ONTARIO PUBLIC SERVICE EMPLOYEES UNION
RESPIRATORY THERAPY SOCIETY OF ONTARIO
ONTARIO ASSOCIATION OF SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS
ONTARIO SOCIETY OF OCCUPATIONAL THERAPISTS
NORTH OF SUPERIOR COMMUNITY MENTAL HEALTH PROGRAM
NORTHWESTERN ONTARIO CHIROPRACTIC SOCIETY
MIDWIFERY TASK FORCE OF ONTARIO
THUNDER BAY DENTAL ASSOCIATION
CANADIAN ASSOCIATION OF PASTORAL EDUCATION
CONTENTS
Monday 19 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 Public Service Employees Union
George Fieber
Rev Richard Willans
Danny Gilbert
Respiratory Therapy Society of Ontario
Handicapped Action Group Inc
Donald Hood
Roger Patola
Ontario Association of Speech-Language Pathologists and Audiologists
Mary C. Marasco
Ontario Society of Occupational Therapists
Rupert Flatt
Kate Fammer and Alan Cranton
North of Superior Community Mental Health Program
Northwestern Ontario Chiropractic Society
Yvonne Slivinski
Midwifery Task Force of Ontario
Thunder Bay Dental Association
Linda Mickelson
Salme Lavigne
Hanusia Tkaczyk
Ted Murphy
Canadian Association of Pastoral Education
Adjournment
STANDING COMMITTEE ON SOCIAL DEVELOPMENT
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)
Substitutions:
Johnson, Paul R. (Prince Edward-Lennox-South Hastings NDP) for Mr Silipo
Jackson, Cameron (Burlington South PC) for Mrs Witmer
Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski
Clerk: Mellor, Lynn
Staff: Drummond, Alison, Research Officer, Legislative Research Office
The committee met at 0902 at the Valhalla Inn, Thunder Bay.
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
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. The standing committee on social development is now in session.
ONTARIO PUBLIC SERVICE EMPLOYEES UNION
The Chair: I am going to call first OPSEU and I would announce some changes in the schedule. At 10:10 we have the Handicapped Action Group. OPSEU filled a spot that came available when we had a cancellation, so you have 10 minutes for your presentation. We would ask you to leave a few minutes for the committee to ask questions, if you would. You can begin your presentation now, please. Welcome.
Ms Pycko: I am Anne Pycko, president of Local 734. I work at St Joseph's Hospital. I am a lab technologist. Fran Zaitz is a lab technologist, Bev Dalys is a research education officer for OPSEU and Bob Reid is a respiratory therapist.
On behalf of the 10,000 OPSEU members who work in health care facilities across the province, I would like to thank you for the opportunity to express some of our views on Bill 43, the Regulated Health Professions Act, and on its companion bills. Because this legislation will spell out different consequences for different OPSEU members, we have chosen to focus on specific concerns in each of our presentations to this committee.
The task of developing a provincial health care system which will address many outstanding weaknesses in our current system is by no means simple. The Health Professions Legislation Review carried out by Alan Schwartz beginning in 1983 and which brought us where we are today responded to concerns raised by many groups. Among the concerns was that brought forward by hospital administrators, who wish to make more efficient use of their staff. It is this point that we will address today, as OPSEU is concerned that the review's response to administrators will have a negative impact on the integrity of the work done by our members and the conditions under which they work. It will breach the quality of health care that Ontarians have come to expect.
Restructuring the delivery of health care in Ontario has been a priority for the three governments that have been in power over the past eight years. During this time our health care crisis has intensified. All three governments have been forced to grapple with the conflicting goals of equalizing and preserving a system of quality health care for all Ontarians, preparing for the needs of an aging population and containing the high cost of health care. Many of the interim solutions we have seen come under the rubric of government divestment. At OPSEU we feel these changes have had a negative impact on the quality of health care and on the health care worker. OPSEU is now concerned that the legislation under review, the Regulated Health Professions Act, will be yet another component of divested health care.
In reviewing the materials concerning the impending changes in health care, particularly the ministry's briefing to this committee two weeks ago, two words come up repeatedly: flexibility and competition. Given the geographical realities of Ontario, we expect that the government will search for ways to provide better service to people in rural areas. This is where the idea of flexibility is reasonable. If the authority of on-site health care workers is extended in such a way as to enable patients or clients to get the help they need when they need it, certainly that is beneficial. OPSEU, however, has some very serious misgivings about the downside to this flexibility, particularly when it is defined in terms of competition and privatization.
If there is any one area that demonstrates how flexibility and its counterpart, competition, can harm the public and reflect poorly on a profession, this area is laboratory technology. OPSEU members are currently having problems in laboratories because work that properly belongs in the hands of registered technologists is delegated to non-registered laboratory technicians. The volume and cost of these tests have led administrators to the conclusion that this cost-cutting is an absolute necessity. It is, however, the technologists, not their assistants, who are responsible for the accuracy of the test results. In hospitals and in private labs where administrators are closely watching budgets, they may be losing sight of something else: quality service. This means that the numbers of well-paid registered technologists are dwindling while non-registered technicians take on tasks for which they may not be properly qualified.
Under the proposed legislation, these current problems will be exacerbated and the registered technologists will carry the responsibility. Given that laboratory technicians are not covered by and cannot be charged under this act, we are very concerned about technologists who seldom have control over task delegation but are responsible for outcome. We are further concerned because it is already fairly standard practice for laboratories to get by on skeleton staff with as few qualified technologists on hand as possible. Opening the road to even more competition in this underregulated field will be devastating for the public and for the profession.
Accurate results from the laboratory are the foundation of patient management and protocol. Inaccurate test results can lead to serious errors being made by other health care professionals. As a basis for nursing assessments, laboratory results will become more crucial in patient management. Mismanagement and underevaluation in the laboratory can ripple throughout the health care setting, with tragic results. Clearly it is crucial that the work being done in laboratories be respected for its role in the health care system, and the critical task for which the laboratory technologists have been specifically trained should be deemed controlled acts. OPSEU represents other highly trained health care workers whose specialized tasks will not be deemed controlled under this legislation. We will turn our attention to these groups in a later presentation.
The excessive pressure under which registered technologists are currently working has become their primary concern with respect to working conditions. Lab technologists who are carrying the responsibility for the results of work they never assigned to the technicians are in a terrible bind. This is a terrible inconsistency and, as we have said, an inconsistency which contributes to the high stress level. Workers should not be responsible for work over which they have no control -- that is, work they have not performed and that they have not assigned to others. If we are to properly protect the public and rectify this outstanding and worsening problem, quality provisions must be ensconced in this legislation.
The concerns we have just raised about accountability are exacerbated by the pressure put on hospitals to stay in the black, the ever-increasing attempts of hospital administrators to cut costs by cutting corners, the trend towards privatization of medicine that we are seeing in for-profit laboratories and, most recently, the government's action to open the way for more competition in medicine.
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While we laud the government for seeking ways to provide more service in rural areas, we believe upholding competition as a legitimate factor in health care delivery is an ill-conceived concept and one which may have tragic consequences for all Ontarians.
As we have said, this is complex and far-reaching legislation, and while your committee is meeting with interested groups across the province, so too is OPSEU continuing to meet with its affected members. We are planning to have more concrete proposals to present to the standing committee on social development in a written submission towards the end of this month.
We thank you for your time and welcome any questions.
The Chair: Thank you very much for your presentation. Question, Mr Owens?
Mr Owens: The Ontario Society of Medical Technologists raised briefly in its presentation the issue around grandfathering. Do you think grandfathering is an issue this committee should be concerned with, and do you have any thoughts on its potential effect on health care in this province?
Ms Dalys: Grandfathering is certainly an issue that OPSEU is concerned with. It is actually one of our biggest concerns, and for that reason we are deferring that till a later presentation. To answer your question a little more specifically now, we know that the work that is being done by lab technologists who have been in the field for 30, 25 or 20 years -- however long, but for a long time -- are doing a good job.
Technology has changed. Qualifications have become more standardized and more education-oriented. Certainly the people who have been doing those jobs for a long time are doing quality jobs, and they have to be caught up in this legislation. That, of course, applies to a lot of other professions as well. We will be addressing that in more detail at a later date.
Mr Owens: Any idea how many people we are talking about at this point?
Ms Dalys: Not really, no. I will get the figures for you at a later date.
Mr Owens: I would appreciate that. Thank you.
Mr J. Wilson: Thank you for the presentation. You mentioned that there are certain controlled acts that you think should be included in this legislation for laboratory technologists. Can you give us some examples of what those acts would be?
Ms Dalys: I am going to pass that question over to the lab technologists that we have here. They are the professionals. I will mention that we have been discussing that with some of our technologists already. We have not come down with a definitive list.
Ms Zaitz: Because OPSEU is representing so many different professions right now, as Bev has said, we are looking at what controlled acts will be expected to be passed off to different members. I cannot say just simply as lab technologists, quality assurance, assessing, the reportability of test results. My specific specialty would be analysis of drugs, testing body fluids. I do not want to specifically aim right now at any particular one because I might exclude someone who is actually just as important.
Mr J. Wilson: You are planning on including this in your next submission that you will be putting forward later?
Ms Zaitz: Yes, we have a set of other presentations. Yes, we will be.
Mr J. Wilson: Thank you, that would be helpful.
Mr Hope: Just to point out some of the concerns you have dealing with watching the budget, competitiveness, privatization -- and you indicated later on in your brief that you are going to be sending the committee more substantial information dealing with it -- will you be concentrating on the rural area or will you be doing it as a global OPSEU presentation?
Ms Dalys: We are looking at a global picture of it. It is difficult that competition and flexibility are flip sides of the same coin. We know the geographical realities of Ontario. We know that somehow service has to be provided in smaller areas that do not attract the same kinds and numbers of professions that you get in bigger centres.
What we have difficulty with is selling off health care to private enterprises where cost-cutting becomes -- well, it is just so central to the whole idea of business. We have spoken to technologists in one private lab who were saying they have been told in that lab to finish up all the reagents before they buy more and it does not matter if these reagents are expired. That obviously has a very negative impact on health care. It creates bad results.
I think many of us remember reading stories about the United States when lab technology, for example, was divested. Cytology labs started hiring unqualified people to look at slides. They were paid on a piecework basis and cancer rates shot up because a lot of abnormal cells were not noticed on earlier swabs. That is the danger. That is something we cannot afford to have happen here.
Mr Reid: Excuse me, just to add to what you were saying about the control-factor part of it being employed by an employer, they set the setting, they set the working environment for us. Also, with the condition that the health care is in right now, as far as its finances are concerned, that sets a scenario for the working conditions too, so basically, as an employee, you have no control over your working environment. Then to be legislated upon as being responsible and being addressable for your actions as a therapist, a technologist or as a health care professional out there, it puts you in that jeopardy situation where you are responsible for something you have no control over. That is one of the things we address.
The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee this morning and we will be looking forward to your written submission when it is ready.
For the information of everyone here, groups and individuals are encouraged and welcome to communicate with the committee in writing over the course of the hearings. I know you will feel free to do that.
GEORGE FIEBER
The Chair: I would like to call now George Fieber. Welcome. You have 10 minutes for your presentation and we would appreciate it if you would leave a couple of minutes at the end for questions from the committee.
Mr Fieber: My name is George Fieber. I am a registered nurse and I work in the intensive care unit of a general hospital here in Thunder Bay. I also work as a clinical instructor, teaching nursing and nursing assistant students.
It is my intent today to present my concerns regarding the Regulated Health Professions Act and specifically the Nursing Act from my perspective as a working nurse, as a nurse educator and as a consumer of health care services in northwestern Ontario. As a nurse employed by a hospital and as a member of the Ontario Nurses' Association, I fully support the position of the ONA regarding this proposed legislation as it was articulated by ONA president Eileen Davidson during her appearance before this committee on August 7.
For the sake of brevity, I will not review the ONA position except in regard to the problem of double jeopardy, as it was identified in the ONA review of the draft legislation. The double jeopardy referred to -- that is, my being responsible to both my employer and the College of Nurses of Ontario, whose standards often conflict -- has created and will continue to create situations where I must make decisions where I weigh my professional obligations to my patients against the demands of the administrators who employ me.
If no resolution is found to this dilemma and the proposed legislation is passed in its present form, the possibility of fines and imprisonment for making the wrong decision will add more stress to an already stressful job. The safety of patients may be compromised.
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As a nurse educator, I believe the Nursing Act should explicitly state that nurse administrators, educators and researchers should be fully accountable to the College of Nurses. As an educator, I have a great responsibility to ensure that the nurses I train can provide safe, competent patient care, and if I fail to do this properly, I should be held accountable to a professional body, expert in the standard of practice expected in my profession.
This question of patient safety also demonstrates the need for nurse administrators to be accountable to the college as well. The decisions of these management nurses in areas of staffing, policy and procedure have direct impact on patient safety. Accountability for their decisions might also reduce the occurrence of the double jeopardy situations already discussed. Accountability for nurse researchers would help ensure that research would be conducted in an ethical, professional manner and that patient safety or privacy would not be compromised.
Finally, as a consumer of health care services in northwestern Ontario, I believe that the draft legislation, by prohibiting nurses from performing a single controlled act independently, will diminish the quality of patient care available to the people of this region and will in fact create situations where patients may be put at risk.
Hospitals in northwestern Ontario are not staffed like the teaching hospitals of the south. They do not have medical staff on the premises 24 hours per day. In some cases, like the hospital I work in, they share the services of an emergency department physician on night shifts and weekends with another hospital. This means that in the event of an emergency, it may not be possible to contact a physician for several minutes to obtain orders.
Time and time again, life-threatening situations have been averted by the intervention of experienced nurses who knew what to do and when to do it. Restricting the ability of these nurses to use their experience and training is an insult to them and a disservice to the public. It will reinforce the widely held belief that the people of this region are given low priority when provincial health care policy is developed and when health care resources are allocated.
In closing, I believe the public can best be protected when all registered nurses are licensed and have a defined scope of practice where the double jeopardy as employed professionals has been resolved. All registered nurses, including administrators, educators and researchers are included in the scope of practice and are made accountable to the public for their actions. Finally, as many nurses as possible are trained and allowed to perform more controlled acts, especially when patient safety is at risk and a physician is not available.
I would now be pleased to answer any questions the committee may have.
Mr Hope: I have just a couple of concerns. I see you work in the intensive care unit of the hospital. You talk about obtaining orders from a physician. In the rural settings, do you already have standing orders that are in place dealing with patients?
Mr Fieber: There are certain protocols. For instance, I am certified in advanced cardiac life support, and there are certain protocols that I can follow. There are certain lifesaving interventions that I cannot, at the present time, go ahead and do without having a physician present.
The problem though, as I explained, is -- and this has happened several times over the last few years -- in the event of a cardiac arrest in our hospital, the only physician who might be available is approximately two miles away at another hospital. Your only chance of making it is if I do my job properly. The problem is, at the end of my list of protocols there are certain things I can still do to save your life, but under this legislation, if I did them, I would be accountable for a $25,000 fine or imprisonment. So you are putting me in the position of either doing what I am trained to do or letting me go.
The Chair: I have an intervention from the parliamentary assistant to clarify.
Mr Wessenger: Yes, under section 28 of the proposed act, there is an exception saying an act by a person is not a contravention if it is done rendering first aid or temporary assistance in an emergency, so emergency situations, I believe, are covered by the act. In the situation you raise, I believe you would be covered by the act.
Mr Fieber: The situation I was thinking of specifically is one of the controlled acts that -- I do not know the exact wording -- involves the application of an energy source. I was thinking of the application of external pacemaking, for instance, in the event of someone whose heart has stopped.
As the legislation sits now, you say I would be protected in that case. I do not think I would be backed up by the hospital in the event of an error, and I think under the present draft it is still vague enough that I could end up facing charges. If this is clarified, fine, but as I read this legislation, I understand it is quite possible I could be held liable.
The Chair: Thank you very much. We appreciate your presentation before the committee.
REV RICHARD WILLANS
The Chair: I would like to call next Richard Willans, who will be representing all Anglican parishes, northwest section of the diocese of Algoma. Please come forward and introduce yourselves. You have 20 minutes for your presentation. We welcome you to the standing committee on social development this morning. Please begin your presentation now.
Mr Willans: Thank you for the opportunity to bring before you the concerns that we have with regard to Bill 43.
I will be brief and succinct for two reasons: first, obviously, your time is valuable and I am just one person out of many, but second and perhaps more important, the concerns I have to bring before you are not new. I apologize for that, but I present them to you none the less because I believe that if reasonable people hear the same concerns surfacing over and over again, although they may find it extremely wearisome, they will agree at the very least that there may be a problem which needs to be addressed.
My name is the Rev Richard Willans. I am the rector of St Thomas' Anglican Church, one of the numerically largest Anglican churches here in the city and indeed, in the whole of the diocese of Algoma. In addition to that, I am the regional, or sometimes called "rural," dean of our Anglican deanery here, which comprises 12 parishes and goes out to Manitouwadge.
I belong to the diocese of Algoma and I am charged, with Bishop Leslie Peterson, with the responsibility of representing to you the concerns of the Anglican clergy and our lay workers and people here.
I must add that I do not in any way claim to be an expert on the implications and ramifications of this bill. The concerns that I bring before you are those which other diocesan experts have highlighted. None the less, I do personally endorse them.
With me is the Rev Joan Mitchell, priest in charge of St Stephen's, one of the smaller, yet dynamic, churches in the north ward of this city. Joan is with me because she has had much greater experience than I have in some of the areas of pastoral care that this bill could affect, in particular having been for some time in an official chaplaincy position at the Lakehead Psychiatric Hospital.
In addition to those credentials, I think it is worth mentioning that we are also both members of the local council of clergy, and Rev Mitchell is currently the treasurer. We do not speak on behalf of the council. The council was not able to get its act together, but we do know that our concerns are the same as those of many of the individual members.
We have spoken with Mrs Lisa Strasser. She is the chairperson of a local ad hoc group of hospital chaplains and pastoral care workers charged with the specific task of making a written presentation to you in September. Because the most capable people are on vacation at this time, they judged themselves unable to make a verbal presentation today. Again, we do not claim to speak for them, but we do know that our concerns are essentially the same.
I have been using the word "concerns" in the plural, but as I understand it, there is one primary concern and I will concentrate on that. This primary concern relates to the implications of section 23, and especially clause 2, dealing with the definition of a controlled act. I will not read that, because I am sure you know it backwards.
It would seem to us that, given a strict reading of this clause and section, any clergyperson, pastoral counsellor or hospital lay visitor, to name but a few, who does something which fits the above description, would be technically guilty of a criminal offence. If that presumption is even technically correct, then many of us would be in potential trouble very quickly, given the comprehensive and somewhat loose nature of the terms disease, disorder, and dysfunction.
The above wording could logically include, for example, my suggestion to a parishioner that marital and personal problems possibly stemmed from perhaps unresolved grief or unresolved guilt or an overwhelming sense of personal inadequacy, or that a teen was possibly in need of substance abuse counselling and so on. You are familiar, I am sure, with the scenarios, and these are just a few of the common pastoral problems that land on our doorstep, usually late at night.
As I said -- you have heard this before -- we know that the government has stated that it does not intend this act to be applied in a rigorous and literal fashion to creditable, unregulated workers. However, history is littered with examples of situations in which the intention and spirit of legislation has little to do with how the letter of the law has been subsequently applied. We do have a serious and sincere concern about this, particularly given the possibility of private prosecutions based on this clause and section. We do not presume to offer solutions. These are best provided by yourselves and by others who have the appropriate expertise and oversight. We do ask, however, that real consideration be given to this concern because it may affect, not just clergy and parish workers, but all those who support our health professions in countless creditable ways, yet are classified as unregulated.
Finally, just so there is no doubt in anyone's mind, we do applaud the intent of Bill 43 and support the greatest part of its particulars.
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The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee this morning. Questions? Ms Haeck?
Ms Haeck: Actually, I think Mr Hope had his hand up first so I will defer to him.
