Transcription du comité 1991-août-26 | Assemblée législative de l'Ontario

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

Allergy and Environmental Health Association, Ottawa branch

Ontario Naturopathic Association

Jenny Thomas

Jack Gryfe

Association of Concerned Citizens for Preventive Medicine

Matthew Yeager

Ontario Psychiatric Survivors' Alliance of Ottawa-Carleton

Andrée Durieux-Smith

Bereaved Families of Ontario, Ottawa-Carleton branch

Attendant Care Action Coalition of Ottawa-Carleton

Jay McSpaden

Cindy Harrison

Coalition of Ontario Midwifery and Birth Schools

Ontario Medical Association

Ontario Medical Association, section of ophthalmology

Ontario Chief Psychologists Association, eastern region

Ottawa Academy of Psychology

Canadian Society of Hospital Pharmacists, Ontario branch

Janise Johnson

Community Health Nurses' Interest Group

Cecilia Branch

G. Lawrence Nelms

John Cox

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:

Grandmaître, Bernard (Ottawa East L) for Mr Cordiano

Jackson, Cameron (Burlington South PC) for Mrs Witmer

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

Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski

Clerk: Mellor, Lynn

Staff: Gardner, Bob, Research Officer, Legislative Research Service

The committee met at 0859 in the Delta Hotel, Ottawa.

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 sur les professions de la santé réglementées et les projets de loi, 44 à 64, qui l'accompagnent.

ALLERGY AND ENVIRONMENTAL HEALTH ASSOCIATION, OTTAWA BRANCH

The Chair: The standing committee on social development is now in session. I would like to welcome everyone this morning. I call as our first presenter, the Allergy and Environmental Health Association. You have 20 minutes for your presentation. We would ask if you will leave a few minutes at the end in case any of the committee members have any questions. Please begin your presentation now.

Mr Brown: Thanks very much, Madam Chairman, and thanks very much to the committee for this opportunity to talk to you. I am speaking on behalf of the Ottawa branch of the Allergy and Environmental Health Association. This is the largest branch of our association in the province -- we have about 300 members -- and we are also the largest per capita branch of the association.

People with environmental sensitivities are people who react to substances in the environment at levels of exposure that do not affect most other people. George Thomson, who is now Deputy Minister of Labour, who I am sure is familiar to all of you, did a report in 1985. In his report he listed symptoms involving every system of the body, with effects ranging from mild discomfort to serious disability. For some people, environmental sensitivity is an annoyance. For the more seriously affected people, it is a disabling problem.

We have achieved some progress, thanks to some of you, and thanks to people in human rights commissions and so on. The most recent thing that I would like to inform you about is a letter from Marion Boyd, Minister of Education. She writes that her ministry now agrees that environmental sensitivity should be considered as a possible contributing factor in learning disabilities and behaviour problems in schools, so school boards should take this into account when applying the Education Act, and meeting children's special needs.

Environmental sensitivity is not an illness. It is a phenomenon of reacting to substances, as I have described, which can be caused by a wide variety of illnesses. Some of them are well understood. Others are not well enough understood for medical intervention. The only method of treatment that people know of is avoidance of sensitive substances. The problem is not new. I mention a couple of these things because there is a lot of mythology in the media about this problem, and in some other circles.

Environmental sensitivities have been experienced for generations. They are not new to the medical community either. Medical literature goes back for a couple of centuries. The Department of National Health and Welfare published a bibliography a couple of years ago with hundreds of articles dating back decades. The information is not hard to find. Within an hour of being diagnosed in 1979, I was reading a book on the subject in a library. The book was published in 1951, so this is not a new problem, and it is not new to medicine.

Just a bit of background about our association. We are the largest of five self-help groups in Ontario. Our main activities include self-help, helping people deal with lifestyle changes required for dealing with this problem, dealing with employers, dealing with various authorities, and helping people, for instance, with human rights concerns related to having this disability. Most of our activities in the Ottawa branch relate to helping people deal with adverse differential treatment by Community and Social Services, Ministry of Health, and authorities outside the provincial purview.

There are a number of attachments. I mentioned the letter from Marion Boyd. There is also the last page of a letter from Darlene Koski, president of our association -- which had a different name in 1984 -- talking about suicides of people caught in this adverse differential treatment in the health community. There is a letter from the coroner relating to a suicide of a person who was told by the Ministry of Community and Social Services that his problem was all in the mind; a letter from Catherine Frazee indicating her willingness to help the Ministry of Health deal with some of the attitude problems on this illness; a statement of the federal human rights commissioner talking about some of the abuse that people with this problem experience.

Most of the concerns in the Ottawa branch relate to adverse differential treatment. This relates quite closely to this legislation, because it is something that I think consumers should have recourse about. A lot of these problems have stemmed from the fact that over a period of time various authorities said that persons with this problem did not have a legitimate medical problem -- that their symptoms were all in their mind, that these people were so crazy they were making themselves sick, and so on. In other words, statements were made which had a negative effect on the people's reputation for soundness of mind, their credibility as professionals, their expression of special needs within the community with landlords, employers, and so on.

This statement was made on the expressed reason of not understanding the physiology involved. I would suggest, and I think you would agree, that it is is inappropriate to make statements which reflect poorly on people's credibility, and on their reputation, when those statements are based on an absence of information. In order to make statements that hurt people, one requires evidentiary reason, due process and opportunity to respond. Such statements should not be made on the basis of an absence of information, or on the basis of people having a particular disability.

This is what happened, and there were a number of consequences which I would like to mention, and then discuss how this relates to the legislation that is proposed. The first of the consequences -- and these consequences go from the least important to the most important for the three that I will list -- relates to the actual damages that were caused to people by the fact that this statement was made. The insult was more damaging than the injury that it was added to. Families broke up. Professional reputations were ruined. People did not receive benefits. People were caused increased disability by doctors who ignored their concerns. A number of people were killed. As I mentioned earlier, there have been a number of suicides of people who became frustrated with the health-care system, with the way officialdom was dealing with them, and with the fact that small things they needed, which were manageable, became impossible to deal with because of the attitude pollution around.

As bad as the first problem is, the second consequence is worse. We are a community of people who have been abused in the way that I have just described. Many of our people have had their careers ruined. And many people involved in this issue have friends who have either been caused disability unnecessarily or who have, in some of the extreme cases, committed suicide.

Material evidence relating to this concern has been brought to the authorities for some time. There has been some action towards research. There has been some action in Community and Social Services recently, and in Housing. But the abuse in the health care system has not been addressed. As a result, the people with this problem, the people coming forward, are coming forward with a very heavy emotional load, usually with a victim mentality. Our community is very fractured as a result of the tension which results from this kind of treatment. At the one end, we have people whose rage is not understood by others. At the other, we have people who may be financially independent who are trying to appease the bullies.

Between these two factions, and with a lot of other tension in our community, the second consequence I want to mention is that we have a problem as a community bringing forward a coherent statement of our concern, with an integrated representation. There are about five self-help groups in the province and, to be frank, there is a lot of tension. I think that sometimes the authorities have been confused by receiving conflicting messages from the various parts of our community.

The third consequence is worse. It is that the very authorities now in a position to help us -- this includes some of the professionals covered by this act, some parts of the Ministry of Health, and some other parts of provincial government -- are the authorities that have participated in or tolerated or been compliant with the abuse. For these authorities to act now in a forthright manner, to speak the truth about the abuse, to act on the concerns that people have, would be an implicit, in some cases an explicit, acknowledgement that what has been done to this group is unethical. It is not just that it caused damage, but that it is unethical.

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I want to emphasize, underline and put in bold letters, that our organization is not bringing forward the issue of compensation. We are not looking for a witchhunt. We are simply trying to identify the political logjam that is preventing a constructive resolution of concerns on this issue.

If I could be permitted one quick aside, I will come back to relating what I have just said to the legislation. There is a strong likelihood that many psychiatric patients have undiagnosed sensitivities as the cause of their problem. Thomson relates a list of central nervous system symptoms which are listed here. Perrin Beatty, when he was Health minister, wrote us acknowledging support for the United States study which won a World Health Organization award, which strongly recommends checking for environmental sensitivities before embarking on potentially detrimental psychiatric interventions. The authors of this study, done for the New Jersey state department of health, are Ashford and Miller, a doctor of jurisprudence from the Massachusetts Institute of Technology and an immunologist for the University of Texas.

The focus in the Ministry of Health has been on conducting more research. I would suggest that when you have this kind of recommendation, and when the practice of screening psychiatric patients for sensitivities is not in place, you have a very, very strong likelihood, a virtual certainty, that some percentage of psychiatric patients should not be psychiatric patients but should be treated for environmental sensitivities. We would say that this group of people is being abused by the health care system, including by the mental health facilities branch of the Ministry of Health. That is an aside just to emphasize the importance of forthright action on this concern, and the importance of getting people out of the frame of bobbing and weaving to avoid acknowledging previous abuse and to get on with dealing with this problem.

I mentioned that the focus has been on research. If you see somebody down the road from your house, a kid being beaten up repeatedly or some other form of abuse -- it is very useful to encourage research, but I think the onus is on the authorities to stop the abuse. I do not think that the government has acted on that. I think the government has a debt, given the previous encouragement of this attitude by the Ministry of Health.

With respect to the legislation, when there is widespread abuse in a profession -- for instance, when there is toleration in the medical profession of dismissing consumers' concerns as being all in the mind when people are dying because of this -- there should be some means of appeal around that profession. It should not be necessary for the consumers to go to a college representing that profession's interests. Even if we acknowledge that there is an interest in the College of Physicians and Surgeons of Ontario to have good medicine in the province, it should not be the case where people being abused by a profession have to go to a self-regulatory agency to make their case. There should be some formalized institutional process of being able to go directly to their representatives, in this case representatives in Queen's Park and probably in the Ministry of Health, to deal with ethical and human rights concerns, which surely should take precedence over medical treatment.

The other elements I have in the brief relate to the section about controlled acts, I think it is subsection 26(2), and paragraph 26(2)13 relates to allergy testing. It was a little confusing to us why there was what seemed to be arbitrary specificity here, a level of specificity in regulating allergy tests and singling them out for regulation. That is a question there may be a good answer to, but there are a couple of concerns, if it is there, that I think you might want to address.

One of them is that there are many different kinds of sensitivity besides allergy, and if you are going to single out allergy you might want to single out all kinds of sensitivity, including allergy and non-immunological types of sensitivity. Reactions to toxicological sensitivity and food intolerance, for instance, which are not allergies, strictly speaking, might be covered in the legislation. The other element of that sentence relates to the fact that the type of act that is being controlled is where the positive indicator is a reaction of an allergic type.

So two points again: One, what if the positive indication is a reaction of a non-allergic type, which is life-threatening? In other words, if you are going to protect some of the members of the Allergy and Environmental Health Association of Ontario, the ones who have allergies, why not protect all of them, the ones who have other kinds of sensitivities? The second part of that is the idea that quite often the positive result of a test is not a reaction. For instance, in serial dilution titration testing recommended by Thomson in 1985, the positive reaction of the test is a neutralization of symptoms. However, a positive reaction can be caused on the route to finding a neutralizing shot or sublingual dose. So if you are going to protect people with allergy, why not protect a broader group of people with sensitivities? If you are going to protect people from tests where the reaction is an allergic reaction, why not protect them from tests where there are toxicity reactions? If you are going to protect people from tests where the reaction is positive, where a positive indication is a reaction, why not protect them from tests where a positive indication is other than a reaction, but a reaction may be caused during the course of the test?

I think that is all I need to put in a summary. Thank you.

Mr Grandmaître: In your brief you are saying that environmental sensitivity is not a medical illness, but sensitivities can be caused by a number of illnesses. You were diagnosed in 1979. Tell me about your life before 1979. Were you struck with some kind of illness?

Mr Brown: I would rather avoid a description of my personal situation. I had this problem all my life. I went to a variety of specialists over a long period of time to find out what the problem was. Finally in 1979 I was fortunate enough to come across some British work on this subject and to find a doctor familiar with it and to be diagnosed. I had medical problems before 1979, but I want to emphasize that the difficulty people have is more with the stigma attached, with the fact that they have been trashed on the basis of an absence of information. That is where the difficulty lies. In terms of this legislation, the concern is to try to give people an option for appeal other than going to the parties who are aligned with those who are carrying out the abuse.

The Chair: I want to thank you very much for your presentation this morning. The committee has received your written brief, and I would inform you and anyone else who is listening this morning that if there is additional information you think would be helpful to the committee during its deliberations, please submit further briefs and information in writing through our clerk. Thank you for appearing this morning.

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ONTARIO NATUROPATHIC ASSOCIATION

The Chair: I would like to call next the Ontario Naturopathic Association. Please come forward and introduce yourselves to the committee for the purpose of Hansard. You have 20 minutes for your presentation, and if you will leave a few minutes at the end of your presentation for questions we would appreciate it. The committee has received the three written briefs you submitted. Please begin your presentation now.

Ms Rivard: My name is Darcelle Rivard. Je suis ici ce matin pour dire quelques mots au sujet de la naturopathie. Je vous remercie d'avance de prendre le temps de m'écouter.

Good morning. I am a graduate of the Ontario College of Naturopathic Medicine. I am a full-time practitioner of naturopathic medicine in Timmins. I have a diverse practice providing naturopathic care to francophones, English-speaking citizens and members of the first nations. My services are utilized by many people living in northeastern Ontario, including Kapuskasing, Iroquois Falls, Cochrane and Matheson, to name a few.

I entered this profession to help people be well and enjoy their years free from suffering and illness. If I am unreasonably restricted or held back from using the basic skills and training I have worked hard for, I will actually be forced to move away to practise the career that I love. Please understand that neither I nor my colleagues want to expand our scope to be medical doctors or anything else other than doctors of naturopathic medicine. However, we also do not want to be reduced to a level of practice that does not use our training and our skills.

I spent many years reaching this level of training and I believe it will be wasted if our scope of practice is eroded. I would like to thank you for this opportunity to express my feelings on this important matter. Since I am a relatively new doctor of naturopathic medicine, I have therefore invited Don Warren, an experienced colleague of mine, and a patient of his, Margaret Smiley, to complete this presentation.

Mr Warren: Good morning. I am a full-time practitioner of naturopathic medicine here in Ottawa. I am also a member of the board of directors of the Ontario College of Naturopathic Medicine as well as being a professional member of the Ontario Naturopathic Association.

You have had several presentations from our profession, from the Ontario Naturopathic Association, so what I would like to do this morning very briefly is give some details to the background of the training of a naturopath and really what kind of implications new legislation will have upon our college in Toronto.

The Ontario College of Naturopathic Medicine is the only Canadian college recognized by the licensing jurisdictions of various Canadian provinces and the various states in the United States that license naturopaths. To become a naturopath requires three years of pre-medical training at a recognized university and then four years of training at a recognized college of naturopathic medicine. Along with the basic medical sciences, we are trained in the clinical sciences of botanical medicine, clinical nutrition, homeopathy, oriental medicine and acupuncture, naturopathic manipulation, physical therapy such as heat and light, electricity, and hydrotherapy. We are also trained in the areas of radiology, in clinical and laboratory diagnosis, including venepuncture. We are also trained in minor office procedures.

This range of training is consistent with the scope of practice of the licensing requirements of the various jurisdictions that license naturopaths in North America. Our students are given a complete and broad range of training in subjects and methods that are not taught to any other health care provider in Ontario. We use time-proven, effective, non-invasive low technology in most cases, very gentle forms of medicine that actually work and have been proven by years of use, not only within our culture but in other cultures over many years.

We are also interested though in what is happening on the latest fronts within science, such as the discoveries of immuno-modulating natural substances that help stimulate the immune system. So we are an eclectic combination of things that are time-proven, and we are trying to keep abreast of what is happening in science in the areas that fit our principles and scope of practice.

There is also, obviously, a natural overlap between our training and other health care providers, including that of medicine. However, as was mentioned by Darcelle earlier, we have no interest in encroaching on any other health care provider's territory or turf. We feel we offer a unique set of services that we are trained in. This is what we want to be able to continue to give.

The Ontario College of Naturopathic Medicine has become and is becoming a world leader in training competent and well-trained naturopathic practitioners. The success and growth is indicative of the increased public demand and public interest.

As an aside, I have been practising for four or five years. I left a career in business and the family business here in Ottawa, went back to the University of Ottawa, did my pre-medical science training there. Then I had to go to the United States, because in 1979, we did not have a college in Canada. I studied at the National College of Naturopathic Medicine in Portland, Oregon. On graduation it was something I was very excited about, coming back to practise here in Ontario, because I knew we had a law that permitted us with a reasonable scope of practice. I had great fears when things started to go in an opposite direction. However, with the work of the previous government and the present government, I feel much better about the future of naturopathy.

What you do as a government will affect whether we as a college continue to be a leader in natural health care training. The public demand is there. I have been practising only for four or five years, but at this point, I have about a year's waiting list of patients who are chronically ill. Certainly, if a person was acutely ill we would see them. But a patient who is chronically ill takes about a year to get into our practice. This is just by word-of-mouth referral. So there is a great need for well-trained, competent naturopathic physicians or practitioners here in the province.

Your law will affect what we are able to teach. What we are able to teach will determine what students we will be able to attract. If our scope of practice in Ontario is such that we can train students to go and practise in BC or other provinces, then we will keep our students here in Canada, otherwise we will lose them to the States. We also have a great opportunity to attract students from the eastern seaboard in the United States to our school.

So we appreciate you listening and we hope you will continue to give this study. The future of our profession, the future of our school, depend upon the details and scope of practice that will come out of this legislation and future legislation. Thank you very much.

Ms Chalin Smiley: I am here as a private citizen and as a patient of a doctor of naturopathy. I am here to seek your support in ensuring that I continue to receive the full scope, range, of treatment I have been receiving. I understand that under the new law the naturopathic profession will have to apply to define its scope and range of services. I am really concerned that I continue to receive this without having to leave my home province.

About a year ago I could not walk from where I am now to where you are without tremendous difficulty and without total exhaustion. I sought out naturopathic treatment on the advice of a colleague. From the very beginning, my condition improved dramatically. I received the range of treatment that Dr Warren has described, particularly the homeopathic remedies, which I found to be extremely effective in my condition. Now I can exercise, I can ski, skate, swim, rollerblade -- I do everything. At that time the prognosis was not good. It was not expected that I would be able to return to my job full-time. I now am working as a senior manager in the federal public service. I have energy. I have excellent health and I really attribute it to my visits to my naturopath.

The treatments are non-invasive. I was told to expect a lifetime of drugs, possibly surgery. When I was in the hospital -- I was in the hospital for over a month a year ago -- I was subjected to all kinds of treatments. I was receiving 1,000 cc of steroids, prednisone, by intravenous drip. So I had a fairly serious condition.

My doctors are amazed. They are very enthusiastic. They are extremely supportive of my homeopathic treatment. In fact I have not had steroids since last fall. And I have a consulting neurologist, a rheumatologist and my general practitioner, and all three of them are very supportive of my seeking this treatment.

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Mr J. Wilson: Thank you for the presentation, Ms Smiley. You mentioned in your brief, I think, that you hope that this committee does not leave the naturopathic scope of activities at the mercy of the system without comment. My question is better addressed to the parliamentary assistant. What exactly will be the process for defining the scope of practice for naturopathic medicine? It is my understanding that the advisory council will be doing that. Certainly it is not really the purview of this committee at this time. Perhaps you would like to comment on that.

Mr Wessenger: Yes, it will be the advisory committee but for more details I will refer it to the staff.

Ms Bohnen: The advisory council will be created as soon as possible after the legislation completes its course in the legislative process. The bill sets out a skeletal framework for the advisory council. For example, no regulated health professionals will sit on it, largely to ensure that it will take an impartial, objective look at the matters that are referred to it. The advisory council will have to have a support staff, a full-time secretary, information available to it, and will have to determine its own procedure and its own criteria in considering matters such as this.

The Chair: Supplementary question, Mr Wilson?

Mr J. Wilson: Perhaps one of the two doctors of naturopathic medicine could let us know now -- what are some of the key things you will be looking for in a defined scope of practice, that you want to make sure they do not leave out?

Mr Warren: Certainly there are some things in Ontario that we are hindered in under the Drugless Practitioners Act. In fact, in many ways it has been an obstacle to us in being able to perform as we are trained. One of the things that we are concerned about is the access to the labs. Although we have the opportunity of taking blood, venepuncture, we do not have any labs that will take our work because we do not have that covered in our scope, so we are limited in some of the diagnostic aspects. There are other areas such as radiology. We want to make sure that we have the ability to continue to take and read X-rays. Particularly in diagnostics, the area of laboratory diagnosis, it is very important we have that so we are able to be complete. Where I trained in Oregon, we had a much broader scope of practice, especially in that regard. In other jurisdictions, such as BC, they have this scope of practice. We want to be able to ensure that this happens here in Ontario.

Mr Beer: I sense one of the points in the collection of your briefs is whether as a committee we have the right or are likely to comment on this particular issue. The committee is free to comment on anything, in addition to the concerns you have expressed about how you would be dealt with by the advisory council. There are some other sectors that have also raised the issue of how the advisory council would function. And as has been noted, I think one of the important things is that body not be made up of regulated professionals so it will be a more impartial body.

But that does not prevent us from certainly urging that this is a matter of importance and should be looked at fairly quickly. One of the questions, and it follows along from Mr Wilson's, in terms of your scope of practice: Is the scope of practice in the United States one that is determined state by state or is there the same scope of practice right throughout the country? And I take it, at least in Oregon, it is more expansive than what currently exists in Ontario?

Mr Warren: It is determined state by state, although there is a fairly consistent pattern throughout the states that have licensing. In answer to Mr Wilson, as well as yourself, we are really looking for maintenance of a scope of practice that is already in the law -- we do not want a shrinking of that scope of practice -- plus the insurance of a few things such as laboratory diagnosis --

Mr Beer: You want to insure what you concurrently do under the Drugless Practitioners Act --

Mr Warren: Exactly.

Mr Beer: -- but you also want the diagnostic element that you mentioned before -- is that blood testing?

Mr Warren: Right.

The Chair: I know you are aware that if there is any additional information you think might be helpful, you can submit it to the committee through our clerk over the course of our deliberations.

JENNY THOMAS

The Chair: I would like now to call Jenny Thomas. Welcome to the standing committee on social development. You have 10 minutes for your presentation. Just begin now, and also leave a few minutes for questions; we would appreciate that.

Ms Thomas: My name is Jenny Thomas. I am a dental hygienist practising here in Ottawa. I have been practising for the last 20 years in both private practice and specialty practice for a periodontist, which is for treatment of gum disease. I have worked in public health and until recently worked at the outpatients' clinic here at the Ottawa Civic Hospital, where we treat medically-compromised patients.

I should like to introduce two escorts of mine, Doreen Slingerland, who is a registered nurse and has worked with me on projects in nursing homes, and Russell Cecchini, who is one of my clients and is a consumer of dental hygiene.

I have taken the opportunity of meeting with you this morning because as a dental hygienist practising in the field and in continuing dental education, I have two professional concerns, both of which may be affected by the new health legislation. I am giving this presentation for myself. It is not a representation of my official organization and it is not a referenced work.

My two concerns are basically the following. One is the treatment for periodontal disease or gum disease in Bill 43, subsections 27(1) and 27(2), which is the delegation of controlled acts. The group that this affects primarily is the general population. It is the patients of private practitioners -- that is yourselves, ladies and gentlemen, and members of the audience here and the population at large. My second concern is access to dental treatment by certain population groups such as the homebound, residents of collective living centres, refugees and the working poor. This will be found in legislative writing of Bill 47, section 4, for authorized acts.

Let me first turn to my first concern, the treatment of periodontal or gum disease. The causes of periodontal disease are many but the prevention and early treatment of this condition is considered to be best accomplished by assessment, treatment planning, treatment by thorough, meticulous periodontal scaling and the use of antimicrobial substances, and then an evaluation and follow-up. Apart from the periodontist, who is a specialist, the dental hygienist continues to be the most thoroughly trained and accomplished dental professional in these areas, particularly with respect to the treatment or the scaling.

