either. We should be exempted." I think we can see the need here for a different arrangement, so I am interested in how you would see defining that in a way that would make sense and still provide protection to, say, an individual person who might be misused by an attendant.

Mr Willi: I do not know if it will ever happen, but we would like to see recognition of the concept of self-directed attendant services in the act. This has never occurred before. What may happen in a hospital may rightly be called health services, but you or anyone else cleaning their ears at home are not performing a health service on yourself, for heaven's sake. On one hand, we do not like to quibble over definitions. This is an act to regulate medical professions, and they want to call these things health services? Fine, they should regulate health services. But where we do it and how we do it is a critical difference. When we do it that way, it is not health services. That is our feeling. There is a very fine but extremely important line there.

Think of the attendant as the arms and legs of the individual. That is what an attendant is. This is not a demeaning relationship, either. Attendants are not ordered around by people. This is a very subtle, Zen-like interplay between two individuals who come to know each other and depend on each other and together this really nice thing happens. So it is very difficult to articulate it. It is even more difficult to get people away from the idea that people with disabilities universally need taking care of, protection from themselves. It is very difficult to allow the average person to think of disabled people as having and wanting and critically needing the ability to take risks and fall flat on their face.

Mr Beer: In effect, the protection would be the same as for anybody else in society, and the attendant is just seen as, in effect, an extension of yourself.

Mr Willi: That is exactly right.

Mr Beer: I think we will be really interested in looking at what you come up with, because I think the important thing here is that you are actually saying, "You might word it this way," or "Here is a proposal," because that is where it gets at times more difficult.

The Chair: You have one minute for a comment, but no questions, Mr Wilson.

Mr J. Wilson: It seems to always happen. Thank you very much for joining us. I do appreciate it. I must admit that yesterday we had a disabled person appear before us. I did not quite understand, and I think you have done a good job of articulating what you mean by self-directed attendant care. I now see that the Ministry of Health's exemptions in here where it talks about treating a person can be very offensive.

Just for your information, we have asked towards the end of these hearings to have Community and Social Services people come in, because the remedy you seek may not be in this act. It may not be within the purview of the Ministry of Health. It may be that we have to have a discussion with Community and Social Services about the type of language in their acts dealing with attendant care.

I think you have outlined the difference between the type of treatment in the home that is daily routine treatment and the medical intervention treatment that this act is trying to deal with, but rest assured we are going to keep struggling with it. Towards the end, we will be talking to Community and Social Services and see if we cannot get the language of the different acts so that you could be more comfortable with it.

Having said that, though, I would be very interested, as Mr Beer has pointed out, in seeing what your possible amendment to this section, maybe a 28(e), would be. It may be that its legal bearing is not terribly significant, but its comfort level is.

The Chair: Thank you very much for your presentation. We appreciate it. The video is here. Members of the committee will avail themselves of the opportunity to view it and I know that there will be considerable discussion on this issue over the course of the hearings.

Mr Willi: You will be the first in Ontario to see it.



The Chair: Mr Jaan Pill, co-ordinator of the Stuttering Association of Toronto. Welcome, Mr Pill. You have 20 minutes for your presentation.

Mr Pill: I want to thank you for the opportunity to speak with you today. My name is Jaan Pill. I will be discussing Bill 43 as it affects speech-language pathologists.

I will begin by saying a few words about myself. I am the co-ordinator of the Stuttering Association of Toronto, which is a support group for people who stutter. I am also one of the organizers of the first-ever Canadian conference of self-help groups for people who stutter, which will be held August 22-25, 1991, in Banff, Alberta. These kinds of groups offer emotional support and help people maintain their fluency after treatment for stuttering. One of the outcomes of the Banff conference will be the creation of a Canada-wide network of self-help groups for people who stutter.

As well, I am a member of the support groups/consumer affairs committee of the International Fluency Association, a new, non-profit, international, interdisciplinary organization dedicated to international contacts among speech pathologists, researchers and support groups involved with fluency disorders.

My remarks will focus on the role of speech-language pathologists within the proposed legislation. I will begin by saying a few words about the area I am most familiar with, and that is stuttering.

I will begin by defining stuttering. Stuttering is a communication disorder in which speech is disrupted by involuntary repetitions, prolongations and blockages of syllables and words. It is usually accompanied by tension and struggle behaviours, such as facial grimacing. The person may feel frustrated and anxious when trying to talk and may attempt to avoid certain words and speaking opportunities.

Research indicates that stuttering is not a psychological or emotional disorder, but is instead associated with anomalies in neuropsychological functioning. There is no cure for stuttering, but treatment methods that are now available enable up to 80% of people who stutter to maintain control over stuttering and thus communicate effectively.

