BEFORE THE MEDICAL BOARD OF CALIFORNIA

DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

In the Matter of the Accusation ) Against: )

) )

ALI HAZRA TI, M.D. ) )

Physician's and Surgeon's ) Certificate No. A 112180 )

j · Respondent )

File No. 800·2017-038784

ORDER WITHDRAWING ACCUSATION

TO ALL'PARTIES:

The Accusation in the above-entitled case is hereby withdrawn.

DATED: November 30, 2018

MEDICAL BOARD OF CALIFORNIA

REDACTED

FILED

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.XAVIER BECERRA Attorney General of California JANE ZACK SIMON Supervising Deputy Attorney GerferaI EMILY L. BRlNKMAN . Deputy Attorney General

STATE OF CALIFORNIA MEDICAL BOARD OF CALIFORNIA

SACRAMENO /'ti®. 8 20 .L'L BY t

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

2 Medical Practice Act may have his .or her licens~ revoked, suspended for a period ~bt to exceed

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

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

5 5. Section 141 of the Code states: I

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

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

8 or by another country for any act substantially r~lated tO. the practice regulated by the Califofnia

9 license, may be a ground for disciplinary action by the respective state licensing poard. A ·

1 o certified copy of the record of the disciplinary action taken against the licensee by another state,· 11 an agency of the federal goveniment,' or another country ~hall be conclusive evidence of the

12 events related therein.

13 "(b) Nothing in this. section shali preclude a board from applying a specific statutory . . 14 provision in the licensing act administered by that board that provides for discipline based upon a.

15 disciplinary action taken E1gainst the licensee by· another state, an agency of the federal

16 government, or another country."

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

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

conduct. In addition to other provisions of this article, unprofessional conduct includes, but is not . . . limited. to, the following:

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22 ''.(b) Gross negligence.

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

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

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

26 "(!) An initial negligent diagnosis followed l;iy an act or omission medically appropriate

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

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

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

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

3 · .ree~aluation of the dlagnosis or'a change in treahnent, and the licensee's.conduc; departs from the 4 applicable standard of .care, each departure constitutes a separate and distinct breach of the

5 standard of care.

6 . "( d) Incompe\ence.

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CAUSE FOR DISCIPLINE

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

10 7. On September 15, 2017, the College of Physicians and Surgeons of Ontario; Canada

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

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

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

14 College Decisi~n required Respondent to complete continuing education related to infonned ·

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

16 of'. the Ontario College Decision is attached as Exhibit A.

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

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

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

20 consent from ei.ther the patient or hls parents. The Decision also noted that R~spondent had.

21 · previous cases involving informed consent before the Ontario College in 2015 and 2016. . . . . . 22 · 9. Respondent's conduct and the actions of the Ontario College as set forth in

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

24 and conduct subject to discipline within the meru1ing of section.141 of the Code.

25 PRAYER

26 WHEREFORE, Complainant requests that a hearing be held on the matters hereii:i alleged,

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

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

1 1. Revoking or ·suspending Physician's and Surgeon's Certificate Nuniber A 112180,

2 issued to Ali Hazrati, M.D.;

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

4 supervise physician assistants and advanced practice nurses;

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

6 probation monitoring;· and

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

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10 DATED:

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May·3, 2018

Executive Direc or Medi.cal Bpard of California Department of Consumer Affairs State of California Complainant

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

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EXHIBIT A

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

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

l . . ' '!'I

COMl'LAINANT:

PATIENT:

. ,'' . CERTIFIED TRUE COPY

Staff: .l.,,,.(L::.~::;;::~~~::_~

Oate: . 01( 3D/ I '(3 College il1 Physicians and ~urgeons of Ontario

INQUIRIESrGOMPLAINTSAND REl'ORTS:CGMMITIEE ·.· (the ·"committee~')

. DECISION AND REASONS .

•• • ~ESPONDENT: · Dr. Ali Hazrati {CPSQ# S3925)

CPSO FILE NO.: 105030

INTRODUCTION.

11111 sent the College a Jetter, received on January 10, 2017. She expressed concern about the care her 15-year-old son, 1111; received from Dr. Hazratl (General Surgery ·and Family · Medicine). · ·

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

ROLE OF THE COMMITTEE

the College's ·~omplalnts proce~is provides· a route for members of the public to raise concerns · about a doctor's practice or conduct. The Conimittee; with the assistance of staff, conducts an investigation, the.n meets to review the.written record of investigation and to reach a decision .