Although there are some geographic variations in demand, there is currently a potentially explosive situation arising in the area of dental human resources. Some dental practitioners are not employing dental hygienists, and the dental profession is pushing for intra-oral duties for dental assistants, including the polishing of teeth. These duties resemble those of dental hygienists but are totally inadequate for the treatment of periodontal disease. These duties should not be used as substitute services for periodontal scaling, and neither should the non-regulated personnel doing them be delegated periodontal scaling or the controlled act of a dental hygienist.

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I was interested to see on the inside cover of the pamphlet this morning that the consumer's view of health care was an expectation that the person who provides you with care is qualified. I therefore feel it is important that subsections 27(1) and 27(2) pertaining to delegation must be revised to ensure that under no circumstances should other non-regulated, ie, non-qualified, dental team members, be allowed to be delegated duties that may result in gross mistreatment of gum disease, thus rendering harm to the public.

My second point is access to dental treatment by certain population groups. The supervision of dental hygienists has a long and involved history, and I am sure that you are familiar with it. I have therefore made the assumption that you are cognizant with both how the supervisory clause has been interpreted in the past and that direct supervision requires the presence of a dentist in the office during treatment activities. The implications of this are threefold for collective living centres, community health centres, and the people whom they serve.

First of all, the cost increases, because it becomes necessary to provide two operatories and to pay a dentist. Second, staffing with full-time dentists in these situations is very rare, so the use of the physical space is very inefficient. And, third, if one operatory only is provided, it means that the dentist is the only professional who can practise in that operatory.

I am concerned because over the past eight years I have been dentally treating people who are chronically ill, elderly, and otherwise medically compromised. These people are the most difficult people to treat, both in terms of patient management -- for example, keeping them in the chair if they have Alzheimer's disease and like to wander around, and helping them to keep their mouth open -- and in terms of physically accessing at least adequate equipment. Taking them to a dental operatory often requires personal escorts, special transportation arrangements, ambulance service and accessible buildings. If dental hygienists were able to practise in the residences, or within community health centres, either indirectly or unsupervised, access to dental treatment would be much more readily available both physically and financially. And of course the referral system to a dentist would always be available.

I have already introduced you to my escorts today, both of whom have personal experiences with regard to accessing dental treatment. Doreen is a registered nurse and knows only too well the very great need for hygiene services within nursing homes and similar collective living centres. Russell is a consumer. In brief, it took us about 20 appointments to complete what would normally have been done in four or five. The point here is that dental hygienists should be employed in salaried positions within community health centres so that the services rendered to these people are not tied to fees for service, government insurance codes, or business deadlines. Allowing dental hygienists to work at arm's length with global budgets within collective living centres and community health centres would enable that to occur.

The current inclusion of the phrase "on the order of a member of the Royal College of Dental Surgeons of Ontario" could lead to restrictive interpretation that might prevent dental hygienists from providing necessary and less expensive treatments to these people. In my opinion, it should either be removed or the definition of arm's-length supervision well provided for.

I should like to open up the presentation to you for any questions.

Mr Owens: In terms of bringing your service into group homes, nursing homes and things like that, how would you as a hygienist deal with issues around patients who require prophylactic antibiotics to prevent endocarditis and some of the other problems, if we take your concerns and put them into legislation? Would you work with the registered nurse, or would you have that medically compromised person dealt with by a dentist?

Ms Thomas: I do not ever foresee a dental hygienist working isolated in one of these collective living centres or community health centres. I see the system set up so that dentists are there when they are needed. I see a dentist's services required in part of the diagnostic services at the beginning, so that the patient would have been diagnosed and looked at by a dentist, and a dental hygienist can carry out the services that may have been suggested as being applicable. At that time, medication such as prophylactic antibiotics can have been prescribed and the medical personnel on staff in the nursing home can prescribe them and give them.

Mr Beer: Following up on that question, because certainly under long-term care we are going to see the need for more and more of these services in other settings outside of dentists' office and the like, presently when you are providing the service you provide, in practice how does that work when you go into some of these other centres? Do you have to bring everybody into the dentist's office, or do you have arrangements with dentists with whom you work to do certain things?

Ms Thomas: Currently here in Ottawa we are very lucky, because I work out of the outpatients' clinic of the Ottawa Civic Hospital where we have special arrangements made. In most of the cities and towns in Ontario that does not occur, so basically these people do not receive treatment.

Mr Beer: Those special arrangements, is that in the form of a written special arrangement? If you are going out to treat patients, how is it you are allowed to do that?

Ms Thomas: Even here in Ottawa I cannot at the moment do that without the dentist being on the premises. I am not doing it at the moment. But this is where I see the need arise, because I could then go out to nursing homes if the case arises, which it does. We see the need all the time, but at the moment I cannot do that. I can only do it when people come to me. I have had access to very inadequate portable equipment where the dentist and myself have gone out, but it has been a very efficient use of time, facilities and resources.

The Chair: The committee appreciates your coming today. We appreciate your presentation. Thank you very much. I know that if there is any additional information you feel might be helpful you will submit it to the clerk in writing. Thank you all for coming.

0950

JACK GRYFE

The Chair: I call John Gryfe. Welcome. Please begin your verbal presentation now and, if you would, leave a few minutes at the end in case any of the committee members have a question.

Dr Gryfe: My name is John Gryfe. Actually, I prefer to be known by Jack. I am an oral and maxillofacial surgeon. I practise in the city of Toronto. For those who may not know, an oral and maxillofacial surgeon is a professional with a dental degree and then formal surgical training, which may vary but encompasses a minimum of three years, and may have as much as five years, post-dental education. I practise in the city of Toronto. I am also the chairman of the Canadian Dental Association's committee on community and institutional dentistry, and one of the areas we have been very interested in has to do with the technology in dentistry, including the uses of energy.

The Chair: Are you here today as an individual?

Dr Gryfe: I am here today as a private individual.

The Chair: In that case you have 10 minutes for your presentation.

Dr Gryfe: Madam Chairman, ladies and gentlemen, I come before you today as a concerned dentist. In the short time allotted to me I hope to impress upon you the dangers of certain energy modalities currently in use in dentistry when they are handled by inappropriate hands. The proposed health acts legislation, while recognizing this, fails to understand that dentists are trained to use this technology properly. Unfortunately, the proposed legislation provides medicine with the exclusive authority to apply and order the application of these forms of energy.

Specifically I will be reviewing possible hazards in the clinical application of laser technology, other visible light energy, and electrical energy. Yet these are used successfully and safely by the dental profession today.

Electrical energy has been used in the healing arts for almost as long as the modality has been known to man. Electrocoagulation is a well-accepted method for surgical management of certain soft tissue problems. The effectiveness of this treatment is also the likely basis for peril. The hotter the instrument's tip and the longer the tip is applied to the tissue site, the greater depth and extent of tissue destruction. Because the gum tissue covering the bone of both the upper and lower jaws is quite thin, the possible destruction of not only the soft tissue being treated but also of the underlying bone is a real consideration. This is equally true of the fibres that support the teeth in their sockets.

More recently, electricity has re-emerged as a means of therapeutic or pain-decreasing management. In 1987 the American Dental Association issued a status report on TENS, transcutaneous electric nerve stimulation, noting that "among factors influencing TENS performance are training, proper usage and patient selection involving psychological screening." HFNM, high-frequency neural modulation, a recent advance, uses the same techniques as TENS, only with higher electrical current and increased frequencies. The current edition of the Journal of the Canadian Dental Association contains an article on electronic dental anaesthesia, yet another modification of the same technology.

Such potentially harmful forms of energy are commonly used by dentists throughout Canada.

During the last decade, a group of restorative dental materials has evolved that requires exposure to high-intensity white light in order that these substances be cured completely. The light is applied by direct exposure from a fibre optic beam in a hand-held source. Different materials require different exposure times. Failure to cure these materials properly will make them ineffective in preventing further tooth injury. While this light may appear to be harmless, the manufacturer's instructions direct that both the dentist and the patient wear specially tinted glasses to prevent the possibility of eye damage. Because of the effectiveness of these materials, it is likely that their use will become even more widespread in future years.

Perhaps the most exciting energy source is the use of lasers. Laser, an acronym for light amplification by stimulated emission of radiation, is recognized as having the potential to make a significant impact on the practice of dentistry in hard and soft tissue applications.

Three different wavelength groups -- ultraviolet, visible light and infrared -- produce a wide spectrum of energy beams. These energy beams are converted into heat energy which, when directed at any tissue, begin to increase that tissue's temperature. Depending on the temperature achieved, the target tissue may be coagulated, cut or vaporized. The amount of heat produced is controlled by the laser's power, the laser's wavelength and the duration of exposure. The effectiveness of this energy is also a product of its absorption into a tissue and the extent of scatter of the energy within that tissue. Different tissues have different percentages of water and organic material, each of which can significantly affect the amount of energy penetration and scatter.

At present, lasers are used to vaporize dental decay within the tooth structure, desensitize teeth to certain pain-inducing phenomena, perform certain soft tissue surgery, and sterilize and vaporize necrotic tissue in a tooth's nerve canal during root canal therapy. A different group of lasers are being studied for their effectiveness in controlling post-surgical discomfort.

Knowledge and professional skill is critical to the effective use of such forms of energy.

The most commonly used lasers in dentistry at present are created using either carbon dioxide gas -- the CO2 laser -- or neodymium yttrium aluminum garnet crystal -- the Nd:YAG laser -- as the laser medium. These two lasers, both described as being hard lasers, have totally different capabilities. The CO2 laser is a surgical tool which rapidly develops large amounts of heat energy, whereas the Nd:YAG is not capable in its present state of creating a great deal of thermal damage unless it is misused. When using either laser system, however, both the patient and the dentist must wear specific eye protection to prevent optic tissue damage. The patient having CO2 laser treatment is expected to have his or her eyes protected by the placement of wet gauze sponges over the eyes, followed by the positioning of clear safety glasses over the gauze sponges prior to the onset of laser use.

Energy-producing technology has become an integral part of dental treatment. The techniques required to use these modalities demand a thorough understanding of the physiologic, pathologic, anatomic, chemical and physical implications of their application to prevent a wide variety of misadventures and complications. All of these basic science disciplines are included in the formal education of a dental student.

It is my belief that neither the omnibus bill nor the dentistry bill in their present form properly ensure that these technologies will continue to be available in the dental office. I agree with the review that the ordering and application of these energy technologies should be controlled by a specific act. Further, I would suggest that this controlled activity must be extended to the Dentistry Act. Just talking off the prepared text for a second, I would suggest that what is in subsection 26(7) of the omnibus bill should be reproduced in the dentistry bill directly. Dentists are properly prepared to manage this treatment modality. Under the RHPA we require the authority to continue to use such technology in the treatment of our patients. Thank you for your attention.

Mr J. Wilson: Thank you, Dr Gryfe. I expect the Ontario Dental Association appeared before the review committee on many occasions over the years. Do you have any idea why dentists were not given a controlled act pertaining to energy?

Dr Gryfe: No, I do not. I really have no idea. I did not write the legislation.

Mr J. Wilson: Neither did we.

Dr Gryfe: I only had the opportunity to read it.

Mr Owens: Should we extend this controlled act to your profession, what would be the benefit to the public by having this act within your scope?

Dr Gryfe: My concern is that by not having this as part of the Dentistry Act directly, we are going to lose the ability to use technology which is proven in the health care of our patients at the present time. This is what my fear is.

The Chair: We have a request from the parliamentary assistant to clarify.

Mr Wessenger: I understand the whole matter of energy use is to be allowed under the regulations, and I will ask ministry staff to indicate the reason for that.

Ms Bohnen: I think the issue for the ministry is just really which legislative mechanism is most appropriate. There is absolutely no intention on the part of the government to prevent dentists from using forms of energy which they use in their practice. It is just a question of where within the legislation the authority is best placed.

Dr Gryfe: May I comment on that? Totally acknowledging my glaring deficiencies in not being legally trained, it seems that if the subsection that I referred to is not reproduced directly in the Dentistry Act, then either we are possibly excluded or I suppose the alternative is that anybody else whom the act currently covers in any of the appendages to the umbrella of Bill 43 could theoretically use the same energy. I do not believe that some of these disciplines have the proper training to do so.

Ms Bohnen: Until a regulation is made under the Regulated Health Professions Act specifying hazardous forms of energy or their applications, and further specifying which professional groups may use those forms of energy, the controlled act really has no meaning. It will be through the regulation-making process that, first of all, the hazardous forms are identified and protected and then allocated to the appropriate professions.

Dr Gryfe: Does the paragraph specifically reappear in the medical bill?

Ms Bohnen: It does, for the reason that -- according to any view of what forms of energy will be listed, for example the first one that comes to everyone's mind is ECT, electroconvulsive therapy -- physicians will be utilizing it.

The Chair: I want to thank you for your presentation before the committee today. If at any time you wish to communicate further with the committee, please feel free to do so in writing through our clerk. We appreciate your appearance today.

1000

ASSOCIATION OF CONCERNED CITIZENS FOR PREVENTIVE MEDICINE

The Chair: I call next the Association of Concerned Citizens for Preventive Medicine. Please come forward and introduce yourselves. You have 20 minutes for your presentation. We would ask you to leave a few minutes at the end for questions.

Mr Dugas: Thank you, Madam Chairman. My name is Ron Dugas and I am the president of the Association of Concerned Citizens for Preventive Medicine, a non-profit, national consumer organization which is dedicated to the development of preventive health care in Canada. It is incorporated under a federal charter and has a membership of 9,500 members across Canada.

The ACCPM has been associated with the process leading up to this proposed legislation since its inception many years and several governments ago. Because it has reservations on some points, the ACCPM gives a guarded welcome to the proposed legislation. The legislation makes a real effort to ensure that self-governance by professions will be guided by true attention to the public interest. We recognize that effort and appreciate it.

The new law intends to increase public participation in the councils of the colleges. We also welcome this idea. However, we do find the procedures and rules too complex. To deal with this, we urge a simplification of the procedural rules set out in the health professions procedural code without diminishing the efficiency and fairness of self-governance. The system set out in the procedural code and the individual professional acts fails to provide for an essential committee -- one to promote and provide continuing professional education.

We welcome the fact that the "monstrous harm" or "potential for harm" clause has been omitted from the legislation before you, along with the draconian penalties proposed by the Health Professions Legislation Review committee. We wish to advise the committee that there are interests which wish to revive some form of harm clause, for whatever reasons. Our concern is that the committee be alerted to any attempt by any person or any organization to reintroduce such a draconian, irrational and unfair clause again. The ACCPM is firmly opposed to the introduction of any such clause.

As has been demonstrated by the attempts made previously, the only result of such a clause is unjustified restriction of normal constitutional freedoms. The safeguards in the Criminal Code of Canada and under the proposed controlled acts are quite sufficient to provide the necessary remedies and protection. The whole clause offended against common sense and fair play. It was apparent that it was intended to intimidate any person who was not regulated.

We object to the designation of diagnosis as a controlled act and consider it should be struck out. The language has been changed to avoid the term "diagnosis," but this is what is meant and intended. In our view, this clause lacks the rationality found in the remainder of the legislation.

First, it prevents an unauthorized person from stating to the patient what he or she believes to be the problem, and the causes of the person's health difficulty. This is, as far as we are concerned, an infringement of free speech and communication.

Second, it means that a patient is expected to accept treatment from someone who has to explain what treatment they intend to apply or advise but is not permitted to explain the whys and the wherefores.

Third, there is only one rational explanation for this clause, that is, it is intended to make impossible the practice of any form of physical, nutritional or psychological therapy by any person who is not a member of a regulated profession. That was an intent also of the original harm clause and the original diagnosis clause. It continues to be the reason for the diagnosis clause under review here.

Fourth, this clause will make impossible -- except through exemption by regulation, for which there is no guarantee -- the practice of natural healers, psychotherapists, social workers, pastoral counsellors, parole officers and crisis counsellors. With this clause included, the act would throw thousands of unregulated health care workers into legal jeopardy.

Fifth, if you leave it to the courts to settle what the clause means, you will be putting all unregulated and many regulated workers in legal jeopardy.

An article which appeared in the Globe and Mail of August 8, 1991, under the editorial section supports the practice of traditional medicine and a regulatory regime which does not suppress it. This is what the Globe had to say in part:

"The practice of traditional forms of medicine is growing rapidly in Canada. Many Canadians, dissatisfied with the conventional system, are turning to these healers, and practices new to Canada have been brought here by the recent influx of migrants of non-European origin. It is based on centuries of human experience.

"While many Canadians might not want to seek the advice of natural healers, their reluctance should not translate into a regulatory regime that denies others the opportunity. In both Europe and Asia, conventional medicine and traditional medicine live alongside each other and work together for the health of the people. They need to learn to do so better in Canada."

This clause is an offence against common sense and fair play. It can only be supported on the basis of trying to maintain a monopoly situation. It cannot be justified and should be deleted.

The naturopathic profession has been omitted from the legislation although it has been a regulated profession since 1925. However, the wrong which has been done to the naturopathic profession has been recognized. The Ministry of Health is proposing to include a naturopathy act after this legislation has gone into effect. Meanwhile, the present legislation allows for the continuation of the Drugless Practitioners Act in such a way that naturopaths will continue to be regulated. However, as we point out in our submission, the presence of the diagnosis clause and the exclusion of the naturopathic profession from the schedule of regulated professions would effectively bar this profession from practice.

We feel that in order to deal with this situation a naturopathic act should be added to the legislative package with consequent amendments. The ACCPM is appreciative of the proposal made by the former Health minister, Ms Gigantes, that acupuncture will also be exempted from the controlled act. If acupuncture is not to be a regulated profession, as we believe it should be, then it is fair and right that provision should be made to exempt acupuncture from the prohibition of using the controlled acts which it needs to employ in order to be able to continue its practice.

Unfortunately, the promise made by the former Minister of Health, although sensible and well-intentioned, is general in its terms. It does not say what licensed acts, nor does it specify when the exemption will be implemented. We recommend that acupuncture be added to the list of health professions in schedule 1.

Madam Chairman and committee members, these recommendations from the ACCPM are intended to support such major factors as justice, fairness and non-discrimination. Thank you very much.

1010

Ms Haeck: Thank you very much for a very informative presentation. We have had a few presenters with a, shall we say, strictly consumer orientation rather than a professional one. I will have to admit my own bias in this: I would like to see broader consumer education.

How would you approach that particular issue of informing the general public about the variety of specialties? You mention naturopathy and acupuncture as two that are of interest to you, as well as the concern about the diagnosis clause. How would you, in the process of preventive medicine and all the things that you stand for, make the public much more aware of those kinds of concerns?

Mr Dugas: We honestly believe this is a dual role. Not only the consumer organizations but the government itself have to play a leading role in informing the public as to what the different disciplines are, the qualification, competency of groups, and so on. It is very, very important for the government -- and I think it will be with this advisory council which will be formed later on after this becomes law -- to work co-operatively with consumer groups to relay this type of information to the public.

Ms Haeck: With the diagnosis clause that you obviously feel quite strongly about in its current format, do you not believe that it is really going to protect the unregulated professions as well as the public?

Mr Dugas: I think it is a foregone conclusion. I am sure you know that many groups have addressed the committee and have indicated their gravest concern about this particular clause. As we have explained in our submission, how can we support, as an example, unregulated practitioners and also regulated practitioners, if they cannot actually give a diagnosis to a patient? We feel this is an impossible task.

As we have indicated also in the submission -- and this is one part I think that the committee members have to fully understand -- if I as a consumer am prepared to pay out of my own pocket to see a natural healer, at no cost to the taxpayer, why should I have restrictions in the law which will not permit me to get a diagnosis from someone I feel is competent, if I feel I do not want to be treated by conventional means, be it drugs or surgery, as an example? We feel this is a very important factor and should have an impact on this legislation.

Mr Beer: The two intentions, as I understand the legislation, are: one, to protect the public, and second, to develop greater access. Clearly, in the areas that you are discussing, for many people there are many new practices that are, if you like, pushing the envelope, changing the way we look at health care and health services. I wonder if you might comment on the advisory council and its proposed role once this legislation, with or without amendments, goes forward, in terms of dealing with perhaps what we call newer professions that will come along wanting to be self-regulated. What are the key things that you would want to see in the way that advisory council functions? Perhaps you could give us some comments on that.

Mr Dugas: We have had a good look at the area of the advisory council, and I must say that we are pleased with the manner in which this has been struck. With many of these new disciplines that might be up for regulation, very definitely we feel the safeguards are there. I cannot add too much, because I personally, as president of the organization, and our organization are quite pleased with the proposal under advisory council.

But I would like to make one more point, and I think it is important. Often we hear about charlatans, and I think it is good to raise this, because as a consumer I feel it is important for people to understand where we stand and where we are coming from. Many times when we are speaking of a traditional medicine, people think immediately of charlatans. Let me give you an example, and this is where we can have a professional group, be it the medical doctors or anybody else, have a complete monopoly on a system. Let me give you an area that you should be having a good look at, because you can have charlatans among medical doctors the same as you can have in traditional medicine.

There is one controlled act which really concerns us, and that is the controlled act 4, which has to do with the moving of the joints of the spine. Let me tell you, if you were, as an example, to see the background and the education of a chiropractor, where the general thrust of what he learns has to do with the manipulation of the joints, he does this continually. He becomes a specialist in it. The way this is now drafted, any doctor, a general practitioner, as an example, can actually work the spine on a patient. Maybe that general practitioner, as an intern, has taken a course of maybe a few hours' in manipulation of the spine. I can understand if you are talking about a specialist who deals in surgery about back problems. He certainly has all the competency that you would want. But I would much rather go to a chiropractor than go to a general practitioner when it comes to my spine.

So I say, is this not a bit charlatans when you talk about -- it is not the fault of the medical people. But I am saying, let's have a good look at the law. It is not because a group is professional that they have the competency in dealing with the health care situation.

The Chair: Question, Mr Wilson, one minute.

Mr J. Wilson: Just going back to the diagnosis clause for a second, you mentioned, as a number of groups have, that it should be scrapped. But do you have any suggestions for the committee on what might replace it, given that we have all read in the papers and as members we have all had the calls to our offices by people who have visited so-called quacks? You are right, when people pay out of their own pocket they expect a level of competency. But fortunately the legislation is being introduced to try and get rid of the quacks. So what would replace that section?

Mr Dugas: I am sure you have met with Professor Evans, and we have worked with him all along. There is one particular clause in there which maybe we as consumers feel we could live with, and that is the competency clause. But this would be difficult again. The only thing we would worry about is if you went before the courts and had a judge, or he had a committee, completely versed in conventional medicine, and not knowing anything about traditional medicine, maybe then they would not get a fair shake due to the fact that the judge or the courts do not fully understand what this other medicine is all about. But maybe there is something that could be worked from that competency clause with regard to the different disciplines.

The Chair: Thank you very much for your presentation.

1020

MATTHEW YEAGER

The Chair: I call Matthew Yeager. Welcome. You have 10 minutes for your presentation and we would ask you to leave a few minutes at the end for questions.

Mr Yeager: Thank you. My interest in the legislation, Bill 43, is primarily with respect to the disciplinary systems currently in operation among the five health professions regulated by the Health Disciplines Act and the improved system that is proposed in the bill presently before this committee. My motivation is that of a researcher long fascinated by the area of white-collar deviance, and therefore I come to this area with a perspective markedly different from most of the witnesses you have heard.

To date, I have had an opportunity to conduct a preliminary inquiry into the disciplinary systems of four of the largest professional colleges, those being the College of Physicians and Surgeons of Ontario, the Royal College of Dental Surgeons of Ontario, the College of Nurses of Ontario and the Ontario College of Pharmacists. Together these four colleges, as you know, represent about 180,000 licensed practitioners in this province.