The Chair: The reason I gave you the opportunity to speak first, Ms Haeck, is that Mr Hope has asked questions already.
Ms Haeck: Clause 28(c) talks about "treating a person by prayer or spiritual means in accordance to the tenets of the religion of the person giving the treatment...." Do you feel, in that area of this particular proposed Act, that you do have the -- I am trying to choose my words carefully here -- kind of safety net that you may not feel you have under section 26.
Mr Willans: I think, in certain senses, yes. But perhaps they could legally be seen to be contradictory and the one might outweigh the other.
Ms Haeck: I have met with clergy in my own riding and I know they have expressed a particular desire to be very clearly exempted from this legislation. Is that the kind wording you would like to see included in the act?
Mr Willans: I am not really sure on that because I have not thought it through. And I would need to just say that and be quite honest about it and leave it there. I do not know whether it is in our interest and in the interest of lay workers, because they are also involved in this, to be regulated or unregulated.
Mrs McLeod: I think it may be a comment more than a question. It certainly was the intention of our government, when we were initiating this legislation, to ensure that this would not be a problem for the unregulated professions; that this restriction would not be one which would lead to concerns about legal prosecution. As difficult as it is to find the exact wording which will provide that degree of protection, the current government will also want to make sure that, as a result of the recommendations of this committee, that assurance is provided. There is an assessment clause which is quite clear in providing unregulated professionals with the ability to carry out assessment in their field of concern and communicate that assessment to the individuals who they are working with. We have to make sure there are not inconsistencies that would lead to your concern about legal prosecution.
Mr Willans: We are aware of the intention that has been stated over and over again and I referred to that in my presentation. I think my primary problem -- perhaps I could sit here for a moment less as a clergyperson and more as a former history and constitutional teacher. As I said in the presentation, the intention of the law is not necessarily what happens when you get down to the letter of the law. So we are asking you to look particularly at that clause and perhaps, if necessary, tidy it up or whatever might be done so it is completely clarified.
Ms Mitchell: So we are not put into jeopardy -- because, with the majority of people with whom we deal, there is an assessment, an evaluation and a referral. You cannot get around that.
Mr Hope: This is a question outside of your presentation here. By the sounds of it, you represent the northern rural area which is of particular interest to me. In your conversations with the general public, does the legislation, on the whole, look like it is going to do what it is supposed to do in protecting people from those out there who may cause problems to our health care?
Mr Willans: I have to choose my words carefully now, too. Anything which does what this bill proposes to do, in tightening up health care provisions and making sure people are not abused in any way, will do the job. That is the way I see it and that is the way other people have referred it to me.
Mr Hope: Will it meet the public concerns in rural areas about health?
Mr Willans: In terms of the concerns I am dealing with here, yes. If you want to open the whole question of health care in the rural areas, I am not even qualified to speak on whether this bill would do that job.
DANNY GILBERT
The Chair: I would like to call next, Karen Gilbert and Danny Gilbert. Please come forward now. Welcome to the standing committee on social development.
Mr Gilbert: It is only Danny Gilbert.
The Chair: Welcome Danny Gilbert. Is that because we are a few minutes early? Is Karen going to be coming?
Mr Gilbert: No, that is because my kids had an emergency dental appointment, so it is just me.
The Chair: I am sorry to hear about the emergency dental appointment but we are pleased you are here this morning. You have 10 minutes for your presentation and we would ask that you begin now.
Mr Gilbert: Madam Chairperson and other members of the committee, I would like to thank you, first of all, for this opportunity to express my concerns regarding the proposed Bill 43. It should be pointed out that I am not a professional in any way. I am here to express the concerns I have as a parent of a handicapped child. I am in support of the bill, in general, in that it is designed to protect the consumer of health care in this province; and that protection is necessary. There is one area, however, that I feel could adversely affect not only my son, but also the thousands of other children in the province who suffer from the same syndrome, both diagnosed and undiagnosed.
First, I should tell you that my son has fragile X syndrome and my daughter is a confirmed carrier of the syndrome. Most of you I am sure have either never heard of fragile X syndrome or if you have, your knowledge is probably very limited. For that reason, I will briefly explain what it is and what affect it has on the individual.
Fragile X is an inherited abnormality of the X chromosome. In an individual with fragile X, there is a narrowing of the long arm of the X chromosome at the Q27.3 site. This narrowing of the chromosome causes varying degrees of problems for those who carry it. The effects range from mild learning disabilities to severe mental regardation, autism or autistic-like behaviours, behaviour problems, attention deficit problems, hyperactivity, sensory integration dysfunction, various medical problems such as mitral valve prolapse and a triad of physical characteristics which are: large ears, long, narrow faces and large testicles. Fragile X syndrome is the leading cause of mental retardation next to Down syndrome and the leading cause of familial mental retardation. It is also responsible for approximately 14% of the cases of autism. It has been estimated that one in 1,000 individuals are born with fragile X, yet very few are ever diagnosed with it.
This brings me to my first concern with Bill 43 and that is paragraph 26(2)1 which states: "Communicating to the individual or his or her personal 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 personal representative will rely on the conclusion." With fragile X, it is absolutely imperative that a diagnosis be given as early as possible, preferably at birth. My son was seven before he was diagnosed. The problem arises because very few doctors actually diagnose fragile X because they rely very heavily on the triad of physical features I mentioned earlier as well as the presence of retardation. Unfortunately the retardation is not always present or if it is, it is not an across-the-board retardation as is the case with Down syndrome.
To complicate the situation, the triad of physical features is not present in all FX patients and those who do have the features generally do not get them until after puberty. This can cause a delay in diagnosis of up to 13 years or can result in no diagnosis at all. My son was seen by several doctors, including a neurologist, and they all missed the diagnosis. It was not until we insisted on FX testing that a diagnosis was made by chromosome analysis. There are two professions, however, that have been very helpful in assessing and explaining to us the symptoms of fragile X in our son. One is an occupational therapist and the other is a speech language pathologist. As the health act reads now, neither one of these professionals could perform a "controlled act," paragraph 26(2)1.
The two areas that affect virtually all fragile X children are sensory integration dysfunction and speech and language delays. Doctors do not generally do either sensory integration assessment or speech-language assessment, nor do they usually interpret the results of such assessments. This is done by the professionals in the field, occupational therapists and speech language pathologists.
Obviously, not every child with either sensory integration problems or speech-language problems has fragile X syndrome, but it is my right as a parent to know what is a possible cause of these problems. It is obviously not a definite diagnosis. My family doctor cannot give me a definite diagnosis. That is done with chromosome analysis or DNA analysis.
One of my concerns with paragraph 26(2)1 is that an occupational therapist may not be allowed to tell me or another parent that my child's problems could possibly be caused by a specific disorder or several disorders. This would not only curtail their ability to properly apply their training, but it would also cause a considerable delay in information reaching me. In the case of fragile X, it is imperative that information reach the parent as quickly as possible.
Paragraph 26(2)1, as it stands, would also prevent an occupational therapist from telling me that my son has sensory integration dysfunction, simply because it is a dysfunction that causes specific symptoms. It seems rather ludicrous to me that an occupational therapist can do an assessment on my son for sensory integration but cannot tell me that my son has sensory integration dysfunction. To have to relay this information back to a doctor is simply overtaxing already overtaxed doctors and delaying therapy that should be started as quickly as possible.
It would also seem to me that this paragraph would curtail both occupational therapists' and speech-language pathologists' ability to explain to me how a particular disorder was causing my son's problem. As a parent, it is very important for me to understand that my son's insistence on certain types of clothing is not stubbornness but, rather, it is a symptom of tactile defensiveness.
This information takes a tremendous amount of pressure off both my son and myself and allows us to concentrate on more important things. This information is essential for me to know how to properly deal with my son's other problems and to help him develop to the best of his ability.
It is also important for my son to understand that his problems stem from a physiological cause; that he is not a bad kid. It is also important to understand that a doctor or other health professional may not be aware that sensory integration dysfunction occurs in fragile X syndrome, or if they are aware of it, they may not have as much information about it as an occupational therapist would have.
I would not expect an OT to explain to me or to give me much information about mitral valve prolapse, nor do I expect a doctor to give me much information about sensory integration dysfunction.
When I receive any information on my son, I want it to come from the professional in the field that I am dealing with. The controlled act 26(2)1 could prevent that from happening.
It is also imperative, in dealing with children who have fragile X syndrome, that a team approach be taken. For this to occur, professionals involved must be able to communicate freely with each other as well as with the parents.
The important thing to remember is a parent is the most integral part of the team. We are the ones who must co-ordinate and implement many of the suggestions made by the professionals. We are also the ones who live with our children and have the most concern for them. To help our children, we must be fully informed as to what the problems are and what the causes of these problems are. For this to happen, every professional must be freely able to communicate with us, to give us the information we need to help our children overcome their handicaps as much as possible.
Once again, the controlled act 26(2)1 could prevent this from occurring and the people who suffer the consequences would not be the professionals, they would be my children.
The purpose of the Regulated Health Professions Act is to protect the public; people like me. I believe the best way I can be protected is to be educated and informed. Some of this knowledge can be obtained by reading, but much of it comes from the varied professions I am involved with. Through them I have learned and can continue to learn how best to help my son deal with and overcome many of his handicaps. Because of this knowledge, I can find professionals who are truly qualified to help us and avoid those who are not.
It is my fear that the controlled act 26(2)1 could quite feasibly stop the stream of information and severely affect my son. I believe this possibility could be avoided, however, by the addition of a subsection to subsection 26(2).
I am sure that politicians and lawyers are much more qualified than I am to decide the wording of such a subsection. It should, however, be to the effect that regulated professionals would not be contravening a controlled act as long as the assessments and information relayed to the patient were within the realm of their expertise and training.
Such a subsection would ensure that my wife and I, as well as other parents, would continue to get the information that is actually and vitally needed to help our children.
Once again, I would like to thank you for giving me this opportunity to speak to you.
The Chair: Thank you very much for a very thoughtful presentation.
Ms Haeck: I recognize that you have become an expert on this particular syndrome out of the need that your own family has undergone. What kind of process did you undergo in order to find the experts who ultimately helped you?
Mr Gilbert: Initially we went to our family doctor. My wife is a psychiatric social worker, so we then went to a psychologist she happened to work with, who gave us the idea of developmental delays, etc. We then went to a specialist in Halifax, Nova Scotia. We then went to a neurologist in Halifax. The information we finally got as the diagnosis of fragile X came from a lay person. Since that time, we have also been in contact with speech-language pathology, occupational therapy, etc.
Ms Haeck: I have to say that we are all definitely very much concerned about the diagnosis and communication portion of the act. We have heard from a number of people who make this presentation, but we have also heard from consumer groups who have a very strong concern about public education, about the availability of various services out there. What you are describing is probably a lengthy process through which you went as a parent to find out what problems your son was having. How do you feel that the whole public education portion for the Ministry of Health should be structured so that other people do not necessarily have to go through such a long process?
Mr Gilbert: That is actually a very hard question to answer. I can speak only for fragile X. We have started up fragile X resource centres throughout Canada. There is a new association started up, and support from the ministry for this endeavour. Whether it be fragile X or some other disorder that is not well known, to get information to people is very difficult. How it could be speeded up is hard to say, because fragile X is a disorder that has been around for ever, but it really has only been diagnosed for the last 20 years, so you are in a position where a lot of professionals simply have never heard of it before. We do get professionals from across Canada phoning us asking for information on fragile X.
I do not think it is a matter of just simply sending out more information. The professionals have got to have the opportunity to speak freely to me.
Our occupational therapist was out the other day to give us the final results on my son's sensory integration assessment. I realized when I was talking to her that if this section went through, probably most of the things she had told me she could not have told me.
With fragile X it is very imperative. By the time these children hit puberty, most of the help they can have is over with. My son is already nine. If she could not have come out and given me that information on Saturday, I would now be in the position of making a doctor's appointment so my doctor could give it to me, and I would be talking probably six months down the road, because it is not an emergency situation as far as the health professions are concerned, which it is not. It is not life or death. It affects his life, but it is not an emergency.
The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee this morning.
Mr Gilbert: Next time I will bring my wife.
0950
RESPIRATORY THERAPY SOCIETY OF ONTARIO
The Chair: I would like to call the Respiratory Therapy Society of Ontario. You have 20 minutes for your presentation. We would ask if you would leave a few minutes at the end for questions from the committee. Please introduce yourself for Hansard.
Ms Bubar: My name is Dawn Bubar, and as a practising registered respiratory therapist in northern Ontario and a director at large for the Respiratory Therapy Society of Ontario, I am here to express both support and concern for Bill 43 and Bill 64 on behalf of the registered respiratory therapists of northern Ontario.
We are in support of Bill 43, the Health Professions Regulation Act, which provides for the regulation of health professions and the delivery of health care services. In general, with the exception of section 15, we support Bill 64, the Respiratory Therapy Act, which provides for the regulation of the profession of respiratory therapy by the College of Respiratory Therapists of Ontario.
As mentioned, we are concerned with section 15 of Bill 64, which covers the proposed restricted titles. Because of such concerns, we wish to recommend the following amendment to Bill 64. We request the addition of the word "registered" as follows:
"15(1) No person other than a member shall use the title `registered respiratory therapist';
"(2) No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as a registered respiratory therapist."
The term "registered" must be part of our restricted title, as it is with nursing, since there is a difference in the standard of education between a respiratory therapist and a registered respiratory therapist. The registered respiratory therapist is a graduate of an accredited educational program who has successfully passed the Canadian Society of Respiratory Therapists registration examination in respiratory therapy. These examinations are prepared and administered by a subcommittee of the joint Canadian Anaesthetists' Society, Canadian Thoracic Society and the Canadian Paediatric Society committee on respiratory therapy. The conjoint committee is a committee of the Canadian Medical Association.
On-the-job-trained personnel function in some health care facilities as respiratory therapists. Also, individuals who have graduated from an accredited facility but who have not yet written or who have not passed the Canadian Society of Respiratory Therapists registration exam are also called respiratory therapists. The term "registered" denotes that a specific level of prescribed education has been successfully achieved.
It is imperative for the protection and awareness of the public that the Respiratory Therapy Act, 1991, be amended as proposed. With the advanced technological practices and equipment that registered respiratory therapists are required to perform and to work with, it is imperative that the public be able to recognize, for their protection, the difference between a therapist who has received full training in all these areas and who has achieved a standard level of education, versus those therapists who have not received this level of education. We cannot emphasize this enough.
This would conclude my statements today, and I would like to say that a written submission will be forthcoming.
Mr J. Wilson: Is the term "registered respiratory therapist" what you would use now to distinguish?
Ms Bubar: Yes, it is. For those who have achieved or successfully completed the examinations by the Canadian Society of Respiratory Therapists.
Mr J. Wilson: So do you feel that this is an oversight in the act that we do not have it in there?
Ms Bubar: To my understanding, it was initially in there but it was dropped in the revisions that had been made, and therefore that is why we are back here again requesting that it be put back in.
Mr J. Wilson: Was it dropped, though, so that the act would be sufficiently broad to include those who may qualify for entry into the College of Respiratory Therapists?
Ms Bubar: I think it was dropped because they did not understand the difference between the respiratory therapists and registered respiratory therapists. I think the assumption was that they were one and the same, and we feel the distinction must be made for the protection of the public and for their awareness.
Mr J. Wilson: Would respiratory therapists, then, who do not have the title and the education of a registered respiratory therapist, require separate legislation to be registered?
Ms Bubar: No, they could still practise. They would still be under the same umbrella. It is just that we have to be able to distinguish between -- as in nursing, they graduate; they are a respiratory therapist, and once they complete the examinations to ensure a standard consistent throughout the country and province, then they become registered therapists.
Mr Wessenger: I would like to have ministry staff give some clarification in this regard.
Ms Bohnen: The effect of section 15 of the Respiratory Therapy Act as proposed would be to prohibit anyone other than a member of the college from using the title "respiratory therapist" or "registered respiratory therapist." If it is your view that people who have not become members of the college should be permitted to use the title without the "registered," I would think that presents to this committee the issue of whether the public could differentiate between registered respiratory therapists and respiratory therapists. I mean, the public interest issue that the government was seeking to advance was that the public needs to have a simple way of differentiating people, and the way you differentiate them is with this title "respiratory therapist," so do not let anybody except a member of the college use the title "respiratory therapist," "registered respiratory therapist," or some other variation of it.
Ms Bubar: That would take care of those persons who are using the title but have not received any training whatsoever. However, those who have successfully completed the educational process through an accredited facility have up to three years in which to successfully complete the Canadian Society of Respiratory Therapists examinations. In those three years, they can still practise as a therapist; they just have not achieved the next level up. So by prohibiting the use of calling them respiratory therapists or from leaving them out of the college, we have no control over a number of therapists who are practising for a period of up to three years.
Ms Bohnen: If I can just go on, it depends on how the college determines the requirements for registration or various classes of registration, as a respiratory therapist. The college could certainly say, and I am just making this up, "For three years, post whatever program you take, you are registered as a provisional member of the college," and those people could still use the title. There is not a direct link between who gets to register and the title. I will stop there.
The Chair: I would like to thank you very much for your presentation today. If in the course of these hearings there is anything further that you wish to communicate with the committee, please feel free to do so in writing through our clerk. Thank you very much.
1000
HANDICAPPED ACTION GROUP INC
The Chair: The Handicapped Action Group is next. Welcome to the standing committee on social development. We appreciate your coming before the committee this morning. You have 10 minutes for your presentation. We ask that you introduce yourself first for the record and leave a few minutes for questions from members of the committee. Please begin now.
Mr Holmwood: Good morning, Madam Chairman and members of the board. I am John Holmwood and I represent the Handicapped Action Group Inc. The recommendations contained in the above-named report and the suggested regulations in Bill 43 are a serious concern to the members of the board of directors of our organization. The Handicapped Action Group is a broad-based, multifaceted disabled consumer organization that provides non-professional attendant services -- support care, if you will -- to the physically disabled individuals in northwestern Ontario.
We feel that the recommendations and regulations will have adverse ramifications for all consumers in our catchment area. The entire independent living movement, including the Ontario government's commitment to community-based services, will be seriously compromised by the recommendations in the above-noted report. Presently, a number of services that this report calls "human health care services" are performed by lay individuals under the direction of individuals who are receiving the service. This service enables individuals to live independently in the community by assistance with those functions that they are unable physically to perform themselves.
Costs for these services are presently being picked up by the individuals themselves, insurance companies, the Workers' Compensation Board and the Ministry of Community and Social Services programs, ie, support service living units, outreach programs and vocational rehabilitation. Under this proposed legislation, unlicensed individuals carrying out services will be at risk of legal charges and, if convicted, fines or imprisonment.
While it is important that standards be developed, the whole area of service provided by these attendants should not be a health matter or part of the health legislation. If organizations such as ourselves are to provide comprehensive community-based service in this province, the issue related to the severely disabled adult must be appropriately addressed.
Section 28 of Bill 43 should include as exemptions to the act the following key points. These points were developed by an extensive consultation conducted by the Attendant Care Action Coalition:
(A) A relationship between a person with a disability, PWD, who self-directs his or her own service, and the attendant who assists, is unique in that all responsibilities and control rest with the person with a disability.
(B) An amendment to Bill 43 must apply only to the consumers of the attended services who self-direct their own services.
(C) Self-directing assistance with routine functions of a daily nature by reason of having a physical disability is part of a healthy, socially active lifestyle and not a health-related activity.
Legislation that looks at controlling and regulating attendant services or undermines the responsibilities of the consumer who self-directs those attendants on the basis of physical disability is discriminatory and violates the basic human rights of the persons with disabilities to live independently in the community. I thank you very much and I will take any questions.
The Chair: I have a request from the parliamentary assistant to clarify. I also have a copy of Hansard with us that addressed this issue at an earlier time during the committee. I will ask the clerk to give you a copy of that.
Mr Wessenger: Thank you very much for your presentation. I assure you the previous minister and the existing minister have both confirmed that your concerns will be attended to. It is really just a question of working out the mechanics of ensuring that this care is not affected by this act. I can assure you it is being worked on now and there will be changes to the legislation.
