Professional regulation of physicians in Ontario operates across three distinct domains of duty: clinical conduct (the standard of care owed to patients during treatment), documentation conduct (the integrity of the medical record), and fiscal conduct (the proper use of public health insurance funds). Each of these is independently subject to oversight by the College of Physicians and Surgeons of Ontario (CPSO) and the Ontario Physicians and Surgeons Discipline Tribunal (OPSDT). A breach in any one of them can lead to professional discipline. A pattern of breaches across all three signals a deep failure to meet the basic expectations of the profession.
College of Physicians and Surgeons of Ontario v Sharma, 2025 ONPSDT 5, released by the OPSDT on March 3, 2025, is a recent case engaging all three domains. The respondent, Dr. Vijay Sharma, is an anesthesiologist who was found to have failed the standard of practice in two procedures, to have altered patient records after adverse outcomes, and to have systematically misbilled OHIP across dozens of patient encounters. The Tribunal imposed a ten-month licence suspension followed by clinical supervision.
The decision is doctrinally important for several reasons. It is one of the clearest recent articulations of the “vigilance” framework that underlies the standard of care in anesthesia practice. It addresses the particularly serious category of misconduct involving retrospective alteration of electronic medical records following an adverse outcome. It applies the disgraceful, dishonourable, or unprofessional (DDU) statutory framework to systematic OHIP billing irregularities. And it illustrates the interaction between three independent strands of professional duty, all of which can be examined when one comes under scrutiny.
The clinical context — anesthesia, sedation, and vigilance
A brief clinical overview is useful for the analysis.
Anesthesia for endoscopy. Gastroscopy (the examination of the upper gastrointestinal tract with a flexible scope) is typically performed under sedation rather than general anaesthesia. The level of sedation varies from minimal sedation (where the patient remains responsive) to deep sedation (where the patient may not respond reliably to verbal commands and may require airway support). The choice depends on the procedure, the patient, and clinical judgment. Deep sedation in particular requires continuous monitoring of the patient’s airway, oxygenation, ventilation, and hemodynamic status because the physiological reserve that protects the awake patient is diminished.
The “vigilance” framework. The Canadian Anesthesiologists’ Society (CAS) Guidelines for the Practice of Anesthesia describe vigilance as the indispensable element of safe anesthesia care. The anesthesiologist’s continuous physical presence at the patient’s side, with attention focused on the patient’s clinical status, is the foundation of safety. Mechanical and electronic monitors (pulse oximetry, capnography, electrocardiography, blood pressure monitoring) are aids to vigilance rather than substitutes for it. The monitors provide data; the anesthesiologist integrates the data with direct clinical observation (the patient’s colour, chest movement, response to stimuli, airway position) to maintain the safe conduct of the anesthetic.
Why direct observation matters. Electronic monitors have meaningful limitations. A pulse oximeter may show falsely reassuring readings during desaturation events. A motion artifact, a misplaced sensor, or a brief signal dropout can produce misleading data. A patient who has stopped breathing may continue to show a normal heart rhythm and a falling but not yet alarming oxygen saturation for a brief period before the cascade to hypoxic injury accelerates. Direct observation catches the change in the patient before the monitors fully reflect it. Direct observation also identifies problems that the monitors do not measure: airway obstruction by a tongue position, secretions in the airway, gastric content regurgitation, a developing rash suggesting allergic reaction, and so on.
The desaturation cascade. A patient under sedation can desaturate (drop in blood oxygen saturation) for several reasons: airway obstruction, respiratory depression from sedative medication, aspiration, or worsening of underlying cardiopulmonary disease. The cascade typically follows a recognizable pattern. The oxygen saturation falls. If unrecognized, the patient becomes hypoxic. Hypoxia produces sympathetic activation initially (with tachycardia and hypertension) but if not corrected progresses to hypotension and bradycardia as the heart muscle itself becomes hypoxic. Cardiac arrest follows if the hypoxia is not reversed. The cascade can occur within minutes. Prompt recognition and treatment of early desaturation typically prevents the progression; failure to recognize allows the cascade to develop.
The role of comorbidities. Elderly patients with comorbidities (cardiac disease, pulmonary disease, renal disease, cerebrovascular disease) have less physiological reserve and are at higher risk for adverse outcomes during sedation. The standard of care for these patients includes more cautious medication dosing, closer monitoring, and earlier intervention at signs of compromise. The vigilance framework applies with particular force to higher-risk patients.
The first procedure
The first procedure took place in March 2023. The patient was 74 years old and had multiple comorbidities. The procedure was an emergent gastroscopy. Dr. Sharma was the anesthesiologist.