. . The Committee cannot award .financial compensation of any kind. Its process Is not focussed on determining liability, or on punishing doctors. The Comrnlttee evaluates the Investigative Information ayailalile .. It then determln,es what action, If any, is.warranted, taking Into account the seriousness and cont!'!xt of the concerns·raised, the physldan's insight lnt9 his or her practice, capacity for remediation, and relevant College history, if any.

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_....:._,, __ . ----'-·-· The ·committee's.role; broadly, i~ to protect the public by determining whether reme.dlal action Is necessary and, If so, wnat actiOnwould best enhance the quality of medical care of the particular physician, .and the general qualitycif medical-care.in Ontarlo,-byrei'nf0rclng the standards of practice.

The range of dispositions available to the Committee.Includes taking no further action, providing advice/rec0mmendations, requiring a physician to atfend at the College to be . cautione'd, or. requiring a physlclari to' complete a specified continuing education or remediation program. With the Committee's approval, a physician may enter into .a remedial ·agreement or· an undertaking with the College.

In a small number of very serious cases, the Committee may refer a 'specified a/legation of professional misconduct o.r incompetence to the College's Discipline Committee. The Committee will do this where It believes that referral to the Discipline Committee is In the public Interest, and that th.e avJJilable informatlo~ has a reasonable chance of ~upportlng a successful prose~utlon. . . .

The Committee appredates M'fa bringing these· concerns to the College's attention. Public engagement aids the College in protecting 'the.public interest and lmpr.oving the quality of physicians' care throughout the province. The Committee also acknowledges Dr. Ha~rati for demonstrating professional account.ability by providing a ·response to the complaint.

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INFORMATION BEFORE THE COMMITIEE

The Committee always has before It applicable legislation.and regulations, along with' policies that the Coll'ege has developed1 which reflect the College's professional expectations. for · physicians practising In Ontarl~. Current versions of these documents are available on the College's website at www.cpso.on.ca, under the heading ''Policies & Publications." .The. · Committee will provide a copy of any policy it. refers to in this decisi.on. In this case, the· College's policy on Consent to Treatment (#3-15) Is attached.

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

The Committee carefully reviewed all the information gathered qurlng the investigation, Including Mil communications ,about.the complaint (including enclosures and medical literature), and Dr.Hazrati's response. . ,

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Concerns Raised In the Complaint ' "

· •. is concerned that Dr. Hazratl failed to provide adequate· care to ·her son in December .. · 20161 in that he:

• failed to obtain consent and exp'lain the procedure prior to using an "anus:expander" [also known as a Hill Ferguson anal retractor] -

• performed a flstul8 probe without anaesthesia

• · used forcewhen doing th·e anal exam.lnation arid abscess probe

• caused her son to have a lot of pain and bleeding and may have perforated the ' '

rectum. · ·

Context for the Complaint

• On December 3, 2015; IJ'll!l family physician contacted Dr. Hazratl regarding an jnguinal mass or·abscess on his buttocks; Dr. Hazratl recommended-attend the Emergency Room (ER) at Scarborough General Hospital for ari assessment. 11111 was

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'initially seen in th.e ER by , and then by Dr. Hazrati in consultation: Dr. Hazrati Incised, drained, and packed tl:ie abscess. · ·

On December 7, Dr. Hazrati sawllJlfor a.follow~up app~intment atthe Greenestone Clinic (the Clinic).

• ·oh December 22, Dr. Hazratl next saw l'ili tor follow-up at the Clinic. At that visit, Dr. Hazrati inserted an anal retractor and probed the abscess. According to Ill, Dr. ' ' Hazratl never obtained consel)t from her or her son, and because of how Dr. Hazrati conducted the procedures, it caused pain, bleeding and additional injury to her son.

• . Dr. Hazratl referred 1111 to ·a gastroenterologist at Sickl

Dr.·Hazratl's Response

Dr. Haznitl provided Information In re5ponseto the.complalnt,.including:

Re: fa/led .to obtain consent and explain the procedure prior to using an "anus expander"

• Anal examination does not require written consent. By bringing & to the examination room arrd positioning.him In proctology position, he and his parents provided tacit consent for the examination.

Re: performed a fistula probe without anaesthesia

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

• ll!lil felt uncomfortable and his mother was anxious a't watching the examl~aticin. He then terminated the examination. Ill tolerated th'e incision·and drainage· of the .. abscess very well, which is a much ril'iire painful and bigger procedure'than a rectal examln:atlon; · · ·

Re: used force when. doing the anal examination and abscess probe . . ·• The size of the probe is even smaller than a Q-tip in len~h and diameter. He gently

Inserted the probe In the incision site.