Mr Hope: I was just going to elaborate a little bit more, as you raised some concerns, and being the parliamentary assistant to the Minister of Community and Social Services. A number of concerns you raised deal with attendant care, as you understand, the multi-year plan, where we are trying to make sure most people are out of institutions and into the community living, and also with long-term care. It is our goal to make sure there is quality care and at the same time attendant and other care and making sure a person lives independently in the community and, as you reiterated on your concerns, as a lay group, understanding what is going on and making sure the important values of service provided in communities such as this one are essential to people living in the community. Your concerns have been echoed a number of times and we will make sure those parts of the legislation are addressed and clear.
The Chair: Thank you very much for your presentation before the committee today. We appreciate your coming forward. The committee would be happy to receive any further submissions in writing at any time over the course of these hearings.
Mr Holmwood: Thank you. I think it is on its way.
The committee recessed at 1005.
1023
DONALD HOOD
The Chair: The standing committee on social development is now in session. I would like to call Donald Hood. You have 10 minutes for your presentation. We would ask you to leave a few minutes for questions from the committee.
Mr Hood: I am Donald Hood. I am here speaking as an individual, though I am a professional in the field of audiology in northwestern Ontario. I am actually wearing two hats today. One of them is as a private practitioner in the field of audiology in Thunder Bay, and I have been here for 13 years. I chose to come to this underserviced area of the province on my own, I might add, at no cost whatsoever to the Ministry of Health or the taxpayers of this province.
The second hat I am wearing is as a co-founder of the Canadian International Hearing Services, which is a federally registered charitable non-profit organization that helps developing nations of the world establish viable, effective, efficient hearing health care services. We have been doing that since 1976, so that is 15 years. We work in an ongoing way in about 20 nations. In fact -- I apologize for my slightly slurred speech -- I just got off the plane from India, doing the same thing over there. My apologies in advance if I seem to lapse a bit in my 10-minute time period.
I wanted to address the issue of perhaps missing the forest when you are looking at the trees, with respect particularly to the issue of diagnosis and prescription. In the field of audiology this relates to informing the patient, obviously, about the results of the testing and then prescribing an appropriate course of remediation that is non-medical and non-surgical.
Also, I would like to touch briefly on our definition of "risk of harm," which I know this committee has dealt with probably in great depth. In the field of audiology, I jokingly say, there is no such thing as an emergency hearing test, which is one of the reasons I chose this field. I do not get called at 2 o'clock in the morning to come in to do a hearing test. We are not concerned with life-and-death matters. We are not concerned with loss of limbs. We are not concerned with matters like that.
But we are concerned with harm that can arise out of inappropriate management, inappropriate diagnosis of hearing impairment in the area of physical harm, where a person may in fact be inappropriately fitted with something like a hearing aid or an assistive listening device -- something other than a hearing aid -- or where the hearing aid may be too powerful and in fact cause additional hearing loss.
Then there is the area of psychological harm: If a person is fitted inappropriately he may become more depressed. He may in fact turn other people, who can benefit from a hearing aid, off seeking help because of the misfitting.
Social harm: Inappropriately fitted means they will not be able to integrate as well into society if they have not been counselled appropriately and fitted appropriately with a hearing aid or assistive device.
Vocational harm: If they are inappropriately fitted with a hearing aid they may in fact not fit back into the workplace adequately or as effectively as they might if they had been treated and handled adequately.
Again, we are not really talking about life-or-death matters, but quality-of-life matters, and there is a continuum of quality of life. As in any health care field, when care is provided, that care provides little or no help or a great deal of help, so there is this continuum of improving the quality of life. Our objective, as health care professionals, and for me specifically in audiology, is to move the person as far as I can along that quality of life continuum, so that we do not cause physical, psychological, social or vocational harm.
I think we can best achieve this by dealing with hearing health care, as I advise other nations to deal with hearing health care, in a holistic way, by dealing with the four factors of health care. These are not new to you either: identification, assessment or diagnosis, management -- or, in this case, prescription -- and prevention in education. Those are the four topics we deal with internationally, and they address virtually all aspects of hearing health care and other kinds of health care as well -- identification, diagnosis, prescription in this case, and prevention in education.
As with the quality-of-life continuum, dealing with these four factors is also on a continuum; each one must be addressed by the professional with four things in mind or four bits of knowledge. One is the depth of current knowledge. The second is an understanding and availability of the latest technology. The field of audiology is very young. We grew out of the Second World War. About the time I was born, audiology was born. Third, we need good communication skills to convey information to the patient, and you can only do that if you have a good background of knowledge, the number one issue that I referred to.
Fourth, you need appropriate motivation. That is to say, a person should choose to be in a caring profession to deal with all aspect of hearing loss, all those aspects I mentioned just a few moments ago, and not with the main reason of making a living from the sale of hearing aids.
When the diagnosis and prescription process is approached in this holistic way -- that is, dealing with all four of those topics: identification, diagnosis, prescription or management, and prevention in education -- the government of Ontario will have attacked the problem of hearing loss with the best quality-of-life bang for the taxpayers' bucks. More appropriately prescribed hearing aids, funded in large part, as you know, through the Ministry of Health assistive devices program, would be worn more often rather than left in dresser drawers. Ladies and gentlemen, there is no such thing as a hard-of-hearing drawer, but that is where they end up. Thank you for your attention this morning; I will be pleased to answer any questions you might have related to this area.
Mr Owens: The hearing aid dispensers have argued that if the legislation goes through as proposed, access to service, especially in the north, is going to be limited, which is going to result, I guess, in a duplication of billing to OHIP, having to refer south or to the nearest audiologist. Is that the case?
Mr Hood: This committee has already been presented with information in the brief from the Ontario Association of Speech-Language Pathologists and Audiologists: statistics showing very clearly from the assistive devices program, from the Department of Veterans Affairs and from the Workers' Compensation Board that in fact, in underserviced areas of this province, audiology services are more accessible to the public than they are in urban areas. You can get in to see an audiologist more quickly in northwestern Ontario than you can in Toronto, due in part to the fact that people like myself have chosen to come here, and because we feel we provide in this area, a more efficient and effective service in audiology than perhaps in Toronto. That is my own personal opinion. But to answer your question, accessibility is very much better in the north than in the Toronto area.
Mrs McLeod: We are running out of time and, in any event, Don, I am not sure that I want to draw you into an area which you did not address in your presentation, although it is one we have talked about, and that is the question of the use of the doctoral term for PhD-trained people in the health field. It may be something you do not want to pursue today.
Mr Hood: After thinking about the issues and discussing this with my colleagues in Toronto, I felt that this particular issue of the holistic approach, of dealing with hearing impairment, was more critical than dealing with the doctoral issue, although that is an equally important one.
The Chair: Thank you very much for your presentation before the committee. If there is anything further at any time, please feel free to communicate with us in writing.
1030
ROGER PATOLA
The Chair: I would now like to call Roger Patola. Welcome to the standing committee on social development. You have 10 minutes for your presentation. We would ask you to leave a couple of minutes for questions at the end.
Mr Patola: I own and operate a ski retail business and I am an avid skier. I am told that the proposed new law would prohibit chiropractors from diagnosing non-spinal joint disorders, and I am here to criticize this as a retrograde step that makes no sense to me. When my chiropractor, Dr Dan Gleeson, asked me to take time to appear before this committee I readily agreed for reasons I now explain.
Although my main sport is skiing, I have played a lot of basketball, football, hockey and racquet sports. Over the years, I have had many injuries from minor joint strains to severe sprains. Like many people I know I started by seeking medical advice, but then found that chiropractors seemed to be able to provide much more detailed diagnosis and effective treatment.
It is obviously going to cut down on freedom of choice in the marketplace if chiropractors are now prohibited from diagnosing joint problems, and the law recognizes medical doctors as the only ones able to do this. This seems to be against the interests of consumers. Changes to the health care system should give more options for effective, less costly treatment, such as chiropractic, rather than requiring referral to the medical profession for diagnosis.
One of my worst injuries was a shoulder separation while skiing about 10 years ago. Conditions were very hard and icy. I flew over the top of a knoll and lost a ski and slammed into what we call a mogul. I separated my shoulder and the pain, let me tell you, was intense. I wanted very thorough investigation and treatment of this problem because I was in the middle of the racing season in Thunder Bay and on the Molson senior circuit and I was building for the North American ski championships at Lake Tahoe.
My previous experience had been that medical doctors could not understand these injuries well or offer effective early treatment. By this time, for various injuries I had been to see Dr Dan Gleeson, a chiropractor here in Thunder Bay, with good results. I saw him, he did a wonderful job and I was back racing -- admittedly with the arm in a sling, and gingerly -- two days later.
With a problem like this, Dr Gleeson seems to be able to diagnose and treat all the elements, the restriction in the shoulder joint itself and the contributions of all the tendons, ligaments and muscles. He spent a lot of time with me, moving the joint and working all the muscles. Because he got to the source of the problem quickly and treated all the affected tissues extensively, the improvement was dramatic. As I say, I went from excruciating pain to ski racing within two days.
Currently, chiropractors are allowed to diagnose and treat shoulder joints and other non-spinal joints. As a member of the public, I have shopped around and found that a chiropractor can make a more accurate diagnosis than anyone else. I fail to see how it can be in the public interest to pass a law prohibiting this.
I put a little note at the bottom. A medical doctor's eyes are his scalpel. A doctor of chiropractic's eyes are his fingers. Both get results, one with a lot less mess.
I am open to questions.
Mr Beer: I would say to Mr Patola in the first instance that we have had a number of submissions on this point. The Ontario association did present specifically on this matter and it is one I think we recognize that we do need to look at very carefully. I guess the issue, as you put it, is in terms of how we relate consumer choice to protection of the public, and I take it, in your view, in your own experience, you believe that this is an area where as a consumer you should be able to make that choice with respect to a chiropractor.
Mr Patola: Most definitely. There are a lot of athletes around and there are more older athletes around now. They are the ones who need treatment for a lot of sprains and things that we get as we go along. We tend to overuse our body. The medical profession can give you pills and do this and do that, but the chiropractors can go right into the source of the problem, move things around and, doing that, get the blood supply going through that system and make sure that the healing occurs a lot faster than if you have to just be immobilized for a long period of time.
The Chair: Thank you very much for your presentation before the committee.
ONTARIO ASSOCIATION OF SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS
The Chair: I would like to call now on the Ontario Association of Speech Language Pathologists and Audiologists, Thunder Bay branch.
Please come forward and introduce yourself to the committee. You have 20 minutes for your presentation and we would ask if you would leave a few minutes for questions from members. Welcome. Please begin your presentation now.
Ms Ball: Thank you. My name is Judith Ball. I am here representing OSLA. I will use that term rather than the full name. I thank you very much for this opportunity to appear before you.
Speaking, hearing and understanding are essential skills in today's information-driven and service-based society. People who have a disability which prevents them from communicating normally are isolated from friends, family and colleagues and often from education and employment as well. These disabilities can affect all age groups, from infants to the elderly.
Speech-language pathologists and audiologists are professionals who assess and treat people with speech-language and hearing disabilities. These specialists, working co-operatively with other professionals, provide services through hospitals, schools, rehabilitation centres, government agencies, universities and private practice.
As members of a professional association, OSLA, we welcome the majority of regulations and recommendations set out in the Regulated Health Professions Act and the accompanying Audiology and Speech-Language Pathology Act. There are several key issues, however, which OSLA feels should be more clearly defined or expressed in the legislation to ensure that the public interest is protected.
In general practice today, audiologists and speech-language pathologists assess, diagnose and treat a very specific group of communication disorders and dysfunctions. As a logical extension to this scope of practice, they routinely present conclusions to the patient or the patient's family and counsel them regarding the results of the assessment as part of the assessment process.
OSLA has serious concerns about subsection 26(1) of the Regulated Health Professions Act, and I am not going to read this. It is in my brief and I know you are all very familiar with the wording. As currently written, only physicians and psychologists would be allowed to communicate the conclusion of a hearing or speech-language assessment to the patient. For the patient, this means visits to an audiologist or speech-language pathologist for the assessment, then to a physician or psychologist, who may have minimal knowledge or understanding of the assessment process, for the conclusion, then a return to the audiologist or speech-language pathologist for treatment. This could result in the patient receiving less than completely accurate explanations of assessment results and ultimate confusion regarding the expected course of treatment.
Most important, however, this process will result in unnecessary delays in the start of treatment, delays that have been known to have a negative impact on the rehabilitation process. Early intervention is considered to be essential in dealing with both hearing and speech-language difficulties. Considering the fact that many of our clients have initial waiting periods for assessment, it is vital that once the initial assessment has taken place the conclusion be communicated immediately to the client or his or her representative and that, where indicated, the rehabilitation process begin immediately.
OSLA believes that in the case of communicative disorders or dysfunctions, assessment and diagnosis are inseparable. Assessment is the process by which the audiologist or speech-language pathologist tests the patient, draws conclusions regarding the disorder or dysfunction and decides the best course of treatment.
1040
In the spirit of the new health care legislation, patients must have the right to discuss their assessments and resulting diagnosis with the professional best trained and most knowledgeable in the area. As the legislation is currently written, it would be impossible for audiologists or speech-language pathologists to discuss with their patients the results of their assessments and diagnosis of their condition.
These restrictions will cause particular hardship for patients in remote communities who must travel significant distances for an assessment by a qualified audiologist or speech-language pathologist. In these cases the client would be unable to complete the assessment, receive the results and immediately begin a course of treatment. Rather, this process may require several visits at considerable cost, time away from work and delays in the initiation of rehabilitation. In the worst scenario, the patient or family may determine that the whole process is too time-consuming, expensive and frustrating and therefore may not seek what may be a service that could dramatically change that individual's quality of life.
In the case of Ontario's native peoples, the services of a speech-language pathologist and/or audiologist may be available either periodically on specific reserves or available in communities within reasonable access. Because of language and cultural differences, these visits are difficult enough and at times lead to confusion and lack of understanding. With the ability to give immediate feedback of assessment results and allay concerns and fears, the speech-language pathologists and audiologists can and have provided a comprehensive, high-quality, user-friendly service. In many of these situations there may be only a once- or twice-yearly visit to the community; therefore, it is vital that following the assessment, where indicated, a course of treatment involving significant support workers in the community be initiated. To date, this is the accepted course of assessment and feedback of results and treatment in native reserves provided by physicians, dentists, optometrists, audiologists and speech-language pathologists. We ask that in the interests of this particular segment of our society the status quo continue.
As often stated, the basic purpose of the act is to set up autonomous self-regulating professions, accountable to the public, and which operate within their areas of expertise. Section 26, as written, undermines the whole foundation on which the legislation is based: the need for a more open, responsive and accountable health care system.
One of the ways in which the act will provide greater public protection is through restriction of titles to the regulated professions. Bill 44, subsection 15(1) restricts the use of the title "speech-language pathologist" and "audiologist" to members of the college. OSLA strongly supports the title restriction in the act, as it provides precise language for the public to distinguish between regulated and unregulated health care providers. For this reason, OSLA believes that it is essential to the protection of the public that the title "speech therapist," which is the historical designation for the profession of speech-language pathology, also be restricted under the act.
Within many settings, including school boards, government agencies and hospitals, "speech therapist" is used as a professional title and a descriptive title in many recruitment ads and job descriptions. Many members of the public, as well as other professionals, continue to use the title "speech therapist" when seeking the services of these professionals. In the past there has been confusion and discussion about the difference between professionals using either the title "speech-language pathologist" or "speech therapist." By not protecting this title under the act, the public might be confused as to whether individuals using this title are qualified and regulated.
As well, protection of this title protects the public from individuals who call themselves speech therapists but who are not qualified in the field of speech-language pathology.
Because of the various resources and different levels of service available to consumers in northern and remote rural communities, we are not looking to restrict or limit these services. We are, however, wanting the public to be aware of and have an understanding of the types of speech-language and hearing services they may access.
In many smaller northern communities, speech and language programming in schools is provided by teachers, with additional courses or professional development in communication disorders. These people are generally referred to as speech-language teachers and speech correctionists. Similar services are provided in preschool programs by infant development and mental health workers.
These services often complement the work done by the speech-language pathologist; however, they are a different level of service and certainly do not replace the assessment and subsequent programming provided by an individual whose specialized training and scope of practice is strictly in the area of communication disorders, that is, the speech-language pathologist/speech therapist. With the act protecting the titles "speech-language pathologist/speech therapist," the consumer will have the option of choosing the desired level of service in an informed manner, with the knowledge that there are variations in the services available and those who provide those services.
Because of the broad range of services provided to the communicatively handicapped across various settings, we believe the legislation should remove the phrase "providing or offering to provide, in Ontario, health care to individuals." Given this narrow wording, consumers seeking these specific services outside of health care facilities would have no protection under this legislation. As stated above, with the growing number of audiologists and speech-language pathologists employed outside of health care -- in schools, Community and Social Services agencies, industry and private practice -- we must offer the broadest scope of title protection in order that the consumer is always protected, regardless of the setting in which the service is accessed.
Bill 44, subsection 15(2) reads, "No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as an audiologist or a speech-language pathologist or in a specialty of audiology or speech-language pathology."
This loosely worded section may lead to ambiguity of service available. We would like, therefore, to have a more precise definition of holding out using the following wording: "No person shall take or use any name, title or description implying or calculated to lead people to infer that the person is qualified or recognized by law as an audiologist or speech-language pathologist or speech therapist."
With this definition, in all cases and in all settings, those claiming to be qualified audiologists and speech-language pathologists are exactly that. This will ensure that patients can choose their own form of health care with a clear understanding of the qualifications and professional responsibility of the care giver, first by way of titles used, and second by the way the services are described. As stated in the brief presented to this committee by OSLA in Toronto on August 12, there is ample precedent for more clearly defined legislation as documented in Bill Pr70, passed in June 1990, An Act respecting the Human Resources Professionals Association of Ontario.
I am not going to cover the section that is included in my brief on hearing aids and the scope of audiology. Dr Hood did a fine job of that on his own. So I will come down to my conclusion now.
In conclusion, OSLA supports the introduction of the Regulated Health Professions Act, 1991, as a positive move towards providing the consumer with necessary protection in accessing the professionals working in audiology and speech-language pathology. We strongly encourage the standing committee on social development to consider the concerns expressed above and recommend the necessary changes to the Minister of Health.
We are concerned that with the existing restrictions, especially in the area of diagnosis, many audiologists and speech-language pathologists, most particularly those working in private practice, may feel that the limitations placed on them will force them to relocate to another province. With the existing shortages in these professions already evident in this province, specifically in northern Ontario, we cannot afford a reduction in services. In addition, the extra costs to the health care system both in time and dollars will put a greater strain on health care delivery than ever before.
Thank you. I am open to questions.
Mr J. Wilson: In this part of Ontario, are there a number of people who are holding themselves out as speech-language pathologists or speech therapists who are not necessarily trained sufficiently in those areas?
Ms Ball: I do not believe there are people who actually come out and state that they are speech-language pathologists or speech therapists. People do state that they are offering speech therapy without appropriate credentials. I am aware of that having happened, as has been conveyed to me by many parents who have accessed services and have indicated to me, "Yes, my child has received speech therapy before." When we discussed where the speech therapy was delivered, it was not actually speech therapy, it was services offering some remedial aspect of speech and language but it was not provided by a speech-language pathologist. So that is where our concern comes in. People do not stand up and say, "I am a speech therapist," but they lead parents to believe that they are offering a comparable service.
Mr Owens: Can you tell me the difference in the academic qualifications around a speech-language pathologist and a speech therapist? Second, while speech therapists will not be regulated, should they themselves also be allowed to communicate an assessment?
Ms Ball: There is no difference in qualifications. That was one of the points I was trying to make: that there is no difference. Historically, our profession started out as being titled "speech therapist." Many British-trained and European-trained people in the area whose qualifications have been recognized in Ontario as being equal to those of a speech-language pathologist have what is termed a licentiate in speech therapy. So they hang a diploma on their wall that calls them speech therapists. Their credentials are identical.