With reference to treatments, extensive research has also been conducted on the effectiveness of treatments for stuttering. Psychotherapy has not been found to be effective as a treatment for stuttering. However, behaviourally oriented treatment methods have enabled many people who stutter to achieve and maintain a marked increase in their level of fluency.

About 125,000 adult Canadians, 0.5% of the adult population, stutter. In Ontario we have an estimated 49,000 people who stutter. Also, up to 5% of very young children stutter during the time they are acquiring language. Up to 80% of these children subsequently acquire fluent speech during the normal course of maturation. The remaining children in this group require specialized assistance from speech pathologists who specialize in stuttering treatment. Among this group of children, the earlier the condition is accurately diagnosed and treated, the better.

I myself have been the beneficiary of two treatment programs for stuttering, conducted by PhDs in speech-language pathology. I undertook treatment in an intensive three-week program in Toronto in 1976 with Robert Kroll, who has a PhD in speech-language pathology. The program was called the precision fluency shaping program, developed by Dr Ronald Webster, a psychologist in Virginia. Dr Kroll introduced this program to Canada in 1974. Second, in 1987 I attended a program with Dr Einer Boberg at the Institute for Stuttering Treatment and Research in Edmonton.

Canada is recognized as a world leader in stuttering treatment and research. In this context, Einer Boberg, a treatment specialist at the University of Alberta, was recently elected head of a new organization, the International Fluency Association. William Webster, at Brock University in St Catharines and earlier at Carleton University in Ottawa, is a researcher specializing in the neuropsychology of stuttering whose work is widely cited in the international scientific literature on fluency disorders.

To turn to Bill 43, in most ways I find this is a good bill. It will define who does what in delivery of health services in Ontario.

However, the proposed bill does indicate that a person who has a PhD in speech pathology cannot use the title "doctor." That title has been reserved for medical doctors, optometrists, dentists, chiropractors and psychologists. The rationale for this decision is that it will reduce confusion to the public. I submit it will instead add to the confusion and is likely to detract in the long run from effective delivery of treatment to people in Ontario who stutter.

In North America, advances in treatment and research have been made by professionals in a wide range of fields. Some MDs in the United States have made stuttering their specialty. There are also neuropsychologists who have devoted a significant part of their research to the topic of stuttering. One of the standard references in North America concerned with the maintenance of fluency skills after treatment for stuttering is written by two specialists living in Ontario, namely, Marie Poulos, a speech-language pathologist at the Ottawa Rehabilitation Centre, and a psychologist, William Webster, whom I referred to earlier. Also, one of the standard references for Canadian physicians seeking current information about stuttering in children is a recent article by William Webster and Einer Boberg, and I have the references at the end of this material.

I also wish to refer to diagnosis, which in Bill 43 refers to the "communication to a patient or his or her representative of a conclusion as to the cause or identification of a disease or dysfunction."

Physicians are not typically experts in the diagnosis of stuttering. The literature available to physicians is sometimes out of date. For example, there are still references in standard medical tests as recent as 1988 which describe stuttering as primarily a stress disorder. That kind of perception of stuttering in scientific literature was popular around 1950, 1960. Members of self-help groups have offered anecdotal reports of physicians attempting to treat stuttering by prescribing tranquillizers.

As well, it takes expertise -- expertise of the kind available to speech-language pathologists who specialize in the treatment of stuttering -- to distinguish between those children who stutter and who will recover spontaneously as they mature, and those children who are not likely to recover without treatment by speech pathologists. If the parents of a child in the latter category are told by a physician that the child will grow out of it, that child loses the opportunity for timely treatment.

Earlier discussions about the bill have noted that a number of participants in previous reviews have submitted that members of other professions with doctorates should be permitted to use the title "doctor" and that it was insulting to suggest they would mislead consumers about their profession or be permitted to do so by their college. Against these submissions, according to earlier documents, "The review has balanced the consumer's right not to be confused or misled, especially when seeking primary health care."

Is there strong evidence that a person with a medical problem, let's say a severe abdominal pain, would walk into the office of a PhD in speech pathology and mistake that person for a medical doctor?

I also note that the restriction on the use of the title "doctor" may also have long-term consequences on salary levels among PhDs in speech-language pathology in Ontario. The quality of service delivery and the quality of research in a rapidly developing field such as stuttering treatment and research are likely to be affected negatively. In economic terms, when you enable a person to gain control over stuttering, you enhance his ability to communicate effectively and you enhance his ability to secure employment that matches his capabilities.

