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Dr. Tsatsi

The Sunrise Health Region and the Cypress Health Region, acting in collaboration with the Ministry of Health, have announced their intention to have radiologists review and interpret all of the Diagnostic Imaging studies previously interpreted by Dr. D. Tsatsi in both regions.

The Health Regions have indicated that they were prompted to take this unprecedented patient safety measure as a consequence of concerns about Dr. Tsatsi's professional performance raised to their attention by the College of Physicians and Surgeons of Saskatchewan (CPSS).

The College alerted both the Sunrise Health Region and the Ministry of Health of its concerns about potential risks to patients as a consequence of two sequential public protection processes. I am pleased to provide information about these two processes and their application to Dr. Tsatsi:

The Diagnostic Imaging Quality Assurance Program (D.I.Q.A.)

The CPSS is committed to assuring that Saskatchewan citizens receive high quality medical services. One of the mechanisms for optimizing the quality of any service is to objectively measure the quality of the service and provide feedback to the service provider about his/her performance along with recommendations for future improvement of the service. Such measurement and feedback programs are known as Quality Assurance programs.

With funding support from the Ministry of Health, the CPSS operates a Diagnostic Imaging Quality Assurance Program. This program applies to all doctors who generate and/or interpret diagnostic images in the course of their medical practice and their participation in the program is mandatory under College bylaw 57. Radiologists are doctors who devote all of their time to diagnostic imaging, but obstetricians and cardiologists undertake some imaging as well. Diagnostic imaging technologies include ultrasound, conventional X-rays, CT Scanning, and MRI.

The CPSS D.I. Quality Assurance Program strives to review the performance of every doctor engaged in diagnostic imaging at three year intervals. One of the components of that process involves random selection of previous D.I. studies done by the doctor and these studies are reviewed by physician peers (ie: doctors with similar skills as the doctor being reviewed). The peer reviewers are required to generate a report which is considered by the Advisory Committee on Medical Imaging (ACMI) of the CPSS.

After considering the peer review report the ACMI discloses the report to the physician under review and also provides "quality improvement" recommendations to that physician. If the ACMI identifies domains of the physician's practice with significant room for improvement it may review that physician's practice after a specified interval to ensure that the recommended changes have been implemented.

The primary purpose of any Q.A. program is to make good practice even better. They function on the principle that performance can always be improved. Q.A. Programs are not designed to "find bad apples" and they are not designed to be punitive.

However in the course of its review of individual physician performance, the D.I.Q.A. program may identify physician performance that is so suboptimal that it may place patients at unreasonable risk of harm. In those circumstances the ACMI may refer its concerns about a physician's performance to the governing Council of the CPSS.

If the governing Council of the CPSS has reasonable ground to believe that a physician may not be competent to practice medicine, it has statutory authority to order a formal investigation of a physician's competence and to act upon the outcome of that investigation. A description of the competency investigation process follows.

The Competency Investigation/Determination Process

The statutory process for determining if a physician is or is not competent to practice medicine is set out in section 45 of the Medical Profession Act.

If the Council has reasonable grounds to believe that a physician may lack the requisite knowledge and skills (ie: competence) to practice medicine it may appoint a Competency Committee for the purpose of investigating that physician's knowledge and skills.

A Competency Committee may use a variety of investigational tools and procedures. For example it may require the physician to undertake various standardized tests of knowledge and it may actually observe the physician in practice.

At the conclusion of its investigation, a Competency Committee must submit a written report to the College Council. If that report affirms that the physician has adequate knowledge and skills, that is the end of the process. If the report indicates that the physician lacks essential knowledge and skills, the Council appoints at least three of its members to serve as a Competency Hearing Committee. It is the Competency hearing committee that must make the final determination if the physician is or is not competent.

A Competency Hearing Committee considers the report from the Competency Committee along with any evidence that the physician in question wishes to submit to the committee. At the conclusion of its hearing, the Competency Hearing Committee must submit a report to the Council.

If the Competency Hearing Committee report contains a determination that the physician is not competent, the Council convenes a hearing at which it may impose a number of remedies described in Section 45 of the Act. For example, the Council may suspend the physician from practice until it is satisfied that the deficiencies in knowledge have been remediated. If the Council perceives that the physician is not remediable, it may revoke that physicians licence to practice.

Application Of These Processes To Dr. D. Tsatsi

A peer review of Dr. Tsatsi performance through the College's Diagnostic Imaging Quality Assurance program identified performance deficiencies that were sufficiently worrisome to cause the ACMI to refer the matter to the College Council.

The Council concluded that it had reasonable grounds to believe that Dr. Tsatsi may lack skill and knowledge and it appointed a Competency Committee to investigate.

The Competency Committee submitted a report to the Council which noted some deficiencies in DR. Tsatsi's knowledge and skills.

Through his legal counsel, Dr. Tsatsi made a request that he might be permitted to voluntarily undergo remedial education rather than proceeding directly to a Competency Hearing. His request was accommodated.

Dr. Tsatsi completed a remedial education program at McMaster University. The feedback provided to the College in Saskatchewan by the McMaster Faculty involve in his remedial education program did not satisfy the Council that Dr. Tsatsi deficiencies in knowledge and skills had been satisfactorily remediated.

The Council appointed a Competency Committee to conduct a second competency investigation. In the course of that investigation the Competency Committee reviewed a randomly selected series of 103 D.I. studies which Dr. Tsatsi had interpreted after completing the remedial education program at McMaster.

The report of this Competency Committee identified a high incidence of disagreement with Dr. Tsatsi's interpretation of D. I Studies and a worrisome proportion of those disagreements involve clinical situations in which a diagnostic error could have devastating adverse consequences for patients.

The Executive Committee of the College Council has appointed a Competency Hearing Committee and a hearing to formally determine Dr. Tsatsi's competence is pending.

Because the disputed interpretations of several cases reviewed by the Competency Committee have profound implications for the patients in question, the College of Physicians and Surgeons alerted the Sunrise Health Region and the Ministry of Health to these findings so the Sunrise Health Region and/or the Ministry of Health might have an opportunity for timely intervention that can mitigate risk of patient harm.