That is why we are looking to regulate that, because I think it could be somewhat confusing to the public. They seek services from somebody who has a diploma that says "speech therapist" as opposed to somebody else who has a diploma that says "speech-language pathologist" when in fact the credentials are essentially the same. That is why we feel it is very important to protect these titles, because the public has a right to realize that these two are the same. There has been confusion through the years with people asking, "Are you a speech-language pathologist? Are you a speech therapist?" and I try to explain that the two are exactly the same.
There is a difference in terms of some of the other terms that are used in the speech and language area, one of those being speech and language teacher or speech correctionist. Those people are essentially teachers who take some extra development in the speech and language area, but they are not trained in speech-language pathology/speech therapy specifically.
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Mr Owens: In terms of extending the right to communicate an assessment, you would draw the line, then, at speech-language pathologist/speech therapist as opposed to extending it further?
Ms Ball: Yes.
Mr Beer: Could you tell us how, in the present circumstance, you would work with a patient around this assessment diagnosis question? I think sometimes it helps us to understand how you do it today versus the concern about what this would mean.
Ms Ball: I operate a small, part-time private practice. In my practice, patients generally come to me because there is a long waiting period in the clinical setting. They come to me because they know they can have an assessment immediately and can find out immediately if there is a problem, especially when we are dealing with very young preschool children. So in my practice, a parent would come with a child and I would assess the child. Immediately following the assessment, I sit down with the family and discuss my findings and I tell them whether or not I feel there are difficulties. If in fact there are difficulties, we begin to chart a program. We offer parent programs. We cannot slot these people into our parent programs if we cannot tell them there is something wrong with the child. It is a matter of giving immediate feedback and it is part of the entire process.
If things stay the way they are written in the act, I will have to say to parents: "Thank you very much for coming with your child. I will write a report. By the time it gets to my secretary and gets typed, it might be a couple of weeks. It will go to your family physician. By the time you get to see him, it might be a couple of weeks, and that is being lucky. If he or she is able to convey my results as accurately as I would be able to convey them, you might have some idea of what is happening. Then you will have to book another appointment with me, and maybe the whole process, after six months, can get started," as opposed to starting immediately.
Mr Beer: I take it those people come to you, in most cases, on their own or through the school, or would they have been referred by a medical doctor?
Ms Ball: The majority of my private clients are referred by a medical doctor.
Mr Beer: What would you do at the present time following your assessment and discussion with the patient? Would you then send a report or talk over the phone with the doctor again? What is the ongoing link there?
Ms Ball: I send a report. I give a copy of the report to the family. First of all, I give in-person feedback immediately following the assessment report, as much information as I can possibly give the family, as well as some management strategies for them to follow immediately upon leaving my office. I send a report to the physician with an open-ended comment at the end of my letter saying, "If there are any things you would like to discuss about my report, please feel free to contact me." So the physician, in the case of the physician referring, always gets a report. If it is a patient referring himself, then I ask the family, "Would you like me to send a copy to your family physician?" In most cases they do like that to happen.
Mr Beer: So the concern is that, as you read and as your association reads this legislation, you would not be able to do that? I guess what has been said by the government, the previous one and this one, is that there is no intention to limit your ability to make assessments, but you would still see there needs to be a more specific definition of the assessment clause in your own act so that you could communicate that?
Ms Ball: Absolutely. I think otherwise we are just doing half of our job and we are sending people away without the complete assessment being carried out. If I can take it one step further, although audiology is not my area, I work very closely with audiologists. This is very much the case in an audiology office, where the audiologist assesses, especially when we look at a young child who needs amplification if there is a hearing loss. The way it sits now, when the audiologist does an assessment, if in fact he or she finds a hearing loss, an impression is made immediately so that a hearing aid can be fitted as quickly as possible. This will not be able to happen if the legislation goes through as written, because in order to begin to fit the hearing aid and to take the ear mould impressions, the audiologist would have to convey what he or she has found in a diagnosis, and he or she will be unable to do that. So we feel we are being cut off halfway, that we cannot carry out the complete process in the logical way and the way we have always been doing it.
We are the people who are trained. Physicians are well trained in the area of medicine, but they are not trained in the areas of speech and language development and disorders and hearing disorders and diagnosis of hearing disorders. They certainly do not have the level of training that speech-language pathologists and audiologists have, and I know that physicians with whom I interact make it abundantly clear that they wish me to give the feedback to the families, not themselves.
The Chair: Thank you very much for your presentation. We appreciate your coming before the committee today.
MARY C. MARASCO
The Chair: I would like to call next Mary Marasco. Welcome to the standing committee on social development. You have 10 minutes for your presentation, and if you would leave a couple of minutes for questions from the committee, we would appreciate that.
Ms Marasco: Good morning, Madam Chairman, committee members. My name is Mary Marasco and I am a physical therapist at the rheumatic disease unit at St Joseph's General Hospital here in Thunder Bay. I received my degree of bachelor of science, physical therapy, from the University of Toronto.
I would like to take this opportunity this morning to express my pleasure with the proposed legislation. I am very pleased that physiotherapists have been recognized as primary care givers. I am also very pleased with the suggested amendment to Bill 62, the Physiotherapy Act, that has given us the controlled act of tracheal suctioning, which is something we currently do.
However, there are three major concerns with the proposed legislation. This morning I will only offer you my biggest concern, one that I feel is extremely important to the practice of physical therapy, and that is protection of title. We have two equally valid descriptors: physical therapist and physiotherapist.
In the province of Ontario and throughout Canada, physiotherapists are also recognized as physical therapists. Historically speaking, in Ontario many physiotherapists were foreign-trained. Many came from Britain and used that designation. Throughout the rest of the world, and particularly the United States, the title "physical therapist" is used. Hence the use of both titles here in Ontario.
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Today most Canadian physiotherapists graduate with a degree as physical therapists, like myself. The Drugless Practitioners Act, which is the present legislation governing the practice of physiotherapy, protects both titles. Seven out of nine provinces also recognize and protect physiotherapists and physical therapists.
The cornerstone of the Health Professions Legislation Review when it was enacted in 1982 was to protect the public from harm. This is what I based my thesis on when I graduated. Restricting the use of professional titles was identified by the Schwartz commission as a means of protecting the public from unlicensed, untrained and unethical practitioners who hold themselves out to be something they are not. The present wording of the RHPA, as it stands today, does not protect the title "physical therapist." I believe this will be confusing and misleading to the public and contrary to the fundamental principle of the legislation, which is, to reiterate, to protect the public from harm.
Through my clinical experience and in speaking with my clients, they view physical therapists and physiotherapists as the same thing, with equal training, education and competency. Many other health care professionals with whom I work also recognize the two terms as synonymous. The potential here for harm exists when the public seeking physiotherapy tries to distinguish between a regulated, licensed physiotherapist from an unregulated, unlicensed and possibly unqualified individual holding himself out to be a physical therapist.
As a concerned physical therapist, I believe that in order to protect the consumer, prevent confusion and be consistent with the present legislation, as we are regulated now, the two titles, "physiotherapist" and "physical therapist," should be protected titles. My recommendation to the standing committee is to amend Bill 62, the Physiotherapy Act, to include "or physical therapists" wherever "physiotherapist" occurs.
If you have any questions, I am open to them.
The Chair: Thank you very much for your presentation. A question, Mr Beer?
Mr Beer: On the issue of speech therapy, I wonder if I could direct a question to the parliamentary assistant. In the discussion in Schwartz, did he set out a specific reason why he felt that the speech therapy --
Mr Wessenger: Physical.
Mr Beer: Sorry, physical -- I am getting confused this morning -- but why that term should not be protected? We have had this raised now on countless occasions. What was the reason?
Mr Wessenger: I will ask ministry staff to respond to that.
Ms Bohnen: Alan Schwartz, in the review, felt the public was best served by having a minimal number of well recognized, well protected titles used -- protected and used to identify members of the profession. For each profession, the review determined which title was that title. For this profession the review determined that "physiotherapist" was the title by which most people in Ontario identify members of the profession and that the terms "physical therapist" and "physical therapy" were more generic, but that people in Ontario really recognize their practitioners as physios.
Mr Beer: One follow-up question, then. In your own work, how do you refer to yourself and what do most of your colleagues call you, when they are being nice?
Ms Marasco: I refer to myself a physical therapist, because that is what I graduated with. Commonly, in the health care setting, we are termed "physiotherapy," but that is inconsistent and we go by both.
The Chair: Thank you very much for your presentation before the committee today. If, in the course of these hearings, there is anything further that you would like to communicate, please do so in writing. Thank you very much.
ONTARIO SOCIETY OF OCCUPATIONAL THERAPISTS
The Chair: I would like to call next the Ontario Society of Occupational Therapists, region one. Please introduce yourself to the committee. You have 20 minutes for your presentation and we would ask you to leave a few minutes for questions by the committee.
Mr McHugh: On behalf of the Ontario Society of Occupational Therapists, region one, welcome to Thunder Bay. My name is Tom McHugh, and I am an occupational therapist working in the field of mental health at the Lakehead Psychiatric Hospital. I am also a director of the Ontario Society of Occupational Therapists which represents Ontario's 2,300 occupational therapists. As director for region one, I represent therapists practising from Marathon in the east, all the way west to the Manitoba boundary. I have four goals for the time that I spend with you today: first, to tell you something about my profession; second, to communicate our response to the proposed Regulated Health Professions Act; third, to point out two small problems, largely problems of language that we fear may limit our current scope of practice; and finally, to answer any questions that you raise.
You will find all of my points outlined for you on the three photocopied sheets that I have provided for you. First, my profession: Occupational therapists believe that human beings have a need to be purposefully engaged in meaningful activity in order to be well and whole. Using purposeful activity as a treatment, occupational therapists work to prevent disability and to promote, maintain or restore wellbeing and function in three broad areas: self-care, leisure and productivity. We follow a process of assessment, program planning, treatment, discharge, follow-up and program evaluation in the treatment of clients.
For example, it is the occupational therapist who will assess the living skills of a person who suffers a stroke, work to maximize these skills through daily treatment sessions, make recommendations on adaptations in the home, or oversee the prescription and purchase of a wheelchair. In treating a person with chronic schizophrenia, the occupational therapist might focus on developing such essential skills as budgeting, using public transit, cooking a simple meal, or doing laundry. We work to give people of all ages and capabilities control over their own lives.
Bill 43, the omnibus bill, and Bill 58, the act to regulate occupational therapists, are, we feel, an important acknowledgement of the important role that occupational therapists play in the delivery of health care in the province, and an excellent means to enhance public protection in health care. Legislation has been the dream of the Ontario Society of Occupational Therapists for 20 years. We are delighted to have this opportunity to communicate our support for the thrust and principle of the proposed Regulated Health Professions Act.
I would like to point out, however, on behalf of the society, two concerns about specific components of the act. In Bill 43, paragraph 26(2)(1), it is stated that only those professions allowed the controlled act of diagnosis or assessment may communicate a conclusion identifying a disease, disorder, or dysfunction as the cause of symptoms of the individual. The controlled acts of diagnosis or assessment are not present in our act. This poses a problem for us. It may mean that the communication of the results of our assessment would have to be done by the doctor. I think that Mr Gilbert has given an excellent example of how this limits current practice as it relates to a child with fragile X syndrome. Let me give you another example.
If your parent is admitted to hospital with a stroke, the doctor may communicate that to you, but what does that mean to you? It may mean partial or whole paralysis of one side of the body. It may mean visual neglect of one side of the body or environment. It may mean spasticity in the hand or arm, or even depression. It will require skilled assessment by a number of professionals, occupational therapists among them, to identify these symptoms.
Our current practice would be to communicate these symptoms to the patient and the family, and help them cope with the impact that they will have on daily living. No provision for these activities is contained in the act. We propose that a paragraph be added to subsection 26(2) which identifies that a person regulated under the Regulated Health Professions Act not be in contravention of this section when performing assessments that are within the scope of their practice, including the formulation of assessment conclusions, and the communication of such to clients.
Finally, the title "occupational therapist" is only protected in the provision of health care. Occupational therapists practise in a broad range of settings which may not be identified as health care. For example, occupational therapists may practise in the school system and in the manufacturing and insurance industries. We feel that subsection 14(1) of the act to regulate occupational therapy should not stipulate title protection in the provision of health care only, but across the diverse settings in which OTs practise. As well, the society suggests the strengthening of the holding out clause, Bill 58 subsection 14(2). This amendment would prevent individuals from misrepresenting themselves as occupational therapists, or from implying that they are qualified to practise occupational therapy.
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To sum up, the society strongly supports the proposed acts. We do have some recommendations to make in the wording of Bill 43, as it pertains to diagnosis, and in the wording of Bill 58, as it pertains to title protection and holding out. You will find our positions regarding diagnosis, title protection, and holding out outlined on the sheet entitled "Position Statement." More important, you will find proposals for specific amendments on the sheet entitled "Proposed Amendments." Thank you for your attention today. I will try to answer any questions that you may have.
Mrs McLeod: Thank you for the presentation. I was interested in the recommendation that you have made about an addition to the diagnosis clause. One of the issues that I think the committee has been looking at to deal with the question of assessment and communication for those who are regulated under the act, is whether or not a definition of assessment, which allows for that communication, would be of assistance. But you seem to have added a component that would ensure that the diagnosis clause would not override that kind of definition. I gather that your association feels it is important, that you not just define assessment but make sure the diagnosis clause would not override the definition?
Mr McHugh: That is right. I can just speak personally. I think that for a long time the occupational therapists' society has been talking about diagnosis, and I really wondered what the fuss was about. But when it is read in the act it really does limit our current scope of practice. I do not want to be the person who tells a patient that they have had a stroke. That is certainly in the ongoing treatment that I am going to provide after that. I want to be able to freely discuss what stroke means to that individual.
The Chair: Thank you very much, it was an excellent presentation and we appreciate your coming before us today.
RUPERT FLATT
The Chair: I would like to call next, Rupert Flatt. Welcome to the standing committee on social development. You have 10 minutes for your presentation. We would ask you to leave a few minutes for questions at the end.
Mr Flatt: Ladies and gentlemen of the committee, my presentation is brief, pertaining directly to subsection 26(2) of Bill 43. The inference of a prohibition of the giving of information in response to a question asked by a patient of a practitioner is not only confining but frustrating. I personally have an interest in any information pertaining to my wellbeing, or my family's, and I expect questions to be answered when they are in the realm of the practitioner's knowledge and training. I do not know how practitioners can operate effectively without asking questions themselves of the patient, and the practitioner will receive questions in return, such as "Why would you want to know that?" or "Why does it feel this way?" or "Why are you doing that?"
I have had a great deal of experience with practitioners over the years, being born with a harelip and cleft palate. I have had speech therapy, and now have problems with hearing. I now wear a hearing aid. I want to understand the function of my hearing aid, and I have asked questions of the person testing and fitting my aid. I must say that the questions were answered to my satisfaction. I do not believe that my medical doctor has the time, expertise, or desire to answer my questions about my hearing problems other than in a general way.
There is often a problem with getting an appointment quickly with my doctor for non-emergency problems. The recommended specialist has a six-month backlog. Unnecessary worry and concern can be created if a practitioner says something to the effect that he or she is going to call your doctor about something that they noticed but without discussing it with you; or they are not prepared to discuss what they think it is. It could be a condition that the patient is fully aware of and being treated for at the present. The loss of time and the creation of anxiety is counterproductive.
In conclusion, I think that controlling information dissemination by a practitioner is not only a frustrating practice, but it can cause unnecessary concern and worry. I thank you for your attention and I will answer any questions that you might have.
Mr Beer: Thank you very much for your presentation. I think it is useful for the committee to have a personal perspective in terms of your own relationship with a professional. I guess we still have to grapple with the question of whether the person providing the information indeed has the expertise or the knowledge and is the one who ought to be doing that. The difficulty is finding a way of both protecting the public and ensuring that you can exercise your choice as a thoughtful consumer in getting assistance from that person.
Is it your sense as a consumer that, where the committee has that issue before it, we should err on the side of the consumer choice as opposed to the public protection, or what our sense might be of a stricter public protection? Where do we find the balance, where do we draw the line there?
Mr Flatt: I can only answer from my own experience that those practitioners I have dealt with -- chiropractors, ear specialists, this sort of thing -- have answered my questions very much to my satisfaction. Only once did the scenario happen in my life where a chiropractor noticed something that he did not think was right. He triggered my curiosity by taking my blood pressure, something he probably should not have done, but he questioned it. He did not say anything to me. He would not tell me what he found. He said: "You go and see your doctor this afternoon. I am phoning him now." My doctor saw me that afternoon and it resulted in getting the situation corrected over the next brief period of time.
The fact he took my blood pressure indicated to me what he thought was wrong. I have known the man since I was a child, so our relationship was very good, but he would not disseminate the information, nor should he have in my opinion. I agree with what you are saying.
However, generally I find that the present practice of dissemination of information is satisfactory. I think to curtail it is what I am speaking of. To make it more difficult to get information than it is now is counterproductive. Thank you.
Mr Hope: How did you know the service that you were getting was accredited service and was going to help you? As you look at the broad consumer groups out there or the services that are offered, how did you know you were getting the best service?
Mr Flatt: I went to my doctor and said, "I am having a hearing problem." He said: "I am going to send you to this man who will test your hearing and examine you. He is a specialist." Five months later I went to see this specialist. He examined me thoroughly and had me tested for hearing. After the test we discussed my problem and decided it was too early for a hearing aid. However, he gave me the names of three different locations which he recommended for a hearing aid. I ended up going there eventually when I needed a hearing aid, when I felt the problem was severe enough and where I got what I felt was excellent help and direction. I now have a hearing aid which works very well.
Mr Hope: You made reference to other services that you were provided. You said you had some questions that you had answered? What were some of those questions, like rehabilitation, or was it just a matter of hearing something?
Mr Flatt: No, I would ask him, for example, when he was examining my ear -- I have psoriasis in my ears, a little bit of it -- if he knew of something that might help clear it up. I had also asked the doctor, the specialist, and he said, "It is a condition that some people have, and I do not think there is anything that works on it particularly." I have since found a product from a skin specialist that works on it quite nicely. But the point is that I do not think his answering, "Yes, I think there is a product; maybe you should see your doctor about it," would have been wrong at that time, had I asked him that question. I did not, but I could have.
With things of that nature, I think the practitioner uses discretion as to what he will answer and what he will not. But I do not think that he should be muzzled to the point where he cannot say why he will not answer. If I am with a hearing specialist, "I am not a skin specialist, and that is a skin problem I think you should see a skin specialist about," is a satisfactory answer to me.
The Chair: Thank you very much for your presentation. We appreciate you appearing before the committee today.
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KATE FARMER AND ALAN CRANTON
The Chair: I would like to call next the Ontario Naturopathic Association, Thunder Bay chapter. Welcome to the standing committee on social development. Please introduce yourselves. You have 20 minutes for your presentation, and we would ask that you leave a few minutes for questions from committee members.
Ms Farmer: My name is Kate Farmer, and I am a naturopathic patient and not a member of the association.
The Chair: Are you here representing the Ontario Naturopathic Association?
Ms Farmer: Yes, but I am a patient. I was asked by Alan Cranton to make a presentation as a patient.
The Chair: Thank you.
Ms Farmer: Naturopathic medicine is very important to myself, my family and many other people I know of, and it is an approach that I value because it considers all aspects of my health and it is a holistic approach. This does not mean that it does not work with traditional MD medicine. In fact, I find that all of these approaches interact for my own health care. There are times when my naturopath has referred me to an MD in situations where that was more appropriate, and I appreciate that.
From what I can understand of this bill, and I have not spent a lot of time with it, this has been rather short notice for me, I feel that those in naturopathic medicine should be able to have the full scope and use of all the training that they receive. I am very glad that it is regulated because I like to know that the title goes with the education that it represents. I find it a safe, dependable and cost-effective form of health care, and usually I have between one and three visits for any given problem, much the same as I would if I went to an MD.