Under the existing act, each college is required to establish a separate registration and discipline committee, and the act gives these committees the legal authority to hold formalized hearings with the legal power to revoke or suspend a practitioner's license.

While the public may assume that these two committees handle the majority of misconduct/incompetence cases, such is not the case, at least by my preliminary inquiry. For example, of the 95 decisions issued by the complaints committee for the dental college from April to October 1990, only 6% were referred to the discipline committee. Apparently even fewer cases are referred by the executive committee to the discipline committee, which initiates its own investigations into some of the more serious rule violations, such as drug trafficking, misuse of prescriptions, drug addiction and sexual abuse of patients and/or staff. With respect to the College of Nurses of Ontario, only 23 cases, that is, 4%, were referred to the discipline committee. That is out of the complaint committee. An additional number of cases were referred to the registration committee.

Because the formal power to revoke a licence is vested in only two committees, all of the professional colleges have tended to keep disciplinary matters away from these two bodies. Indeed, my preliminary studies have found that potential disciplinary cases can be found across a number of different committees in each of the colleges. I say potential because, to my knowledge, no governmental body, including the Ministry of Health, which has oversight responsibility, has conducted an audit of any of the complaints/investigations being processed by any of the professional colleges.

The situation is compounded by the fact that a number of potential reporting sources for assessing misconduct or incompetence are entirely separate and unconnected to the professional colleges. This is true for the Ontario health professionals assistance program, which is a private program that receives moneys from the colleges to only make treatment referrals and conducts no follow-up, and is also true for the various malpractice insurance claim programs where litigation is commenced against a health professional. It is also true, interestingly enough, with respect to the quality assurance program of the College of Physicians and Surgeons, which is kind of a random survey each year of about 250 physicians, where they go in and do an audit of their office.

Indeed, it is difficult to fully understand the scope of professional discipline or to analyse trends from year to year, because none of the colleges has a computerized database for discipline cases that would permit a comprehensive statistical study.

With the above in mind, it is incomprehensible, at least in my opinion, that the proposed legislation would continue to balkanize discipline matters among a host of committees, those being executive, registration, complaints, fitness to practise, quality assurance and discipline. I strongly recommend to the committee that only one entity be created within each college to conduct investigations, receive complaints and dispose of those complaints. This means that the activities of the complaints, discipline and fitness to practice committees should be combined and that all special investigations be managed by this new unit, so that the entire disciplinary process is housed together and therefore better susceptible to external review.

As you well know, the minister has the authority to audit any of the five colleges under the existing Health Disciplines Act, a power which is discretionary, not mandatory. In fact, I was amazed to learn that while the Health Professions Legislation Review conducted a survey of other disciplinary systems in the US and foreign countries, and indeed other provinces, no statistical research was conducted of any of the existing colleges in Ontario. In fact, I am unaware of any research agenda by the Ministry of Health in this area, which in my opinion is the greatest single indictment of government-delegated self-regulation of the health professions. I would therefore recommend that Bill 43 mandate that the minister audit the disciplinary system of each college every several years.

The remainder of my observations are somewhat technical, and I will not bore you with going over them so that perhaps you can ask me a question or two.

Mr Jackson: Professor Yeager, thank you for a very stimulating brief set out very succinctly. I have a dozen questions and I am only going to get one or two on.

Perhaps I can ask staff on your behalf, with respect to recommendation 1, the point you raise of combining the various groups into one body, is it possible for our legislation that we are currently working with, to reach into this area, or are the regulations governing the point raised in recommendation 1 by Professor Yeager found in other legislation or within the regulatory frameworks for the separate colleges?

Mr Wessenger: I would just like to comment with respect to recommendation 1. I think there is a major problem with combining the whole disciplinary procedure with the complaints procedure, in that if you are trying to have the principles of natural justice prevail, it is somewhat unfair to have the prosecution and the judge all on one body. I think it is very important to have a separate body hear the complaints in order that fairness is given to all concerned.

Mr Yeager: The problem, Mr Wessenger, that you have with that theory is that what you have done by creating that structure is you have a very logical behaviour occurring among all the professional colleges. They are doing everything they can to keep the disciplinary cases out of the registration and disciplinary committees.

They have the formal power to revoke and suspend. While you may think in theory that it is good to have a separate complaints unit to investigate complaints, what happens is that the natural tendency is for these bodies -- and of course, they have the power to affect the livelihood of their members -- to keep those cases away from the powerful committees that can perhaps do some damage to their profession.

I think that is really the wrong approach. I think that for the purpose of conducting external review and studies and to look at how they are disciplining, and here we are talking about rates of revocation, rates of suspension, recidivism -- we know nothing about the recidivism of health professionals in this province. I was not able to locate any studies that could tell you over a period of 10 years which physicians or dentists or pharmacists had two, three, four, five, six complaints against them. It does not exist right now. I think I would take a minority point of view and suggest that perhaps the committee reconsider the structure, because this behaviour is normal behaviour that is dictated by the structure of how you set up the committees.

Mr Wessenger: I think I would like to also have ministry staff comment. They would like to have an opportunity as well.

Ms Bohnen: I would like to comment, first to answer the initial question that was asked. It is this legislation which provides the structure and the rules for the committees. It is not any other legislation or the regulations.

In terms of fitness to practise, it is important to remember that it is completely different from discipline. It adjudicates cases where it is alleged that a member may be physically or mentally incapacitated. It starts essentially with information coming to the college. Then it goes to a board of inquiry. Usually outside examinations are conducted of the member's capacity. So I do not see that the same factors or influences come to play in dealing with incapacity as in discipline.

The theory of having separate complaints and discipline is to have a much more consumer-friendly complaints procedure whereby individuals can have easy access to a complaint investigation and it can operate as a kind of screen. I think that many of the colleges and professional associations would certainly dispute the speaker's suggestion that there is an intention in the colleges to keep cases away. I think what might be relevant to that is the fact that of cases reviewed by the Health Disciplines Board brought there by complainants who are not satisfied with the outcome by the complaints committee -- I cannot give you a statistic, but I believe only a small proportion result in a recommendation that the case be referred to discipline.

Mr Yeager: Criminologists historically have dealt with the issue of manifest and latent function, manifest being what rhetorically the colleges say they are doing and want to do, and latent meaning what they are really doing. What they are really doing with the vast majority of disciplinary cases is keeping them out of the formal committee structure. I think that is an error you ought to re-examine. You as a ministry official need to re-examine your whole oversight procedure because you have no ongoing research program and you have no ongoing auditing program in terms of looking at the oversight of these colleges and what is going on.

That would be my testimony. I am sure if the committee has some follow-up, I can be contacted.

The Chair: Thank you very much for your presentation. Similarly, if there is additional information that you think would be helpful to the committee, I would encourage you to submit further briefs in writing.

Mr Yeager: I have a report coming out on the pharmacists. I would be happy to forward that.

The Chair: Thank you. The committee will look forward to it.

1030

ONTARIO PSYCHIATRIC SURVIVORS' ALLIANCE OF OTTAWA-CARLETON

The Chair: I would like to call now the Ontario Psychiatric Survivors' Alliance of Ottawa-Carleton. You have 20 minutes for your presentation.

Mr Carne: My name is Bill Carne. I am the chairman of the local branch. This is Cathy Munroe, a member of our local branch.

This is by way of background. We are a group of present and former psychiatric patients who have gotten together for self-support as well as to try to improve the quality of mental health care, this being one example. As some public relations here perhaps, we prefer the word "survivor" to "consumer," "client," "user" or that sort of thing, as they indicate a very weak and dependent position. We have overcome the crisis. We have come through it with our skill, our knowledge, our wisdom. It shows something much stronger.

We have used the mental health system and we know where it does not work. The presentation I am making here will be covering basically Bill 55, which is our area of experience and interest, the profession of medicine and particularly psychiatry. Our comments may prove of value to other professions. I have four points to cover.

We really would like the principle of self-governance to be examined and perhaps replaced. There needs to be a more effective feedback mechanism so that the profession can be allowed to improve in the quality it presently gives.

Second, the complaint process must allow an ordinary citizen to be able to place a complaint with a reasonable expectation it will be acted upon. The complainant must not be made to go through undue hardship for a valid complaint. As the present system exists, the doctor seems to have great advantages over the complainant.

While I was looking at this early this morning, the present system seems to be grossly flawed, at least in my knowledge of what exists. It seems to require the injured party and not the college to be responsible for detecting, reporting and, in a sense, prosecuting professional misconduct and incompetence.

Third, the percentage of doctors on the committees of the College of Physicians and Surgeons of Ontario should be less than it is at present. We would like a lot of other people to be on there, perhaps even a majority, so that other viewpoints can be seen looking at the health situation. This would allow for a sort of a cross-culturalization of all these perspectives and maybe improvement of all of them by this mixing.

Fourth, there is a need for standards and guidelines of practice. This is quite obvious. How can high standards of health care be expected to be maintained if there are no standards by which to judge if what you are doing is good or bad?

In a little more detail, self-governance seems to be nice for the members of the governing body, but it does not seem to be that effective. The report from the Task Force on Sexual Abuse of Patients indicated there was a lot more abuse than was actually going through the college. In the States the psychiatrists, through self-reporting, said between 7% and 15% of them had sex with their patients. This is clearly professional misconduct, but it is not coming through the college, and so what exists now needs to be changed and improved.

Most of my friends are not psychiatric patients, but they have extreme complaints against the specialists' arrogance and insensitivity. For us the situation is even worse, because when we start complaining about something, that just is seen by the psychiatrist as proof of our diagnosis, that we have another one. Somehow a better system of feedback and supervision is necessary, supervision so that their decisions can be looked at and re-examined and feedback just to make sure they are staying on course. The example I like giving is try driving with your eyes shut. If you have no feedback, you do not get very far.

The next point is the complaint process. Very valid and serious complaints against doctors are not filed with the College of Physicians and Surgeons because people correctly realize that it is not worth it. It is a very unequal contest between the charged doctor and the person making the complaint. As an example, the person who is complaining is an outsider to the field of medicine, its jargon, terminology and attitudes. A doctor has the expertise and money of the Canadian medical protective association on his side, whereas a complainant, I believe, has to use his own money. Most of the people on the committee are colleagues of the doctor. These doctors have been taught to approach a situation in a very narrow and prescribed manner. In many cases, better alternatives do exist. There is also a great deal of trauma involved, especially if a loved one or yourself has gone through some distress because of your treatment.

Again, to me there seems to be a gross flaw in this system. This is not a case of civil court. It is a case of trying to prove the quality of the profession and I see no reason why the complainant should spend his time and money, as well as endure distress over a long period of time, to try to improve the professional standing of the college. To me, this is really the duty of the College of Physicians and Surgeons, not the complainant.

We would also like to make it more user-friendly to the injured party. As I was saying before, the way it is presently written, the implicit assumption is that it is the duty of the injured party to take on the responsibility of the college and that seems to us to be absolutely nonsense. Just as a suggestion, and there will be some extra cost in doing this, but I think if more effective feedback of these doctors were done, in the long run their competence would improve and that would reduce medical costs. It would also the reduce injury, pain and suffering and lack of productivity for those who have suffered injury because of the doctors.

Doctors are taught in medical schools to approach a problem in a strict and limited manner. We would like to have social workers, psychologists and laypeople on there with their own different perspectives of mental health. By having this intermixture, you get a broader view of what has taken place and I think the professionals themselves, all of them, would increase in their competence.

1040

Finally, setting guidelines and standards of practice: I understand the College of Physicians and Surgeons is considering that, but I think this body should put some sort of time limit in there, because it may take an awfully long time. I believe the insurance companies in the States are insisting that doctors set guidelines in an attempt to save money. I can perhaps see the same thing happening here in Ontario. If the guidelines exist, maybe the Ministry of Health can save money.

As one last point that is not in here, this group at 10 o'clock, the Association of Concerned Citizens for Preventive Medicine -- that is one thing our group is trying to do, to have alternatives where they presently exist. I will give you one example. One of our members spent a year in the hospital with a diagnosis of schizophrenia. He spent many years taking the so-called schizophrenic medication and now his hands shake. On his own, he discovered oil of evening primrose. His so-called schizophrenia disappeared. His body did not produce --

I am quite sure there are lots of other cases out there where a diagnosis of mental illness is actually something due to a physiological problem which perhaps these people could resolve if they were not limited by their apparent concerns with this legislation you have. I think that is my 10 minutes I was supposed to speak for.

The Chair: Thank you very much for the thoughtful presentation.

Mr Owens: I think psychiatric patients are probably the most visible scars we have on our society of what can possibly go wrong. You mentioned schizophrenic patients and the effects of Haloperidol.

In terms of the kinds of regulations that you would be looking for the college to write, how could we make that complaints procedure accessible? Would you want signs posted in doctors' offices explaining the procedure and who to get in touch with or where to get in touch with people? What kind of recommendations would you make with respect to that?

Mr Carne: I think that is very hard to do, because every case is quite different. I myself was trying to make a complaint against one of my doctors. I wrote to the College of Physicians and Surgeons about three years ago, asking what standards exist for psychiatry so I could compare what happened to me with the standards and decide whether it was worth while going through the process, but because there were no standards, I just felt it was worthless. I think having some standards of practice within two and four years -- as I recommend, guidelines for two years, standards for four years -- is quite important.

As I was mentioning earlier, it is not a matter that we come there, if you are assaulted by somebody else, the court system takes over and does all the work for you, does the legwork, does the investigation, does the prosecution for you. If you have a complaint against your doctor, it is more like a civil court where you have to lay the charge and you have to prove the charge. Whereas to me, if the College of Physicians and Surgeons, as in our case, is trying to really maintain high-quality standards, it should be doing the prosecution of faulty doctors, not the person who has been injured. Those are two things I can recommend that I can think of.

Ms Munroe: If I can speak to it as well, one of our other concerns is that a great many of us are marginalized and impoverished and oppressed, in a sense, by that system. Whether or not there can be individual notices of process in individual doctors' offices, there should be a system of advocacy and public education in the public hospitals and in the mental health centres and in the community health centres. Perhaps that is another tactic to begin at this point -- I do not think it has been attempted before -- to look at the Advocacy Act and to look at the human rights issues involved in this issue.

Mr Beer: My question is with respect to your comments around self-regulation. Is it not equally important that the professionals have a specific and direct concern about the issue of standards, the way in which they practise? That, in a sense, is why we want to have these professions self-regulated, in that the protection for the rest of us lies in the participation in the college and the kinds of standards and so on that would be drawn up.

I would be concerned, if I understand the thrust of what you are saying, that you could then be saying to professionals, "You don't really need to be concerned about those, because those are going to be dictated by government." Do we not need to find a model where we have both involved, but where we make sure the professional is directly involved in the regulation of his or her profession?

Mr Carne: I will make two comments here. One of my degrees is in social work, and we always talk in terms of filters, in the sense that if you are wearing yellow glasses, everything you see is in yellow. Most professionals get so caught up in their own little area of expertise that they do not see the rest of the world. By having a lot of outside people and outside professions, health-related, they are still talking health but with a much broader perspective than any given profession would.

Second, I believe the College of Physicians and Surgeons of Ontario has lawyers around to provide details and technical competence on the law. I quite readily recognize the need for, say, a surgeon or something like this to make presentations about the technical nature of their thing, but there are lots of cases, like in the case of sexual abuse or cutting off the wrong limb, where professionalism is not required. It is very simple.

So I recognize the need for professionals to have input, but I do not think they should have the total majority say, like they presently do. I think it is outweighed about 4 to 1 in most cases.

Mr Hope: With the increase of laypeople actively involved in the committee, in the area of more direct power, would that not then straighten out the problems that we are seeing? We all understand the issue of trying to access complaints or access to human rights; it is such a complex situation, people fall down. But on the inner side -- and I have always thought if you wanted to change things, you change them from the inner structure. You referred to the yellow glasses, where everybody sees yellow. Would this not bring the blacks, the whites, the blues, the purples and all the other colours in the place, when we increase the lay members?

Ms Munroe: I think that is what we were recommending. Mr Beer had mentioned making it a more consultative process. That is one of our wishes, that laypersons include people who have gone through some of the same procedures, successfully or not. Lay persons might include lawyers, might include professors of ethics, might include other professionals with their own particular viewpoint.

We recognize among ourselves, as survivors of the psychiatric system, that doctors have a position of power and privilege and they have a very strong interest in maintaining this privilege. They do seem to be threatened on all sides by this wish among the society that things be opened up. I do not think it can be done while they are self-contained and while self-regulation is the only practice. There needs to be more equality.

Mr Hope: Now for the second part of that, and that is why I wanted to put it forward again. The second part of it is, would we be drawing battlegrounds inside the area of the councils? You do not want to create more controversy inside of it; you want to be able to do constructive things. I am just wondering how we would do constructive things if we do that.

Mr Carne: I think that would probably depend upon the individual people you choose. Our particular organization covers all ranges, from people who are totally anti-drugs, anti-psychiatry, to people who are very pro-medical model -- whatever the doctor says goes. But there is about 90% in the middle that we all agree on. I would hope you could choose people for your committees who are open to other ideas and prevent this professionalism saying, "I've got the best way and you stop treading on my territory," sort of thing. As long as you have that, you are going to have a mess of a health care system. If you can develop some process -- I do not know how, I must admit -- whereby you get these people working together to improve and say, "This is your area, this is my area," and on a consensus model work together, it will do much better. How, I do not know. I do not know these people who are up to that.

The Chair: Please feel free to communicate with us in writing if there is additional information that you think might be helpful to us. Thank you.

1050

ANDRÉE DURIEUX-SMITH

The Chair: I call Andrée Durieux-Smith. Welcome to the standing committee on social development. You have 10 minutes for your presentation.

Dr Durieux-Smith: Madam Chair and members of the standing committee, I would like to thank you today for the opportunity of coming to address you.

My name is Andrée Durieux-Smith. I am the director of the department of communication disorders at the Children's Hospital of Eastern Ontario here in Ottawa and an associate professor in otolaryngology in the faculty of medicine at the University of Ottawa. I obtained my PhD in audiology at McGill University in 1974, and my research interests and clinical specialization are in the area of hearing screening of high-risk infants. I am here today as a PhD audiologist and as a member of the Ontario Association of Speech-Language Pathologists and Audiologists to express my concerns about section 30 of Bill 43.

Section 30 of Bill 43 restricts the use of the title "`doctor,' a variation or abbreviation or an equivalent in another language in the course of providing or offering to provide, in Ontario, health care to individuals," to members of the colleges of chiropractors, optometrists, physicians and surgeons, psychologists and dental surgeons.

As it stands, section 30 of Bill 43 is unjust to both the public and health care professionals. The reasons are as follows:

First, the title "doctor" has historically been used to address individuals trained at the PhD level. Excluding some PhDs from using this title in health care goes against standard academic practice in other provinces and in other countries. Imagine the situation where a PhD with a university affiliation could use the title in an academic setting but would have to change his name tag when he crossed the boundary between university and health care settings. This situation is illogical.

Second, the government's attempts to reduce confusion on the part of patients and the public are certainly commendable. If the purpose of section 30 is to reduce confusion, it falls short. In fact, it legislates confusion. How is the public to know which professional with a PhD they may call "doctor" and which professional they may not? Imagine a situation where a child has had an assessment by a team of professionals in a teaching hospital such as the Children's Hospital of Eastern Ontario. This team, for example, includes a paediatrician, an otolaryngology resident, a psychologist and a PhD audiologist. The parents meet with the team to discuss the results of the assessment. They would have to be instructed to use the title "doctor" when addressing the psychologist, but not the audiologist. Would this situation not be confusing? Would it not also give a message to consumers about the worth of different professions with similar training?

Third, the proposed legislation would remove the consumer's right to know the qualifications of his health care providers. Consumers have this right, and only then can they make informed decisions about their own health care. Consumer education is an integral part of health care. To promote ignorance about the different training of health care professionals is retrograde.

There is no reason to suggest that non-physicians who have the title "doctor" would willingly mislead patients into believing that they are physicians or surgeons. The Ontario and Canadian associations of speech-language pathologists and audiologists have codes of ethics which clearly state that members must not misrepresent their training or competence to the public. A truthful representation of our training and competence can only take place if consumers are made aware of our qualifications.

Fourth, the proposed legislation is a disincentive to excellence in health care in Ontario. The PhD degree reflects specialization in a clinical area, as well as research expertise. This allows the PhD to bring a broad range of knowledge to the provision of clinical health care services. PhDs also have the skills to objectively measure the effectiveness of clinical practices and to develop new empirically based techniques that will encourage and allow for a greater degree of accountability. The proposed legislation does not recognize the value of enhanced academic qualifications and would certainly discourage many professionals from obtaining higher academic degrees.

Finally, the proposed legislation reinforces gender biases in the health care system. The professions which will be allowed to use the title "doctor" under section 30 are male-dominated professions, with the exception of psychology, whose membership is approximately 50% female. Those professions that will be precluded include speech-language pathology, audiology, nursing, occupational therapy and physiotherapy, which are all female-dominated professions.

Unchanged, section 30 would support the differential treatment of female- and male-dominated health professions and would send a clear message that the government of Ontario does not support equality in the health care system, but rather gender bias.

Section 39 of the act does state that subject to the approval of the Lieutenant Governor in Council, the minister may make regulations allowing use of the title "doctor." It seems illogical that doctorates in female-dominated professions would be required to apply for special permission to use their rightful title.

In summary, these five points clearly illustrate the need for the government to review section 30 of Bill 43 and expand the use of the title "doctor" to those health care professions offering doctorate degrees. Thank you.

Ms Haeck: Thank you very much, Dr Smith. This is in some respects a personal concern, because I have had, not because of my own health but a member of my family, a few too many trips to Henderson General Hospital in Hamilton in the last few years. As you can probably appreciate, there is a sea of white coats that one does have to come to grips with.

Knowing that the vast majority of patients with whom a health professional comes into contact may not be totally aware of qualifications and all of the various specialties, how do you address the confusion that they may perceive in the title "doctor"?

Dr Durieux-Smith: I have been a director at the children's hospital for 17 years and have dealt with families and their children. I do make it clear when I start off. I say that I have a doctorate degree, that I am not a medical doctor.

I am confident that the title "doctor" reflects my level of education. I think consumers have to be educated that if the title is used, it just means that the person has had extensive training, and that they should not be confused with a physician, a surgeon or whatever. I feel that it is through consumer education that these professions can be recognized and that the consumer can become aware of the different levels of education of their health care providers.

I honestly have never had this problem. I have dealt with families from all the socioeconomic strata. My degree is on my wall, it clearly says PhD, and I just describe what I do and who I am.

I have also been able to bring the dimension of research to my department, which I think ties in with quality of care and certainly has an impact on quality of care.

The Chair: Thank you very much for appearing before the committee today. We appreciate your presentation.

1100

BEREAVED FAMILIES OF ONTARIO, OTTAWA-CARLETON BRANCH

The Chair: I call Bereaved Families of Ontario, Ottawa-Carleton branch. You have 20 minutes for your presentation.

Ms Huckabone: I am Jean Huckabone. I am the executive director with Bereaved Families of Ontario in Ottawa-Carleton. Bereaved Families of Ontario is a self-help organization working with professionals in this province. In 1978, there were five chapters throughout Ontario, and today we have 17, and are continuing to grow.

Essentially, with the help of professionals, we train bereaved persons to facilitate small discussion groups and provide one-to-one support. We help families accept the reality of their loss, rediscover the meaning of life, and live comfortably with memories of their child or loved one.

We also educate the public and the health care profession to become more aware of the special needs of the bereaved. Additional support is given families through monthly open-support nights, with an additional night for survivors of suicide. We provide education programs, guest speakers, a newsletter, and an overall caring and compassionate support system.

