Discipline Case Summary

The following is a summary of a matter placed before a five-member panel of the Discipline Committee of the College of Physiotherapists of Ontario on Monday, March 4, 2002. This matter originated from a complaint against the registrant received at the College. 

The College proceeded with the allegation that Raouf Hanna was guilty of professional misconduct, in that he engaged in conduct or performed an act that would reasonably be regarded by members as disgraceful, dishonourable or unprofessional. Mr. Hanna entered a plea of guilty to the allegation of professional misconduct. 

The panel of the Discipline Committee found Mr. Hanna guilty of professional misconduct, and concluded that Mr. Hanna had crossed boundaries with a patient and had engaged in inappropriate billing practices. 

The Evidence

Raouf Hanna at the time of the incidents was a registered physiotherapist working at Britannia Physiotherapy in Ottawa, Ontario. Ms. T. was Mr. Hanna's patient starting in September of 2000 through most of October 2000. 

Boundary Matters

Ms. T. came in for treatment almost every day during the period and felt some improvement almost immediately. Treatment included modalities applied to her back for which she wore her underpants and a hospital gown but no brassiere. Mr. Hanna also included unconventional exercises he'd learned in 1979 from a Swedish therapist. They involved Ms. T. sitting on the plinth with Mr. Hanna sitting on a stool in front of her. Ms. T. would place her legs on Mr. Hanna's thighs and her arms on his shoulders and lean forward towards Mr. Hanna. Another procedure involved Mr. Hanna placing his hands on Ms. T.'s waist while she leaned towards him. Mr. Hanna stopped using these exercises when they were raised as an issue in this complaint. 

During treatment, Ms. T. confided she had difficulties with her son and her husband. Mr. Hanna tried to verbally comfort Ms. T. while doing manual traction on her neck. After this conversation, Ms. T. kissed him on the cheek, following which Mr. Hanna kissed Ms. T. on the forehead. 

At a subsequent session, Mr. Hanna mentioned he'd studied psychology and offered to help the couple with their problems. He informally helps families and couples in his church and said it would not be formal counselling. 

Mr. Hanna told Ms T. they would go out for coffee the following week at lunch. He took her to Tim Horton's where they discussed Ms. T's. family affairs. After, Mr. Hanna drove Ms. T. home. There, they found Mr. T. sitting in his car. Mr. Hanna observed that Mr. T. appeared uneasy. Mr. Hanna drove off without speaking to Mr. T. 

At her next appointment, Ms. T. said she was uncomfortable talking to Mr. Hanna about her problems. Mr. Hanna said he was uncomfortable as well after seeing that her husband appeared unhappy when he last drove her home. They agreed to stop discussing her personal problems. 

Insurance Matters

Ms. T.'s insurance benefit provided for:

• Payment of 80 per cent by the insurer of physiotherapy fees (with a co-payment of 20 per cent by the patient) for the first $500;
• No payment by the insurer for the next $500 of physiotherapy fees; and
• Payment of 80 per cent of physiotherapy fees (with a co-payment of 20 per cent by the patients) for any amount over $1,000.

Mr. Hanna told Ms. T. that he would only charge her $200 for the second $500 for which she was responsible. They never discussed what would happen after $1,000 was reached. Mr. Hanna submitted an account for $2,335.35 to the insurance company but made no effort to collect any of the co-payments. He stated that he never addressed this issue after receipt of the complaint as it was then inappropriate to pursue billing matters. He acknowledged formerly billing third party insurers more for assessments and treatments than self-paying clients, as noted on Ms. T.'s chart. He has changed this practice.
 
The College's Position Statement on Billing Practices indicates that in respect of co-payments, physiotherapists must make reasonable efforts to collect the client's portion of the fee. It also indicates that it is improper to charge a greater fee for different categories of clients. 

Points of Disagreement

There were a number of points on which Mr. Hanna and Ms. T. did not agree. The College and Mr. Hanna agreed that it was unnecessary for the Discipline Panel to resolve these disputed facts. Relying on the agreed upon facts, which the Discipline Panel must do, was sufficient to support the joint submissions. 

The Finding

The panel accepted Mr. Hanna's guilty plea and found him guilty of professional misconduct in that he engaged in conduct or performed an act that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional. It concluded that the conduct was inappropriate and unprofessional, and that Mr. Hanna had crossed boundaries and had engaged in inappropriate billing practices. 