During the procedure, the patient’s oxygen saturation decreased. At the time of the desaturation, Dr. Sharma was at the computer, with his back to the patient. A nurse who was paying attention to the patient stepped in. She increased the patient’s oxygen delivery and alerted Dr. Sharma to what was happening. Both the nurse and the endoscopist reported their concerns about the incident through the appropriate channels.
After the procedure, Dr. Sharma manually changed the oxygen saturation values on the patient’s anesthetic record. The values he entered showed higher oxygen saturation than the electronic monitoring system had automatically recorded. The discrepancy between the automatically recorded values and the manually changed values formed part of the evidence subsequently considered by the OPSDT.
The second procedure
Five days after the first procedure, Dr. Sharma was the anesthesiologist for a second emergent gastroscopy. The patient was 83 years old, also with multiple comorbidities. The clinical course was substantially worse than the first incident.
During the procedure, the patient developed hypoxia (low tissue oxygen), hypotension (low blood pressure), and bradycardia (slow heart rate). The combination is the recognizable pattern of advanced respiratory failure progressing toward cardiovascular collapse. A nurse who was attending to the patient found her in a state described as “dusky” (a clinical term for cyanosis indicating significant oxygen deprivation) with no respirations. At the time, Dr. Sharma was again at the computer, with his back to the patient.
After the nurses alerted them, the physicians in the room confirmed that the patient’s respirations were shallow. The patient’s resuscitation status was DNAR/DNI (Do Not Attempt Resuscitation / Do Not Intubate). Because the patient was still in the procedure room when she was found in extremis, chest compressions were nonetheless initiated. The resuscitation effort restored a spontaneous heartbeat. The patient died a short time afterward.
As with the first procedure, Dr. Sharma manually changed the oxygen saturation values on the anesthetic record. Once again, the values he entered were higher than the automatically recorded values.
The expert evidence on the standard of care
The CPSO retained an expert anesthesiologist to assess the standard of care. The expert addressed two questions: whether the monitoring during the two procedures met the standard of care, and whether the subsequent alteration of the records breached professional obligations.
On vigilance and monitoring. The expert concluded that Dr. Sharma’s monitoring of both patients fell below the standard of care. The clinical context of each procedure required continuous attention to the patient’s airway and oxygenation. The available evidence (the nurse’s observations of Dr. Sharma at the computer with his back to the patient; the desaturation events that were not promptly recognized) supported the conclusion that the level of vigilance was inadequate. The expert framed the issue with reference to the CAS Guidelines: the anesthesiologist’s continuous physical presence and attention is the indispensable element of safe anesthesia care; electronic monitoring devices are aids to vigilance but do not replace the requirement that the anesthesiologist be present and attentive.
On the record alterations. The expert addressed the chart alterations in stronger terms. With respect to the first patient, the expert formed a strong suspicion that the chart had been purposefully altered to suggest that the patient had a patent airway during the relevant period (and thus that there had been no desaturation event requiring intervention). With respect to both patients, the expert concluded that retrospective alteration and falsification of the electronic medical record fell below CAS standards and constituted a breach of professional obligations.
The OPSDT accepted the expert evidence and found that Dr. Sharma had failed to maintain the standard of practice of the profession both in his care during the procedures and through the subsequent modification of the electronically recorded data.
The OHIP billing analysis
The third category of misconduct addressed by the OPSDT was Dr. Sharma’s OHIP billing practices. The CPSO expert reviewed two sets of charts and corresponding OHIP data.
The first review. The expert reviewed 19 patient charts. In 11 of them, the OHIP claims were inconsistent with the services that had actually been provided. The discrepancies took several forms:
- Wrong fee codes billed in the context of colonoscopy procedures
- Use of codes that did not accurately reflect the patient’s documented condition
- Billing of codes that should only be billed by the most responsible physician (MRP)
- Claiming codes that were ineligible for payment based on the type of procedure actually performed
The second review. The expert reviewed an additional 20 patient charts. In all 20 charts, Dr. Sharma had billed inappropriately. The patterns identified included:
- Pre-anaesthetic evaluations billed as consultations (the routine pre-anaesthetic evaluation does not satisfy the criteria for a consultation under the OHIP billing framework)
- Use of MRP-only codes by Dr. Sharma when he was not the most responsible physician
- Fee codes that did not correspond to the patient’s documented medical history or condition
The combined picture showed that across 39 charts examined, approximately 80 percent contained billing irregularities.