My main comment is I would like to make sure that no limitations are placed on the kinds of modalities that a naturopath is now able to use in Ontario, because I think that we have a very good broad-spectrum approach to health care, and I appreciate that.
Mr J. Wilson: I was just wondering, Ms Farmer, what are some of the modalities that a naturopath would use now? I am not familiar with the profession at all.
Ms Farmer: The first thing that comes to my mind is the much more thorough questioning technique when I go in there with a specific complaint or a problem. Say I have a headache, the questioning that goes with this involves have there been changes in diet, changes in your environment, what is going on in your life, as well as the physical kinds of questions that I would receive from an MD. The kinds of modalities I have experienced deal with botanical kinds of medications. I am not sure "medications" is the right word, but they are botanical treatments.
Mr J. Wilson: I know what you mean.
Ms Farmer: There are some forms of gentle manipulation. I believe that X-rays are included. It is a non-intrusive method. It would be my first line of defence for what is going on with me. I have not got a list of exactly what all the modalities are, but I know that the interrelationship of them seems much more extensive and comprehensive than most of the other specialists I have seen.
Mr J. Wilson: I appreciate that, because it does give a general sense of what they do. Various people have tried to explain this to me. I think I am going to go visit one some day, and then I will get a firsthand view of it.
Ms Farmer: That is probably the best way.
The Chair: Mr Owens.
Mr Owens: Where do you draw the line personally between where your naturopath leaves off and where the physician picks up?
Ms Farmer: I do that in conjunction with my naturopath. I do not make that decision by myself, although I would in terms of a broken bone, a car accident, go right to the emergency room. I know that is the appropriate place for me to get bones set and things sewn up and so forth.
I had one specific health problem that I did not know where it was leading or what was going on, and for this problem after speaking with my naturopath he referred me back to an internist. Some tests were run in the hospital setting, which were very appropriate. So I have a great deal of confidence that when a problem needs to have allopathic attention my naturopath will tell me this is the time to go into the regular medical system. So I have not had any problem with that because there has been a good deal of give and take as well as overlap.
The Chair: I believe there is a presentation also from Mr Cranton.
Mr Cranton: I am Alan Cranton and I practise in Thunder Bay. I am a naturopath. I graduated from the Ontario College of Naturopathic Medicine with a doctor of naturopathy degree. I practise full-time in Thunder Bay. I was born and grew up in Thunder Bay and I came back to practise. Thunder Bay is different to southern Ontario, the big city. The fact that because of the time and distance from the city I do not really stay up to date on politics and what is going on down there, I have to be quite self-sufficient up here, working by myself.
The reason I am here to testify is to basically let you know how I feel. I want to see naturopathic medicine continue as it has been practised in Ontario without having any of the modalities modified or eliminated.
I understand that the profession needs to apply to be part of the new legislation, but I do not want to lose anything as that process is going on. I feel it is important to bring the skills that I have been trained with, to bring them together to work in the patient's best interest. For instance, a patient comes to see me about a particular health problem. After a consultation and a physical examination a diagnosis is made and I determine that I am going to use two or three different modalities on him -- manual medicine, botanical medicine, or herbs, and for instance homeopathy. If that individual went to one practitioner to have the spine adjusted, went to another practitioner to have the herbal medicine applied, and went to a third person to have homeopathy prescribed, he would not get the full scope and it would not get the whole approach done to them. It is along those points that I really want to see the scope of naturopathy continued in Ontario.
I see that naturopathy is a very safe and cost-effective means of health care, and part of the definition for me is preventative. It is important to me that you understand that my approach is not available from anybody else, so that if part of the modalities are taken away from my opportunity to practise, there is nobody else that patients such as Kate can go to to receive that type of care.
I work with the medical profession. I see myself as part of the health care team in Ontario. I accept referrals from medical doctors for my type of care, and I also refer patients to general practitioners and specialists.
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Mr Jackson: Alan, I was pleased when you made the reference at the end of your presentation to working with physicians, and having used naturopathy myself and having worked with three different doctors over the course of my adult life, I want to focus on this issue of acceptance and the working relationship that you have within the medical community. Because, as a consumer, and certainly Katharine will identify with this, the system works best when there is an understanding and an ability to work with the groups interchangeably, whether it is -- I mean, 50 years ago chiropractors in this province were in the position you are in today. So one must not completely have a closed mind to these concepts. But within the medical community there is not nearly the acceptance level.
Can you talk a little bit more about that, because I find there is a growing trend in the medical profession of acceptance which has not been really talked about very much in the committee setting.
Mr Cranton: I can only speak from my personal experience. I cannot speak for the rest of the province or other naturopaths or for the association. But my experience in Thunder Bay is that I have been quite well received by the medical practitioners that I work well and closely with.
My practice has been growing since graduating and opening up as a naturopath, and I expect it to continue growing. I guess my future goal in the next four to five years is to open up a multidiscipline clinic where we are all under one roof -- dentists, optometrists, chiropractors, naturopaths, medical doctors, and so on. That is a dream that I hope to bring to reality.
In Thunder Bay, a lot of understanding has to be raised between the different professions, and it is up to me to bring that education to the other medical practitioners. It is something -- because my practice has been busy I have not taken those steps to try to educate the other people. I am quite busy as I am.
Mr Beer: With respect to the discussions that were held around self-regulation for the naturopaths earlier, what concerns do you have in terms of those modalities that you might not be able to practise? Are there some specific things that you are concerned about, or is it just your sense of the unknown in terms of how the advisory council is going to deal with your profession?
Mr Cranton: Speaking personally, I feel it is more of a fear of the unknown, not knowing exactly what they want to regulate, what they want to remove.
Mr Beer: So it is not anything specific that, say, chiropractors may be able to do that you cannot do or doctors. The sense is simply that you are going to be limited if you are self-regulated?
Mr Cranton: Right. I feel that I am quite well trained and skilled at performing what I was trained in at the naturopathic college. If any of those modalities were taken away or limited, then that would have a dramatic effect on how I use those skills to help my patients.
Mr Owens: I am trying to get a handle again on the naturopath, like my colleague Mr Wilson.
Do you see your role as more of a preventative role? You have used that language in your presentation -- more of a preventative role rather than a curative role?
I guess along with my question to your co-presenter, I have a concern if a patient presents to you with a headache, how long do you deal with that patient before you refer to a physician? A headache, as you are probably well aware, can mask other problems.
Mr Cranton: You have asked me about two or three questions.
Mr Owens: Right.
Mr Cranton: Which one would you like me to --
Mr Owens: All three of them. Start with preventative versus curative.
Mr Cranton: I believe that they work hand-in-hand. There are certain patients who will be referred to me or they refer themselves to me once they have got a condition, in which case I am working at a curative role. Other patients will come to see me saying: "I don't have a problem. I don't want to have a problem. I have got a history of such-and-such in my family. What can we do now?" So that is where it works more along a preventative role. I do not see a separation. I think that when I work with a patient, I work on all levels, preventative and curative.
Mr Owens: In terms of how long you deal with a patient with a specific problem, again using the headache as an example, at what point would you say, "Okay, Mr -- or Mrs -- Jones, I think it is time for you to see a physician, an MD"?
Mr Cranton: Personally, again this is not the association answering, but if there are hard neurological signs that I do not deal with, that are not within my scope of practice, I phone up their practitioner and say, "Would you take Mrs Jones in this afternoon?" and I may explain to the patient: "Look, you've got loss of vision in part of your eye which could represent some pressure on a cranial nerve. Let's get you in and get some further checks done."
Mr Owens: So your referral practices, then, would be more individual, patient-specific, rather than having a general rule of, I deal with a headache for one week and then refer if it does not --
Mr Cranton: I do not have a cookbook practice, if that is what you are implying. No, every individual patient, and every individual case for that patient, is taken on a one-on-one basis.
Mr Jackson: I would like to explore what pressures there are for you for the purposes of upgrading. Naturopathy has some new innovations. The one I am familiar with recently is a blood-measuring instrument which looks at the pH level and it is very refined equipment but it also involves the drawing off of blood and the testing, and then naturopathy programs designed around balancing off that level.
My understanding is there is a lot of technical work involved in upgrading. What governs your practice in order to move you to take those kinds of courses and certifications so that you are not setting out that you are qualified to perform some of these more technical -- I mean, the computer age has caught up with naturopathy, as you know, and there are some technical things that are required in that. It is not all herbs and manipulations.
Mr Cranton: Right.
Mr Jackson: What causes you to make those upgrades, and tying that to setting out certain procedures and practices that you might perform, or are you self-governed in that context currently?
Mr Cranton: I would have to refer you to my assistant, who is in the wings. Dan? I cannot answer that question.
The Chair: Would you like to come forward and take a seat before the microphone for Hansard? Please introduce yourself.
Mr Labriola: Thank you. I did not expect to be speaking today. I am Dan Labriola. I am with the Ontario Naturopathic Association. I have addressed you earlier.
In terms of upgrading and additional training, there is a continuing education, and hopefully a continuing competency, requirement that will be included once we are part of the new regulation. At that time, we expect that your question would be fully answered. In the interim, I think our practitioners are like most practitioners in that there is such a wide variety of modalities and equipment and resources out there, a practitioner is required to be certain that he or she has the skill, the knowledge, the equipment and the background to do the particular things he wants to do. Once again, you are addressing a very pertinent point. There is more technology out there than any one individual can learn, whether it is medicine, naturopathy or whatever. So at this point, the practitioner is individually responsible to be certain that he or she is in fact performing a responsible job, doing whatever that is. If that is not done, then that would be contrary to competent practice.
The Chair: Thank you very much for your presentation before the committee. We appreciate your appearance today and we know that if there is any additional information that you feel the committee should have, you will communicate with us in writing.
NORTH OF SUPERIOR COMMUNITY MENTAL HEALTH PROGRAM
The Chair: I would like to call now the North of Superior Community Mental Health Program. Introduce yourself to the committee. You have 20 minutes for your presentation.
Ms Lane: My name is Sally Lane. I am the executive director of the North of Superior Community Health Program. On behalf of our consumers and corporation, I must express my concern over the impending third reading of Bill 43, the Regulated Health Professions Act.
Our agency provides community mental health services and substance abuse and referral services, both funded by the Ministry of Health. We are situated in the rural portion of Thunder Bay district -- that is, to the east of the city -- covering a geographical area of 81,000 square kilometres. We include 10 organized municipalities, unorganized areas and Indian reserves and communities. We have no psychiatrists or registered psychologists resident in our area. We are the only agency available for mental health counselling for non-first-nation clients and one of two agencies offering services to first-nation clients. Our catchment area also includes five municipalities which are designed bilingual under the French Language Services Act and to which we provide francophone services, to the best of our ability.
The agency staff is mainly composed of social workers -- masters of social work or honours bachelors of social work -- with some bachelors of arts and masters of arts psychology graduates. Under the proposed legislation our workers would not be entitled to registration in the proposed college of psychology and thus during their legitimate work could be liable for prosecution under paragraph 26(2)1 of the proposed act. This paragraph is the "diagnosis" reference which states that unregulated workers are prohibited from communicating "a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms."
As our workers routinely, in the case of psychosocial problems, have to draw conclusions and communicate these conclusions, we would be leaving ourselves, in our opinion, open for prosecution by clients and/or the college of psychology. We do not medically diagnose and have no wish to do so. This is handled by our visiting psychiatrists. However, psychosocial problems can be assessed and treated by our counsellors without referral to the visiting psychiatrists.
The demand for our services is considerable. In 1990-91 my agency saw 866 clients. These people could be faced with very limited or no services if paragraph 26(2)1 were to continue in its present form. Revision of the paragraph should permit counselling and non-medical communication in the mental health field.
Thank you for your attention to this matter. The second two pages of my presentation are just maps to give you some indication of what we cover.
The Chair: Thank you very much for a very thoughtful presentation before the committee. All members have received your written communication. If in the course of our hearings there is anything further you would like to communicate with us, you can of course continue to do so in writing.
Mr J. Wilson: I am curious about the last paragraph on the first page, where you say your BA or MA psychology graduate would not be entitled to registration in the proposed college of psychology. Is it your understanding that entry would be dependent upon a doctorate?
Ms Lane: It is the doctorate level.
Mr J. Wilson: Can I get a clarification from ministry staff on that, from the parliamentary assistant?
Mr Wessenger: Yes, that is correct. You have to have a doctorate degree in order to be registered as a psychologist under the act.
Mr J. Wilson: That is a standard set forth by the college itself?
Ms Bohnen: If I could just speak to that, the psychologists, as you know, are currently regulated under the Psychologists Registration Act. Under that act, they require a doctorate to be registered. One of the first tasks of the council of the new college of psychologists will be to determine the requirements for registration as a psychologist with the new college. The Ontario Psychological Association and the Ontario Board of Examiners in Psychology certainly support retention of the doctorate as the qualification. Other groups representing the non-PhDs are very anxious to see a way in which BAs and MAs could qualify for registration. It is an issue that will have to be dealt with in the future.
Mr J. Wilson: You are the first one to bring that up, although I have had seven groups of the non-PhDs in my office. I am curious it did not come up before now in our committee hearings.
Mrs McLeod: I also want to address the question of the BA or MA psychology graduates. I do think that this is one of the issues which is probably less concerned with the diagnosis clause and more concerned with decisions about entry into the college and ability to practise. I wanted to ask about the current situation in the north of Superior area, Sally, where you do have BA and MA people trained in psychology practising. Is there nominal supervision provided now? Perhaps you could just say a word about the difficulty of providing for supervision in those fields.
Ms Lane: We do not have any registered psychologists resident in our area. Neither am I funded for a registered psychologist. I am funded for visiting psychiatrists. These do provide the clinical supervision. The psychology graduates are approximately a quarter of my staff. The rest of my staff are either HBSWs or MSWs, which would never fall under, according to the proposal, the college of psychology. At the present moment, they are unregulated workers. We do not have any direct psychological supervision, no.
The Chair: Thank you very much for your presentation before the committee today. That is the end of the presentations for this morning's session.
The committee recessed at 1145.
AFTERNOON SITTING
The committee resumed at 1400.
NORTHWESTERN ONTARIO CHIROPRACTIC SOCIETY
The Chair: The standing committee on social development is now in session. I would like to call the first presenters for the afternoon, the Northwestern Ontario Chiropractic Society. Would you come forward, please, and introduce yourselves to the committee. You have 20 minutes for your presentation. We would ask that you leave some time for questions from committee members. Please have a seat and begin your presentation now.
Dr Schroeder: I am Dr Brian Schroeder. I am the president of the Northwestern Ontario Chiropractic Society. I graduated from the Canadian Memorial Chiropractic College in Toronto in 1988 and have been in practice in Thunder Bay for the past three years. There are approximately 25 chiropractors in Thunder Bay and about another 10 in surrounding regions such as Nipigon, Manitouwadge, etc.
The NWOCS is a regional society and is associated with and an extension of the Ontario Chiropractic Association. We provide representation for the profession at the regional level.
I would like to thank the committee for allowing us to make a presentation at these hearings, as I understand that the basic thrust is to get feedback from the public rather than the professions. We could have brought our professional concerns to you today as part of our submission, and I must say there are those of us here in the north who are quite concerned over the possible loss of such an integral part of our professional scope. Frankly, we cannot quite see how the Ontario Chiropractic Association has allowed it to come to this. Diagnosis and treatment of non-spinal joints is such a fundamental part of our day-to-day practice that we cannot imagine it being taken away. However, much as we appreciate the opportunity to make such a submission, we have chosen instead to put our energies into co-ordinating patients making presentations, as we realize this is what you are really looking for -- input from the health care consumers.
So for our society's presentation we would like to give you something I do not believe you have had a chance to do, have a patient come up and make her submission and have the patient's chiropractor present to answer any possible questions you might have of a technical nature that the patient might not be able to fully answer. As such, I would like to introduce a patient of mine, Ms Melanie Trognitz, and she is going to make a presentation.
Ms Trognitz: I dance with the International Academy of Ballet and Dance in Thunder Bay and I have danced since the age of approximately three. I hope to either have a career in performance, teaching or choreography.
Early last year I was running in a relay race and strained my left ankle and the next day during dance practice I further injured the ankle when I fell over when I went up on point. There was a lot of discomfort and pain. This was of great concern to me since I was preparing for a dance competition during the Lakehead festival, which was in approximately three weeks' time.
My uncle Irv, who is a medical doctor, recommended to my mother and me that I see a chiropractor because they understood this sort of problem well and could probably provide the most effective treatment. As a result I saw Dr Brian Schroeder, a local chiropractor. He examined my ankle and also my left leg and hip. He did a number of flexibility tests which showed the difference in the strengths and tendons of the muscle groups in my left and right legs.
I saw him several times over a period of approximately two to three weeks and he used the ultrasound, which manipulated my ankle and my hip, and used massage techniques on my tight muscles in my left calf. Immediately I could point harder without pain. My recovery was so good that I was able to compete in the dance festival, which neither I nor anyone in my family thought would be possible. This was particularly important to me because I was involved in some group numbers.
I understood there was some question whether chiropractors could have a detailed understanding in ankle joint problems such as mine. My experience from this, my first visit to the chiropractor, is that they do.
Mr Hope: I have just a number of concerns. As you refer to a local family member who is a doctor, a cousin who is a doctor, if you would not have had advice, would you have seen a chiropractor and, if so, do you think it is going to help, especially what you are trying to achieve in your life as a performer, teacher and a choreographer? Do you think the methods a chiropractor shows you will eliminate the possibilities down the road?
Ms Trognitz: I know people who have been to chiropractors, not for similar problems, but for ankle sprains and strains, and it helped me and I did not think I would be able to go in -- it hurt to walk on. I ended up doing a group number on point. I did not end up going in the festival for the solo number because I had not had enough time to prepare for it, because it was just prior to the competition. What was the other part of the question, about my --
Mr Hope: If you did not have the referral.
Ms Trognitz: If I did not have the referral, I am not sure. I do not know if I would have ended up going in the festival, but I think I would have ended up seeing the chiropractor anyway, because my dance teacher -- I take lessons from two dance schools, the International Academy, which is basically ballet. I take ballet from there and I also take tap and jazz from Fay Steadwell, Fay Gleeson Dance Centre, and she also recommended I see someone at the clinic.
The Chair: Thank you very much for your presentation. We appreciate your coming before the committee today. Anyone is welcome to submit in writing any further information you think might be helpful for the committee during its deliberations. Thank you very much for coming today.
We have had a cancellation, the Equay-Wuk women's group.
YVONNE SLIVINSKI
The Chair: Is Yvonne Slivinski here? Please come forward now. Welcome to the standing committee on social development. You have 10 minutes for your presentation. All members of committee have received your written submission. Please just relax and tell the committee how you are feeling about things. We are here to listen to you. We would ask you to leave a few minutes at the end for some questions from the committee members.
Mrs Slivinski: My name is Yvonne Slivinski and I am a concerned consumer. There are certain things I have come to expect when I use the services of any professional, whether it be a doctor, dentist, optometrist or, specifically here today, a dental hygienist. I should be allowed as a consumer to make some intelligent decisions and choices about my oral treatment that should be based on the advice of my chosen dental hygienist.
It is my understanding that dental hygienists are not allowed a vote on issues concerning their profession and that their regulatory body consists mainly of dentists. Is this type of structure for a regulatory body realistic and progressive thinking? In the 1990s surely the status quo is an unacceptable alternative for dental hygiene. This legislation is a beginning.
My presentation will focus on my choices as an oral health services consumer. My perception that my choices are limited disturbs me. I want to have the option of choosing my own dental hygienist. I may not want the dental hygienist the dentist employs. Would I jeopardize my health by choosing a hygienist other than the one employed by the dentist?
I want to establish a rapport with my dental hygienist, just as I do with my doctor and dentist, etc; one that maintains a professional relationship based on trust, quality of service and follow-up. I want to feel confident that my dental hygienist is going to completely scale, polish and apply fluoride to my teeth with full knowledge of proper procedure and pride in performance. I feel sure my dental hygienist is totally aware of any complications that may transpire during a session and would be capable of handling them, should they occur. A dental hygienist has learned professional skills.
