Revocation of a physician’s certificate of registration is the most severe sanction the regulator can impose. It ends the physician’s authority to practise medicine in Ontario. The CPSO and the Ontario Physicians and Surgeons Discipline Tribunal (OPSDT) reach for revocation only where less severe sanctions cannot adequately protect the public. The framework for that decision is rooted in two questions: does the physician have insight into the conduct that led to the discipline, and is the physician willing to change? Where the answer to both is no, the regulator’s view is that nothing short of revocation will protect the public.
College of Physicians and Surgeons of Ontario v Kadri, 2023 ONPSDT 15, is a clear application of that framework. Following an earlier finding of professional misconduct and incompetence in 2023 ONPSDT 10, the OPSDT revoked the certificate of registration of Dr. Albert Kadri, a Windsor nephrologist, and ordered him to pay $250,510 in costs. The decision is doctrinally important on two fronts: it engages the distinct frameworks for professional misconduct and incompetence, and it applies the Hill line of authority on insight as a precondition for any sanction short of revocation.
Misconduct and incompetence are separate findings
Under the Health Professions Procedural Code (a schedule to the Regulated Health Professions Act, 1991), the OPSDT can find a member guilty of either or both of two distinct categories of conduct.
Professional misconduct is defined by regulation. The Professional Misconduct Regulation (O. Reg. 856/93) under the Medicine Act, 1991 lists more than 35 categories of conduct that constitute misconduct, ranging from specific clinical failings to a catch-all for conduct that members of the profession would reasonably regard as disgraceful, dishonourable, or unprofessional.
Incompetence is defined separately in the Code. A member is incompetent if their professional care of a patient displays a lack of knowledge, skill, or judgment of a nature or extent that demonstrates the member is unfit to continue to practise. Incompetence is therefore not a finding about a specific act of professional misconduct; it is a finding about the member’s broader fitness to continue practising.
The two findings are not mutually exclusive. Kadri is an example of a case in which both were entered, and the distinction matters at the penalty stage.
Background: the model-of-care dispute
Nephrology is the medical specialty concerned with the diagnosis and treatment of kidney disease. Dialysis, a procedure that removes waste products and excess fluid from the blood when the kidneys are not functioning properly, is a treatment commonly managed by nephrologists.
Windsor Regional Hospital, after external consultation, implemented a new model of care for its renal patients. The model involved three principal changes:
- The recruitment of two additional nephrologists to the team
- A requirement that all nephrologists refer patients meeting defined criteria to the hospital’s multi-care kidney clinic (MCKC) for coordinated pre-dialysis and dialysis care
- A rotation of on-call nephrologists, with the on-call physician serving as the most responsible physician (MRP) and billing the chronic dialysis team fee (CDTF), an Ontario Health Insurance Plan fee code that pays an all-inclusive benefit for the services of all physicians participating in the patient’s dialysis treatment
The new model affected how Dr. Kadri practised and how he billed OHIP. He objected to it. The objection itself was not the problem; physicians may legitimately disagree with their hospital’s care models and raise those disagreements through appropriate channels. The problem was the conduct that followed.
The misconduct findings
The OPSDT made detailed findings about Dr. Kadri’s conduct in response to the new care model. The findings included:
- Engaging in disruptive conduct with hospital staff and administrators in connection with his refusal to comply with the new model
- Misleading communications with patients during and after his practice at the hospital
- Billing the chronic dialysis team fee in a manner that effectively appropriated the work of his colleagues, since the fee was structured as a single all-inclusive benefit for the entire team’s services
- Recruiting and misleading a junior physician, whom he used as an instrument in his dispute with the hospital
- Faxing patient orders, sometimes urgently, to a hospital where he no longer held privileges, instead of communicating directly with the on-call nephrologist
- Delaying or failing to refer patients to the MCKC, depriving them of coordinated multidisciplinary care
- Causing patients to be ill-prepared for procedures and to begin dialysis under the care of nephrologists who had not been involved in their prior management
These findings collectively supported the misconduct finding under the catch-all DDU category and under specific categories that capture inappropriate billing and inadequate professional communication.
The incompetence finding
In addition to the misconduct findings, the OPSDT found Dr. Kadri incompetent. The finding rested on his persistent refusal to abide by hospital policies in a manner that affected patient care, his lack of judgment about how that refusal affected patients, and his lack of remorse during the hearing. The Tribunal identified the incompetence finding as a finding about Dr. Kadri’s fitness to continue practising, distinct from the specific misconduct findings about particular acts.
The distinction matters at the penalty stage. A misconduct finding can in principle be addressed through targeted remediation: specific education, terms and conditions, supervised practice. An incompetence finding raises a broader question about the physician’s overall fitness, and the regulator’s response to it is correspondingly broader.
The ICRC order and the patient transfers
Before the misconduct hearing was concluded, the CPSO’s Inquiries, Complaints and Reports Committee (ICRC) had ordered Dr. Kadri to transfer the care of his patients. He complied with the order, but the manner of his compliance produced its own findings.