Re: caused- to have a lot of pain and bleeding and may'have perforaJed the rectum . . .

• There was a ·minimal amount of blood stain on the probe and the anal retractor; which

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is expected f~r this tyf)e of examination. ·

In his·view, Nij discomfort was minimal, but he did acknowledge.it. llfiB was stable and relatively comfortable after the exam.ination.

Comments from R After reviewing Dr. Hazrati's response, E submitted further com merits, and reiterated her concerns abciut the December 22 visit with Dr .. Hazratl, including Dr. Hazratl'sfailure to obtain consent and describe the procedure. She noted that Dr. Hazrati used a 15-cm Q-tlp which was much longer than that used Gy the CCAC nurse ·who saw M the .day before, and measured

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absaess depth as 2 cm. She is concerned about the issues - experienced after the visit, including excessive discharge fr,pmthe abscess and a staph infection. She also submitted excerpts .of several medicai.journaLarticles. ·

ANAL'(SIS AND CONCLUSIONS

The Com~lttee considered the following points In reaching its decision: ·

• On.Decemb.er 22, 2016, Dr. Hazrati performed.a rectal.examinaticin, probed a possible fistula tract, and did a proctoscopy on...__. without d9cumenting

. in writing that he had the Informed consent of either-or one.of his parents, and apparently Without providing an explanation of the procedures being conducted.

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

o in. ord.er for consent to be valid, it must be related to the treatment,- informed; given voluntarily, and hot obtained through misrepresentation or fraud. if any of these requirements are. not mE)t, the consent may not b.e valid ...

. o · When obtaining consent the College requires physicians to engage in a dialogue with the patient or substitui:e decislo.n-maker, regardless of whether or not

. physicians use supporting documents, Including consent for~s.

o ... The College requires physicians to document Information.regarding consent to treatment in certain circumstances, and recommends thatthis be done in all oth~r circumstances. ·'

o Implied consent is inferred from the words or behaviour oft.he patient, or . surrounding circumstanc.es;such that a reasonable person would believe that consent ha·s been given; although no direct, 'explicit, and unequivocal words of agreement have been given.

o Although the Health Care CdnsentAct (HCCA) states that consent to treatment may be express i:lr implied, the .Coliege·strorigly.advises physicians to pbtain express consent, particularly when the treatment is likely to be more than mildly painful, c?rries appreciable risk, will result in abla\ion _of a bodily functio.n, is a surgical procedure or an invasive investigative procedure, or will lead to significant changes in consciousness. [Emphasis add~d] ·

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o A legible, understandable .and contemporaneous not'e lh the patient's record regarding.consent-to treatment ·ls-the bestevldence ·a·physlclan-has to

· dem.oristrate that the.requirements of the HCCA h11ve been satisfied.-

o When a· treatment Is likely to be. more than mildly painful, carries appreciable risk, will result In ablation of a bodily function, is a surgical procedure or an Invasive Investigative procedure, or will lead to significant changes in . · consciousness, the importance of documentation increases. As such, in these circumstances, the Coile.ge requires physicians to document in the patient's record informatiOn regarding consent to treatment.

• Dr. Hazrati's respon.se to t~e College indicat_es that he believes that the ·mere fact that .• was In the examination room .. In proctology position implies tacit consent for the procedure. While the Committee agrees that formal written consent Is not required for' a rectal examination, verbal con~ent is. certainly'required. It Is unclear whether Dr. Hazrati obtained this from either Bl or his mother, or what ff anything Dr.Hazrati ·

. communrcated to them regarding'th'ifexanilnation, given in his response.suggests that he assumed he. had consent based on MN PO?ition. Even Jfwe assume Dr. Hazratr

·had consent to complete the rectal examination, he should have obtained and . documented consent pr.ieir to conducting. a proctoscopy and/or fistula probing.

• The Com.mittee also noted that Dr. Hazrati conducted the proctoscopy and the prol?lng · • of the possible fistula site without anesthetic. Proctoscopy and probing of a fistura can.

be uncomfortable, and particularly so.when the patient is.an adolescent, as·was the case here. Most physicians complete these procedures with .an anesthetic, an.d if one i's not. going to use'_an anesthetic, a physl~ian must obtain consent iJnd explain the procedures will be more painful if no anesthetic is used. In the Committee's view, Dr .. Hazrati should have· offered the optlon°to complete the procedures with a~ anesthetic, explaining the risks and benefits to proceeding without one, and documented the consent discussion. in the record. The Committe.e also observes that probing a fistula· may take time, and often .. requires other modalities, such as injection of methelyene bl~e ·dye into the tract first. All of this should have been explained to and his family and documented In the record.