Who makes the decision as to the length of time it will take to properly clean my teeth? I would like to think it is the hygienist. Is the dentist well enough informed regarding dental hygiene procedures to effectively judge the quality of treatment? Why is it necessary for the dentist to oversee the hygienist's work? Is it fair to take away their professionalism and pride in performance to accommodate the employer's perception of what is required to maintain good oral hygiene?
In 20 years any one of us might be placed in a chronic care institution. I want to know that a dental hygienist will be available to continue to maintain my oral health with preventive care. It is my understanding that presently dental hygienists cannot work in these facilities because of the supervisory restrictions, that a licensed dentist must be present while a hygienist delivers his or her services. We need to remove this archaic thinking.
We all know that continuing good oral hygiene is imperative to the quality of our existence, not only for health reasons but because it has a great impact on our sense of wellbeing. The existing supervisory restrictions totally ignore not only the needs of the elderly but also those people who are institutionalized for any length of time in nursing homes, homes for the physically handicapped, mentally disabled, prisons and detention centres. Is access to oral hygiene limited to only those physically and mentally fit? Do we not need a clarification and revision of supervisory restrictions?
Access to the complaints process of the college is a concern to me. I want to be able to ask questions. Presently, the process is not user-friendly. I do not know how to tap the system.
When I visit a dental office I make the assumption that I will be provided with sterile surroundings, sterile instruments, ethical treatment and a professional who will ensure my medical history is updated. I am happy to see this area is being addressed in the new act.
I submit that hygienists should be policed by a committee comprised of their own peers and consumers. They should be allowed to proceed in the professional manner which is taught them during their formal education. Presently they are restricted, depending on the respect and commitment their employer has to their profession.
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With this piece of legislation I can feel comfortable that the onus will be on the hygienists to ensure that all standards of their profession are adhered to. As a consumer of dental hygiene with concerns and expectations, I feel it is my duty to have a voice here in the process today. Let me have the option of choosing my own dental hygienist, based on the knowledge that they are a self-regulated group able to carry on learned techniques that are required for proper, professional procedures. I need to know that if a member of my family or myself should have to spend time in a long-term facility, the present supervisory restrictions be replaced with a more realistic approach to dental hygiene for the vulnerable. Let the process be user-friendly. As a consumer of dental hygiene services, I feel comfortable knowing that dental hygienists will be regulating themselves and accountable to the public.
Mr Beer: Thank you for the perspective of a consumer. We want to get that perspective as we go through our hearings and welcome that particular look. I wanted to clarify the question of the council, perhaps through the parliamentary assistant, with respect to the statement around the nature of the council and who is going to be sitting on it. Is it essentially dentists who are on that regulatory council?
Mr Wessenger: I will refer this to the counsel for the ministry.
Ms Bohnen: Currently, dental hygienists are licensed by the Royal College of Dental Surgeons of Ontario, but they only sit on the council of that college as observers, they cannot vote. Under the new legislation, dental hygienists would have their own council which would consist entirely of dental hygienists elected, and consumers.
Mr Beer: That was my understanding, and I hope that would meet some of the concerns you have had in terms of the future of the profession and how they develop, because it seems to me at least what this does is to ensure dental hygienists are really more in control, if you like, of their profession and their future. I may have misunderstood, but I thought from your --
Mrs Slivinski: That was the point I was trying to make, that they would be a self-regulatory body consisting of themselves and the public -- the consumer or the public. That would sort of help the consumers have something to relate to or grab on to.
Ms Haeck: This is the first time I have heard someone from the public make comments about dental hygienists so I really appreciate your remarks. I would like to put to you that in the hearings we have had so far, the Ontario Dental Association has been very forceful in its comments. It feels dentists should be supervising the work of hygienists, that the hygienists' training does not go far enough to be able to notice possibly serious problems occurring in someone's mouth and thereby avoiding some serious diseases, including cancer, as one member of the faculty of dentistry at the University of Toronto pointed out. What are your comments to that?
Mrs Slivinski: I would be prepared as a consumer to go on to say that, yes, the dental hygienists need to have a little more education as to that type of thing. If you continue on that thinking and leave it the way it is, as I said in my presentation, what happens to me or anyone if we are unfortunately put into a long-term facility? Are you going to forget about us? Someone who spends all his life really looking after his teeth -- and it does make you feel good about yourself. It is like the gateway to the body. But you have to train maybe the hygienists a little more in that so that they can pick that up, because if you are always going to say that a dentist has to be present, then you are locking all these doors. You are totally forgetting about the vulnerable. I do not have any problem with their being able to learn that, or anything that they need to learn, to go that one step further. I do not have a problem with that at all.
Ms Haeck: I appreciate your comments and I will definitely keep that in mind.
The Chair: Thank you very much for your presentation to the committee.
MIDWIFERY TASK FORCE OF ONTARIO
The Chair: I would like to call next the Midwifery Task Force of Ontario, Thunder Bay chapter. Please come forward.
All members of committee will have received your written brief. We would ask that you begin by introducing yourselves. You have 20 minutes for your presentation, and we would ask that you leave some time, if you wish, at the end for members to ask questions, if they have any.
Please begin your presentation now.
Ms Pudas: I would just like to preface our presentation by letting you know that this is not the presentation by the Thunder Bay chapter. It was originally scheduled that the Thunder Bay chapter take this spot; however, the provincial organization found itself in the unusual spot of not having an appointment in Toronto, and as it happens that I am a director of the Thunder Bay chapter as well as the president-elect of the provincial group, this presentation is on behalf of our provincial organization.
The Chair: Just for the record, would you give us the complete name of the organization?
Ms Pudas: It is the Midwifery Task Force of Ontario.
The Chair: Thank you very much, and introduce yourselves, please.
Ms Pudas: My name is Dianne Pudas.
Ms Reid: And my name is Darlene Reid.
The Chair: Welcome. Please begin your presentation.
Ms Pudas: Darlene is the director of the Thunder Bay chapter, so Darlene is here to participate in the discussion part.
The Midwifery Task Force of Ontario was formed in 1983. We are a not-for-profit consumer organization, so I know a lot of people confuse us with the professional group, but we are in fact a consumer-based organization. We have been working towards the legal recognition of midwifery in Ontario. We have maintained a province-wide membership of over 1,000 since 1985, and we now are proud to have 17 chapter groups across the province, as well as numerous contact people.
We have spent a fair amount of our work lobbying different government organizations and, as the legislation is coming closer to a reality, we are switching our emphasis to public education. Just to outline what we have done in the past, we made presentations to the Ontario Health Disciplines Act review committee between 1983 and 1985, and we did that together with the Ontario Association of Midwives and the Ontario Nurse Midwives Association. Then in 1986 we had nine of our chapter groups make presentation to the Task Force on the Implementation of Midwifery in Ontario. In 1989, our regional representatives made presentation to the Interim Regulatory Council on Midwifery, and then in February of this year we made submission to the Midwifery Integration Planning Project, and of course we are proud now to be able to speak to the standing committee on social development regarding Bill 43 and Bill 56 in particular.
Just to comment regarding the health care system as it was structured under the Health Disciplines Act, it is our view that under that act there were some health professions, particularly those professions that traditionally have been female-dominated, that have not always had their skills and expertise acknowledged or used to the fullest, and we see the Regulated Health Professions Act as a start to rectifying this situation. Bill 43 affords us more choices in health professions than did the Health Disciplines Act and, in so doing, it respects our right to choose our health care providers.
We certainly hope that as this flexibility is introduced into our health care system, the focus which now seems to be on crisis intervention will switch over to health promotion, particularly where childbirth is concerned. We expect there will be more community-based health care available and we think this will result in greater consumer satisfaction, as well as more efficient use of our tax dollars.
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One thing we are really very particularly pleased with is the increase in the public participation that is planned for all colleges, because we think this will allow for more powerful and more effective public representation. We do have some questions and some recommendations, though, as to how those public representatives will be chosen. We just wonder what the government's view is, what your committee's view is, as far as the qualifications required by a consumer are concerned in order that he or she fairly represents the public.
We are particularly concerned, of course, about the public representatives who are chosen to sit on the council of the college of midwives. We have found in our experience that people who are familiar with issues are able to make more comprehensive, fairer, more informed decisions. We have also found that it is not easy to get up to speed all the time. It takes a fair amount of experience and dedication to learn and being willing to listen to all sides of an issue. One thing we found over and over again in our membership concerns choice of birth place. You can read about the safety of choice of birth place or choice of birth outside of a hospital setting, but until you actually discuss it with people and take time to consider it, it does not come easy for people to support it.
We have three recommendations: first, that those people who are chosen to sit on the council of the college of midwives should have a history of active involvement in the issue of midwifery, and further, that they have a knowledge of the current midwifery system in Ontario and how it grew out of the consumer demand; second, that the selection process for public members be made public so that we have an idea of how you are going to go about choosing them; and finally, that once you do have a short list of people you are considering, that you put on a workshop to outline the parameters of the position so that they will be more knowledgeable about what kind of work is expected. We would humbly like to suggest that the Midwifery Task Force of Ontario would be a good resource for qualified public members.
Basically, we are very pleased about this increase in public representation and we think, together with the increase in number of health care providers, that choice, the public has excellent protection from harm.
Turning our attention to Bill 56, the Midwifery Act, for many years women have wanted changes in the maternity care system, but really it has escalated in the late 1970s and throughout the 1980s. Women have started asking for very specific things. We have found the three things they have wanted are more continuity of care, informed choice and choice of birthplace.
We found that the only health care professional, health care provider who was able and willing to give us those three things was the independently practising Ontario midwife. These midwives provided us with a tool we had never used before, called the informed choice agreement. We have found that this informed choice agreement has helped us to make choices, that we have a lot of information to base our choices on and that the informed choice agreement recognizes us and our families as decision-makers. It is very clearly laid out.
Despite enormous political and financial obstacles, practising midwives of the Association of Ontario Midwives have offered us these services for several years. During the course of that time, I would just like to say again, "continuity of care, informed choice, choice of birthplace" is the philosophy of midwifery care that has grown. It is a safe, comprehensive care. It has grown out of two things: consumer demand and midwife responsiveness. Those two things together, we feel, have brought about a very special kind of midwifery care here in Ontario.
Looking at the scope of practice of midwifery as outlined in Bill 56, we were very gratified to see that midwives are recognized as the specialists in normal birth, because that is exactly what we have found them to be. But just to go a step further, the Midwifery Task Force of Ontario has as part of its continuity-of-care statement the belief that midwifery care should be an option for all women. This might mean a woman who might now be classified as high-risk. We believe that woman should have the option of midwifery care. Certainly in very high-risk cases you would need to have a physician as your primary care giver, but a midwife could be acting in a supportive role in those situations if it were the choice of the woman.
When we look at the act, we do not see anything in there that would stop that kind of activity, but we would appreciate any information your committee could provide to us regarding this. If this act actually means that supportive care would not be available, then we would like to know about that.
We were also very interested in the proposed amendments made by the Minister of Health recently to your committee, as well as those made by the Association of Ontario Midwives. We would like to comment on those amendments. However, I have to let you know that our organization has over 1,000 people province-wide. We have a rather rigorous protocol that we follow to get feedback from the membership to our board of directors, and because they are recent, we have not had time to complete that process. We are going to have a board of directors' meeting in Toronto on August 26. We will discuss it then and we will let you know, but today we certainly can comment as an executive. I will give you the opinion of the executive committee of the board of directors of the Midwifery Task Force of Ontario.
The executive feels that in order that a woman be provided with continuity of care by her midwife, she needs to have access through her midwife to the same services currently being provided to her via her family physician with regard to normal pregnancy and birth. If this means midwives have to draw blood or do heel pricks to do screenings, if it means she has to insert a urinary catheter or an intravenous or give certain drugs, whether it be prescribing, administering or dispensing, if midwives do not have access to those activities and it interrupts the continuity of care, then we would request that those be included in the scope of practice. We therefore support the Minister of Health and the Association of Ontario Midwives in their proposed amendments to Bill 56, the Midwifery Act.
There is another point that the Association of Ontario Midwives made regarding Bill 43, section 81 -- I think it is section 81; I may have an old Bill 43; I have the first reading -- but it concerns the quality assurance programs and the fact that clients should be protected. Their confidentiality should be protected in the quality assurance programs.
Just finally to finish off, I would like to quote from this wonderful document, Striking a New Balance: A Blueprint for the Regulation of Ontario's Health Professions. The executive committee of this group of people said that "professional regulation is aimed at advancing the public interest, not the interests of the professions." They felt that one way of doing this was by "developing mechanisms to encourage the provision of high-quality care."
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We believe that the introduction of a system of midwifery, which supports the principles of continuity of care, informed choice and choice of birth place will provide child-bearing women with this kind of high-quality midwifery care. We have outlined these three principles in appendix 2, if you would like to read more about our rationale and why it is so important to us. We strongly believe that any amendment that your committee considers regarding either Bill 43 or Bill 56 should give serious consideration as to how the amendments might affect these three principles.
Over the past decade, our members together with their midwives have been instrumental in the development of a very special and, we think, extremely valuable kind of midwifery care. Unfortunately, due to many different reasons -- financial, cultural or geographic -- not all women have been able to access this care that the midwives from the Association of Ontario Midwives have been able to provide. We believe that these two bills will go a long way to solve that problem, and so we await the proclamation of these bills with both great excitement and with great pride, because we feel we have some ownership of it.
We realize that your committee has been given the enormous and important task of hearing many briefs and considering many views, but we would encourage you to deal with the issues as quickly as possible because there are many women in Ontario today waiting for access to midwifery care.
Mr Wessenger: I would like to thank you very much for your very comprehensive presentation, and I am just going to ask counsel to clarify some matters that you questioned.
Ms Bohnen: Just a comment on your concern that nothing in the bill prevents midwives from providing supportive care. There is nothing in the bill that should prevent that. I think you are aware of the fact that the controlled act that authorizes midwives to manage labour and conduct deliveries does refer to spontaneous, normal vaginal deliveries. I do not know if the kind of supportive care you were referring to meant attending high-risk deliveries or not. I think you were intending to convey the kind of supportive care that a midwife provides during pregnancy and labour with a physician there as the primary-care giver. But in addition to that, any controlled act can be delegated, subject to standards of practice put in place by the relevant professions, so that delegation also provides a vehicle whereby a controlled act that is only authorized to a physician, let's say, could be delegated to a midwife.
Ms Pudas: Supposing a woman was labouring, everything was normal, and eventually, it ended up in a caesarean birth. The woman is in the operating room, and what we would view as a continuation of supportive care would be that the midwife could be there with the woman, and then provide her with that part of her care that continues to be normal, because there is only a part of her that is high risk and a lot of her that is still perfectly normal that the midwife could care for. It would be horrendous to us to think that a woman would be followed through entirely pre-natally by her midwife, then all of a sudden at the end of the labour, goodbye and see you in six weeks or whenever.
Ms Bohnen: I mean nothing in the bill would force the midwife to leave the room. She obviously could not perform the caesarean, but nothing in this bill would require her to abandon her patient, which is what you would be describing as the unacceptable thing.
Ms Pudas: That is right. Yes.
Mr J. Wilson: I, too, want to thank you for a very comprehensive brief. Near the beginning, you mentioned the appointments process and the public members on the college councils. You are aware that the cabinet will be making those appointments. It adds up to a couple of hundred new political appointments for the government of the day, and we have argued for some time now they may have a very difficult time finding qualified people for all those appointments that they have to make at the various college councils.
You make a very good point that you would prefer to see people with some background in midwifery, but I will throw out -- to play devil's advocate -- it may be helpful and in the public interest and in public safety interest to have people with an open mind who, perhaps, do not know much about midwifery, to sit on the college council. Do you want to comment further on that?
Ms Pudas: I have thought about that, and I can see you would want to have some people to whom this is a new fresh issue. I do not know if there are to be five or how many public representatives on the council of the college of midwives, but if four of them know very little of midwifery, it is going to take a lot of time to get the work done. It would be better, I think, to have fewer people that are really fresh at the issue, and in our experience, the more we learn, the less biased we get, the more open-minded we get.
Mr Owens: Just a quick question around access to hospitals. Do you find at this point difficulty in getting access to hospitals, especially in some of the smaller centres in the north? We were talking about the process where the caesarean takes place, and you would like to be part of that process in a supportive way. Are you having difficulty now?
Ms Pudas: Are you wondering if consumers -- we are a consumer organization -- if we are having difficulty having our midwives with us?
Mr Owens: That is right.
Ms Pudas: It is very, very specific to the hospital, the particular people who work there, their acceptance. It is specific, too, to the midwives that are working in that community. So it can be very easy or it can be very difficult depending on who is around.
Mrs McLeod: I understand that the Ontario Nurses' Association is one organization that has expressed some concern about the lack of limitations on the section of the act that would propose that midwives be able to administer or inject a substance -- that you could administer a substance by injection or inhalation. I wonder if you could tell us what that would mean in practice.
Ms Pudas: You are referring -- I am sorry.
Mrs McLeod: I understand that is one organization which may have expressed some concern that there are no limitations. It seems to be a very broad description under the controlled act, the ability to administer a substance by injection or inhalation, so I am wondering what that actually means in practice.
Ms Pudas: As far as consumers go, we recognize that midwives use very, very few drugs. We do not want midwives to have access to any number of drugs. We have a very limited number of drugs that normally labouring or normal pregnant women need access to, so I do not really understand the nurses' concern. It would not be a lot of different kinds of drugs. Is that the concern that they have?
Mrs McLeod: I cannot speak for them. I am really asking what that section of the act means to the practice of midwifery, to have the ability --
Ms Pudas: It means that midwives, if they can administer drugs that we need in normal circumstances, have continuity of care. If they are not able to administer those drugs, we have an interruption of that continuity.
The Chair: Thank you very much for your presentation. During the course of these hearings, if there is additional information that you think would be helpful, please feel free to submit it in writing at any time through the clerk of the committee.
THUNDER BAY DENTAL ASSOCIATION
The Chair: I would like to call next the Thunder Bay Dental Association. All members of the committee have received your written brief. You have 20 minutes for your presentation. We would ask that you begin by introducing yourself to the committee, and please leave a few moments for questions, if you would, at the end of your presentation.
Mr Peltoniemi: My name is Reijo Peltoniemi. I am the vice-president of the Thunder Bay Dental Association, and the members wish to thank the committee for the opportunity to present our views and concerns with respect to Bill 43, the Regulated Health Professions Act, and Bills 47, 48, 49 and 50 related to it.
As time is limited, we would like to address only four areas where this new legislation, as proposed, is not in the best interest of the consumers of Ontario, the government or the professions. I would be happy to discuss other areas of concern with respect to this legislation with MPPs at a later date.
Our first area of concern is what appears to be the broad ministerial powers granted to the Minister of Health under this new legislation. While present legislation gives the minister extensive power, is this new wording not too broad?
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The new wording under Bill 43, clause 5(1)(d), gives the minister power to "require a council to do anything that, in the opinion of the minister, is necessary or advisable to carry out the intent of this act, the health professions acts or the Drug and Pharmacies Regulation Act." Would this broad power not undermine the principle of professional self-government if the minister is responsible for everything? Perhaps this wording should be reviewed further.
Our second issue concerns Bill 49, the Dentistry Act. The government has always maintained that no profession would be denied any controlled activity they are currently performing. Electrosurgery and laser surgery are examples of forms of energy currently being used in dentistry for surgical procedures involving both hard and soft tissues. Both these forms of energy, among others, are vital to providing the consumer with quality, up-to-date dental care. The legislation, as currently proposed under the Dentistry Act, Bill 43, omits the use of forms of energy as a controlled act. This omission must be an oversight.
We feel Bill 49, section 4, authorized acts should include, "Applying or ordering the application of a form of energy prescribed by the regulations under this act," from Bill 43, paragraph 26(7). Omission of this clause would deprive consumers of quality dental care available today and would prevent the development and use of future technologies, further depriving Ontario residents of the best in available care in the future.