The Penalty

The parties filed a joint submission on order in addition to which the parties agreed that Mr. Hanna would undertake

• To pay up to $10,000 for any therapy and counselling for Ms. T. during its term of five years. The College will screen criteria concerning the funding, and make payments for any funding, which Mr. Hanna will reimburse within 30 days of being invoiced.
• To cease performing the stretching procedures described and use other more recognized procedures unless the prior approval of the Registrar is obtained in writing.

Decision Regarding Penalty

The panel noted that his was the first disciplinary finding against Mr. Hanna, that he did cross a boundary and engage in unprofessional conduct, but saw himself as a helper and friend, not recognizing the significant consequences of his actions for Ms. T. All events, outside the insurance billing, occurred in one week. There was no overt sexual contact. He understood and accepted the consequences of his actions and was willing to adjust his practice. His cooperation saved the College a potentially costly trial and saved the complainant the difficult emotional task of having to testify in person.

However, the conduct was of a serious nature. It included kissing and touching, and questionable dressing of the patient for the particular treatment. The stretching techniques and verbal cues used were unconventional. Taking the patient to lunch and driving her home also crossed professional boundaries. Conversing with Ms. T. about personal matters without formal training in such areas was unprofessional and inappropriate. 

The panel concluded that the penalty order will send a message that the profession takes seriously its responsibility of dealing with the public with integrity. Physiotherapists must respect the boundary between themselves and their clients. The order offers the opportunity of remediation to Mr. Hanna, allowing him to resume practising, once he has complied with its conditions.

The Order

The panel therefore ordered and directed:

1. That the Registrar be directed to suspend the certificate of registration of Mr. Hanna for a period of three months, but that the suspension itself shall be suspended if Mr. Hanna complies with and successfully completes all other provisions of this order.
2. That the Registrar be directed to impose a term, condition, and limitation upon the certificate of registration of Mr. Hanna that he successfully complete, in the opinion of the Registrar, at least two courses consisting of at least six hours of instruction on the maintenance of boundaries and the prevention of sexual abuse, within twelve months of the date of this order.
3. That the Registrar be directed to impose a term, condition, and limitation on the certificate of registration of Mr. Hanna that he successfully complete, in the opinion of the Registrar, a course of remediation over a period of about twelve months regarding the maintenance of boundaries and the prevention of sexual abuse, and billing practices, that includes the following:
   • Fully cooperating with a remediator appointed by the College at two meetings where the remediator will review and evaluate Mr. Hanna's current policies, procedures, and practices regarding the maintenance of boundaries, the prevention of sexual abuse, and with a remediator appointed by the College at an additional two meetings where the remediator will provide three hours instruction overall in billing requirements and will review and evaluate Mr. Hanna's current policies, procedures and practices regarding billing. The remediator(s) will provide written reports to the College with any recommendations.
   • Implementing any recommendations made by the remediator(s).
   • Paying for the costs of the remediation sessions (to a maximum of $1,000 for all the sessions) within 30 days of being invoiced.
4. That the Registrar be directed to impose a term, condition, and limitation upon the certificate of registration of Mr. Hanna that he successfully complete, in the opinion of the Registrar, followup evaluations to assess whether Mr. Hanna has successfully integrated the information learned in the course of remediation, that includes the following:
   • Undergoing the evaluations, which will take place about six months after the course of remediation.
   • Fully cooperating with evaluators appointed by the College at one meeting, or two if necessary, where an evaluator will review and evaluate Mr. Hanna's procedures and practices, regarding the maintenance of boundaries, the prevention of sexual abuse, and an evaluator will review and evaluate Mr. Hanna's procedures and practices regarding billing and provide written reports.
   • Paying the costs of the evaluation (maximum $500 for all the evaluation meetings) within 30 days of being invoiced for it.
5. That the Registrar be directed to impose a term, condition, and limitation upon the certificate of registration of Mr. Hanna that he not act as a supervisor for a student or a holder of a supervised practice certificate of registration or any other arrangement in which a supervisor is required for another member by the College until he has satisfactorily completed the requirements set out in paragraphs 2–4 of this order.
6. That Mr. Hanna pay to the College $5,000 towards the costs and expenses of investigating and prosecuting this matter, payable in equal monthly installments over a period of 24 months commencing the month after the date of today's order.

The panel's written decision and reasons was issued on May 31, 2002.