I am here today to make a presentation to this committee regarding the Regulated Health Professions Act, known as Bill 43. Specifically, Bereaved Families of Ontario is concerned with that part of the act known as the diagnosis clause. This clause could, in our opinion, greatly affect the ability of social workers, with whom we work a great deal, to readily provide services to our families who have recently experienced the death of a family member.

As I understand the information that has been brought to my attention, the diagnosis clause under subsection 26(2) would severely limit the ability of social workers to communicate or discuss a medical diagnosis with a patient or a family member.

Usually of course, it is a physician who presents a diagnosis to a family about their loved one. Unfortunately, it is often the situation that the actual interpretation of this medical diagnosis for the family is left to other members of the health care team. Interpretation may involve discussion related to prognosis, lead time until death may occur, the possible ramifications for individual members of the family and the family system, and discussions of levels of interventions and medical options available.

The experience of Bereaved Families of Ontario is that the team member frequently called upon to carry out these tasks is the social worker on the hospital medical team. It is critical, in our experience, that our families have an opportunity, prior to their member's death, to discuss and prepare for the eventuality.

We know clearly that those family members who come to us after experiencing the death of a loved one, and who have not had an opportunity to review carefully the impact of the death, to take part in decisions related to the quality of life and the death experience and come to grips with some of their intense feelings, do not manage as well as those families who had an opportunity to work through and experience these aspects.

There are many scenarios that could be related to the committee to explain the importance of social workers to the families that come to us. A current issue is that of patients with AIDS or who are HIV positive. A case might involve a young mother who has contracted the virus unknowingly from her husband. To further the tragedy, she has passed this HIV-positive trait on to her newborn. It is our hope that, prior to this woman coming to see us for assistance, she has had the opportunity to deal with her intense feelings of anger, guilt, bewilderment and so on with a social worker at the hospital. When she comes to see us, we will carefully monitor her progress with the assistance of our social work consultant while she participates in our self-help group. Should she require further assistance that is beyond the capability of the self-help group, our social work consultant is available to meet with her.

How any of this could take place without discussion of the husband's diagnosis of AIDS and her own and her child's diagnosis as being HIV positive, is impossible to conceive.

The fact that, under the terms of the proposed act, the social work profession is not included as a regulated health profession and that, furthermore, the act calls for fines and imprisonment should a social worker carry out one of the controlled acts, is reason for serious concern. It would be impossible for social workers assisting our families to discuss with them the events leading to the family member's death, their personal feelings of guilt, anger, sadness and heartbreak, and then help them to pick up the pieces of their life once again, without discussing the medical diagnosis.

If there is any possibility that a legal interpretation of this proposed act could put social workers at risk when trying to help our families, they will not be able to assist us or our families adequately.

On behalf of Bereaved Families of Ontario, I am asking this committee to recommend that this diagnosis clause be amended or deleted so that social workers will be able to carry out the function for which they are aptly trained. Failure to do otherwise will clearly hamper their efforts to provide service to the public and quality health care to families already in grief.

I would like to thank the committee for its time, and I would now like to turn it over to my two colleagues.

Mr Giles: I am Bob Giles. I am director of social work at Ottawa Civic Hospital. I am also here as a member of the Ontario Association of Social Work Administrators in Health Facilities.

Ms Tataryo: I am Karen Tataryo and I am director of social work at the Children's Hospital of Eastern Ontario here in Ottawa.

Mr Giles: We will take questions actually. That is what we are available for.

Mr Owens: Thank you. Formerly in my life I was involved in volunteer work with terminally ill patients as well as sitting on a psychosocial committee on the treatment of AIDS patients at the Toronto General Hospital.

My question is, how do you see the discussion of a diagnosis contravening the controlled act of diagnosis? As a social worker or as a volunteer, we are not making that diagnosis, simply discussing the diagnosis of AIDS or whatever the condition may be. I am not quite sure how that contravenes the controlled act.

Mr Giles: The discussions we had around this seemed to revolve around the word "communicating". It is open to very broad interpretation. When we talked with Jean and she was expressing her concerns, this kept coming back; that even though there is a formal diagnosis that only a physician should be portraying for the first instance, it is the continued involvement of that diagnosis that seems to get in the road, identifying diseases or disorders or dysfunctions as cause of symptoms and so on.

That part in the legislation is just so broad and open to interpretation that we would really like to see if we cannot either amend it to firm it up or get rid of it completely so that it leaves social workers, working with families from Bereaved Families, for example, more open and free to deal with the patient's concerns.

Mr Beer: Just one further question on that specifically. I guess what we are wrestling with here is trying to still protect people from those who should not be giving diagnoses, and obviously the intent is not to stop you doing what you are doing.

If this were taken out, or if social workers had their own act, is that seen -- particularly the second one, because some have mentioned that might be a way of protecting those who are performing this function. Or do you think there would need to be specific exemptions for clergy, social workers, designated groups? What is your sense about the best way to get rid of what you feel is an overly broad definition?

Mr Giles: Well, there are some options. You are quite right. The social work profession is trying to gain legislation, actually through the Community and Social Services ministry, because they are excluded from this particular act, and everybody agrees that legislation or regulation is a good idea. So either in this act one could make reference to professions licensed, I suppose, under another ministry or another act, or actually list exemptions.

As to which is the best, I am not really sure which would be better, but somehow it has to be clarified. There are others besides social workers who would get involved in this. I am thinking of pastoral care people, for example, who are not listed in this act, and I am sure they also would be wanting to be in the list of exemptions. Right now there is no way in this act, as I see it, that we can be exempted from this activity.

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

1110

ATTENDANT CARE ACTION COALITION OF OTTAWA-CARLETON

The Chair: I call the Attendant Care Action Coalition of Ottawa-Carleton. You have 20 minutes for your presentation.

Mr Simpson: My name is George Simpson. I am one of the board directors of the Attendant Care Action Coalition. I am also on the Ottawa-Carleton Independent Living Centre. With me are Avril Gunter, a director of the Multiple Sclerosis Society of Ottawa-Carleton, and Don Damiano from Ottawa Care Option.

The Attendant Care Action Coalition, ACAC, of Ottawa-Carleton is comprised of adults with physical disabilities, living in the community and directing their own lives and attendant care services and representative organizations providing attendant care which makes such independent living possible. Our membership includes representatives from the Ottawa-Carleton Independent Living Centre, the Multiple Sclerosis Society of Ottawa-Carleton, the Muscular Dystrophy Association, the Daly Co-op Support Services and Ottawa Care Option.

When the Schwartz report Striking a New Balance: A Blueprint for the Regulation of Ontario's Health Professions, came out, many people had objections to its recommendations. It was obvious to physically disabled adults requiring attendant care that such services would be impossible if certain of the report's recommendations were to be put into effect under the bill.

I will turn the second part of our presentation over to Avril, who will talk about the significance of attendant care services.

Ms Gunter: We would like you to understand the relationship between an attendant and a person with a physical disability whom they assist. The attendants provide the hands which enable the person with a disability to carry out the functions of daily living. Most of an attendant's duties do not involve actions which are controlled acts under Bill 43, but others such as bowel and bladder care, feminine hygiene, some injections and the changing of colostomy bags are so defined under the bill.

For someone who is working, and many of us do, services must be performed on time, at home or at work. Only a patient can afford the time to wait around for a nurse to perform intermittent catheterization or bowel disimpaction, and we do not consider ourselves patients. If a medical professional has to perform these services there will be a great increase in the cost to OHIP and it will restrict our ability to direct our own lives. With the help of attendants we can live as productive members of the community.

Paragraphs 26(2)5 and 6 are the things we are objecting to. These would prevent attendants from performing many necessary tasks for persons with disabilities. We feel an amendment must be added to section 28 of the bill which would recognize the following facts: first, that adults with physical disabilities have the right to direct their own lives and, second, that attendants should be exempt from controlled acts in the same manner as household members.

Mr Damiano: In respect to the proposed passing of Bill 43, we feel that due to the individualization of attendant care needs by consumers, an amendment to Bill 43 for attendants in such procedures outlined in the bill should be considered a right, not a privilege, for every person should have the right of choice, consistency and access to his or her care requirements, whatever they may be. In the area of attendant care, we feel we are a community-regulated field, as it includes responsible professionals, administrators of government-funded attendant care programs, family members, consumers and service providers.

Since some of the procedures outlined in the bill are a daily requirement for day-to-day existence by consumers of attendant care services, if Bill 43 is passed without amendment for attendants you will be passing a bill which regulates existence, quality of life, human dignity and the freedom surrounding their own person, therefore disabling their ability to control their own destiny, for living one's life is what makes existence so worth while.

Mr Simpson: I will conclude by saying that we have physical disabilities which prevent us from performing some of the necessary functions of daily living, and thus we need assistance in order to live independently in the community. Any legislation aimed at controlling our attendants is detrimental to our ability to be contributing members of society. Thank you.

The Chair: Thank you very much for your presentation. We have had some extensive discussion at committee and there is a Hansard which has the ministry's response to this point, that has been raised by others. I am going to ask the clerk to take your names and addresses and we will mail you a copy of that Hansard. I apologize that it is not here this morning. We have it on file. Parliamentary assistant, do you want to have ministry response?

Mr Wessenger: Yes, I think perhaps I should indicate to you that the minister and, I believe, the previous minister have indicated there will be some sort of exemption provided under the regulations for attendant care.

Mr Simpson: That will be included in the act itself?

Mr Wessenger: No, the undertaking is with respect to the matter of regulations. However, regulations legally have the same status, basically, as an amendment under the act. They are all part of the legislation. Legislation includes both the act and the regulations that are passed under that act, so they all are considered legislation.

The Chair: When you read the Hansard you will see that there is commitment from all three caucuses and all members of this committee to support attendant care and living in the community and there is a desire among everyone here to ensure that you have that information. There is no desire by anyone in any way to restrict individuals who can live independently in the community. We will send you along that Hansard and after you receive it, if there is additional information that you think would be helpful to the committee, please feel free to communicate with us in writing.

Ms Gunter: We feel that we should not be subject to regulation. As we said in our brief, we do not feel that we are patients and we feel we have struggled for a long time to get away from being medicalized and do not want this bill to return us to that status.

The Chair: The point you make has been made before at the committee and there has been some discussion in the Hansard as to the difference between personal care and health care services, and commitments have been made to define that and exempt that by regulation. The regulatory development process will also be a part of the advisory council which will be established, and that is included in the commitments in Hansard as well. Thank you very much.

1120

JAY MCSPADEN

The Chair: I call Jay McSpaden. Welcome to the committee.You have 10 minutes for your presentation.

Dr McSpaden: Good morning. My name is Dr Jay B. McSpaden. I am a trained teacher of the deaf, a certified audiologist, a licensed hearing instrument practitioner and a professor in graduate programs in audiology and communicative disorders. I am on the medical staff of a hospital and, most important, I am a consumer of hearing aids and assistive listening devices.

I am here today to urge you to not make the prescription of hearing aids a licensed act in Ontario. In my view, making the prescription of hearing instruments a licensed act limited to physicians and audiologists is not in the best interests of the citizen consumers of the province. Rather, it is based upon an overreaction to rumour and myth and is not in the best interests of the government, physicians, audiologists or the hearing instrument practitioners.

Permit me to explain. First and foremost there is no record of a risk of harm to the consumer in the fitting of hearing instruments by professional hearing instrument practitioners within this province. To pretend that the purpose of this proposed clause in the bill is to reduce the risk of harm to which the consumer is subject is to play upon the rumour and myth that such cases exist, that they exist in large and/or significant numbers and that the professional association to which the practitioners belong is incapable of policing its members and their activities. This is not the case. There is no record of such a problem. Therefore the avowed purpose of this bill is obviated and, in terms of reducing the risk of harm, it is a case of chasing ghosts.

Second, it is important that you understand that the technology involved in the identification of the ideal hearing instrument fitting is an extremely dynamic one. It involves keeping current with the latest technological advances. There are counselling aspects of adaptation to the instrument which must be facilitated, close supervision and maintenance of difficult and problem cases and the establishment of the basis for a long-term working relationship which can optimize the communicative efficiency of the aided consumer.

Third, these activities require continuing education and upgrading. They necessitate continual modification and improvement of the knowledge base. They require dedication and commitment, and those activities take time. It is virtually impossible for anyone to keep up with more than one of these fields. To be a physician and keep up with all the advances in technology in the field of hearing instruments is, I submit to you, a truly unrealistic expectation. Yet, if physicians are to prescribe hearing instruments, they must keep abreast of the leading edge of the technology which is completely outside of their area of expertise. If they do not keep absolutely current with the growth of this technology, in addition to keeping abreast of advances in their own medical specialties, the consumers of this province can only be treated to an increasingly aging technology which cheats them, does not optimize their residual communicative potential and in the final analysis does place them at risk of harm by default.

Fourth, these same arguments must be made regarding the professional clinical audiologist. The growth of clinical awareness, improvement in equipment and techniques pertinent to the identification of expanding otopathology and its impact of increasingly complicated contribution to health care places enormous stress upon the clinical audiologist. The impact of an entirely new field of technology, which in itself is continually expanding, is unreasonable for the audiologist, unfair to the government and unrealistic for the patient. The outcome of such a system fosters the practice of the history of the profession rather than to be able to offer to your constituent consumers its cutting edge.

Ladies and gentlemen, I have taught in graduate training programs for the training of audiologists and physicians off and on for more than 20 years. I am well aware of the amount of training in hearing instruments and hearing instrument technology to which they are exposed. With a very few notable exceptions, the clinical audiologist is not sufficiently trained in the cutting-edge hearing instrument technology to prescribe such instruments in this decade. They may well understand the history of the profession and its technology, but they do not, understandably, have the time necessary to concentrate on the technology which consumers deserve to have available to them in their own quest for communicative efficiency in their lives. This is not anyone's fault. It is simply a statement of fact. If they are licensed to have prescriptive control of these devices, the patient, the government and the consumer will be poorly served.

Licensing the prescription of hearing aids to physicians and audiologists alone ignores the group of qualified, registered, established hearing instrument practitioners who currently conduct their services throughout Ontario. These professionals have steadfastly co-operated with the government in upholding the standards of their profession and the honour of their individual persons. They are an integral part of the hearing health care delivery system within the province and as such they have a vital role to play.

It is important that you understand the current and potential demand for services within this province and the availability of professionals to meet those needs. Those hearing instrument professionals are an important part of the success of the system in Ontario. Without them, I believe the system becomes a logistic nightmare which penalizes the communicatively impaired consumer by forcing him or her into a mechanism in which the delays are unconscionable and the dangers of conflict of interest unrestrained.

The ultimate effect of this legislation is not increased consumer protection. Rather, in my opinion, it guarantees income in perpetuity to authorizing and dispensing audiologists and physicians. It removes any possible question as to the appropriateness of their prescription, as no alternative authority would exist. There would be nothing to compel them to keep pace with the technological advances, as without competition or any real threat of malpractice, quality delivery of service would be defined by them.

Two points need to be made. A hearing aid is simply a tool which, if appropriately used, improves communicative efficiency. Can it cause harm? Certainly it can, as with any tool which is improperly utilized but -- and this is critical -- that statement is equally true regardless of who fits or dispenses the hearing aid. Regardless of the prescription, there is never a guarantee that it could not be misused and, if so, would not cause a risk of harm. Making prescription a licensed act cannot diminish that risk.

Second, I believe there is a serious misperception afoot here in the province. A majority of the audiologists working in this province are American-university trained. Their exposure to hearing instrument practitioners in the United States does not reflect the quality of these practitioners who have been Sheridan College-trained, who have been evaluated, examined and regulated more highly than almost any profession in this province and who are currently authorizers in Ontario.

This group, the practitioner-authorizers of the Association of Hearing Instrument Practitioners are, as a group, some of the best-trained, most highly professional and most highly experienced specialists on the North American continent. I travel all over that continent, ladies and gentlemen, and that is exactly correct.

The matter before you is not, I submit, being driven by a real need for consumer protection. The consumers have already spoken and they do not want prescription to be a licensed act. It is being driven, I believe, by a desire for a legislative monopoly which guarantees income without quality control or interference. If you pass this bill unchanged, who protects the consumer then?

I urge you not to make the prescription of hearing aids a licensed act. Properly trained practitioners combined with medical clearance would address any concerns for potential risk of harm or conflict of interest. I would be happy to answer any questions that you have.

Mr J. Wilson: Sir, you touched briefly on the conflict of interest question. From what we are hearing from ministry officials, for the government the issue surrounding the prescription of hearing aids is boiling down more to the fact that there is an inherent conflict of interest in having the same person prescribe and dispense. Could you just comment on that a little further?

Dr McSpaden: Yes, I would be happy to. I have several thoughts on that matter. One of them is that I do not find that similar question being raised about physicians who recommend surgery and then perform the surgery and I do not find it raised about audiologists who are both authorizers and dispensers. It occurs to me that this is a caste system of some sort or other which says that if you actually have a master's degree or above, you can go ahead and do these things and you are not ethically capable of committing a conflict of interest. I do not find that to be true.

I do not see that there is a conflict of interest in an ethically managed and policed organization, and it has been my experience with the existing practitioners' group that it is such a group. So that is the short, Walt Disney version of the answer. There is a long answer that will take several hours if you would like to sit somewhere with me.

Ms Bohnen: To respond to Mr Wilson's question, the ministry's view is that potentials for conflict of interest between the same practitioner both authorizing and dispensing are really handled adequately by the policies of the assistive devices program, at least in so far as the government of Ontario is paying for hearing aids for individuals. Other similar agencies such as the Workers' Compensation Board and the Department of Veterans Affairs no doubt have their own ways of ensuring that there is not a conflict of interest between the prescriber and the dispenser.

Dr McSpaden: May I make one additional comment? I have the ineluctable opportunity to travel all over both the United States and Canada speaking and teaching and whatever. I must reiterate my point that while there are times when what happens at home does not look like it is the best of all possible worlds, these people here in Ontario and the people in Alberta turn out to be the best-trained hearing instrument professionals on this continent. Second to, perhaps, the graduates of the two-and-a-half-year university program in Germany, they are, perhaps, the best-trained hearing instrument professionals in the world.

The Chair: Thank you very much for your presentation.

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CINDY HARRISON

The Chair: I call Cindy Harrison. Welcome to the committee. You have 10 minutes for your presentation.

Ms Harrison: I am Cindy Harrison. I am a speech-language pathologist.

Ms McLean: I am Megan McLean. I am an audiologist.

Ms Harrison: I would like to take this opportunity to thank you for allowing me to provide comment on the Regulated Health Professions Act and the accompanying Audiology and Speech-Language Pathology Act.

The Ontario Association of Speech-Language Pathologists and Audiologists welcomes the majority of regulations and recommendations set forth in these acts. There are, however, certain issues that we feel need to be more clearly defined.

As you are aware, the issues that OSLA wishes to pursue further are diagnosis as a controlled act, title restriction, and prescription of a hearing aid as an authorized act. For the purposes of my presentation I would like to address the issues surrounding diagnosis and title restriction.

I do feel that diagnosis needs to be regulated. The act of diagnosis as it pertains to speech-language and hearing is an act requiring a great deal of education, specialization and training. According to OSLA's legal advisers, the legislation as written could prevent me from communicating the results of an assessment directly to my client.

As a speech-language pathologist I routinely provide feedback regarding the speech-language assessment results, associated factors, prognosis, treatment and home programming suggestions. Invariably the individuals and their loved ones have many questions. Following assessment, a great deal of time is spent discussing factors associated with the communication difficulties, the impact of the client's communication challenges on the family, and strategies to deal with the communication difficulties in the home, school, workplace and community.

Significant concerns exist about subsection 26(1) of the Regulated Health Professions Act, which, as currently written, would allow only physicians and psychologists to communicate the conclusion of assessment to the client. The impact of this is potentially enormous. For the patient, this means a visit to the speech-language pathologist or audiologist for assessment, back to the physician or psychologist for the results, and then back to the speech-language pathologist or audiologist for treatment.

A number of factors must be considered in this instance: the financial burden to the health care system, potential delays in treatment, potential increase in clients' anxiety as they await the diagnosis, and the inability of the psychologist or physician to provide complete and comprehensive feedback regarding treatment and prognosis in the areas of speech-language or hearing.

Recently I discussed this issue with a client whose five-year-old daughter presented with a severe speech and language difficulty and has been in treatment in my practice for two years. I would like to share her comments with you, and I quote: "That's very interesting. In our case, our physician didn't feel there was a problem. I had a three-year-old who wasn't saying a word, and he didn't think there was a problem. It was only after I insisted that I got a referral and got some help. I trust this physician for all medical issues, but he is obviously not informed in the areas of speech and language. How could someone like that have given me your assessment results?

"I also don't think people understand how incredibly stressful this whole thing is. Communication is how we show people who we are. You feel anger, frustration, and real sadness when your child can't communicate. If you had told me that I'd have to wait to get an appointment with my physician to learn the results of what you just spent time doing, I would have hit the roof. If I remember, we spent an hour and a half discussing your conclusions and trying to understand the nature of our child's difficulty. It just wouldn't be fair to do it any other way."

As speech-language pathologists and audiologists we are highly trained to assess, diagnose, and treat varying communication disorders and dysfunctions. We are the most knowledgeable in the areas of speech-language and hearing. Results of the assessment plus the diagnosis, counselling and treatment in these areas should come from us. To fragment this process undermines the idea of comprehensive care for the consumer as well as potentially negating our ability to function autonomously within the scope of our profession.

I would now like to discuss the issues surrounding title protection. I agree that this clause is vital to consumer protection. I am concerned, however, that this clause is open to interpretation. It is my feeling that the legislation should remove any potential confusion or doubt as to the qualifications of the service provider. As you are aware, the historical designation for the profession of speech-language pathology is "speech therapy." Although we now refer to ourselves as speech-language pathologists, the term "speech therapist" is widely used by members of the public and sometimes by other professionals. Since these issues have become increasingly topical, I have been paying particular attention to the use of these terms. It may interest you to note that I found a brochure describing a school-based program here in Ottawa-Carleton in which we were called speech therapists. This was a pamphlet designed and published in 1990.

Recently a client asked me to review an employee benefit package that stated that coverage for "speech therapy" would be provided if services were obtained from a registered "speech therapist." In December of 1990 the mother of a six-year-old boy contacted my office. She stated that her son was assessed by a speech therapist, who stated that he did not require any therapy. Unconvinced, this mother was seeking another opinion. When I asked for the name of the therapist, I was given a name I was not familiar with. I asked if this therapist was a speech-language pathologist. The mother replied, "She said she was a speech therapist." As it turns out, this therapist is not a speech-language pathologist. This child did require treatment, and eventually received service from a qualified professional.

I am continually surprised at the number of people who refer to us as speech therapists. When I am asked what I do, I always reply, "I am a speech-language pathologist." I tell clients that I am a speech-language pathologist. My letterhead states that I am a speech-language pathologist, and I sign my reports as Cindy Harrison, speech-language pathologist. Despite this, I am frequently referred to as a speech therapist. What concerns me is the idea that an unqualified individual can call himself or herself a speech therapist. The consumer, who is accustomed to this historical designation, cannot be expected to question this credential.

I would also like to comment briefly on the clause in the restricted titles section of the profession-specific act for audiology and speech-language pathology which states that people other than members of the college are prohibited from using the titles of "audiologist" and "speech-language pathologist" "in the course of providing or offering to provide, in Ontario, health care to individuals." I am concerned that the proviso "health care" is too limiting to ensure public protection. Consumers may seek the services of a speech-language pathologist or audiologist in educational, industrial, or community settings, as well as health care. While I understand that the intent of the clause is consumer protection, it concerns me that the interpretation of this clause may lead to protection only in a health care setting. I feel that the amendment of the clause to include title protection in other areas such as industrial, educational and social services is vital to ensure consumer protection.