Our third area of concern is under Bill 50, section 4, the Denturism Act. As currently proposed, this act will authorize denturists to provide partial dentures even though they are not trained to diagnose or provide a treatment which will impact directly on the patient's natural teeth.
We believe that properly trained denturists provide a good service to the public, within their present scope of practice, that is, the fabrication of complete dentures to consumers missing all of their teeth.
However, the skills required to diagnose, prescribe and prepare a partial denture are controlled acts, Bill 43, subsection 26(2). These include the taking of diagnostic X-rays to evaluate bone and root support of teeth, prescribing any treatment required to these teeth and supporting structures, and carrying out treatment and alteration of these tissues in order to prepare the patient's teeth and supporting structures to receive a partial denture.
Furthermore, a partial denture is only one option for patients missing some of their natural teeth. A patient should have the right to have all of the available options explained by a knowledgeable and qualified practitioner.
Serious pathology, such as gum disease or short roots under the bone, cannot be detected by a denturist because denturists are not trained to diagnose disease and are not qualified to take or interpret X-rays. Fabrication of a partial denture in the presence of existing pathology will result in the eventual failure of that partial denture and probable damage to adjacent teeth and supporting tissues. We are concerned about the financial and health costs to the patient, should this arise. Thus, sections 3 and 4 of Bill 50 must be amended to ensure that denturists fit and dispense partial dentures only on the order or prescription of a dentist in order to minimize the potential for harm to patients.
Our fourth area of concern is under the Dental Hygiene Act, Bill 47. Section 3, the scope of the practice states, "The practice of dental hygiene is the assessment of teeth and adjacent tissues and treatment by preventive and therapeutic means and, on the order of a member of the Royal College of Dental Surgeons of Ontario, the provision of restorative and orthodontic procedures."
We believe the wording of this scope of practice is improper. This wording would allow hygienists to treat teeth and adjacent tissues by therapeutic means without the order of a member of the Royal College of Dental Surgeons of Ontario.
To treat by therapeutic means, an individual must be able to prescribe and interpret radiographs, determine pathology, diagnose and formulate a treatment plan and prescribe the various treatment modalities, including antibiotic and other drug therapies, surgical procedures, tissue alterations and scaling and root planing. As dental hygienists are not trained or qualified in interpretation and diagnosis and prescription of these procedures, how can they treat by therapeutic means?
As proposed, this legislation could be interpreted to mean that a hygienist could set up independent practice and, with limited restriction, provide preventive services and some therapeutic services without a previous diagnosis, assessment or order of a dentist. Is this the intent of the legislation? The Thunder Bay Dental Association has had no representation by the members of the Thunder Bay Dental Hygienists' Association indicating that they wish an independent scope of practice.
Proper cleaning and polishing of teeth almost always requires a scaling component above and/or below the gums. This scaling can only be carried out under an order of a dentist as it is an authorized act under Bill 47, section 4. Thus, it is difficult to understand how a patient could visit a hygienist in independent practice and receive a complete cleaning. This could fragment a patient's treatment requiring the patient to travel back and forth between a hygienist and a dentist in order to receive a cleaning. The continuity and complete service a patient receives under a dental team, as it exists today, would be lost.
Also, as our population ages, an ever-larger number of people are receiving joint replacements, heart bypass and valve surgery, and transplants of heart, kidney or other organs. They are becoming more and more commonplace. These patients may require prophylactic antibiotic coverage prior to dental treatment, such as scaling and cleaning or polishing of teeth. This is done to prevent serious and possibly life-threatening infections in those replacement joints, transplants or heart valves.
If a hygienist has independent practice, who will know to write the appropriate prescription for prophylactic antibiotic coverage and who will order the prescription to be written? Failure to diagnose the condition and prescribe the appropriate antibiotic coverage could result in a possible life-threatening infection for the patient.
While we feel that hygienists are technically very well trained and highly skilled in carrying out their present duties, we feel strongly that all treatment provided by a hygienist should be on the order of a member of the Royal College of Dental Surgeons of Ontario. This would continue to provide the safe, high-quality dental care Ontario residents receive today and would expect tomorrow. Therefore, to ensure that the dental hygienists' scope of practice is consistent with their authorized acts, Bill 47, section 3 should read:
"The practice of dental hygiene is the assessment of teeth and adjacent tissues and, on the order of a member of the Royal College of Dental Surgeons of Ontario, treatment by preventive and therapeutic means and the provision of restorative and orthodontic procedures and services."
This would be less restrictive than present legislation and will not prevent hygienists from providing services previously prescribed by a member of the Royal College of Dental Surgeons of Ontario in community settings such as homes for the aged, chronic care institutions and group homes.
I would like to conclude my remarks by thanking you for giving me this opportunity to voice the concerns of the Thunder Bay Dental Association with respect to this proposed legislation.
Mr Wessenger: I would like to have counsel give some clarification with respect to your comments concerning forms of energy.
Ms Bohnen: The controlled acts set out in paragraph 26(2)(7) of the main act refer to applying or ordering the application of a form of energy prescribed by the regulations. The government's intention is to list in a regulation those forms of energy which, in consultation with the professions, are identified as hazardous. And then in that same regulation, authorize to the appropriate health profession their usage of that form of energy.
A couple of professions -- dentistry and optometry come most to mind -- have objected, asking why is it that the Medicine Act specifically authorizes to physicians this controlled act but not in the Dentistry Act and not in their act. The reason is that the list has not been prepared; the regulation has not been prepared. That will not happen until there is consultation with the professions. However, it is certain that whatever is on the list, physicians will be ordering and applying those forms of energy because they do have the broadest scope of practice containing almost all -- not all, but almost all -- of the controlled acts. There is certainly no intention on the part of the government to prevent dentists from using what are identified as hazardous forms of energy in their practice.
Mr Owens: A quick question to counsel: What types of restorative procedures do you envision hygienists being able to perform?
Ms Bohnen: Under their proposed act they do not perform restorative ones, except on the order of a dentist. But I believe that some dental hygienists work with dentists and dental specialists who do restorative work and that they would perform procedures of that nature and assist with others of them. But those are not the types of procedures that they could do independently.
The Chair: Thank you for your presentation. We appreciate you coming before the committee today.
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LINDA MICKELSON
The Chair: Dennis Batigelli has cancelled, and Linda Mickelson is next. I believe there is a written submission that you have given to the committee?
Ms Mickelson: That is correct.
The Chair: All members have received it. You have 10 minutes for your presentation. I would ask that leave a few minutes at the end for committee members.
Ms Mickelson: Madam Chair, committee members, my name is Linda Mickelson. I have been a dental hygienist for over 27 years. During these years of dental hygiene practice, I have had a variety of experiences. Presently, I work full-time in clinical practice for six dentists in general practice here. For many years, I taught clinical dental hygiene at Confederation College in Thunder Bay.
Eleven years ago, I was one of the first two dental hygienists elected by my peers as an official dental hygiene observer on the council of the Royal College of Dental Surgeons. My term with the RCDS is unique. Currently dental hygienists are governed by the Royal College of Dental Surgeons. However, we are not members of the RCDS. Therefore, the dental hygiene official observers sit on the college council and other RCDS statutory committees as official dental hygiene observers without voting privileges. I can tell you, you do not get lobbied much if you do not have a vote.
Today I am not representing any group. The comments in this presentation reflect my personal experiences and are based on the knowledge I have acquired during my tenure. I believe in the value of a clean, healthy, oral environment, and also in the capabilities and integrity of dental hygienists.
The mouth is the gateway to the body. The oral environment reflects health or disease of the whole body. The mouth is important for verbal and non-verbal communication. A healthy mouth is just as important, if not more so, than healthy feet -- and the public has access to unsupervised chiropodists who provide foot care. The condition of our mouth determines what we are able to eat, and therefore, how we fuel our body.
The primary function of the dental hygienist is to teach the hows and the whys of a healthy oral environment. By skilled technical means and instrumentation, we remove calcified plaque mechanically. We start the healing process. Verbally we attempt to empower the public to achieve and maintain a healthy, functional, oral environment.
I am really excited about this new legislation. Now dental hygienists will be responsible and accountable for the dental hygiene services that they provide. They will have their own code of ethics, which will be a guide for decisions involving colleagues, employers and co-workers. The patient-client will have to be the first consideration.
This new legislation will allow greater access to oral health services by the public. Under the present dental regulations, the supervision interpretation is very restrictive. A dentist must be on site and examine each patient. This is neither practical nor cost-effective in community living centres, community health centres, hospitals or other institutions.
There are a few specific points that I will bring to your attention with regard to Bill 47, An Act respecting the regulation of the Profession of Dental Hygiene, and Bill 43, the Regulated Health Professions Act. These specific points are: scope of practice, controlled acts, delegation, the register, powers of investigation, and transitional councils.
Scope of practice: It is my understanding that the professions control their own members under the scope of practice statement. Presently the dental hygiene scope of practice statement is not in accordance with the same principles used for the other professions, as it refers not only to the practice of dental hygiene but also to "on the order of a member of the Royal College of Dental Surgeons." Because "on the order of" is included in the authorized act statement, it does not need to be in the scope statement. I recommend that "on the order of a member of the Royal College of Dental Surgeons" be removed from Bill 47, section 3, in order to be consistent with the other acts.
Controlled acts: Dental hygienists do procedures such as pit and fissure sealants and topical fluorides on teeth. I recommend that the word "on" be added so that it reads "in, on or below," or that the wording be changed to read "procedures that alter the surfaces of the teeth."
Delegation: I am concerned about delegation. Consumers of dental services assume certain things. They assume that the instruments are sterile, and that the room and the equipment are clean. It is important that all dental personnel are knowledgeable about disease transmission, sterilization and cleanliness. Some assistants are not formally trained.
I believe it is important that the dental regulations state that unregulated persons employed to assist in dental offices be properly trained and educated. I recommend that delegation be made only to assistants who are formally trained in the educational system. Also, since the dental hygienists' authorized acts are controlled acts for dentists, I would expect that dentists would not be permitted to delegate dental hygiene controlled acts to unregulated persons.
The register: Generally dental hygienists are women, usually employed in dental offices. Is their operatory their business premise? Presently their home addresses are listed in the RCDS register. Many women, to protect themselves, would not want their home address to be public. I recommend that it be specified that the register contain a designated business address.
Powers of investigation: This states that the investigator may examine but it does not specify whether the investigator can obtain a copy of the records. Also, will there be a provision to provide access to other persons who are employers of the dental hygiene members? There needs to be assurance of access to records so that the employing persons will release records pertinent to the investigation.
Transitional council: Bill 47 states that there will be a transitional council after third reading. From this dental hygienist's viewpoint, it cannot be too soon. Working without our present regulatory body makes progress difficult.There is no official spokesperson for dental hygiene.
Presently self-regulation of the professions is mainly reactive and punitive through complaints and discipline. I believe that with the inception of continuing competence and quality assurance the colleges will become proactive, rehabilitative, and preventive in their manner of self-governance.
Finally, I think all the political parties are to be congratulated, as well as the government staff, and certainly the review team. This has been a monumental task. However, I think it is an example of how political parties can work together for the betterment of the public.
Mr Beer: Thank you for your submission. One of the concerns that has been expressed by a number of representatives of dentists groups or individuals, and was expressed again here today, is that of dental hygienists being involved in the mouth and how you are going to be allowed to do that in an unsupervised way. When you are practising -- I note that you are working with six dentists currently -- what has that meant in a practical sense? In effect, is there an understanding which evolves? If you are doing a number of things on your own -- and you say you do not want them all to be "on the order of" -- what is the actual practice, as opposed to the law as it stands? How tightly supervised are you by the dentist you would be working with? What is the nature of that control?
Ms Mickelson: I suppose -- and I have been around for a long time -- that it is a question of the nature of the ward supervision. I have been around long enough that I have seen the interpretation of supervision go through many stages. When I started in practice as a dental hygienist back in 1964 here in Thunder Bay, I think the process was what you would call "on the order of." Then various things occurred over the years and the interpretation of supervision has been tightened up. If you look at supervision in any other areas of society, I think in dental hygiene the interpretation of supervision is probably more restrictive than any other way.
If I may give you my personal interpretation of how supervision should work or how "on the order of" will work in the future, I see it as a collaborative process. Supervision in other areas, whether it is the penal situation or social work or that sort of thing, works so that there is an exchange both ways and so that there is a discussion taking place with regard to the client. Very often that is not the case presently. I think supervision sometimes now can be interchanged with the word "control." I do not know whether that answers your question.
The Chair: Thank you very much for your presentation. On behalf of all the members of the committee as well as government staff and task force members, we would like to thank you for your very nice comments.
SALME LAVIGNE
The Chair: Salme Lavigne; we have all received your submission. I ask that you introduce yourself for the record of Hansard. You have 10 minutes for your presentation, and if you would leave a few minutes at the end in case there are any questions we would appreciate that. Please begin now.
Ms Lavigne: My name is Salme Lavigne. I have been a dental hygienist for the past 24 years and a dental hygiene educator since 1977. I have been directly involved with designing curriculum for dental hygiene programs both provincially and locally.
Through my personal experience as an educator, I view dental hygiene as a dynamic profession whose members are capable of providing quality care to their patients. In addition, they possess the knowledge and skills necessary to initiate and manage community dental health programs in any type of setting, whether it is a nursing home, a chronic care facility or a children's fluoridation program. Thus, I am pleased to see the elimination of "direct supervision" and the addition of "on the order of" in the new legislation, as I believe the dental hygienist is well prepared to assume this responsibility.
Presently dental hygienists must attend college for a period of two years for skill preparation and development. They are educated in all aspects of dental hygiene procedures, including not only the technical aspects but with the major focus on the development of assessment skills. This includes the understanding of any medical implications disclosed through the taking of a thorough medical history, including drug interactions. The safe treatment of patients is paramount in this assessment process. This enables the hygienist to assess the overall health of the patient in order to make appropriate recommendations for patient treatment and continued self-maintenance.
Under the diagnosis section of Bill 43:
"A `controlled act' is any one of the following done with respect to an individual:
"1. Communicating to the individual or his or her personal 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 personal representative will rely on the conclusion."
Since dental hygienists are taught to assess the condition of the oral soft tissues, they are capable of communicating to the individual the condition, dysfunction or disease. In addition to assessing the nature of the condition of the patient's soft tissues, they are well qualified in judging the time necessary to treat each individual patient. The dental hygienist is actually better able to judge the time necessary to treat soft tissue conditions than the dentist who is directly supervising under the present regulation. Therefore, I believe the dental hygienist is well prepared to accept the responsibility of making these judgements.
Again under the same section, paragraph 2, involving procedures:
"2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth."
I believe certain procedures performed by dental hygienists on tooth surfaces which alter the surfaces of the teeth, such as application of fluorides and pit and fissure sealants, should be included as controlled acts. Presently they are in the public domain. I therefore recommend that the wording be changed to include those procedures which alter tooth surfaces.
Under the delegation section of bill 43, which is section 27:
"(1) The delegation of a controlled act by a member must be in accordance with the regulations under the health profession act governing the member's profession."
When the dentist delegates a procedure, I would like assurance that the procedure be performed by someone formally trained. For example, individuals responsible for sterilization of dental instruments must have knowledge of infection control in order to prevent the transmission of diseases such as AIDS and hepatitis. Therefore, I recommend the regulations address all non-regulated procedures.
Under the quality assurance section of Bill 43, which is section 78:
"The council shall make regulations under paragraph 22 of subsection 91(1) prescribing a quality assurance program."
I am happy to see the inclusion of quality assurance in the legislation. Presently there is no provision in the legislation that professionals maintain competency. Currently, in a private practice situation, dental hygienists often may not have control over the quality of services provided. Sometimes time restraints directed by the supervising dentist restrict the quality of the delivery of care. With the inclusion of a quality assurance program for all professions, both dentists and hygienists will be obligated to maintain standards of practice through continuing education programs.
In conclusion, it is an exciting time for the dental hygiene profession. In response to this legislation, the new educational opportunities that will be created will result in better health care delivery to the public.
Mr J. Wilson: In the Thunder Bay area, one of the other witnesses prior to you mentioned that there was a void there and the need for dental hygienists to go into nursing homes and chronic care homes. Can you explain briefly what the situation is here? Is there really a void, that dentists are not covering those homes up in this area?
Ms Lavigne: Basically, right now there are not any dental facilities as far as I know in any of the nursing homes. I believe there is a group of dentists who have formed a volunteer committee and they do go around and help individuals out in nursing home situations, but I do not think they are delivering any treatment. There are not any hygienists or dentists hired by institutions other than the Ontario hospital, I believe, the psychiatric hospital.
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HANUSIA TKACZYK
The Chair: Hanusia Tkaczyk.
Ms Tkaczyk: My name is Hanusia Tkaczyk. I have a master's degree in psychology and I have been practising in this area for over 10 years. The concerns I have are concerns of many other clinicians like myself, and these are in two major areas of the Psychology Act as proposed: first, the inclusion issue or access to registration, and second, the diagnosis clause. Regarding the first, the legislation as currently proposed will use the Ontario Board of Examiners in Psychology as the transitional body to the college of psychology. Unless that is amended, this will result in a grave misrepresentation of psychology in Ontario today.
The current reality is that fully two thirds of practitioners in psychology are not PhDs. Most of us have MAs, which involves five or six years of university training. We work independently of the psychologists. We do exactly the same type and quality of clinical work and carry exactly the same size of case load. We are not assistants or technicians. Our clinical job assignments are completely interchangeable with those of the PhDs and, as a matter of fact, in northwestern Ontario particularly, until a few years ago when there started to be more psychologists in the area, we were doing all the work and doing it quite competently.
But in Ontario we are nothing. We are second-class citizens in our own agencies and we cannot attain the full status of recognized and responsible professionals within our own provincial organization. This is because the entry requirements, as they stand and as they are defined by the PhDs who are in control there, are academic credits from a PhD program. This is a body of background knowledge about human behaviour, but these programs do not necessarily include training and how to work with clients, particularly programs that specialize in research or experimental work or include it to varying degrees.
Meanwhile, clinicians who have had years of hands-on experience, who have often taken extensive clinical training from established experts in the clinical field, are shut out. There is absolutely no way, no opportunity, for us to be registered and accountable. OBEP and the psychologists will say to you that is not necessary because they cover us through a system of supervision. Well, quite frankly, it does not work. The numbers are unworkable. For example, just in the region of northwestern Ontario there are 30, 40 or more non-psychologists who rarely if ever see a psychologist for supervision because these people cluster in Thunder Bay and in Kenora. They do not get out to the other areas.
Psychologists and other clinicians are so busy that there is hardly time to do supervision anyway. There are so many people to be seen. If the psychologists were to supervise us according to the OBEP guidelines even as they exist, there would be so little time to see any of their clients that it would just be unworkable. The reality is that there is an absolute minimum of supervision. There is occasional contact, some discussion as if between colleagues as to what is going on, but really very little.
Yet, you should be aware that most PhDs are quite comfortable with this minimum of supervision, although supposedly their licences are on the line, so you would think they would be prepared to argue that we are competent professionals and do not have to have somebody looking over our shoulders at all times. Yet the psychologists have given themselves sufficient power that they could prevent us, their supervisees, from working in an area of their established competence if the psychologist does not have training there. So, for example, if I had years of experience and background work in neuropsych and I get a new supervisor who does not have that, he or she is supposed to say to me, according to the OBEP guidelines, "You can't do that any more unless we find somebody who is trained in it who has a PhD also and can supervise you." In northwestern Ontario where resources are scarce that is a real problem.
The current supervision system allows a brand-new grad from the PhD program to tell a veteran who may have 20, 25 years of experience what to do. If anything, it would probably be more useful for the new grad to benefit from the experience of someone who has been there, who has learned skills which cannot be taught and are simply not taught in academic circles. As a matter of fact, there is nothing in PhD programs preparing these people to supervise anyway. There are no courses in it.