Ontario has the opportunity to continue to play a leading role in stuttering treatment and research. However, Bill 43, as it stands, is apt to discourage young PhDs specializing in speech-language pathology. They are likely to go to more hospitable climates, such as Alberta's Institute for Stuttering Treatment and Research.

In conclusion, as one spokesperson for people in Ontario who stutter, I want to emphasize that the needs of people who stutter would be better served if PhDs in speech pathology in Ontario were able to continue to use the term "doctor" in the same way as psychologists and if they were permitted to diagnose speech disorders that come under their area of expertise.

Mr J. Wilson: Thank you for your presentation. Just on the title "doctor" again, I think the government's intent in bringing forward this legislation, particularly that section which deals with the title protection of "doctor," was not to open a can of worms.

I have a brother, for instance, who has a PhD in zoology and teaches at the med school at the University of Western Ontario. Under the current act, he is allowed to put "PhD" behind his name but he is not to be using "doctor" under the Health Disciplines Act now. It is already restricted to certain -- well, this act is expanding it to chiropractors and psychologists.

I do not know what group of politicians started on this slippery slope, but clearly, in my opinion, I agree with you that it is a political decision. We are now going to chiropractors, giving a prestigious title of "doctor." It has been given in the past -- I do not know what remedy we can come up with -- to essentially people with undergraduate degrees. Society has placed a high regard on the term, when in academia a doctorate of philosophy is the highest degree possible.

I am not sure what we are going to do. If we continue the slippery slope of adding everyone else to the list of people who can use "doctor," I do not think we are serving any useful purpose there, widening the system further. If we stick to what the intent of the bill is now, which is to let people continue to use PhD behind their names, there is no prohibition on the use of "PhD" in this bill.

Mr Pill: There is a very clear indication that, for example, a PhD in psychology can call himself or herself "doctor." I see no rational reason, no reason I can think of in the world, in terms of people who are doing research in the field, why, let's say, a PhD in neuropsychology or a PhD in speech-language pathology cannot call himself or herself a doctor.

Mr J. Wilson: I agree, so I guess my question is, given that under the current legislation in Ontario three different groups -- optometrists, MDs and dental surgeons -- have the ability, and given that I think we are going to have a difficult time as a committee deciding where we should be granting the ability in the future and where that list should stop, do you perhaps think maybe we should not do what this act proposes, which is just to extend it to chiropractors and psychologists, but stop whatever has been done in the past and not proceed with it, take it out of this bill, for instance, and just let things stand as they are? If you are using "doctor" in practice, that is fine. The only onus now is if the medical profession decided to sue you -- and the fact is that I do not think there have been any law cases. My brother is not going to get sued because at the university he is known as Dr Wilson, even though technically under the Health Disciplines Act -- I could be wrong -- he is not really supposed to be using that. He is supposed to be John Wilson, PhD.

Mr Pill: I could also refer to something in the background documentation. There is a reference to the fact that: "Any person may use the title in a hospital laboratory or other regulated institution. Restrictions apply only to persons using the title as an occupational designation relating to the provision of human health care." That particular statement is not in the final bill, as far as I know. There is no clarification on that point. In terms of logic and consistency and in terms of practice in other jurisdictions, I think it might be an idea to look more closely at that.

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



The Chair: We have Mrs Manolson. Welcome. I said yesterday that the committee gets very friendly at about 5 to 4, so please relax. You have 10 minutes for your presentation.

Mrs Manolson: I am executive director of the Hanen Centre. It is an organization that is committed to ensuring that children get the opportunity to be able to communicate to the best of their ability. Our purpose is to support families and teachers to make that happen. As a centre, we employ many speech-language pathologists and are very pleased that the government is proposing to regulate our profession. This regulation will benefit the public by ensuring that the profession develops and maintains a standard of practice that is in the public interest. But as you are aware, I am here because we feel there is a problem.

In Bill 43 there is, in section 26, a controlling act that is omitted in our legislation. I will cite that. It reads "communicating to the individual or his or her...representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her...representative will rely on the conclusion."

This is a lot of legalese. To talk about diagnosis, to be able to look at a child who is not developing language properly, to assess what the problem is and then to have the ability to share that information so that the person can act upon it -- in the legislation, as it is now written, we as speech-language pathologists do not have that authority. This controlling act does not appear in Bill 44 and limits the scope of our practice. We believe this omission is not in the public interest and that this restriction will impair the availability and accessibility of our centre's service and the services of other centres like ours.

We achieve the goal of ensuring that every child learn to communicate to the best of his ability by providing parents with the knowledge and support to be able to effectively intervene to allow that child to reach his potential. In practical terms, it means that the parents can refer themselves to our centre. We as speech-language pathologists assess them, and if our assessment results indicate that we can help that family, then that conclusion is communicated to the family. It is essential that each family know as much as possible about their child's language development so they can make an informed decision on what they can do to improve it.