It is also my feeling that the holding-out clause, subsection 15(2) of the Speech-Language Pathology and Audiology Act, needs to be strengthened to provide more comprehensive protection. Currently the act reads, "No other person other than a member shall hold himself or herself out as person who is qualified to practise in Ontario as an audiologist or speech-language pathologist or in a specialty of audiology or speech-language pathology." OSLA suggests that a more detailed definition of qualifications would more adequately prevent unqualified individuals from implying or inferring a level of qualification which they do not have. I also feel that the protection of the title "speech therapist," title protection in all settings in which speech-language pathology and audiology services are provided, and a more detailed holding-out clause will combine to help the public to distinguish regulated health providers from those who are not.

Finally, I would like to reiterate my support for this legislation. I feel that its impact will be significant not only for the consumer, but also for the professional. I thank you for listening to my concerns in the areas of diagnosis and title restriction. I sincerely hope that your committee will make the proposed amendments to aid us in ensuring consumer protection. Thank you.

The Chair: Thank you very much for appearing before the committee today.

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COALITION OF ONTARIO MIDWIFERY AND BIRTH SCHOOLS

The Chair: I call the Coalition of Ontario Midwifery and Birth Schools. You have 20 minutes for your presentation.

Ms Fafard: I am Jenny Fafard and I am speaking on behalf of the Coalition of Ontario Midwifery and Birth Schools. If you look at our presentation, there is a list of the people we represent at the back of the first section of our written submission. We are a group of birth schools from around rural Ontario.

COMBS is a coalition of schools and groups of educators and students across Ontario representing currently practising midwives as well as many apprentices, clients and activists in the Ontario midwifery movement. Most of us are located outside of Toronto in both urban and rural settings. Some of us have no formal affiliation with other midwifery organizations, whereas others have extensive provincial, national, and international links. We are delighted for this opportunity to provide input since we have not been able to access other avenues to our satisfaction. We enclose the submission we are sending to the ministries of Health and Colleges and Universities because it is the basis of the issues we are going to raise again today. That is the first piece of paper you have.

We are experts in understanding what midwifery is; we are not experts in the legislative process. However, we have the following suggestions we feel will ensure that midwifery remains responsive to the women it was created to serve.

1. Referring to Bill 56, section 3, scope of practice: We note that the location of practice is not addressed. We would suggest that a clause from the definition accepted by the International Confederation of Midwives, the International Federation of Gynecologists and Obstetricians, and the World Health Organization be added at the end. That quote is, "She may practise in hospitals, clinics, health units, domiciliary conditions or in any other service." We also believe that some reference should be made about the midwife's role with high-risk situations. We suggest the addition of the phrase, "When the care provided extends beyond her abilities, the midwife arranges for consultation, referral, continued involvement and collaboration."

2. Referring to Bill 56, section 4: There are several omissions here, including administration of substances by oral methods, catheterization, and oral and nasal suctioning of the newborn infant. Other acts such as nurses' and physicians' acts include specific references to acts such as these.

3. Referring to Bill 56, section 15: We would like to draw your attention to the definition of "midwife" in our position statement, which is, again, that first section of the paper. As you can see from this discussion, the term "midwife" has an important history. The government and the new college of midwifery would be making a gross assumption to think that they have the prerogative to claim ownership over a title which is generic and which is already owned. We do believe that the government can make claims to own the title "licensed midwife" or "registered midwife," however. The college of nurses calls its members "registered nurses" as opposed to simply "nurses."

4. Referring to Bill 56, sections 6 to 14: We need to make it clear that contemporary midwifery has arisen in reaction to the very structure of the various health care professions providing maternity care in Ontario. To structure midwifery in the same hierarchical manner as the other health disciplines is to undermine the very reason for its existence. Fundamentally, the structure outlined in the bill will entrench inequality and will result in a profession that will be unable to respond adequately to the women it has been called to serve.

We suggest some of the following changes:

1. In reference to Bill 56, subsection 6(1), we feel that the college of midwives should be reflective of midwifery; that is, it should be community-based. Therefore, in order to be representative, the council should be regionally representative. The council should also be reflective of the diversity of midwifery practices.

2. In reference to Bill 56, section 7, we submit that the council should have neither a president nor a vice-president but should be run by consensus, reflecting a feminist approach to organization.

3. In reference to Bill 56, section 8, we submit that in keeping with a feminist approach to organization, there should be no executive committee.

4. In reference to Bill 56, sections 9 to 14, we submit that the members of any committees of the council should be elected from among the members of the college by the members of the college.

5. In reference to Bill 56, sections 9 to 14, we submit that the members of the college and consumer organizations should be free to establish any other committee deemed necessary. We suggest that the following committees should be considered: (a) education; (b) public education; (c) interprofessional relations; (d) intraprofessional relations; (e) client relations; (f) community liaison, specifically with community groups and individuals; (g) competency; and (h) affirmative action, which would address cultural appropriateness.

6. In reference to Bill 56, section 18, we submit that this item should read, "The college may make regulations after approval from the membership." Any changes affecting the practice of midwifery should have input from the membership affected.

7. In reference to Bill 56, clause 18(a), this item should include a reference to substances administered orally.

8. In reference to Bill 56, section 19, we again must submit that the transitional council appointed by the Lieutenant Governor be regionally representative and reflective of the diversity of midwifery practices in this province. Thank you.

Mr Beer: Thank you for the presentation, and particularly for underlining the point of view perhaps of those outside of the Metropolitan Toronto area. I want to make sure that I understood part of your submission. Really, in terms of the way in which the transitional council is functioning, I take it that you do not agree completely with the way this matter is proceeding and are concerned about the structures that you think will see the council evolve as a council similar to the others we have. Could you elaborate a bit on that in terms of some of the points you made in your brief, because we have not had too much on the structure. We have talked a lot about ensuring that midwives are going to be able to practise and that kind of thing.

Ms Daviss-Putt: May I just say that we have a fair amount of history in Ontario in practising midwifery. Some of us have as much as 10 to 15 years, and it has been very difficult for us to break into the process. It has been continual for several years. We have noticed that as the legislation process has continued and has reaped a certain amount of recognition, it has been increasingly difficult for us to break in, because certain people represent us who we do not necessarily think are representing all of the views right across Ontario.

We think it is really important that you continually go back to those regions by having regional representation. We really believe that midwifery is a very community-based profession, perhaps more so than many other professions that we know, and to the extent that we do not even call ourselves necessarily a profession but a vocation and a calling. It is incredibly important to us that the women we are serving can approach the college themselves, without a great deal of hierarchical structure.

1150

Mr Hope: Along that line, I guess when we were in London we heard from some people who did not want to make this look like a professional organization. They did not want to take away the human dignity of midwifery. In your number 5 is that what you are proposing, that it be brought back, when making changes in regulations, that they be approved by the membership? Is that what the governance of that is, to try to keep it the human element of things instead of the non-professional?

Ms Fafard: Yes, that is part of it. You are talking about by the members, right? The other part of it is that we feel that particularly with midwifery, because it is so community-based, different communities feel different ways about different parts of practice, and this should be brought out, when necessary, through the members. This is not possible if you have an executive committee that is making all the decisions, but if anything involving practice goes back to the members, they can decide what is going to happen. We think that is quite important because the types of practice are so different around the province in different areas.

Mr J. Wilson: I found your presentation quite interesting, particularly your comments in the brief I gather you are sending to the minister about apprenticeship. You do make the point that midwives should be able to choose really their own avenue of training and education, but do you envision sort of final exams before someone would become a registered midwife?

Ms Daviss-Putt: Because of our history in court competencies, we really believe that it is important for a midwife to be competent in what she is doing, and we do believe that our evaluation process has really been lacking. However, we are at the point now where we have been developing our schools and we are starting to have an evaluation process in place. We are developing it with a number of schools even in the States that have an evaluation process, and we would very much like to ask the government's help in evaluating that. We are concerned somewhat that the government is not making use of the present structures, the present schools that we have, in that process.

Mr J. Wilson: And the government would take the lead role, or the college of midwifery, I guess, would standardize --

Ms Daviss-Putt: Right, and it is apparent to us also by the way the college is being set up that it is working at a very different --

Mr J. Wilson: Different model.

Ms Daviss-Putt: Different way than the way in which we had practised for many years in Ontario.

Ms Haeck: I would like to actually pursue the point Mr Wilson made, and thank you also for your presentation, because it does raise a number of points that we have had a chance to discuss with different groups. Various people who have come before us have raised the issue that they wanted to make sure that the foreign-trained midwives had access to being midwives here in Ontario. Possibly ministry staff, through the parliamentary assistant, could clarify this, but it is my understanding that in fact the college will be working with the various groups out there to establish the criteria under which midwifery will be practised here in Ontario. Am I under the correct assumption?

Ms Bohnen: Are you referring to the pre-registration program, which I believe the committee heard something about, that will assess the qualifications of current practitioners?

Ms Haeck: Yes.

Ms Bohnen: Then you are correct.

Ms Haeck: Possibly for the presenters you could expand on that.

Ms Bohnen: You may be aware that there will be a pre-registration program for current practitioners, which will provide a way for them to become registered as midwives in Ontario.

Ms Daviss-Putt: We are very much aware, but what we are somewhat concerned about is that that will not be a continuing, ongoing process. We think that apprenticeship is a route for midwives that is actually a very viable one, and probably one that is more community-based than a very centralized school. We really believe that route of entry should not be cut off, that people should always have the option of beginning in their community and starting to apprentice with various people there and then choose their own form of acquiring the core competencies, have an evaluation process and become a midwife.

Ms Haeck: The standards for practice were being set so that in fact some of these concerns might be included in what the college sets down as standards for practice?

Ms Bohnen: Yes and no. I think it is important to say that the model of midwifery education that is envisioned for Ontario after the transitional period is not an apprentice-based system, it is a system based on a professional midwifery education in an educational institution. However, there is a very strong desire and intention to have it decentralized so that people can do components of the program in many locations throughout Ontario, but it is not an apprentice-based educational model.

Mrs McLeod: I think my colleague also had a question. I am prepared to waive to him. I know we are running out of time.

Mr Grandmaître: No, go ahead.

Mrs McLeod: I am intrigued with your comments about non-hierarchical organizations, particularly with a community-based focus. The question I have is whether that becomes more costly and whether that is a concern for you. Looking towards a college which is a group of newly regulated professionals, whether just your cost of putting that kind of process in place may be prohibitive for you.

Ms Daviss-Putt: Our experience in the last few years is that it is incredibly important for the central community that is proposing the midwifery legislation to become responsive to the rest of the province. We believe that if there is a major problem with our representation because we cannot go down to Toronto, it is time for us to start to use telecommunications. Our very coalition has started that system. We communicate by telephone. Many of us are not represented here today because we are in Ottawa, but our members from Windsor and from North Bay and from Powassan, from right across the province, are here because we have made telephone calls in the last six months preparing this submission. To us, it is more important that we are representative and have fewer meetings perhaps in one central place and use telecommunications. Yes, I believe it is possible.

Mr Grandmaître: You referred to having your own evaluation process. Can you elaborate on this? Who would do this evaluation, your own people or outside?

Ms Daviss-Putt: No, we would have no problem with the college doing the evaluation. I have no problem with that at all. As a matter of fact, the midwifery integration planning program has come up with a number of very creative suggestions about how to do the integration of the present practising midwives. It is just that we believe that that process should be extended. There are already apprentices now who have trained who are almost full midwives. They would like to have the ability to do the same kind of evaluation procedure that the present practising midwives have been offered, and we believe that the apprentices of the present apprentices should be allowed to do that as well, if they have chosen to become apprentice midwives as opposed to midwives who have trained in an institution that is central.

The Chair: We appreciate your taking the time to appear before us. If at any time in the future there is additional information that you feel would be helpful to the committee, I know that you realize you can submit briefs in writing to our clerk. Thank you very much for appearing today.

The committee recessed at 1158.

AFTERNOON SITTING

The committee resumed at 1400.

ONTARIO MEDICAL ASSOCIATION

The Chair: I call the Ontario Medical Association. Leave a few minutes at the end of your presentation in case committee members have any questions. You have 20 minutes.

Dr Guzman: I would like to first of all say how pleased we are to be able to speak to you this afternoon on this issue which we have been so involved with for so many years. My name is Carole Guzman. I am a practising physician in the Ottawa area and I have been chair of what we used to call the Health Professions Legislation Review committee, in the old days, since its inception about eight or nine years ago.

With me is Dr Ted Boadway, who I am sure many of you know is the director of health policy at the Ontario Medical Association and has also been involved with this particular activity since those very early days. We have served on this committee together.

I think from the beginning it is public record that we have recognized the need for this legislation in order to standardize and update existing legislations and also to bring under legislation those health professional groups which had developed really over the last 10 or 15 years and worked with us, side by side, in a professional capacity.

We are fully aware that the primary focus of the legislation is the protection of the public and certainly we have tried to contribute to that aim throughout these years in our activities in dealing with this legislation. As part of our mandate as an association, our motto or our mission statement, is to serve the medical profession and the people of Ontario in the pursuit of good health and excellence in health care.

We are also fully aware that we have a mandate to serve our members, so in some respects one could say we have a conflict of interest in these mandates. What we have tried to do over the course of dealing with this legislation is to deal with that challenge and to try and bridge those conflicts. In fact, the legislation itself has competing goals because it is to protect the public, but at the same time, any legislation of this type has to be aware of the true justice that must be given to those individuals who are caught up in it. So we feel that the outcome has been a good balance between competing goals for all those considered. We have by no means achieved everything we have wanted along the way and we accept that. I think that is true of every group and it is inevitable.

I think perhaps what is astonishing in this legislation is, in our perception, how little there is left that we feel needs addressing. It is a massive piece of legislation of a totally revolutionary concept.

We have chosen today to address in our brief four issues. We wish to speak in the few minutes we have on three of these issues. The first one deals with wording and is self-explanatory in our brief. We will just skip over that for now. The other three areas we wish to spend a couple of minutes on are diagnosis, the harm clause and the quality assurance committee.

First of all, if we go to the diagnosis issue, I think it brings us to consideration of the concept of controlled acts, which I think really was quite a revolutionary concept, from legislation which controlled individuals in what they did to legislation which controlled the acts that were done by any number of individuals. This was a very difficult concept for all of us to grasp initially and a lot of time and effort went into trying to define what these acts should be.

We at the OMA have had some experience in trying to define this in the crass activity of setting up fee schedules, but our fee schedules consist of thousands of items. The question is, how can you reduce these to harmful items that can be put in legislation? So a lot of work went into this. We consulted within the profession; a lot of consultation went between professions, outside the professions, and it became clear to us that one of the most risky things we do as physicians is what we call diagnosis. There has been a lot of angst back and forth about this term and I want to just spend one minute to describe -- and there are further descriptions in our brief -- what we mean, as physicians, by a diagnosis.

Very simply put, if you come to me -- I am a chest physician -- and you have a cough or shortness of breath, what happens is that I will take a history. That means I will ask you everything possible about it briefly. This may take quite some time. I will do a physical examination and then come up with a list of the possible causes of that shortness of breath. Is it due to something in the heart or the lungs or the stomach or the head or wherever? That is the role of the physician. And then I will order the appropriate tests.

So if I make the wrong list at the beginning or if, as I comb down to the ultimate cause of your cough or shortness of breath, in the course of that process make an error, significant harm is done, because everything that follows from that is the management or the treatment or the dealing with that cough or shortness of breath. The diagnostic process for a physician includes the taking of the history and the physical examination, the forming of a list of possible causes of the abnormality, the ability then to know the nature of these ideological factors and to choose from them what the most likely are and then to order the appropriate tests. So even though the tests might be dangerous, the most dangerous part is if I make errors along that diagnostic process.

Once the physician has decided in his or her judgement that this is the diagnosis, then communication with the patient and subsequently with others becomes very important. Many other players in the field will also use that information to help the patient understand, so they in turn will communicate the diagnosis to the patient.

I work in a team concept in rehabilitation and once the diagnosis is made, many of those people who work with me, the psychologists, the physiotherapists, the nurses and so on, will carry on in their own spheres to help that patient further understand the meaning of the diagnosis and the way it affects their function.

We just wanted to clarify for you that our perception of what we do in diagnosis is a risky business. We would make a suggestion that, as you have to deal with this, you consider returning the definition to its original in the controlled acts, which was simply "diagnosis."

The second issue we want to talk about is the harm clause. In making up the controlled acts scheme, some were concerned there may be holes, there could be dangerous things not covered in that list which had been made and there was no precedence for such lists. There was never any absolute certainty that things had not been left out, and there was the concept then of making a clause that would cover this eventuality and would cover perhaps those who might do things that were harmful by getting around the acts. This was so-called the harm clause.

Effort went into wording the harm clause and this proved to be difficult. There were some groups prior to the previous first reading in the Legislature who felt that it restricted their ability to counsel patients because of the way the harm clause was worded. Certainly, that was not the intent. I do not think anybody at any point ever intended social workers, clergymen and other counselling professions to be in any way inhibited by this legislation.

We are supportive of the concept of a harm clause, first, because we feel that it probably has to be there to prevent abuse by non-regulated professionals or others who might try to find their way around it. Second, we must remember that this legislation puts a very high standard of performance on regulated professionals and unless you have some way of ensuring that those who are non-regulated can be prevented from doing harmful things, this in a way will denigrate the legislation.

We are supportive of the presence of a harm clause and in thinking about the wording, we were favourably disposed to the wording put forth by the Ontario Chiropractic Association to you people recently. They took the previous wording but have adjusted it somewhat, added "unjustifiable" and "significant." We feel this is probably as good as you are going to get if you decide that a harm clause is necessary and if you are looking for wording that will satisfy the needs of the legislation and not inhibit legitimate activities of unregulated practitioners in the other fields.

The third issue I wish to address at this time is the quality assurance committee. I think this has been an extremely positive feature of this legislation and I think you all know that the chairman of your committee was in fact one of the key proponents of this particular part of the legislation being put in.

The reason we think it is so positive and are not criticizing it here but rather complimenting it is that it is a new focus. I think it should be clear to the committee members that it is a different focus from all the other committees. All the other committees under existing legislation focus on punishment and deterrent, penalizing for wrong doing. This particular part of the legislation focuses on encouragement of quality of care, encouragement of maintenance of competence. It leaves the flexibility for colleges to devise ways in which they are going to ensure that their own professionals maintain their competence, and this will differ from college to college or from group to group.

We feel that it is extremely important to maintain this in an open and flexible way. Within our own profession, the whole area of competency is under intense study and intense research. You might at first say, "Surely you know when a physician is competent or not," but it is not that easy. Somebody can test my knowledge, can give me an exam and test my knowledge and even my skills, can watch what I do. But it is very hard to measure attitudes, it is very hard to measure whether I apply in my daily practice what I know. I may know how to treat high blood pressure, but is that what I actually do in my practice?

How we measure competence and how we encourage maintenance of competence in such a rapidly changing field as health care is an area of intense study. In fact, an example of this is that the nation's specialty body, the Royal College of Physicians and Surgeons, has recently assigned $1 million to the study of maintenance of competence and measurement of competence within our profession. The college of family practice nationally is also involved in many different projects to try and get a hold on how we do that.

Until this area becomes more defined, we think that to codify how it is to be done would be inhibitory to the evolution of proper competence measurement, proper competence assessment. We are bringing forth our full support for these particular clauses in the way they are, because we feel they have the flexibility and will encourage people to move along in these areas of quality assurance and competence.

In conclusion then, we are supportive of the legislation. We have highlighted in our brief a few of the areas which we feel are in need of further discussion. We will be submitting a further brief on some of the technical issues which arise out of the government's proposed amendments, and also on the subject of incorporation which has not really been addressed up to this point but which we believe should be. We will be submitting a written submission on that.

We would be pleased to answer any questions.

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Mr Jackson: Thank you, Dr Guzman. Good to see you again. I could not help but note on page 2 you say not what is wrong with this legislation but rather "how little there is left to complain about." I guess after four weeks we have certainly heard a bit that people have been complaining about.

One of the items which has been brought to our attention, very cogently I might add, is the concern that chiropractors have with respect to their current practice, which would be adjusted to ensure that their scope remains within the spinal areas and not the outer extremities. I would like to hear from you if you support that, and if so, why? How will that have an effect on the physicians? I would assume that the physicians would then be responsible for the manipulations of the arms and legs and feet and those kinds of things that are the outer extremities they are looking at.

Dr Guzman: I am going to let Ted carry on from here.

Dr Boadway: I would first like to know if you intended a pun when you said that their scope would be adjusted, or whether that was unintentional.

When we have been dealing with this issue all along, it has always been difficult to know what adjustment means, because adjustment for a spine is considerably different from adjustment for an elbow. In your spinal joints there is a definition of adjustment which means that with a short thrust you carry it beyond the usual range of motion of that joint, but you cannot do that with your elbow. When your elbow gets out there, with any thrust you cannot carry it beyond that point unless you are willing to break something. So it is very difficult to think that an adjustment of a spinal joint is the same as an adjustment of a knee joint or an elbow joint. In a diseased joint the same thing pertains in that you cannot take it beyond the normal range of motion for that particular joint. So whether it is health or disease, the definition of adjustment would be quite different, whether it was in the back or in a peripheral joint.

Mr Owens: We have heard a number of deputations from the nursing profession with respect to the legislation containing the phrase "on the order," and it is their wish that phrase be removed in the process of our amendments. I wonder if you have any comments on whether we should entertain that amendment or leave it as is -- that nursing functions be carried out on the order of a physician or a qualified health practitioner?

Dr Boadway: I think you should entertain it and you should think about it very carefully. Much of what nursing does is on the order of someone else at the present time. If you are in a post-op situation where people need to have dressing changes, anything from dressing changes right through to intensive care unit work, someone is usually in charge of that and that is usually the physician who did the operation, and the rest of the team works on those orders.

It is a question of whether or not the scope of practice would be expanded legitimately with that. Quite frankly, we believe that in most circumstances there are protocols within institutions and there are also standing orders which look after much of this. In fact if you go back about 10 years, nursing's role has been rapidly evolving. Now, in intensive care units, to stay with the same example, they are doing very significant things, very important acts with great risks associated with them, and doing them extremely competently. None of that is in question.

Right now they do that on the order of, and in the future if they were to do that on the order of, it would not impair their ability to do them. So I think it is possible in fact for you to go either way. What you want to look at first and foremost is where the protection of the public is greatest. At the present time the public is well protected by being on the order of the person who is the principal performer.

Mr Beer: I would like to go back to your comment about diagnosis and I wonder if for the record you could just tell us how you saw that being worded. What were you replacing in terms of your original recommendation that I guess you made to the review? How is that framed in the context of these controlled acts?

Dr Boadway: This has always been a problem in the review, right from the beginning. We have always had difficulty with this; everybody has had difficulty with this. So, congratulations.

Our recommendation in the very first place was to put down the simple word "diagnosis" and that would look after capturing the things doctors do quite adequately. So we would not have trouble with our profession, making sure they were caught. But a lot of other people found there would be a problem with it.

Our recommendation was that you look at people who are diagnostic practitioners -- and there are clearly people other than ourselves who are diagnostic practitioners -- that they simply be given the right for diagnosis according to their abilities, and clearly they are able. So our original recommendation was that the word be "diagnosis" and that it be granted to those who are diagnostic practitioners.

Mr Beer: That would be reflected then in each act. Was that the sense, that you would have to repeat that in the other bills we have before us for those who clearly perform some sort of diagnostic procedure?

Dr Boadway: Yes. At the present time, if it is a controlled act, each controlled act that is granted to a group is in their particular act. And, yes, it would be one of those repeated in those acts.

Mr J. Wilson: Given what you have just said, and it also appears on page 5 of the brief concerning the diagnostic controlled act, perhaps I could ask the parliamentary assistant a specific example. For instance, in the case of speech-language pathologists, why are they not given the controlled act if the OMA seem to have no objection to it?

Mr Wessenger: I refer that to ministry staff.

Ms Bohnen: The review concluded that the appropriate characterization of what speech-language pathologists do was not diagnosis but rather assessment. That was the reason. Of course, among the regulated professions there are professions in addition to medicine that have been authorized to perform that controlled act, but not all of them, obviously.