Experienced non-doctoral clinicians in psychology do not even have a proper title; we exist by a variety of strange names. We are trained in psychology, have experience in psychology and practise psychology, yet we are not recognized and OBEP has been actively lobbying to continue the current practice of threatening us with legal sanctions if we attempt to communicate by a title, designation or description anything that reflects our valid and hard-earned abilities.
If the purpose of the current legislation is to assure the public of a high quality of health care through duly regulated and legally accountable professions, then the non-doctoral clinicians in psychology must be included, but using OBEP as the transitional body will simply perpetuate an old system that is closed to anyone without a PhD. Inclusion of non-PhDs would result in legislative protection for the public of Ontario by realistically reflecting current psychological practice. This would be based on meaningful entrance criteria that reflect not only the very necessary academic credits, but equally valuable real-life experience in the profession and other forms of valid clinical training.
Regarding the second issue, the diagnosis clause, as proposed now this could only be done by members of the college, and if OBEP remains in charge, that will effectively limit it to the psychologists. There are many clinicians who have training and experience in areas other than psychology per se who can and do communicate conclusions about psychologically based disorders; for example, social workers, addiction counsellors and others. Why prevent them from doing their work?
The basis of treatment for most clinicians is some conclusion reached after an assessment period, and the professional is normally expected to communicate that to the referring agency.
Again, let's take an example, particularly in northwestern Ontario in areas where there is not a psychologist anywhere on site. Let's say the clinician gets a referral from a family doctor about a client. Is this person depressed? Do they need therapy? What does the clinician do under the new legislation? Do they wait until a PhD turns up to sanction their conclusion and communicate it? Do they consult on each and every case? That is unworkable because of the numbers involved, and you heard a bit about that earlier today. Do they ship the client to Thunder Bay, several hours away? None of these scenarios reflect a decent quality of health care for citizens in northwestern Ontario, who already do without quite a lot. Clinicians I have spoken to in preparing for this presentation are saying, "I'm not going to be able to do my job any more if this is upheld as it stands."
Of course, diagnosis is a very serious business and should only be done by people who are duly qualified and the public deserves protection of this particular clinical activity. However, limiting it to PhDs, limiting it to those academic requirements, is not the answer.
Again, within psychology, experienced clinicians are hampered or discounted. Imagine doing all of the testing, all of the assessment, interpretation, treatment planning and report writing for a client. Then you have to have a psychologist co-sign it. This is somebody who may never have clapped eyes on your client, would not know him if he fell over him in the parking lot. Yet the psychologist has the legal responsibility to co-sign because only he or she has the legal right to diagnose.
That system exists now. The co-signing implies that the non-PhD was some kind of technician, and that is not the case. Rest assured that few agencies have the luxury of having us doing just testing. We are all carrying a full case load. There is lots of work to be done. We are as capable and as ready to be responsible for our actions as the PhD colleagues.
More important, I think this co-signing system is dishonest. It implies an ownership of the work and a responsibility for it which deceives the public. We non-doctoral clinicians are concerned about it and we want to see that end.
In diagnosis and in all areas of treatment, non-doctoral clinicians in psychology no longer wish to ride on the coattails of their PhD colleagues. If this legislation is to carry out its stated purpose, we must be included. We are the bulk of service providers in psychology. We are prepared to be directly accountable for what we do, and we find the current supervision system incapable of doing that.
The public deserves an accurate and accountable system of professional regulation. The best way to assure this is to require that the College of Psychologists have not only PhDs but also non-PhDs who have full status and equitable representation on all relevant boards and committees of that college. I urge this committee to amend the legislation or make whatever recommendations are necessary to see that this is carried out. That concludes my presentation.
Mr J. Wilson: Thank you for the presentation. I and my colleagues in the Ontario PC caucus have a great deal of sympathy for the non-doctoral clinicians. We have all been visited by a number of those, and also the PhDs. At one point you do begin to think it is kind of a turf war.
But having said that, I would like to take this time to just ask the parliamentary assistant and staff, through him, what the thinking of the review committee was in this area. You made a comment earlier today that it is something the committee is going to have to work out, but what did the review people have to say about the non-doctoral?
Mr Wessenger: I will have staff reiterate and perhaps further elaborate on that point.
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Ms Bohnen: The review really did not consider entry requirements to become a registered member of a profession. It was concerned with identifying the professions to be regulated, establishing the structure for regulation, what their scopes of practice should be and so on, but it did not address for any profession what the qualifications should be, because those are the responsibility of the governing body when it makes its regulations. Those regulations will not come before a committee like this, but under this legislation they may well, and in all likelihood will, go before the Health Professions Regulatory Advisory Council.
Mr J. Wilson: But did the question not come up when they were discussing the transitional council, specifically for this bill for psychologists, because the transitional council is made up of the old council, as I understand it.
Ms Bohnen: I think you should ask Alan Schwartz that. My impression is that the answer is no, but I think you should ask him that.
The Chair: Thank you very much for your presentation. I appreciate your coming before the committee today.
TED MURPHY
The Chair: Ted Murphy? You have 10 minutes for your presentation. We have all received a copy of your written brief. Please begin your presentation now and we would ask that you leave a couple of minutes at the end for questions.
Mr Murphy: All right. As a private citizen, I have just come to speak for the chiropractic association, and I will turn over to page 2 on the little résumé that I handed out.
I am told that suggested new legislation would not recognize the ability of chiropractors to diagnose knee joints and other non-spinal joints. The new law would recognize that only medical doctors can do a complete diagnosis of a knee disorder. I think this runs quite contrary to my own experience and it is rather hard to understand. I have been treated for about the last 15 years by a chiropractor, and I have found he seems to have a much better understanding of the knee problems than anyone else. From the point of view of the patient and the public, I think the law should be encouraging freedom of choice, recognizing the work that chiropractors do and do well.
Also, I have difficulty with the idea that they cannot diagnose. I do not know how they are going to treat if they cannot diagnose.
On the front it just gives my background as involved in athletics all my life and with the physical education association of Ontario and as a consultant with the Ministry of Education for 15 years and so on. The injury I picked up at McGill University, and it is something that seems to catch up to you as you get older and older. But I have found Danny Gleeson. He is a local chiropractor who is, I think, one of the tops in his field. David Irwin, as many of you know, of the Crazy Canucks, the skiers, gives Danny credit for keeping him on the ski tour. Also I think your infamous Maple Leafs from Toronto sent down Wendel Clark for two treatments --
Interjection.
Mr Murphy: Yes, I am sorry about that. They will be good next year. They brought him down twice for Danny to work with and they brought Danny down twice to Toronto to work with Wendel Clark.
I feel that in many ways they can be very beneficial. Also, without the ability to diagnose, it is going to really cut down their ability to help people. That is all that I have to say. Are there any questions?
Mr J. Wilson: Just a quick question that is not in your presentation: You are obviously fond of chiropractors, but I am wondering what you think about us now moving to legislate, give them authority to use the term "doctor." A number of them use it. They are not supposed to use it.
Mr Murphy: I just accept it more or less, because a lot of them use the term "doctor."
Mr J. Wilson: Our concern is that the public may think these people are all MDs.
Mr Murphy: Most of the people associate where they go. They look at the people as chiropractors and a doctor of chiropractic, not as a doctor as far as medicine is concerned.
The Chair: Further questions? Thank you very much for your presentation. We appreciate your coming today.
Gary Sartain? We have tried to contact the Canadian Association of Pastoral Education. Apparently they have been contacted and are on their way. We are a little ahead of schedule, so I would suggest that we recess for about 10 minutes, get ourselves ready to depart, and reconvene so we can hear the last presentation. Hopefully they will be here within 10 minutes. Gary Sartain? He has not arrived yet. All right.
As this is the first time that this committee has travelled together out of town, the clerk has asked me to remind everyone to ensure that the airline stub is submitted to the clerk at the end of each travel day. That is what is left of your ticket. Do not throw it away. They take out two pieces of your airline ticket and the remaining stub has to go to the clerk -- not the boarding pass. So if we could just make sure that every member is aware of that, we will do that. We will just recess for 10 minutes.
The committee recessed at 1526.
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CANADIAN ASSOCIATION OF PASTORAL EDUCATION
The Chair: I call Gary Sartain. Welcome. I ask that you begin your presentation. You have 20 minutes. We ask also that you leave a few minutes for members to ask questions, if they have any, at the end of your presentation.
Mr Sartain: My thanks for being allowed to appear before you. My name is Gary Sartain. I am an ordained clergyperson with the Evangelical Lutheran Church in Canada and a fellow with the College of Chaplains. Until last Friday I was chaplain and manager of pastoral service for McKellar General Hospital here in Thunder Bay. Today I begin a new position as northwestern Ontario regional co-ordinator of chaplaincy services for the combined ministries of Health, Correctional Services and Community and Social Services for the province of Ontario.
I am in the process of becoming a provisional teaching supervisor for the Canadian Association of Pastoral Education, which is the program through which most spiritual care givers in institutional settings are trained in Canada.
It is the Northwestern Ontario Section of the Manitoba-Northwestern Ontario Region of CAPE on behalf of which I speak to you today regarding the proposed legislation. Our particular concern is the diagnosis clause, which we feel puts us, our immediate supervisors and our employing institutions in legal jeopardy for continuing to do our jobs appropriately and in the very way required by the standards of the Canadian Council on Health Facilities Accreditation, the national accreditation body for acute and long-term care institutions.
At the very time that there is a growing recognition of the need for and the push towards holistic, team-based patient care in our health care institutions which includes attention to the spiritual dimension, a potential barrier looms that will inhibit the functioning of spiritual care givers and give those considering making them a part of their team cause for concern.
The proposed legislation would preclude those of us in chaplaincy who are unregulated practitioners from "Communicating to the individual or his or her personal 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 personal representative will rely on the conclusion." I quote from paragraph 26(2)(1).
While the list of examples is almost endless, let me share with you several recurring scenarios from my previous employment that I would be constrained from doing should this paragraph remain.
First, at McKellar General Hospital, when a person was brought into emergency with vital signs absent, it was my responsibility to contact family and get them to the hospital and/or to sit with them in a private area while the emergency response team worked on their loved one. I would act as the liaison between the team and the family, passing on information that the medical team wished them to have -- ie "We have succeeded in getting his or her heart going," "Things are going okay, you can relax a bit now," "We don't hold out much hope but are doing all we can," etc -- as dictated by the situation and the needs of the family. I should add that the bottom line of this was that medical information was dispensed only with the permission and with the direction of the physician or medical team. Often, when a person was pronounced dead, the team would ask me, who had the relationship with the family and the expertise in handling such situations, to bear the news. Once the family had gotten through the shock, the attending physician would come in and provide details.
While I was never making the diagnosis, my communicating a diagnosis on behalf of the medical team was integral to our handling of a difficult situation for a family in the most caring way possible.
By contrast, I think back to how, early in the development of the chaplaincy program at McKellar before this team approach was in place, a person had been brought in in the middle of the night dead on arrival. I called the family asking them to come to the hospital, not advising of the medical circumstance at that point, and then sat with them for 45 minutes until the physician who had pronounced the patient dead came and passed them information. He was unable to do so before that because he had gotten tied up with the delivery of a baby prior to their arrival at the hospital.
That family felt betrayed by me and by the hospital, that we could let them linger that long in limbo making small talk and acting like there was potential for things to be all right when we really knew otherwise. I can even remember them asking me to pray for the person to be okay and I was constrained from telling them the truth. My feeling is that the present paragraph will force the team back into this kind of untenable situation, which is not in the best interests of patients and families nor of the care-giving team.
Second, it was common practice on our intensive care unit for me as chaplain to be present, along with the patient's total care nurse, when a physician held a consultation with a family, particularly when the circumstances were dire; ie, impending brain death, organ donation requests, etc. I would remain for family support when the other members of the team returned to their medical duties.
Often I would discover that families had misheard or misinterpreted what the doctor said. Sometimes the appropriate thing was to get him or her back to restate, if it was convenient or deemed necessary, but when this was impractical or impossible, I would restate what was said, not making the diagnosis but communicating it in a way that facilitated the process of the family coming to grips with the situation. If I were unable to do this, and I believe the present wording of the proposed legislation would preclude it, the family would be left in limbo and their relationship with the physician and nurse jeopardized. The very people the legislation seeks to protect would be harmed.
Third, as a chaplain and member of our palliative care team, I was seen as the resident "specialist" in the area of grief. Often I would receive referrals from within and without the hospital to see and assess a person around a situation of loss.
When the referrals would come, the bottom line for the person referring and/or the referred was, "This is what is happening, is this normal?" "Is this a normal grief reaction?" "Do I need psychiatric help?" I was being asked now to make a diagnosis that the counsellee and person referring both thought was within the scope of my expertise and practice. How does one refer, say, for psychiatric help on the one hand, or deflect from the busy psychiatric team where appropriate on the other, without making and communicating a diagnosis that you would foresee and hope the persons involved would rely on? Yet the proposed diagnosis clause would preclude this. There must be provision to allow chaplains to make and communicate a diagnosis that is within the scope of their expertise and practice. My example is the diagnosis around issues of grief and so forth as contrasted to a medical diagnosis, such as when someone has a cancer or something like that, which would be totally outside of my expertise and practice.
We are well aware that it has been the contention of the Ministry of Health that it is not the intention of the legislation to preclude chaplains doing the above. We do not dispute your intentions, but that could change. Furthermore, we are concerned that the wording of the legislation will take precedence over the intent of the writers in our courts of law. We fear that disgruntled clients will initiate prosecutions which, even if they are not successful in the sense that we are found guilty of contravening the intent of the legislation, will still be costly in terms of finances and reputation to defend. We implore you, therefore, to revise the clause to reduce our vulnerability. I must clearly state that we have no opposition to the general goals espoused in this legislation, but we do feel strongly that revision of the diagnosis clause is mandatory.
We believe the latest draft proposal of the Coalition of Unregulated Practitioners does the job for those working as a part of a health care team, when it suggests that one cannot perform a controlled act unless the person is authorized by a health professions act to perform such act, or has been delegated the responsibility by someone so authorized. In each of the examples I quoted you, that was happening. The authorization was either given by the team or in the process of the referral. We remain concerned for chaplains in other settings, however, and for pastoral care givers in parishes. We understand there was an amendment to the act to exempt clergy from a particular faith group from treating their own parishioners by prayer or spiritual means in accordance with the tenets of their religion. But often these clergy are sought out for counsel and advice by non-members, particularly in sparsely settled areas such as in the north. Are they still exempt by wording as well as by intent? We would doubt it, and we see it as mandatory that they be protected. Perhaps, in the end, the solution is to have a clause which states that the controlled act concerning diagnosis applies only to the regulated.
Finally, a personal observation. The Ministry of Health response to date seems to indicate a significant lack of understanding of the scope and nature of the profession of chaplaincy and the creative interface between community clergy, health care professionals, and health care institutions, particularly as it plays out in more remote or rural areas where resources are limited. I share that just from the fact that this response about the clergy was the initial response to our concerns.
Because of this, and in hopes of helping you make revisions to the diagnosis clause that I hope I have helped you realize are necessary, I am appending sections from the McKellar Pastoral Care Policy and Procedure Manual, written by myself, that delineate the functions, duties and responsibilities of the various providers of pastoral services, from paid professional to lay volunteer, including community clergy. I am also appending a copy of a letter to you from two chaplains at St Joseph's General Hospital in Thunder Bay who concur with the presentation here. Other area chaplains and clergy have also been mobilized and will be writing you. I thank you for the opportunity to appear before you.
The Chair: Thank you very much for your presentation. Before I call for questions, I would like to tell you and anyone who is here that if at any time during the committee's deliberations there is additional information you would like to make available to the committee, you can do so in writing to the clerk of the committee. That is for any individual, organization or group of individuals who would like to submit. Just for the information of everyone here, we have also had presentations in video form. As long as there is a covering letter, we would be happy to receive any information anyone would like to submit in any written or audio-visual format. All written material does become part of the public record.
Mr Martin: I want to thank you for coming forward today and bringing what I think is a really interesting perspective on this whole thing from the view of the chaplain. Certainly it highlights a concern we all have re how this Regulated Health Professions Act has a tentacle that reaches out into other areas and has potential to impact. I think that is particularly acute in the north, which is, as you say here, an underresourced area. We are for ever trying to find someone who can respond to a situation, a crisis, and now with maybe the potential to have a suit brought. Perhaps you might want to expand on that a little further.
Mr Sartain: One of the things we have been working very hard at in the north and one of the reasons I was really enthused about taking my new position when the opportunity afforded itself is that we are working very hard at training people to be spiritual care providers. The emphasis has changed significantly. It used to be that a chaplain went into an institution representing his own faith and functioning from the tenets of that faith group, often only with people of his own faith group. Now the emphasis is on determining what the spiritual resources are of the client or patient or family that you are meeting and using those resources and finding ways to mobilize and strengthen those kinds of resources. So a lot of training is going on along that line.
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Two years ago we had a training program here funded through chaplaincy services. Last year we did a training program in Fort Frances, Ontario. The people we trained were people doing chaplaincies in various institutions on a part-time basis who had had no training. One of them was in a home for the aged, another a nursing home in Kenora, one in Fort Frances in a jail, another in the hospital in Fort Frances, and another was a community clergy person in Emo who was very involved in that area in the areas of sexual assault and wife abuse and so forth.
We are also concerned about what kinds of implications this has for training, because if the supervisor, whether it is the educator or the institution, is liable for one of these students communicating a diagnosis, what does that mean? Probably we would be protected, but I can see certain administrators who may have a tendency from the outset to not want to take the risks involved, using that as an excuse not to proceed. So we are very concerned that as doors are opening for chaplaincy in areas that have previously been closed people will feel that in order to protect themselves they are going to have to back off.
I was also very involved when the Dryden disaster occurred here, and I would have to honestly ask questions about whether I would feel free to go to the airport and function in the way I did that night with this sort of thing involved. I am sure I probably would still do the same thing, but it is a concern that we have to start thinking about it. It is not that we do not always have to think about what is ethically moral and appropriate in terms of how we deal with people, and I think we do that, and that is why I included some of the things from the McKellar manual that I think are very important, but we are concerned about going beyond what is necessary and actually inhibiting constructive work being done. I agree: the loose cannons just cannot be allowed to function, but the people who are being an integral part of our medical health care teams and whose work is being really appreciated, I think we need to facilitate that rather than hinder it.
Mrs McLeod: Obviously the concern you bring forward is a very real one, and I think all members of the committee have heard it in other settings and other occasions, but one of the things the committee and ultimately the ministry and the minister will have to struggle with is whether or not there is a cure which is less drastic in its implications than the presenting problem. I wonder, with that in mind, if you could say a little bit more about how theoretical the concern is in a legal kind of way versus how real you think the prospect would be of a chaplain who had been working within a counselling setting actually prosecuting afterwards.
Mr Sartain: I think it would be very real, and the reason I think it would be very real is that in the three years I was at McKellar hospital I wrote two letters for doctors and one letter for a nurse to their respective colleges where they were being challenged by people for things that just had no basis. One of the things, for example, was a physician who was accused of not doing his job such that the chaplain had to do it for him. It was a situation where he had spent 20 minutes explaining to the family what the situation was and they were so predisposed to not hear him that they did not hear it, and when we restated it, then all of a sudden we were the hero. There was no real way they could see to touch me, so I was made Mr Wonderful and everybody else in the place whom they thought they could sue was Mr and Mrs Bad Person or Miss Bad Person. Just seeing the kinds of things people do and the kinds of reasons, I am convinced it would not be very long before somebody would put this to the test. People have some really funny ideas also about religion and chaplaincy and so on and so forth. That is one example, and I guess I could think of several others quite quickly, but time is limited.
The Chair: Thank you very much for your presentation.
The committee now stands adjourned. The receipt I mentioned earlier is this one at the back of the airline. It is the white piece. The clerk requires that, and the clerk has asked me to inform you that there will be four taxis at 4:20 at the front doors to take anyone who wishes to go to the airport to catch the plane. Thank you very much.
The committee adjourned at 1615.