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

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procedures or that he expl·ained the rl.sks and benefits of them, lncludlngthatth~ procedures may be done with anesthetic. ·

• ·Dr. H·azratl has a histo'ry of°College Investigations and/or complaints, which raised similar is'sues with communications and/or consent as the case before us. In FE;ibruary 2016, the Committee advised Dr. Hazratl on.th.e importance of ensuring good communication with. a patient and/or their family regarding discharge from hospital. In April 201-5, th7 Committee advised Dr. Hazratl respecting full consent discussion, full documentation of consent and of OR (operating room) procedure, and full communication with patients post-operatively.

• Dr. Hazrati's response to the College, In which he state.d taclt'.consent was sufficient, suggests to the Committee that.Dr. Hazrati lacks Insight Into the deficiencies In communications and the consent P.rocess that arose in this case. Dr. Haz~ati's history of" similar complaints further elevated· our concern,. such that the Committee wished.to meet with Dr. ·Hazratl in per·son to impress upon him the lmportance of obtaining and documentlng·fully informed consent when conductlng·invaslve lnvestlgative·11rocedures .. The Co.rrimittee also felt Dr. Hazratr could benefit from education to Improve his p·ractice in these areas. · ·

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

First, the Committee requires Dr. Hazrati to attend atthe College to be cautioned.In person with respect to obtaining and documenting informed cons·ent. A caution In person. arises when· the Committee is concerned about an aspect of a physician's practice, and believes that the physician would benefitfrc:im direction provided In person about t.he Issues raised. 'It.ls also Intended to protect the public Interest, and a summary of the decision will appear on the College's public register. At Dr. Hazratl's attendance at the College, Committee members will provide dfrection to him about steps the Committee believes he must take In order t.o avoid future difficulties:

Second, the Committee has the power.under section 26(3) of the Code to require a· physician to complete a specified contlnufng education or remediation pr9gram and It.has determined that it Is appropriate .to do so In· this case in light of the deficiencies Identified In Dr. Hazrati's practice. The Committee therefore requires Dr:Hazrati.to undergo a specified continuing education or remediation program (the Program}. The Program Is lnte'nded to address the Committee's concerns and to protect the public interes.t and a summary of the decision will appear on the College's public register. ·

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The Colle.ge will monitor the Program set out below.

A. Courses/Programs

Note: If ci cour$e mentioned Is no longer available, Dr. Hazrat/ shall successfully complete a su/table alternative, acceptable to the College. ·

AND.

1. Group .Courses

Dr. Hazrati shall attend anct successfully complete the.next available!'!-learning module on Informed Consent, offered by the cariadian Medii:al Protective Association, or an alternate course provider indicated by the College. The member Is to.provide pro-of of successful completion of the course.

B. Self-Directed Learning

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

c. Other

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

a. All costs

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... DISPOSITION .

The Committee requires.Dr. Hazratl to attend at.the.College to be cautioned. in-this-matter:. . . ' . ' ' .

·Any failure on th.e p·art of Dr:- Hazratl to attend for this caution may res.ult In fur.th er . consJderatlon and action by the College. · ·

-AND-

Dr. Hazratl Is required to complete the specified continuing education· or remediation program, as o,utlined in this decision.

\)~~. PANEL MEMBERS: September.15, 2017

. o. MERCER, Mb~ chair, icR ~6mn1ittee . A. HAMILTON, MD

R. HOLLENBERG, MD E. MARGOLIN, MD H. ERLiCHMAN- Public.Member

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Janua'ry 31, 201.8

Ms. ~ara Pasion Staff Services Analyst Discipline Coordination Unit Medical Board of California zoos·~vergreen Street; SuJte1200 · . · Sacramento CA 95815-3831. United States

·Dear Ms: Pasion: .

THE

COlll£Gill OF

.JP>Jll!lYSliCKANS AND

§1URGJ£0N§ OF

ONTARIO

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

Dr. All Hazratl CPSO Reg. No.: 83925 Date of birth:'

· Current Ontario Practice Address:. Suite 300, 5734 Yonge Street, ·Toronto ON M2M 4E7

Enclose·d are certified.copies of the following (thiid-party names redacted): . ' '

1 .. Certified copy of the Detjsion and R·easons. of the CPSO's Inquiries, Complaints and Reports Committee, dated September 15, 2017. ·

Please let me !