Mr J. Wilson: Maybe I could ask the professional opinion of the witnesses. It is one of the examples that comes to mind very frequently with witnesses, the speech-language pathologists and the diagnostic controlled act. Did the OMA have any objection or did you deal with that profession specifically?

Dr Boadway: No. We were very careful never to support or not support any professional group in its quest for diagnosis. It was not our position to judge. We have never asked for that position and we do not take the position that we should be able to judge now. In order to determine whether someone is a diagnostic practitioner, we think you can look at how people are trained, the kind of training they have, the kind of clinical experience they have, the availability they have to diagnostic tools and their experience in making differential diagnosis, which Dr Guzman had explained to you. To make a diagnosis, there is a skill set one must have, which we have outlined in our brief. If someone possesses that skill set, then he is a diagnostic practitioner.

Mr J. Wilson: That is refreshing because some groups, whether they were referring specifically to the OMA or the College of Physicians and Surgeons of Ontario, certainly would accuse you of having protected that. It is refreshing to hear that you did not take a stand on any of the particular professions.

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Mr Jackson: I have concerns about whether a certain treatment will now fall outside of the scope of practice and therefore the physician will be called upon to perform that practice. It raises the question of their ability to perform that. There is a lot of presumption. An example is a physiotherapist performing under the supervision of a physician not necessarily a qualified physio. Another example is a chiropractor. I use "chiropractic" in the case of readjusting of the bones in the hand by a chiropractor with the training, versus a doctor who the legislation says should be doing it but may not have the training. We have satisfied the intent of the legislation, but how can we ensure that the actual treatment is done at that competent level?

Dr Boadway: Physicians manipulate peripheral joints every single day in this city and every other city of this province and they do it in conditions which are very dramatic even and not ones where people can walk through the door. Physicians manipulate joints after serious injuries. They manipulate joints in conjunction with fractures and they manipulate joints for arthritic conditions. They manipulate locked knees, frozen shoulders, diseased elbows. The thought that you have just raised that physicians may not be trained to manipulate joints is a new one to me in that it is something we do in very dramatic conditions, as well as lesser conditions, on a daily basis.

The Chair: I would like to thank you very much for your presentation before the committee. I know you are aware that if you feel there is additional information that would be helpful through the committee deliberations that you will submit a written brief or communicate through our clerk.

ONTARIO MEDICAL ASSOCIATION, SECTION OF OPHTHALMOLOGY

The Chair: I would like to call now the section of ophthalmology of the Ontario Medical Association. Please come forward and introduce yourself for committee members and the purposes of Hansard. You have 20 minutes for your presentation. We would appreciate it if you would leave a few minutes at the end for questions from committee members.

Dr MacInnis: I am Brent MacInnis. I am a medical doctor and an ophthalmologist, which is a specialist in eye medicine. I have asked for special consideration from the committee with respect to our section. I am also the chairman of professional affairs, the section of ophthalmology of the Ontario Medical Association. We felt there were sufficient grounds with respect to the differences between our concerns as a section, with overlap with other opticians and optometrists as well as other areas of medicine, and there were specific areas of the proposed legislation that address concerns with respect to the eye, the visual system and also with respect to the supporting adnexal structures.

When it comes to the proposed bill for medicine, there are several sections specific to our area of medicine. One is that a member is authorized to perform the diagnostic clause, which is communicating a conclusion identifying a disease as the cause of symptoms or signs. Another is that they perform a procedure on tissue below the dermis, in or below the surface of the cornea. Others are: administering a substance by injection, applying or ordering the application of a prescribed form of energy, prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eyeglasses and other simple magnifiers, and allergy challenge testing.

I would like to spend just a few moments on each just to refresh the minds of the committee with respect to how that would concern ophthalmologists and later spend some time on the proposed definition of the scope of optometry and also opticianry to determine whether there is some input we may have that may be of use to you.

When it comes to the first one, communicating a conclusion identifying a disease as the cause of symptoms, I think it is important that we understand that an incorrect diagnosis, as Dr Guzman has alluded to, can convey a wrong conclusion and can lead to very devastating consequences.

The example I have chosen here is that if you have an ocular tumour, for instance a metastatic carcinoma from the breast or from the prostrate or from the lung, that can metastasize or spread to the eye and be seen as a retinal detachment overlying that tumour mass. The wrong conclusion, obviously, can have the implication with respect to the general health of the individual as well as to the ocular health of that individual. So a wrong conclusion may be blinding and indeed may be fatal if it is carried to the nth degree.

What people have a tendency to forget with the definitions as they appear is that the detection of problems can be performed in the assessment portion of somebody's scope of practice. For instance, if you look at the proposed Optometry Act, the assessment of the eye and vision system, what is controlled is communicating a conclusion. They can still see a retinal detachment. What they cannot do is convey the conclusion that there is an underlying carotal tumour that is metastasized from the lung and is causing that retinal detachment. That in no way precludes a complete assessment and examination of that.

I would like to defer a little bit with respect to that and come back to that when I define some of the problems associated with other scope matters.

I think it is equally important to understand that there is definitive harm in invading the integrity of the dermis and also the integrity of the cornea. The cornea is the front surface of the eye that is responsible for the refracting strength of the eye and focusing rays, in addition to the other ocular apparatus that are present, so the integrity, if it is disturbed, if it is central, will immediately impair the central visual acuity and cause disturbance to that. I think any procedure that violates the integrity of the surface of the cornea really has to be protected from individuals performing procedures upon it.

The other thing to keep in mind is with administering a substance by injection. There is not only the substance that has the potential harm but also the vehicle the substance is in and its preservatives which can be administered for diagnostic or therapeutic reasons. I think the brief from the general OMA has addressed this issue quite adequately. I would also like to point out that there are of course threatening diseases with any violation by an injection with respect to hepatitis, AIDS and other communicable diseases.

One area that is especially important with respect to ophthalmology is the administration or application of prescribed forms of energy. You can have ultrasound energy that can destroy the part of the eye that is responsible for secreting the aqueous that gives the intraocular pressure. You can have laser energy administered to destroy tumours, to close off abnormal blood vessels. There is a multitude and host of prescribed energy forms that have implications that can produce great harm if administered in a way that is not controlled.

Prescribing or dispensing contact lenses is currently something that only licensed practitioners are capable of doing and we fully concur that the implications of corneal ulceration or permanent visual loss are such that this again should be a controlled act and the prescription and dispensing of these contact lenses should be only by licensed practitioners.

Allergy challenge testing is something, just by the inherent nature of the words involved, that involves a challenge. Unless you are equipped medically to handle the ultimate response, which is anaphylaxis or a severe shock to the allergen test, it is something that again should be controlled.

Some things we are running into now in ophthalmology are that the preservatives used in contact lens solutions and in drops are the same preservatives that are used for hepatitis, influenza, tetanus and other forms of immunization. So somebody who is determined to have a sensitivity to that preservative may indeed run into problems and should not be treated with this immunization. I recently had in a dental hygienist who could not receive her hepatitis vaccination because of a thimerosal sensitivity induced from contact lens wear. The implication is there. If you are not aware of it being as a vehicle in other medicaments and other vaccines then the medical implication may escape you.

I would like to go into some of the more controversial areas. The proposed bill for optometry has defined the practice of optometry as "the assessment of the eye and vision system and the diagnosis, treatment and prevention of vision and oculomotor dysfunctions of the eye."

We, as a section, believe this definition is too restrictive. We believe that optometrists indeed do diagnose and treat disorders, but the disorders they treat are refractive diseases and disorders of the eye. We have met with the registrar of the college of optometry and we have met with the review and it is our opinion that we cannot come to a consensus with respect to a modifier. We cannot go along with no modifier, giving the diagnosis of all diseases and disorders and dysfunctions of the eye and visual system in that it indeed is beyond the current scope of optometry and does not reflect adequately what the existing status of the profession is.

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We presented a brief in April of this year and in previous years along the process of the review, and feel that "refractive diseases and disorders" adequately characterizes the nature of the scope of optometry. We are comfortable with that. To us, the acceptable definition of optometry might be: The practice of optometry is the assessment of the eye and visual system and the diagnosis, treatment and prevention of refractive diseases and disorders of the eye and of sensory and oculomotor disorders and dysfunctions of the eye and visual system. We feel that is a compromise we can live with, and one we have hammered out over the course of years.

I have enclosed, within the appendix, an addendum 1. This addresses the scope issues, other diagnostic features that optometry has felt in the past fell outside the realm of refractive diseases and disorders but which we feel are all within the realm of refractive diseases and disorders. I would again like to stress that this does not limit the assessment of the eye and visual system. An assessment will detect symptoms and signs of cataracts, retinal detachment, glaucoma and all these things. It is communicating a conclusion identifying a disease as the cause of the symptoms that is the controlled act. Many of the voiced concerns of optometry appear to fail to make this distinction. If the proposed definition is accepted, then of course the licensed acts and controlled acts would have to be adjusted accordingly.

With respect to opticianry, we have no objections to the proposed bill as it reads, as long as dispensed subnormal vision devices, contact lenses or eye glasses comply with the prescription which we indeed write, and conform to the patient such that we are happy and the patient is happy. I thank you very much for your time.

Mr Beer: Thank you for your presentation. You touched on a number of the questions in relation to optometry. We have had a number of submissions from their association, as well as from individual optometrists. They see Bill 60 as limiting what they are going to be doing. If we look at what you do today and optometrists do today, and if the acts went through as they are, without the changes that you are proposing, what is it, in your view, that it is then giving to an optometrist to do? What are some of the things that they would be able to do, from your perspective, that they would not be able to do if your definition was in place?

Dr MacInnis: If you take, for instance, an individual who has a different length eye, so that one eye is stronger than the other, one eye may be more far-sighted than the other eye is, which may be conducive to having a turned-in eye. What can be done, and should be done, if it is a young child under the age of visual maturity, which would be under the age of seven, eight or nine, is that the child should be treated with glasses and should be treated with patching or occlusion therapy. That corrects for the imbalance between the two eyes and puts a patch over the stronger eye to make the child use the weaker eye.

That would be a refractive diagnosis where, because of the difference between the two eyes, the brain suppresses the image from the weaker eye and turns that eye off and it becomes blunt or amblyopic, as we call it. By correcting the difference with the glasses and by stimulating the poor eye by making them use the poor eye with the correction of the glasses, that is a refractive treatment that is treating a refractive disease and disorder of oculomotor dysfunction as well.

Mr Beer: And an optometrist could do that today?

Dr MacInnis: They currently do that. But that would be a disease, as opposed to a disorder or dysfunction that under the proposed bill they would not be able to do. So the current bill is restrictive in that fashion. Whereas if you encompass the refractive diseases and disorders, then that would adequately encompass what they currently do.

Mr Beer: The other question is the number of ophthalmologists in the province. Are there sufficient numbers to handle what, in the view of the optometrist, would be the cases they would have to refer because they would not be able to do certain things? The argument has been that they can do those and that would help with the cost and that there would be a difficulty with referrals. What is the sense of your association?

Dr MacInnis: Currently there are 350 ophthalmologists in the province of Ontario, which represents a ratio of approximately one in 30,000, which is the ratio that is recommended by the World Health Organization, the Department of National Health and Welfare and our own association. We feel we are in a manpower-balanced situation that is very good.

You have to remember also that primary care is provided not only by ourselves and by optometry but by general practitioners. If you come in with a corneal foreign body, for instance, in virtually every community the family doctor is on call for the emergency department and plucks out foreign bodies, treats infections and does all these things not only on a 9-to-5 basis but on call and on a weekend basis, provides coverage for that sort of primary eye care. Certainly optometry does provide primary eye care within a lot of the smaller communities in Ontario and certainly is appreciated by the family doctors and by the ophthalmologists in the community.

As a rule, ophthalmologists and optometrists on a personal level get on very well.

The Chair: Thank you very much for your presentation before the committee today. We appreciate your coming out. If there is any additional information you think might be helpful to the committee, you will communicate with us in writing.

ONTARIO CHIEF PSYCHOLOGISTS ASSOCIATION, EASTERN REGION

The Chair: I would like to call now Ontario Chief Psychologists Association, Eastern Region. I ask that you come forward and introduce yourselves for the committee. We would appreciate it if you would leave a few minutes at the end of your presentation in case any of the committee members have questions. You have 20 minutes for your presentation, and I would ask that you begin your presentation now, please.

Dr Blouin: We are pleased to make our presentation today on behalf of the eastern region of the Ontario Chief Psychologists Association. I am Dr Arthur Blouin, director of psychology at the Ottawa Civic Hospital. My colleague here is Dr Sal Colletta, director of psychology at the Ottawa General Hospital.

We will try to keep our comments quite brief. We are certainly pleased to bring our perspective from the general hospital psychology departments to this committee, and we would like to say at the outset, I think, that we are basically very much in support of this legislation. We think that in general, as our written document indicates, the act represents a progressive approach to the delivery of health care in Ontario.

There are four principles that are important here. First is the increased public protection from unqualified health care providers. Second is the encouraging of the provision of high-quality health care. Third is enhancing the public ability to exercise freedom of choice in health care services. Fourth is encouraging the flexibility of roles which the various health care professions can play in the delivery of health care. We are looking forward to seeing these principles incorporated in the new legislation. We are of the opinion that certain components of the legislation regarding psychology are best addressed in the manner that we are about to discuss.

The first area is title protection. First, in maintaining two of the major principles of the legislation, the public protection and freedom of choice principles, we believe that the term "psychologist" should be protected, as is now written into the legislation. We believe that "psychological" and "psychology" should also be protected, because we do not believe that the general public can clearly distinguish between a licensed psychologist and someone who holds himself out or advertises himself as providing psychological services.

In Ontario now, to become a licensed psychologist requires a doctorate in psychology, a minimum of at least one year of post-doctoral training and supervision and, at the end of that process, passing stringent written and oral post-doctoral exams. So for the public to distinguish between someone with that level of training and someone who advertises as providing psychological services is a difficult one. We do not think it is an abstract issue in semantics; it is a very practical one and important not only for the users of psychological services but also even for those who refer to psychologists for psychological services, physicians and other health care workers.

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So we believe there is a general difficulty in distinguishing between the levels of training of individuals providing services in this area. Unlike other health care professions, the end point of most of our training programs is the doctoral level and the required stage for independent practice has been accepted as the licenced psychologist. The general public, we feel, is not clearly aware of this, and to protect the public and ensure that free choice is also informed choice, we feel that these terms should be protected from misuse. In addition, we feel that the public will become increasingly confused as to who is and who is not a qualified psychologist if the title protection is restricted only to those providing services to individuals providing health care.

For example, if someone -- as the legislation I believe would now allow -- presents himself as a psychologist in a newspaper column or on a radio talk show but is not qualified to be a licenced psychologist in the health care system, that would be okay. He could hold himself out as a psychologist but the public would readily come to believe that the level of training of that person is representative. When the public goes to the health care setting, we ask the question, "Will the general public clearly be able to make an informed and free choice in distinguishing between someone offering psychological services and someone trained and licenced as a psychologist?" Unless the title is protected for all services offered, the ability to make these distinctions in the mind of the general public will, we believe, become very difficult. So we see this as an issue of freedom of choice, informed choice, and protection of the public against misunderstanding in those terms.

The second area we would like to address is diagnosis. We generally agree with the OMA to return to the simple term "diagnosis," and we believe that there are areas that psychologists have been trained to diagnose. In a general hospital setting, much of the work of a psychologist is to act as a consultant to other professions. This may be to psychiatry, other medical disciplines and health professionals. In carrying out this responsibility, the role is frequently that of a diagnostician, and the referring disciplines want us to clarify and/or make diagnoses. The reports we write specify diagnostic information, and treatment plans are based on these diagnoses. It is important to patients and to referring disciplines that psychologists continue to make these diagnostic decisions in the areas that psychologists have been trained to make them.

In many areas in the field of mental health, the psychologist is simply the best-trained professional in the team to make the kind of diagnosis that is being sought. In the general hospital setting, psychologists provide services in the area of assessment, which is essentially descriptive; diagnosis, which is essentially fitting symptoms into known and well-defined syndromes with specific names; and treatment and consultation.

So it is important that psychologists are legislated to make diagnoses in order to provide the general public with optimal care. We state again, however, that we feel the communication of conclusions does not have to be restricted to the psychologist, but that the authorized act, the act of diagnosis, should be. So in summary, and briefly, as representatives of the chiefs of psychology in Ontario hospitals and, in particular, chiefs at general hospitals, we strongly urge you, in the new legislation, to protect the terms "psychological" and "psychology," along with the title "psychologist." We would also recommend that the diagnosis be a controlled act of a psychologist, as proposed in the current legislation.

Mr J. Wilson: We have had many non-doctoral psychologists -- anyway, people practising in the field of psychology -- appear before this committee, and we have had some psychologists themselves, the PhD, appear and express similar concern to continue the protection of the terms "psychological" and "psychology." There is a memorandum of understanding signed between the two groups. My concern is that if we go ahead and include in this legislation the protection of the two additional terms and there is never an agreement reached over the next 18 months with the non-doctoral practitioners, we may be cutting off something that may be useful to them. We clearly had evidence that there are a number of non-doctoral psychologists practising, in northern Ontario, for instance, where they never see a PhD or claim to seldom see a PhD. We cut off some terminology that under this new act they would be able to use, for instance hanging out on their shingle that they are providing psychological services. To be perfectly frank, I am worried that might lose some of the impetus to come to some agreement about who will be future members of the college of psychology. Do you want to comment on that?

Dr Blouin: My understanding is that there is a committee struck to address the issue of bringing in or somehow allowing that group to come into legislation as well. I think our recommendations would not cause any greater restriction on those people as they are providing services now, because I think the current legislation does protect those terms. We are certainly not of the opinion that their activities should in any way be curtailed, but I think it is very important, in general, that the public be aware of the distinction between a fully licensed psychologist and anyone else, whether it is the non-PhD provider of services in psychology or anyone else who can offer himself as providing psychological services. That is a very great problem for the public.

Under this legislation, anyone can say "services in psychology," not just those people who do not have a doctoral degree and are not registered as licensed psychologists. That we see as a big problem for the public. That is the very fundamental issue. We would be very much in favour of having those who are providing services incorporated in some way and given the scope of practice for which they are trained and accountable for as well. I think that would be a far better situation. In the meantime, it opens a door to anyone besides those people.

Ms Haeck: I think you are probably well aware, Dr Blouin, that we have received quite a number of presentations, be it from the master's-level psychologists, your own group, as well as the unregulated group. Can you comment at this time on the whole perspective as has been opening up to the public? "Access to a variety of services and making the public aware" is one of the comments that you have made about what a psychologist does. Because of the array of people who in fact do counselling, what kind of consumer education would you foresee having to take place to make it clear what all of the differences are going to be? Because there is really a vast array, as our representations can well attest.

Dr Blouin: We would be in agreement with the general principle of opening up the services. I think as psychologists we all run into the confusion of someone you meet not being clear as to what it means when you say "psychologist." My understanding is that under this legislation we could be in the position where, outside of the health care setting, people who are not licensed to practise could call themselves psychologists.

Within the health care system you have to be licensed to call yourself a psychologist. Then you have a whole other group of people who are unregulated who do provide psychological services. Then you have a whole other group of people who have no training in psychology who may provide some sorts of services and ask for fees for those services. I think under this legislation the amount of public education required to clarify that would be enormous. It is a very difficult distinction for the public to make under the proposed legislation.

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Mrs McLeod: I am not sure whether to direct the question to the presenters or to ask counsel for some comment, but it is in relation to the issue you have just touched on again, title protection outside of a health care setting. It was my understanding that certainly the intent of the legislation was that a controlled act would be a controlled act wherever it was carried out, whether in a health care setting or not, and that controlled act and title protection necessarily go hand in hand, so that title protection would also extend outside the formal health care setting. Do you have a concern that this may not in fact be the case?

Dr Blouin: Yes. I am not that well versed on the nuances of the way all of the forms of the act read, but my understanding was that the term "psychologist" was restricted to health care and that people who are providing activities that are totally unrelated to health care and may not have the qualifications could still present themselves as psychologists and if they are not doing the acts and they are not providing health care, they could still call themselves psychologists. Now, if this was, for example, a newspaper column, the public perception could easily be distorted into thinking that person is a psychologist representative of psychology. When they go to the health care system, there is great confusion. That is what I would be concerned about. If there are provisions to correct that, then my concern is not justified, but that is how I have understood it.

Mr Hope: Mine deals around the title protection issue. You have been referring to the ones with the PhD and the MA levels, and then you are saying there is another segment of society out there that is using these titles. Do you have any statistics at all of how many people without MAs are out there using this?

Dr Colletta: There are none as yet. Under the new legislation as it is written, if it were passed, following on points made in the presentation, individuals who would be providing services that would not fall under the narrow definition of health care that is in the proposed legislation could present themselves as being psychologists and, at the very least, could present themselves as providing psychological services or psychological consultation, which the present legislation does not allow to happen. As the law stands now, the only people who can use the terms "psychologist," "psychological" or any derivative of the word "psychology" are licensed psychologists. There are none now. It is a question of if the legislation goes through as it is written. It really does open the door to individuals being able to provide services that would not be well controlled.

The Chair: There were questions for the parliamentary assistant to clarify.

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

Ms Bohnen: I would like to clarify first what the current state of the law is under the Psychologists Registration Act. Section 11 of that act restricts to registered psychologists the use of the title "psychologist" or titles, designations, descriptions incorporating the words "psychological," "psychologist" or "psychology." It is not restricted to any particular kind of service. However, there is an exception from that general title protection, first for legally qualified medical practitioners, second for a person in the course of his employment by the government of Canada, government of Ontario or a university. So we already have many exceptions. Many psychologists are employed in academic and government situations. Many people providing psychological services are employed in those settings and there is no restriction on their use of the title.

In the proposed legislation there are two kinds of protection. First of all, the use of the title "psychologist" and any variation, translation, etc, of it is indeed restricted to individuals providing or offering to provide health care to individuals. But it does not say "health care settings"; it says "health care."

I think the presenters are quite right in saying this legislation would not prevent a newspaper columnist from describing himself or herself as a psychologist even if not registered in Ontario as a psychologist. Quite frankly, it has not been the government's intention to try to stop cocktail party uses, academic uses, media uses of these titles, but really to restrict how these titles are used where they can truly mislead people, which is at the front line where health care services are being delivered.

Of course, supplementing the specific title protection is the additional holding-out clause which in not very many words, and far fewer words than it seems some groups would like, does prohibit individuals who are not members from holding themselves out as persons qualified to practise as psychologists. I hope that clarified it a little bit.

Dr Blouin: Just in responding to that, that is one of the issues. If people can write a newspaper column and call themselves psychologists, it is going to be very difficult to make members of the public aware when they go into the health care system as to what a psychologist is.

The Chair: Thank you very much for your presentation.

OTTAWA ACADEMY OF PSYCHOLOGY

The Chair: I call the Ottawa Academy of Psychology. You have 20 minutes for your presentation.

Dr Bush: Thank you, Madam Chair. I am Clarissa Bush. I am the past president of the Ottawa Academy of Psychology and I work at present in a chronic health care facility in Ottawa. My colleague is Wendy Richardson, president elect, also working in a general hospital in the Ottawa area. I am presenting on behalf of the Ottawa Academy of Psychology.

The Ottawa Academy of Psychology is concerned that introduction of Bill 63 may reduce the public's ability to obtain good health care. I would like to invite you to glimpse with me a scene that could take place if the Psychology Act is passed as it is now written.

The year is 1993 and the Regulated Health Professions Act is in place. Due to very serious professional misconduct in 1992, my licence was permanently withdrawn at the beginning of the year. I have lost my hospital job and am faced with the prospect of trying to earn a living another way. After careful reading of the Psychology Act, I place the following advertisement under the new heading "Psychological Services" in the yellow pages, "Clarissa Bush, doctorate in clinical psychology, expert in neuropsychology: Assessment and treatment of all types of cognitive and memory problems; psychological support and therapy to care givers and families; remediation and rehabilitation."