To suggest, as the legislation does, that speech-language pathologists are limited to doing assessments and can no longer identify the problem and discuss possible solutions with the family would indeed mean a lessening of the quality of services these families are currently receiving. If the legislation is followed to the letter, a speech-language pathologist at the Hanen Centre would do an assessment and then inform the family that they must visit their doctor, or someone else who has this authority, to discuss their conclusions.

We feel that this affects our service in many ways. We feel that the quality of the service would be reduced in that the doctor having to discuss the speech-language pathologist's conclusion would interfere with our ability to be direct with the families, to gain their trust, to establish a rapport in which they can begin to assume some responsibilities for decision-making and action.

We question whether the consumer will be well serviced by this system. As an administrator, I am aware that this will involve increased demands upon us. We have to set up a system whereby after the assessment we book appointments with doctors and the doctor's assessment is referred back. In addition, there is an increased cost, because this will cost my time, my staff's time, the doctor's time, and we really wonder whether this money is well spent. I mentioned just briefly, but I think, for my purposes, the most significant thing is the lessening of the credibility and rapport we are able to establish with our families and in that way it really lessens our credibility.

We fund several projects, but one particularly that this affects is one at Jane and Finch where we have been able to provide speech-language pathology services in high-rises where single moms on welfare live. These mothers are not able to access the system. To gain their trust is our first major accomplishment, and we have been able to do that. I know that if we said to them, "Look, we'll have a look at the situation here, but then we're going to refer you to a doctor; the doctor will tell you and, if he thinks it is okay, then you can come," we would lose all those mothers. It has been a very interesting and very enlightening experience to recognize just under how much stress some families must live and how much support they really should have in order to ensure that their children have the opportunities to grow and develop and have opportunities that these mothers have not had. These mothers are anxious and willing to participate in something that will help their children, and I feel that this would really impede it.

The irony of this restriction is that it entrenches what a lot of our families feel is wrong with the system, and that is that parents have often expressed a disappointment when they have gone to doctors and said, "Look, my child is not communicating well." Our field is a relatively new field. For us to keep current is a real commitment. For doctors, who have so many other responsibilities in also developing areas of their expertise, to have the knowledge to be able to identify children at risk of language delay, or even those who are language-delayed, is problematic. So many parents come to us and say, "You know, I went to my doctor, but he said not to worry; Einstein didn't talk till he was five, but my child is five and he's still not talking, and I'm very upset because he's going to school and he's not going to be able to cope," and a lot of time has gone by. So I guess my concern is that the omission of that controlling act is going to perpetuate a problem that already does exist.

In conclusion, I would like to point out that the model we have developed at the Hanen Centre does not only service Metro Toronto; we have registered with us over 100 speech-language pathologists throughout Ontario who also follow this model. Whatever restrictions and loss of effectiveness we will suffer, that would be perpetuated and increased and multiplied throughout Ontario.

I would like, in conclusion, to ask the committee that it recommend an inclusion in Bill 44 of that controlling act that would allow speech-language pathologists to communicate their diagnosis on the disorders and dysfunctions related to their scope of practice.

Mr J. Wilson: In your own words, why have you not been given the ability to communicate the results of your assessments? In your own words, why do you understand you have not been given that? I think I am going to ask every witness this.

Mrs Manolson: I have tried to find out. It is a very political question, in my mind, because the limited exposure I have -- and I have asked -- is that possibly it is an oversight. Possibly there is a feeling that, "Well, it isn't there, but it doesn't really matter because we all know it's going to be okay anyway." Possibly it is because somewhere way, way back somebody in the medical profession felt that, "Really, this is a domain that we really should monitor, and this is the system and rules by which we would like it to be played." I am not sure which of those -- and it could be something else. I would like to know the answer.

Mr J. Wilson: Thank you. We are grappling with it.

The Chair: Thank you very much for your presentation. Our committee appreciates hearing from you.

Members of the committee, we have had our last presentation for the day.

It was decided that there would be a meeting of the subcommittee following immediately for just a few minutes. This is the end of the first week of public hearings. I would be interested in hearing from anyone, through the subcommittee or otherwise, any comments or suggestions about future hearings.

The other thing is, would you take everything with you tonight? It will not be possible to guarantee that if you leave them in this room everything will be here by Monday because the room is being changed over the weekend, so we would ask that you take everything that you are going to want home with you. If you leave it here, it will probably disappear and you may never get it back.

The committee is officially adjourned until Monday at 10 am.

The committee adjourned at 1602.