The transfers were left to the last possible moment. Some patients were not transferred within the required timeline. Patients were not advised of their transfers in advance, and on some occasions Dr. Kadri provided patients and families with misleading information about the transfers. The result was patient confusion, distress, and delays in care.
The Tribunal found that the manner of compliance with the ICRC order was itself professional misconduct. An ICRC order is put in place to protect the public and is to be honoured. Disorderly compliance, executed in a manner that produced harm to the very patients the order was designed to protect, was itself a breach.
The Hill framework: insight as a precondition for remediation
At the penalty stage, the OPSDT turned to the question of what sanction was adequate to protect the public. The Tribunal applied the framework set out in College of Physicians and Surgeons of Ontario v Hill, 2017 ONCPSD 21, affirmed by the Divisional Court in Hill v College of Physicians and Surgeons of Ontario, 2018 ONSC 5833.
The Hill framework rests on a logical sequence. Sanctions short of revocation (terms, conditions, suspensions with conditions) all rest on an assumption: that the physician will eventually return to practice in a manner that is safe for patients. That assumption in turn requires that the physician has insight into the conduct that led to the discipline, and is willing to change. Where insight and willingness to change are absent, the lesser sanctions are unable to perform their protective function, because the physician will return to practice with the same dispositions that produced the original misconduct.
The OPSDT’s application of that framework to Dr. Kadri’s case, at paragraph 23 of the penalty decision:
Dr. Kadri is entrenched in his belief of the propriety of his actions. He has no insight into how his actions impacted not only his patients but also his nephrology colleagues, hospital staff, and a young physician who considered him his mentor. Dr. Kadri did not present any evidence that he would make changes or would abide by terms, conditions or limitations on his certificate of registration. On the contrary, he has already shown that he is not prepared to abide by terms, conditions or limitations, as evidenced in his failure to comply with the ICRC orders. If a physician has no insight into his deficiencies and is not willing to change, remediation is not possible. In such cases, nothing short of revocation will protect the public.
That passage is the doctrinal core of the case. Lack of insight and unwillingness to change foreclose the possibility of remediation. Where remediation is impossible, only revocation adequately protects the public.
The penalty
The OPSDT ordered:
- Revocation of Dr. Kadri’s certificate of registration
- Costs to the College of $250,510
The cost award is on the higher end of the OPSDT’s typical range and reflects the length and complexity of the underlying misconduct hearing.
The doctrinal context
Kadri belongs alongside Hill in the body of Ontario regulatory jurisprudence on revocation. The framework can be summarized:
- Revocation is the most serious sanction available and is reserved for cases where less severe sanctions cannot adequately protect the public
- Less severe sanctions (terms, conditions, suspensions) rest on an assumption that the physician will return to safe practice. That assumption depends on the physician having insight and being willing to change
- Where insight and willingness are demonstrably absent (through entrenched belief, lack of remorse, failure to engage with criticism, refusal to abide by ICRC orders, or other indicators), revocation is the only adequate response
The framework has obvious connections to the duty-to-cooperate jurisprudence engaged in CPSO v Luchkiw and the “ungovernability” finding in College of Physicians and Surgeons of Ontario v Trozzi, 2024 ONPSDT 2. All three lines of authority converge on a single principle: the regulator’s protective function requires the physician’s engagement, and where engagement is refused, the regulator’s only available course is to remove the physician from regulated practice entirely.
Why this case matters
For patients. Kadri is an example of how the CPSO responds to a physician whose conduct, taken as a whole, demonstrates that they cannot be trusted to practise safely under any conditions. Patients who experience disruptive conduct, disorderly handovers, misleading communications, or other forms of conduct that compromise their care can raise those concerns with the CPSO. The regulatory framework is structured to remove physicians from practice where the conduct cannot be remediated.
For physicians. The case is a reminder that disagreement with a hospital’s care model is a legitimate position to hold, but must be raised through legitimate channels. The conduct that took Kadri from a model-of-care disagreement to revocation was not the disagreement itself but the response to it: disruptive conduct, misleading communications, inappropriate billing, and a refusal to engage with regulatory and institutional authority. Physicians who find themselves in disputes with their hospitals should think carefully about the difference between vigorously advocating a position within the system and acting outside the system in ways that produce harm to patients.
For lawyers advising regulated health professionals. The Hill and Kadri framework establishes that insight and willingness to change are doctrinally significant at the penalty stage. Counsel preparing a client for the penalty hearing should consider how the client’s evidence will be received on those questions. A client who maintains, at the penalty hearing, that the conduct that led to the discipline was justified is unlikely to receive a sanction short of revocation. The strategic implications of that fact should inform the preparation of the penalty submissions.
For more on how the CPSO complaints process works from a patient perspective, see Should I File a CPSO Complaint Against My Doctor? For two related CPSO discipline decisions in the regulatory cluster, see CPSO v Stein: A Boundary Violation and an Attempted Cover-Up and CPSO v Luchkiw: The Duty to Cooperate with a College Investigation. For the broader landscape of complaints and reviews available to Ontario patients, see A Patient’s Guide to Making Complaints About Health Care in Ontario.