Over the next year, the college of psychology received several complaints from members of the public who, aware that their third-party health insurance covers treatment by psychologists, used my services and were then unable to obtain reimbursement. The complainants receive a letter from the college informing them that I am no longer licensed in Ontario but pointing out that as I am not contravening the law in any way, there is, unfortunately, nothing the college can do to restrain my activities. This is because, in contrast to the situation which has prevailed since 1960, the terms "psychology" and "psychological" are no longer restricted to registered psychologists.

It is now 1994. Business is a little slow, but I have heard that the educational field is quite rewarding and, recalling that some of the courses I took as a graduate student dealt with child psychology, I decide to branch out. Under the yellow pages headings "Educational Consultants" and "Psychologists," I insert the following advertisement, "Clarissa Bush, PhD: Educational psychologist; individual evaluation and remediation."

Although my limited experience may put some of my early educational clients at a disadvantage, I am sure that through reading textbooks and a process of trial and error I will soon learn what is needed. As Bill 63 provides only for the restriction of the title "psychologist" to individuals providing health care, I am fairly sure that by labelling myself as a psychologist only in the area of education I can enlarge the scope of my business without getting into difficulties with the college.

The Ottawa Academy of Psychology, whose goals are to improve contact among local psychologists and to increase the public's understanding of the profession, is in strong support of the intentions and almost all of the provisions of the Psychology Act. However, we submit that the effect of section 15 regarding restricted titles will be the opposite of what was intended, leading to confusion and extra distress and suffering on the part of a section of the public which is already rather vulnerable.

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One of the purposes of changing the way in which health professionals are regulated is to provide more information to the public to allow them to make an informed choice about their own care and to protect them better by improving the way in which the regulatory process operates. As a group of people whose main objective is to help others, we wholeheartedly endorse those goals. However, we submit that the goals are not in fact furthered by the proposed Psychology Act as it now stands. Many people will be unable to draw distinctions between shades of meaning, ie, psychologist versus psychological, such as those employed by the act. People seeking our services are, by definition, in emotional distress and will therefore be even less able to do so.

Another point which causes concern is that the term "health care" is left unelaborated in the act, presumably to be defined by the courts. Historically, courts have tended towards narrow rather than broad definitions and this might mean that psychologists providing educational, correction, management consulting and other non-health services would be essentially unregulated.

In summary, in order to provide more accurate information to the public and to guarantee that professionals providing psychological services are properly regulated, the Ottawa Academy of Psychology recommends the restriction of the terms "psychology" and "psychological" to registered psychologists and broadening of the act to include all psychologists practising in Ontario.

Perhaps I can apologize for the redundancy after the last presentation.

Mr J. Wilson: You do not need at all to apologize for the redundancy, because I am going to ask you the question I asked the last group. Just to expand on it a bit and play devil's advocate, would it not be the case that, say, the non-doctoral psychologists, the MAs, perform psychological services now?

Dr Bush: They do, under the supervision of psychologists, and perhaps I could point out that, except for the people who were grandfathered in when the Psychologists Registration Act came into force, there are no non-doctoral psychologists in Ontario.

Mr J. Wilson: I think the committee understands that when I use that terminology.

Dr Bush: Yes, they provide those services, but they do so under supervision and they are not allowed to advertise themselves as providing those services.

Mrs McLeod: I would also follow up and use what you have referred to as redundancies as a chance to seek some further clarification on those central issues. I am going to ask ministry staff, if I may, about the two examples that have been used of advertisements, just to follow up on your explanation given to the last presenter. As I understand it, the first ad would in fact be allowed under the proposed act because it does not use the term "psychologist," but the second ad, describing yourself as an "educational psychologist," would not be allowed because it represents a holding out as a psychologist and therefore someone able to do those controlled acts, even though it is in a non-health care centre. Have I understood your explanation correctly?

Ms Bohnen: Yes. I think it is important to point out that the scope of practice of psychology as it appears in this legislation, again, is not restricted to services provided in health care settings. The kinds of diagnostic activities, let's say, that psychologists perform with children are often provided in an educational setting. The use of the title "educational psychologist" would not mean there was not health care psychology and therefore a title entitled to be restricted to registered members of the profession, as you have said.

If I could just chime in with this, I think part of the difficulty in grappling with title protection with a profession like psychology is that, as you know, many non-psychologists are providing the same or very similar services to what psychologists are providing. What the review tried to grapple with is suggesting title protection that, while it protects the public, is appropriate to a system in which the service is not monopolized by any particular group. You do not want to make it harder for the public to locate and assess the services provided by people who are not members of the regulated profession. That is not public protection either, so I think that is why this is so hard.

Dr Bush: I would like to respond to that, if I may. Certainly we recognize that there are masses of people out there, far more than there are psychologists, providing excellent services that the public needs, and it is very far from our intention to restrict anybody's access to services that they need, but our position is that if the act is adopted as it is now written, it would make it much harder for people to distinguish between psychologists and other people -- and they might be choosing to look for somebody other than a psychologist -- but it makes it less clear rather than more clear.

The Chair: Thank you very much for your presentation.

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS, ONTARIO BRANCH

The Chair: I call the Canadian Society of Hospital Pharmacists, Ontario branch. You have 20 minutes for your presentation.

Mr Babcock: I am Kelly Babcock, and with me is Cheryl Bishop. We are president and president-elect of the Ontario branch of the Canadian Society of Hospital Pharmacists. We represent nearly 1,000 pharmacists practising in Ontario's health care institutions today. I would like to thank you for the opportunity to provide input for the proposed Regulated Health Professions Act and its related legislation. In general, we are very supportive of the proposed changes to the regulation of health professions in Ontario. However, we do have two areas of concern.

First we would like to discuss the issues that deal with Bill 61, the Pharmacy Act, and the Drug and Pharmacies Regulation Act. I feel the best way to illustrate this viewpoint is with the following case scenario.

When you receive a prescription from your physician for an antibiotic to treat an infection you have, you get it filled at your community pharmacy. Your prescription will be interpreted and dispensed by a licensed pharmacist. Thus you are protected by the competency standards set out by the Ontario College of Pharmacists and can feel confident that you will receive the quality of services you expect from your pharmacist.

Unfortunately, you are not guaranteed this protection when you are in a hospital. You could be in an intensive care unit receiving lifesaving medication and not receive any input from a licensed pharmacist. This is because the practice of pharmacy in Ontario's hospitals is not currently regulated through health professions legislation. There is an exemption clause, a loophole, if you wish, in the Health Disciplines Act and in the proposed Drug and Pharmacies Regulation Act that excludes hospitals from the provisions of these acts. In brief, the act states, "This act does not apply to (a) drugs compounded, dispensed or supplied in and by a hospital . . . for persons under health care provided by such hospital."

We are a little bit concerned about that, because other provinces do not have this type of legislation and it has been in Ontario's legislation since 1953 and has been the subject of much debate. We believe the situation is not in the best interests of the public, since it can and does result in pharmacy services being provided to our province's hospitalized patients by people who are not registered pharmacists -- that is, people who are graduates of a pharmacy program but not licensed in Ontario -- possibly by registered nurses or by pharmacy technicians. We estimate that there are approximately 10% of people representing themselves as pharmacists in Ontario's hospitals today who are not licensed with the Ontario College of Pharmacists and therefore are not really allowed to call themselves pharmacists. In fact, there are about 30 hospitals that do not have even the services of a single licensed pharmacist, even on a part-time or a consultative basis.

We see this situation as inconsistent with the legal requirement that every patient in the community must be serviced by a licensed pharmacist. Thus, it can lead to potentially lower standards of pharmacy service in hospital settings compared to that in our community, and we feel that the hospitalized patients are entitled to better protection than this.

We have stated our position a few times in various documents and through the various legislative review processes, and basically we believe that the supply of drugs -- that is, the distribution of them only -- to hospital inpatients and bona fide outpatients should continue to be exempt from the act. Second, the pharmacy services in hospitals should be directed by a pharmacist licensed in Ontario and accountable to the Ontario College of Pharmacists. Third, those hospitals unable to secure the services of a pharmacist would be dealt with on a case-by-case basis by regulation granting temporary exemption from the act. This is how it is done in many other provinces.

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The Ontario College of Pharmacists supports our view. They have recently stated that they agree with the present exemption and that drug supply in hospitals be retained but that the pharmacy service itself must be directed by a pharmacist who is licensed in Ontario and accountable to the college for his or her professional activities.

The Ontario Pharmacists' Association also agrees with this. They feel it is quite unusual that the public at large has to be serviced by a properly qualified pharmacist but those patients in a hospital do not receive such a privilege.

The Ontario Hospital Association has had a differing view until very recently. We met with them a couple of months ago and we discussed this issue at great length. In reality, they have come to the conclusion that there may be a better way of dealing with this issue than the current exemption clause.

Basically, if our position is stated, we feel the following objectives will be met: first of all, to protect the hospitalized patient from unqualified persons acting as pharmacists or claiming to be qualified to provide a pharmacy service; second, to protect the hospitalized patient from poor pharmacy practices; third, to allow the provision of safe and effective drug distribution practices when a legally qualified pharmacist is not present, for whatever reason, and fourth, to permit the continued application of innovative and cost-saving pharmacy practices in a hospital setting.

We have developed a proposed wording of the Pharmacy Act and it is available to you, I think, in the second section. It is on a separate document. This was our initial attempt at rewording the document with potential words. We would definitely want to be involved with the Ministry of Health and the Ontario Hospital Association and the various pharmacy organizations in developing exact wording, but we have pointed out the fact that we think it is relatively simple to provide all parties with what they want and still have licensed pharmacists in hospital while providing for those hospitals which cannot hire pharmacists the opportunity to distribute drugs. Therefore we feel that if the concept is adopted, the interests of the public, especially the hospitalized patient, will be protected.

The second thing we would like to comment on is in Bill 43, and our only major concern is with section 30: "No person shall use the title `doctor'...in the course of providing or offering to provide...health care to individuals." There are a number of exceptions listed in the subsequent section: chiropractors, optometrists, physicians and surgeons, psychologists and dentists. However, many pharmacy practitioners in Canada today hold doctorate degrees, either a PhD degree or a PharmD degree. The holders of these degrees are frequently employed in senior clinical positions in Ontario hospitals and provide excellent leadership in the profession as teachers, researchers and practitioners in the field of drug consultative services.

The Ontario branch believes strongly that members of the Ontario College of Pharmacists holding these degrees should have their credentials acknowledged by permitting the use of the title "doctor."

Therefore, in summary, we have two areas of concern: first of all, the exemption clause, we want hospital pharmacy practice to be regulated so that we ensure that the public, mainly the hospitalized patient, has its interests protected; second, that members of the Ontario College of Pharmacists with doctorate degrees be allowed to use the term "doctor" in their practices.

Are there any questions?

Ms Haeck: Thank you very much for this presentation. It does add an interesting perspective to an area I have not heard very much about so far. I have a small hospital in my own riding and I know it does not have a hospital pharmacist who is exclusively there, say, on an eight-hour shift. In fact, he is a volunteer. I would say he is not totally a volunteer. I would assume there is some remuneration. But this gentleman does run his own pharmacy and does put in a few hours every week to deal with the pharmacological needs of the patients in that hospital. What he is doing would then contravene this, in your opinion, or your suggestion?

Mr Babcock: No. What we are stating is that we realize that there are not going to be too many hospitals that have a 24-hour pharmacy service. In fact, I think there is only one in Ontario. Drugs still have to be distributed outside normal, if you want to say, pharmacy hours.

What we are proposing is that the distribution as such -- the count, pour, lick and stick, as it is well referred to in the old pharmacy colleges -- of getting pills from the big bottle into the little bottle and out where they belong should be allowed to happen without the pharmacist being there. However, we feel that a pharmacist should be responsible for ensuring quality assurance mechanisms to ensure that, first, the procedure for doing that by whoever is doing it is done properly and that proper audits are there and, second, if the pharmacist is available that, of course, the pharmacist be supervising. We just realize that it would be impossible to have that in all hospitals 24 hours a day.

Mr Beer: Through the parliamentary assistant, I would just like to get for the record, with respect to the review's decision not to include hospital pharmacists, was it simply because of the existing situation it was felt that was the best way to handle it, or were there some other considerations brought to bear?

Mr Wessenger: I will ask ministry staff if she could comment on that item.

Ms Bohnen: Quite frankly, I cannot remember whether the review specifically considered any change to the existing and long-standing exception for hospital pharmacies. I could get that information for you.

Mr Beer: I know we will have a chance to speak to Alan Schwartz and can ask him at that time.

Mr J. Wilson: Is there a body of evidence now that indicates harm is being done because hospital pharmacies are currently exempt?

Mr Babcock: There are existing situations -- for example, at a large teaching hospital where there are plenty of pharmacists -- where the actual director himself is not a licensed pharmacist and does not seem to think they have to become pharmacists. The Ontario College of Pharmacists has sort of stayed away from hospitals due to this loophole.

I know the law states that if you want to be called a pharmacist, you have to be licensed with the Ontario College of Pharmacists. However, we also know that there are pharmacists practising today -- pardon me, people who have graduated from pharmacy who are practising today -- in hospitals, big and small, who definitely do not have a licence and are calling themselves pharmacists, and that the college is not, I guess, enforcing the rule, if you want to call it that. So there definitely is the potential for it to happen, and it does happen.

Mr Johnson: Following the same questioning, in rural Ontario and in the north it is often a cost-saving measure for smaller hospitals and medical centres to dispense with a pharmacy technician as opposed to a pharmacist. What would happen if pharmacists did not want to go to some isolated community to do this? If what you suggest were to become law, that would exacerbate the situation and would indeed increase the cost, would you not think, for these communities?

Mr Babcock: We are not stating that what you have described initially is impossible to do. Currently there are lots of hospitals that are having the distribution of drugs -- and I must reiterate that this does not mean the interpretation of the prescription but the actual distribution of drugs from A to B -- happening quite frequently without a pharmacist being there. We do not have any problem with that, provided a pharmacist sets up the guidelines for how it is handled and does various audits to make sure the drug is appropriately dispensed.

There are numerous situations. I happen to have a hospital in Perth where we have a registered nurse providing the distribution services to the hospital. I provide, through my department, a pharmacist who on a consultant basis goes out once a week, first of all, to ensure that the policies and procedures are up to snuff and that everything is going quite nicely in the hospital, and, second, to provide some type of drug utilization monitoring. For example, you talk about costs. The pharmacist can come in there and see if the drugs are being used appropriately in the hospital and then hopefully make suggestions and recommendations that will actually provide patients with the most cost-effective therapy.

So we do not want to stop the distribution of drugs as such. We want to make sure, if there is any interpretation present, that it is done by a licensed pharmacist so that in case there are any problems, the Ontario College of Pharmacists can at least do something about them.

Mr Owens: Are you concerned, with the advent of pharmaceutical companies coming into hospitals and admixing IVs and packaging unit-dose prescriptions, that your jobs are being deskilled and that this legislation will, if passed without your amendments, aid and abet that deskilling of your profession?

Mr J. Wilson: Say yes; it's good NDP terminology.

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Mr Babcock: I would think a pharmacist's job is certainly misinterpreted. I think everybody feels that dispensing is the function of the pharmacist. We quite strongly believe that is not going to last long; if we just dispense pills we are not going to live long.

We do believe, however, that there is a long need for ensuring that the rational drug therapy is provided to the patient, and that is where we feel pharmacists themselves have the strongest input. Those are the things that we want to make sure are regulated by the Ontario College of Pharmacists. Currently that is not the case. That is what we are concerned about, not so much the distribution.

The Chair: Thank you for your presentation.

JANISE JOHNSON

The Chair: I call Janise Johnson. You have 10 minutes for your presentation.

Ms Johnson: I am Janise Johnson. I am a general staff nurse at the Children's Hospital of Eastern Ontario and I work in the neonatal intensive care unit. I have been there for 14 or 15 years. I would like to thank you for the opportunity to make this presentation to this committee.

My submission to the Regulated Health Professions Act comes as a patients' advocate. I have nursed the public for over 30 years and have some grave concerns about the deterioration of the delivery of health care in this province. Bill 43 must be amended.

The care we give the public can either be fragmented like a wilted flower, with every health care professional plucking at the petals delivering his specialty, or we could attempt to keep the individual person or family whole as a beautiful, healthy blossom. This must be achieved to obtain the optimum in health care delivery.

The majority of people who require access to the health care system are uninformed, new immigrants, aged and weak, or in a trauma or crisis situation. The education of the public to this complex system of health care should be undertaken by the nurse. The nurse is well informed and sees the patient as a whole individual with numerous problems. Communication between the nurse and patient must continue to remain open.

On a patient's admission to the hospital, a physician will do the preliminary examination and the diagnosis. This will create a whirlwind of activity around the patient, with medical consultations, laboratory and X-ray workups, possible ultrasound visualizations, etc. Continuity of care is often lacking. The patient and family may be overwhelmed by all the diagnostic procedures. They need the nurse to teach, explain and orchestrate the various examinations and treatments within their physical and emotional state.

I work in a neonatal intensive care unit. We have from 20 to 25 babies who are critically ill. The staffing for the unit from 4:30 pm to 7:30 am is one physician and 13 nurses. We work as a team, explaining to families the condition and treatment of their infants. If the nurse's voice were muffled, a large void would exist.

The nurse must remain the patient's advocate. This is the only medical professional who is with the patient 24 hours a day, 365 days a year.

In the last few weeks, the government has wisely amended the "prescribed" person. This must also include all nurses. The nurse keeps a constant vigil over patients in emergency departments, medical and surgical wards, labour and delivery, operating and recovery rooms, intensive care units and psychiatry. Nurses must not have their hands tied by having to obtain an order before they initiate treatments. We have been educated to respond to a crisis.

In a neonatal intensive care unit, if we have an infant who has a cardiac arrest, the nurse immediately starts CPR and then telephones the physician. If we delay in our resuscitation, we may have a brain-damaged child. All nurses must have the prescribed power to establish treatment that they have been taught to do. This will save lives.

I am also concerned about the dispensing of medications. Under Bill 43, only pharmacists may dispense medications. This is going to be extremely costly to OHIP. Pharmacists will have to remain in the hospital on a 24-hour basis.

At the present time, if a patient comes into emergency in the middle of the night presenting with a headache and a temperature and the physician's diagnosis is possible meningitis, the nursing supervisor goes to the night pharmacy cabinet to obtain the prescribed antibiotic. The supervisor will deliver the medication to the nursing unit and the bedside nurse will start treatment as soon as possible. Prompt administration of many drugs can save hundreds of lives.

Another concern I have is the management of labour and delivery. This must become a controlled nursing act. Labour is a long process. First babies are often born after 24 hours of labour. The nurse is always in the case room monitoring foetal heart rates and assessing the progress of labour. The physician is notified only if there is a problem with the infant or the mother and when the mother is ready to deliver. Nurses must be licensed to do vaginal examinations, monitor external and internal foetal probes and control epidural anaesthetics. With these skills, a nurse assists the physician and the family in the delivery of a healthy infant.

Midwives should have nursing background. During pregnancy a disease process may surface, for example, gestational diabetes. If the midwife had a broad educational background prior to specializing in midwifery, she would be able to recognize the medical problem and encourage the mother to seek a physician's care.

All nurses must be accountable to the patient, the college of nurses and the employer. Accountability must not be restricted to the professionals giving hands-on care only.

The nurse administrator is responsible for staffing our health care institutions and must do this within budget guidelines.

The present treatment of illness has become so aggressive that often time is not available to give any more than the essential care. This is frustrating to the patients and the nurses and is often one of the main reasons for nurses leaving the profession.

The staff ratio between nurses and patients on a heavy medical floor on a day shift can be one nurse to six patients; on nights, one to 10, and sometimes even one to 20. In homes for the aged it is one nurse to 75 patients. The ratio of staffing in intensive care units is much better, but these patients are more acutely ill and require more nursing care. At times even these ratios become unsafe. The bedside nurse should not have to lower her professional standard and be liable for inadequate staffing.

Physicians, dentists and midwives can perform many of the 13 controlled or hazardous acts independently. Nurses can perform none independently. Instead, they must have an order of another member of the Regulated Health Professions Act or a prescribed person, who might be another nurse selected by the college of nurses. Nurses must be able to perform those acts within their scope of practice as legitimate practitioners without fear of possible litigation.

The nurse could become the primary health professional to introduce the patient to the health care system. Studies have shown that nurses can provide 60% of the services now provided by general practitioners under the current legislation. Nurses in North America perform many controlled acts independently, efficiently and cost-effectively. Also at a lower cost to OHIP, the nurse would have time to speak to the patients and then refer them to the appropriate numerous health care providers.

As well as outpost nurses in the north, outpatient departments in hospitals work on this type of system. Why could it not be developed in every community in Ontario? Unfortunately, the Regulated Health Professions Act as it now stands will not provide this autonomous practice for nurses.

Concerning the effects the Regulated Health Professions Act will have on the profession, we could be found guilty if we contravene Bill 43 and fined $25,000 or jailed for six months, or both.

Nurses have always been accountable to the patient, the profession and the employer. If a nurse is fired for any reason, the college of nurses must be informed. The nurse stands to lose her job, profession and dignity. Many of the professions that are seeking self-regulation are going to be placed in this unenviable position.

Nurses are renowned for putting their patients' needs before their own, but now nurses are aware that they must also protect their own livelihood. All professions will be in triple jeopardy. This may reduce the number of students who enter the health care industry in the future.

I am pleased to bring my concerns to this committee. I trust the government will study this and all the submitted briefs and that you will formulate and amend the Regulated Health Professions Act to best serve all the citizens of Ontario in the delivery of health care.

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Mr Beer: With respect to the question around labour and delivery, we have had a number of submissions from midwives and groups that favour the legislation as it stands. Do you think then that in order to be able to practise midwifery, one must be a nurse?

Ms Johnson: Yes, I do. I work in an intensive care neonatal unit and see the results of some tremendous deliveries. These can be full-term infants and asphyxia and birth trauma can occur in the last stages of delivery. If a midwife has a broad educational background, I think she or he would be more likely to give better care than somebody who has done a specialty prior to a broad background.

Mr Hope: Dealing with the question of dispensing medication, in the presentation given before you today --

Ms Johnson: Yes, it was very interesting.

Mr Hope: -- does that rest your mind at all?

Ms Johnson: I think the pharmacists have a legitimate concern, and nurses, because if we contravene anything that is going to occur in Bill 43, we are actually putting our licence in jeopardy if we are dispensing the drugs. All sorts of responsibilities have been thrown at us and we wonder if legally we have the responsibility to do this or whether we could be fined. This is going on in every hospital in Ontario probably, that nurses are dispensing drugs, and I think the pharmacists have a genuine concern, as we do.

Mr Wessenger: I would like to have staff do some clarification on this item.

Ms Bohnen: I think it is important to note that dispensing drugs is a controlled act that is authorized to physicians as well as to pharmacists, and that controlled act, like all the others, can be delegated by physicians and by pharmacists, based on what you just heard from the hospital pharmacies, as well as what you have heard from nurses. It sounds as if hospitals more or less work in the sensible way in which they will continue to work, in which pharmacists are responsible for establishing and monitoring the processes by which drugs are actually dispensed and, when pharmacists are not there, nurses or other appropriate health professionals dispense the drugs to patients, pursuant to a delegation.

The Chair: Thank you very much for your presentation.

COMMUNITY HEALTH NURSES' INTEREST GROUP

The Chair: I call Eleanor Soulodre. Welcome. Please introduce yourself to the committee.

Ms Soulodre: My name is Eleanor Soulodre. I am a public health nurse. Although it does not state so in your agenda, I am here today to represent the Community Health Nurses' Interest Group. With me is Beth Townsend. She is the acting senior nursing officer in the Ottawa-Carleton health department and she is also the president of the Community Health Nurses' Interest Group. Also with me is Helen McGuire, a public health nurse in the high-risk prenatal program in the Smiths Falls area.

The Community Health Nurses' Interest Group is made up of approximately 1,800 nurses across the province. It is an interest group within the Registered Nurses' Association of Ontario, which presented to this committee on August 13. The CHNIG is in full support of the RNAO's position regarding the Regulated Health Professions Act. However, we do have an additional concern that is of the utmost importance to community health nursing.

Let me begin by saying that the CHNIG is in complete agreement with the basic underlying principles of the Regulated Health Professions Act. Our main concern focuses around the fact that health promotion has not been included in the scope of practice statement within the Nursing Act. "Health promotion" is a term that is not always clearly understood and is often thought to be synonymous with prevention of illness.

Although the two are closely linked, they are not the same. Let me see if I can clarify that for you. Health promotion is approach behaviour while prevention is avoidance behaviour. Health promotion seeks to expand positive potential for health, while prevention seeks to thwart the occurrence of illness. Even in dictionary definitions, there is a distinguishable difference between "prevention" and "promotion." "Prevention" is to keep from occurring while "promotion" is to help or encourage to exist or flourish. Prevention has been included in the nursing scope of practice statement, and that is a very positive thing and very appropriate. However, the CHNIG feels strongly that health promotion must be included as well.

In the document Striking a New Balance: A Blueprint for the Regulation of Ontario's Health Professions, the recommendations and intent of the Health Professions Legislation Review are clearly explained. Within this document, the scope of practice statement is described as outlining each profession's area of permitted practice. By excluding health promotion from nursing's scope of practice statement, it is implied that health promotion is not one of the expected roles of the nurse. However, the Ministry of Health has mandated health units to provide health promotion services in the mandatory health programs and services guidelines. Public health nurses make up the largest group of professionals in health units, and therefore the health promotion role falls largely to them.

The Ontario government has clearly recognized that the Band-Aid approach to health care is no longer sufficient. We just cannot afford it. The Premier's Council on Health Strategy has identified a change of focus to health promotion as a crucial strategy in the provision of cost-effective health care. We must promote healthy lifestyles in order to have a healthier population that will not continue to drain our health care budget.

If nurses are to effectively co-ordinate with other professionals in the delivery of health promotion services, then it must be clearly stated that health promotion is in fact a role of the nurse. Consumers also have the right to be made aware of the area of practice of each professional so that they may make informed choices.

There is no question of the importance of health promotion in the future of our health care system. The government has identified this and has directed many nurses to focus their practice on health promotion. The CHNIG does not feel that health promotion is something that only nurses should do. Nurses are, however, qualified to provide the service to the public and are presently doing so. If health promotion is not clearly communicated as being part of nursing's scope of practice, nursing services will not be utilized to their full potential. It is our hope that this committee will give serious consideration to the inclusion of two words, "health promotion," in the scope of practice statement within the Nursing Act. That concludes my presentation, Madam Chair, and I am now prepared to answer any questions.

The Chair: Thank you very much for an interesting presentation.

Mr J. Wilson: I certainly agree that it is interesting. I think it is the first time the concerns of community health nurses have been brought to the committee's attention, especially wanting to include the terminology "health promotion." Perhaps, first, you could give the committee a feel for some of the programs and some of the activities you take or promote in the area of health promotion. Second, what sort of practical example would be of the effect of not including "health promotion" in the general scope of practice statement?

Ms Soulodre: To answer your first question, nurses are providing health promotion services to all age groups in the community. Some examples of this would include prenatal classes, where nurses are promoting health in pregnant women and therefore also in their unborn child. In the process they are also preparing parents to adequately care for their new child and to encourage healthy relationships within the family.

Another example would be occupational health nurses providing stress management sessions in the workplace or school nurses teaching a variety of subjects, including such things as self-esteem, assertiveness, nutrition and that sort of thing. Another example might be mental health nurses who are helping to develop support groups in the community. Those are just some of the examples of the health promotion services that nurses are offering.

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Mr J. Wilson: Do you feel there would be a practical effect of not including the terminology in the scope of practice?

Ms Soulodre: My understanding is that the purpose of the scope of practice statement is to accurately describe the scope of practice of the nurse. I think if you do not include this you are not accurately describing the scope of practice of the nurse. When you are trying to communicate to the public, the consumer and other professionals what the role of each of the professions is, if you do not include health promotion within the nursing scope of practice, you are not communicating that. As a result, I think nursing services may not be utilized to their full potential.

Mr Beer: Do you know whether the concept of health promotion was recommended as part of the scope of practice of nurses in the initial proposals made by your association?

Ms Soulodre: That is a good question. My understanding was that originally the Registered Nurses' Association of Ontario did request that health promotion be included. Correct me if I am wrong. My understanding was that the feeling of the of the HPLR was that a lot of the professions were involved in promoting health, and rather than including it in everyone's scope of practice, it would not include it in anyone's scope of practice. I am totally in agreement with the fact that many health professionals are providing health promotion services. I think in a lot of the cases it is sort of a peripheral thing. They have a main focus and a peripheral thing is that they provide health promotion services.

That is the case with some nurses as well. Their main focus lies elsewhere. Health promotion is a peripheral thing. But with many nurses their main focus is health promotion. I do not think that is the case for a lot of the health professionals, so I feel strongly that it needs to be included in nursing's scope of practice statement.

Mr Hope: Just to elaborate on that and dealing with the Band-Aid approach towards the health care system, if I am understanding it properly you are saying that if we do not put the other mechanism in there as a preventive issue, and as the public health nurse is the one who delivers it to our school systems and to our seniors, then we are really not fixing the problem of helping people. We should be promoting healthier lifestyles in order to achieve long-term care, the multi-year plan and other plans that are out there. Is that what you are trying to strive at? That is what I am really trying to understand.

Ms Soulodre: Yes, that is exactly what we are trying to say. It is very important that we promote health, and I think that has been identified many times. The fact is that we are doing it now. We are providing many health promotion services now, so it seems only fitting that it would be included in the scope of practice statement.

Mr Hope: It should be expanded upon.

Ms Soulodre: Yes, it is definitely something to be expanded upon in the future.

Mr Owens: Just to play the devil's advocate for a moment, in terms of the types of activities you perform, such as going into schools and examining kids and things like that, do you think the diagnosis clause is not more problematic for you than having health promotion not included in the scope of practice?

Ms Soulodre: I think there are a number of concerns that we as community health nurses have with the RHPA. We are a subgroup of the Registered Nurses' Association of Ontario and we are in full support of its submission to you. I believe they spoke to you on August 13 and that was one of the things they brought up. Rather than reiterating that, we thought we would bring forward what our concern was. I have a slightly different focus from the Registered Nurses' Association of Ontario. Yes, I am in agreement that diagnosis is problematic.

The Chair: Just to clarify, what we just heard you say is that you are in support of the RNAO brief and this is in addition to that. Is that correct?

Ms Soulodre: That is correct.

The Chair: I just wanted to be clear. Thank you very much for your presentation today. We appreciate your coming before the committee.

CECILIA BRANCH

The Chair: I call Cecilia Branch. Welcome. You have 10 minutes for your presentation.

Ms Branch: My name is Cecilia Branch and I would like to give you a brief statement. From the age of 16 until my retirement in 1987 I was a member of the Canadian national track and field team for the 100-metre hurdles. Between 1976 and 1980 I attended the University of Nevada, Las Vegas, on an athletic scholarship. I was selected to the Canadian Olympic team in 1980 and I was Canadian champion in 1985.

Since my 1987 retirement from active competition I have worked as a trainer, more or less a strength and conditioning consultant, with many athletes and teams, including the Ottawa Rough Riders. That is why they are winning. I am also completing my master's in sports psychology at the University of Ottawa.

My chiropractor, Dr Ken Dick of Ottawa, has explained to me that the suggested new law to regulate the practice of chiropratic does not include the right to diagnose extremity joint problems. I do not understand this at all because it is my experience that chiropractors are highly skilled and very effective in this area, more so than any professionals I have consulted during a very long career in athletics.

I pulled a hamstring in my left leg in 1979. In case you do not know what a hamstring is -- some people do not -- it is the upper back of your leg muscle. During the next few years I received a lot of medical advice on what caused the problem. However, no one got to the bottom of it and I had continuing problems that were very frustrating and affected my career.

Then in 1986 I consulted Dr Ken Dick for an injury to my right leg. I also told him about the chronic problem with my left hamstring. He gave me a much more detailed examination and diagnosis than I had ever been given before. He explained how my hamstring problem is related to disturbed mechanics in my knee and pelvis and muscle imbalances in my leg. With a combination of manipulation, massage, interferential and other physical modalities, he completely cured my problem for the first time in seven years. It has been right ever since. Dr Dick has looked after my leg injuries, such as an ankle problem, which is Achilles' tendonitis, since that time and I have referred a number of other athletes to him and other chiropractors with good results.

I have found chiropractic diagnosis of extremity joint problems to be very thorough and of great help in my athletics career. I cannot imagine why a new law would prevent a chiropractor from providing this service.

Mr Beer: We have had a number of people relate personal experiences to us and one of the questions I have had is, when you have done this with your chiropractor and found this has worked well with you, have you discussed that with your own physician or with other medical doctors who have tried to deal with it, in terms of saying: "Look, I continued to have trouble. I went to the chiropractor, who found a way to resolve it. How come you didn't seem to be able to find the answer?" Do you have any sense in what you have gone through as to why that did not happen?

Ms Branch: Basically what happens is you go to many doctors to try to find out what your problem is and, being an athlete, you are very impatient and you want to get down to the crux of the problem and you want to get healed within four to six weeks or less. Therefore, if they cannot properly diagnose you -- and I have been misdiagnosed by physicians, which is quite frustrating, and I have had such incredible success with my chiropractor, Dr Ken Dick, that I do not really like to go back to the physician and tell him that he was full of beans and did not properly diagnose me. No, you more or less move on to find the answer, because we do not have a lot of time to wait to heal. We want to get down to the real crux of the problem and get ready and on the track again. I never went back. I was misdiagnosed by a physician in sports medicine three times and strike three, to me, is you are out.

Mr Beer: That is why you are in sports.

Ms Branch: That is right.

The Chair: Thank you for your presentation.

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G. LAWRENCE NELMS

The Chair: I call Mr Larry Nelms. Welcome. You have 10 minutes for your presentation.

Mr Nelms: Thank you very much. I am a businessman working in Ottawa, obviously in the optical business, as you can see by the letterhead.

Thank you for affording me the opportunity to express my thoughts on the proposed Regulated Health Professions Act. I do not envy the task of the standing committee in rationalizing the needs and wants of all the vested interest groups which will appear before you. It is daunting, to say the least. Let me put into perspective the area of opticianry which I believe will shape the future of our industry.

It appears that this future hinges on precise definitions, which are presently lacking in the proposed act but are recommended by the Board of Ophthalmic Dispensers. The present board is recommending that "to dispense" will mean: (a) interpreting a prescription for, (b) evaluating or advising a person in respect of, or (c) preparing, providing, verifying, adapting, fitting or duplicating a device for subnormal vision, a contact lens or eyeglasses. This definition encompasses all the duties and responsibilities which presently govern the action of opticians in the province today.

You have heard other representations from the Vision Council of Canada, which has suggested that a more liberal interpretation of the definition of "dispensing" be used, namely that the optician be responsible for the final verification and delivery of eyeglasses to persons over the age of 10 years. The optician would be responsible for all steps necessary in the delivery of contact lenses and eye wear to children under the age of 10.

Both groups purport to serve the public interest through a legislated act of Parliament. In reality though, the public is unaware of the protection afforded it now by the Board of Ophthalmic Dispensers because the board has failed to inform the public of its existence and of the powers it has over the industry to protect the public interest.

Its role to the public is passive rather than interactive and any use of its powers to maintain conformity with the present act is initiated by the use of the board inspectors or through action commenced by written complaint, usually lodged by a fellow optician. Thus, the powers of the board are well known within the industry, but the public is oblivious to its function. It is only through this indirect procedure that the public interest is protected.

Consumer complaints today are directed towards the supplier of service, the optician, and when they are unresolved, the prescribing physician, the ophthamologist, becomes the arbiter. I know of no cases where a complaint was referred to the board for resolution. In this manner, the overall industry is seen as being entrusted with the protection of the public interest.

The position of the Vision Council of Canada appears to be based on economic practicality in which it recommends limited use of an optician to perform statutory duties. The membership of the VCC is drawn from the larger optical chains, which typically employ more than one optician per outlet. By reducing the numbers of qualified staff necessary to operate a dispensary, the economic benefits are substantial. Our own firm has several such locations and whereas I presently employ five licensed opticians under current circumstances, I could easily reduce that number to two and increase my net profit by between 10% and 20%. The VCC is proposing a minimalist scenario allowing opticians to remain within the Regulated Health Professions Act, thereby ensuring some form of regulation to restrict practice.

The new college governing the practice of opticians would be impotent to regulate the in situ operations of opticians under the VCC's proposed definition. Thus, there are really only two alternatives your committee can adjudicate: either a college with all the necessary powers to firmly regulate the practice of opticians or else a completely deregulated delivery of eye care services in the province where the marketplace determines the protection level of the public interest. Half measures, ultimately, will not work.

The businessmen and businesswomen who constitute the opticianry side of the delivery of eyecare in our province are seeking a clear, unequivocal set of rules under which they can run their businesses. Whether your recommendation favours regulation or deregulation, we expect our government to make a decision so that we can get on with the rest of our lives. In the event that you follow the recommendations set out in the Board of Ophthalmic Dispensers' submission, I would suggest that provision be made to include a continual public awareness campaign so that the general public of the province know there is an authoritative industry watchdog there to address their concerns. I would also suggest that the annual renewal of an optician's licence to practise be predicated on achieving standards of continuing education.

If instead you prefer the recommendations of the VCC, I suggest you carry its position to its logical conclusion and institute a qualified -- that is, contact lenses and children excluded -- deregulation of our industry with the marketplace being the great equalizer. I am in favour of the former because I know the value of a well-educated and fully trained optician working in my business. The quality of my product would suffer at the hands of individuals who have not undergone formal education. My labour costs would go down, but my laboratory costs would certainly rise if I were to remain conscientious and truly satisfy my customers' needs.

Your decision will affect the thousands of lives of those who work in our profession and impact an industry which trades in the hundreds of millions of dollars annually. To think that all of this is hinged on a definition. I welcome your comments.

Mr J. Wilson: On page 3, you state that the new college would not be able to effectively regulate the operations of opticians under the VCC's proposed definition. I am going to give you an opportunity just to explain that a little further, if you would. It seems to me, just as a layperson, that the liability under the VCC's proposal still rests with the optician, the ultimate liability of whether the glasses are fully constructed and the customer is satisfied and the prescription has been properly interpreted. It seem to me the college still has control over opticians.

Mr Nelms: The college would have control over opticians, but I am looking at current circumstances whereby the regulation of opticians is governed by the Board of Ophthalmic Dispensers today, and in the province there is very little power, relatively speaking, that the board has over the day-to-day actions of opticians in Ottawa. The board inspectors come through here on an annual basis and it is usually once. Everybody in town knows the inspectors are here. Everybody sharpens up. That is not necessarily the way to govern an industry. I think the only alternative to what I term a half measure, where there is only a licence in the store, is to open it up completely. As a businessman, I can deal either way.

Mr J. Wilson: I am missing the point, though. You are saying under the current situation the policing now is fairly ineffective.

Mr Nelms: That is correct.

Mr J. Wilson: So I do not see how this would make it any less effective if it is fairly ineffective now.

Mr Nelms: Precisely so. In other words, are we trying to tighten up the industry through new legislation or maintain a status quo?

Mr J. Wilson: We would be trying to tighten up this particular industry if we had some evidence of cases of harm. Perhaps you would want to comment on that. We did have the board present some cases.

Mr Nelms: I think that Brent MacInnis appeared earlier before the committee, and I cannot cite any instances of harm.

Mr J. Wilson: I do not like tightening up just for the sake of tightening up.

Mr Nelms: Well, tightening up for the purpose of regulation so that, in reality, an unlicensed or an unregistered individual could not practise opticianry. At the moment it is very difficult for the board to police and patrol that. There is a fellow here in town who has been running a business for the last 14 years and he does not have a licence. We do not know how he gets away with it.

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Mr J. Wilson: Somebody should complain to the board.

Mr Nelms: Complaints have been lodged. To date, there has been no conclusive result simply because the board does not have the teeth to go after it. So either we have a regulated industry with teeth in the legislation, or we do not. What I am suggesting is that people in the industry can go either way. We are flexible, but what we expect are the rules. If the rules are wide open, let's go with it. If they are not, fine.

Mr J. Wilson: I appreciate your candour there. Thanks.

The Chair: I think you have articulated the different economic interests extremely well, and we appreciate your candour. Does the legislation as presented represent the status quo, tightening up or loosening up, from your point of view?

Mr Nelms: I think it is slightly less than the status quo because there is not an adequate definition of dispensing.

The Chair: If there is additional information that you think would be helpful, please feel free to communicate with us in writing, but we do appreciate your coming before the committee today.

JOHN COX

The Chair: John Cox, welcome to the committee. You have 10 minutes for your presentation.

Dr Cox: I am a dentist. I am a prosthodontist, a specialty of dentistry which is involved with basically crowns, bridges, dentures, implants; that aspect of dentistry. As a practising prosthodontist, I have a number of concerns regarding the proposed legislation as outlined in Bill 50, which would seem to expand the role of the denturists to allow them to provide removable partial dentures directly to the public. I am very concerned that the denturists are being placed in an untenable position whereby they will be allowed to construct removable partial dentures but not allowed to alter tooth structure in the mouth for the construction of that partial denture. In the construction of virtually all cast removable partial dentures, I feel, and I think the literature supports it, that preparation and alteration of the teeth is required. Also the denturist is ill-equipped to diagnose adequately the condition of the patient's oral cavity prior to denture construction.

Examples of that would include limited medical knowledge to screen for oral pathology such as cancer and limited equipment for assessment of oral cavity; what comes to mind is diagnostic equipment such as X-rays. They are not in a position to be able, with the current legislation, to assess periodontal disease adequately; that is, if you read the legislation as it is proposed, they are not allowed to probe for periodontal pockets or adequately assess the periodontal health of the supporting tissues. If dentists were not to do that, they would be in a position where there would be grounds for malpractice, not adequately having assessed the teeth. They are not in a position to assess adequately the occlusion or bite and, again, they are not able to alter tooth structure prior to partial denture construction.

I feel great concern in this area and that this can only lead to missed oral pathology or disease; missed decay in construction of partial dentures on teeth with decay present, since they do not have the diagnostic equipment to look for it; partial dentures constructed on teeth with gum disease through inadequate assessment; poor occlusion or bite and this in turn can lead to temporomandibular joint problems and, again, dentures constructed with no alteration of tooth structure, which from our standpoint is not a correct treatment.

The denturists have been arguing that price and quality of service are the real issues at stake. It would seem to me, given the limitations imposed on the denturists, that it is hard to imagine the quality provided would be better than that offered in a private dental office with full diagnostic equipment. While price is an important issue, at the present time there is no comprehensive data to suggest that present fees charged by denturists for a procedure that at the present time is unlicensed will be maintained. I feel the real issue in question is the appropriateness of the treatment which is being offered by the denturist, who is able to offer only one service at the present time.

Perhaps an example of this might serve to illustrate my concern. Perhaps we can bring it a little closer to home if we imagine one of ourselves leaving this meeting and tripping and knocking out two front teeth. What is the procedure which is set in process? In the dental office the first consideration would centre around the possibilities of reimplanting the teeth. If they were retrieved clean and intact within perhaps 40 minutes of the injury, then they would be in a position that the teeth could be reimplanted and as such reused. This option would not be available to the denturist or perhaps not suggested. However, assume that the teeth were not retrievable and that we were in a position where we required some form of replacement. Both the denturist and the dentist would likely construct interim or temporary dentures, since these simple acrylic dentures can be quickly and inexpensively constructed, to replace missing teeth. Both offices could provide this service probably within a day in order to re-establish aesthetics and function.

Once healing had taken place, the denturist would be in a position to provide only one option. In terms of a final replacement for the missing teeth, this option would be a cast removable partial denture. This is really the item which is at question today. However, as outlined, there are very serious limitations imposed on the provision of this service, or to put it another way, the denturist is being asked to provide this service with one hand tied behind his back in terms of assessment and alteration of the teeth.

An equally important issue relates to the ability of the denturist to outline the options available for treatment. For the patient to make an informed decision, it is very important that he not only has the possible options presented but also the pros and cons of the different options. We feel that in this position the denturist may be somewhat limited in terms of his ability to discuss and present the options which are possible. There indeed is an ethical concern related to whether the denturist will refer a patient to a dentist, even if he can provide information on the different options.

Getting back to our example of the two missing front teeth, this has become, in our office anyway, a very complex diagnostic problem in light of the wide variety of options which are possible in the dental office. If the teeth adjacent to the space have no gum problems and have adequate bone support, then a conventional fixed bridge could be considered. This option might be more feasible in an older individual, where there are restorations or fillings on the adjacent teeth, since this option requires reduction of tooth structure for the teeth which will serve as abutments. In these days we see many younger individuals with fewer cavities in their mouths who would be reluctant to have adjacent teeth reduced to accommodate a fixed bridge. If there was sufficient space between the teeth, both upper and lower, and lack of grinding habits, then these days we could consider a very conservative option, that being a so-called Maryland or etched bonded bridge. This requires very limited reduction of the teeth but does still require some preparation to accommodate this appliance. However, this bridge has to be used very selectively and does not work in all situations. Again, the diagnostic problem is there and we run into it every day.

Another option in this situation these days involves the use of osseointegrated titanium implants to replace missing tooth structure. Again, this requires a very careful assessment involving close interaction between both the oral surgeon who will be involved and the dentist who will be providing the final replacement. Again, we have a great deal of scientific data to suggest that this treatment option, which has now been followed for approximately 26 years in Sweden, is a viable option and yet another diagnostic consideration.

Another possible option of course is a removable partial denture, as discussed. Again, it gets us back to our chief concern, I think, in terms of today's issue. This option, which is also available in the denturist's office, has wider scope for success if there is adequate preparation of the teeth. It does not necessarily have to involve extensive preparation, but it is very common to see a patient come with an old, broken-down filling which should be replaced prior to construction of a partial denture. If there are large fillings, then sometimes a crown is indicated, and there are a variety of different partial dentures, right down to precision partial dentures, that require construction of crowns prior to construction of the partial denture. At the very least, small recesses or rests should be provided on the surfaces of the teeth, since these rests control all of the forces which are transmitted to the patient's teeth by the partial denture.

The point of my example is only to illustrate that if we were in the position described, I feel it is mandatory that the options possible be outlined for a patient to make an informed decision as to which option he would like to see take place in his mouth. The extension of the role of the denturist into the direct construction of partial dentures once again fragments dental service. It makes it very much more unlikely that the patient is going to be in a position to make an informed decision and, I think, makes it virtually impossible to receive a high quality partial denture, given the limitations that are imposed. Partial denture service should remain a prescribed service in the same manner that a hearing aid or a vision device is a prescribed service.

Thank you very much for the opportunity of presenting the brief. I would be happy to try to answer any questions that might be related to my presentation. I brought along slides to illustrate this, but unfortunately in our discussions with the people at the other end we did not quite get a projector.

The Chair: Just for your information, the committee did receive slides and copies of X-rays or photographs showing some of the things that you talked about, so not to worry that we did not get a chance to look at your slides. We appreciate hearing from you and if there is additional information that you feel would be helpful, please feel free to communicate with us in writing.

The standing committee on social development stands adjourned until 10 o'clock tomorrow morning, in committee room 2, legislative building.

The committee adjourned at 1612.