The OPSDT framework on physician billing. The Tribunal applied the DDU statutory framework. The Tribunal’s reasoning was that Ontario’s health care system depends on physicians to ensure that their OHIP billings are careful and accurate; where physicians fail to do so, public health care dollars are misused and the physician inappropriately benefits. The framework treats overbilling as a breach of public trust even where unintentional. The Tribunal characterized Dr. Sharma’s billing practices as disgraceful, dishonourable, and unprofessional.
The legal framework — the DDU statutory standard
The disgraceful, dishonourable, or unprofessional (DDU) standard appears in O Reg 856/93, s 1(1)33 under the Medicine Act, 1991, SO 1991, c 30. The standard is broad and is applied through accumulated tribunal decisions to capture conduct that falls short of the basic expectations of the profession. The Ontario Court of Appeal in Kilian v College of Physicians and Surgeons of Ontario, 2024 ONCA 226, confirmed the framework that DDU operates as a “professional standards” standard rather than a strict-liability rule, with the trier of fact applying reasonable judgment to whether the conduct falls within the category.
Three distinct categories of DDU misconduct were established in Sharma:
The clinical conduct category — failure to maintain vigilance. Where an anesthesiologist’s monitoring of a patient under sedation falls below the standards articulated in the CAS Guidelines, the clinical conduct can constitute a failure to maintain the standard of practice of the profession. Sharma applies the framework specifically to a “back to the patient at the computer” pattern of clinical inattention. The framework operates in any clinical context where the standard requires direct attention to the patient.
The documentation conduct category — record falsification. Where a physician alters electronic medical records after an adverse outcome to make the contemporaneous data appear more favourable than it actually was, the conduct is treated as a particularly serious breach of professional obligations. The framework is grounded in the foundational role of the medical record as the contemporaneous documentation of clinical decisions and patient response. A record that has been altered after the fact to conceal an adverse event compromises every downstream use of that record: subsequent clinical care, peer review, quality improvement, and potential legal proceedings. The framework is doctrinally important because it captures a category of misconduct that is particularly difficult to detect (the alteration is typically only revealed when, as in Sharma, the automatically recorded data is preserved alongside the manually entered data).
The fiscal conduct category — systematic billing irregularities. Where a physician’s billing practices show a systematic pattern of inappropriate fee code use across many patient encounters, the framework supports a DDU finding even where any individual billing event might be characterized as a mistake. The cumulative pattern is what triggers the framework. Sharma makes the point explicit: even unintentional overbilling can breach public trust where the pattern is widespread, and the consequences for the public health care system support regulatory intervention.
The sanction
The OPSDT imposed:
- A ten-month suspension of Dr. Sharma’s medical licence
- A subsequent period of clinical supervision after the suspension
The sanction sits in the middle range for OPSDT misconduct findings of this scope. The combination of suspension and supervision reflects the Tribunal’s view that the misconduct was sufficiently serious to warrant a meaningful interruption of practice but that a permanent revocation was not warranted on the available record. The clinical supervision component is intended to support safe return to practice and to provide ongoing oversight of the matters that gave rise to the proceeding.
By way of comparison with other recent CPSO discipline decisions:
- CPSO v Trozzi, 2024 ONPSDT 13: licence revocation for misleading and inflammatory public statements about COVID-19
- CPSO v Luchkiw, 2023 ONPSDT 8: licence revocation for refusal to cooperate with CPSO investigation
- CPSO v Thirlwell, 2026 ONPSDT 5: licence revocation for issuing more than 1,400 COVID-19 exemption letters
- CPSO v Li, 2024 ONPSDT 6: 12-month suspension for inappropriate parking permit billing
- CPSO v Nahvi, 2024 ONPSDT 31: licence resignation with permanent undertaking after drugging incident
- CPSO v Sharma, 2025 ONPSDT 5: 10-month suspension plus supervision
The sanction in Sharma is consistent with the framework that the Tribunal calibrates the response to the specific misconduct, with the most serious categories (intentional harm to patients, persistent refusal to cooperate, systematic fraud) attracting revocation and lesser categories attracting suspensions of varying duration.
The doctrinal anchors
Several doctrinal anchors emerge from the case.
The “vigilance as indispensable monitor” framework. The CAS Guidelines articulate a foundational principle for anesthesia practice: the physical presence and attention of the anesthesiologist is the indispensable monitor; electronic monitors are aids. The framework is generalizable across any clinical practice where the standard of care depends on direct observation of the patient. Sharma is the principal cluster authority on the framework in the regulatory discipline context.
The “monitors are aids, not substitutes” framework. The expansion of electronic monitoring in modern anesthesia practice has not displaced the requirement for direct physician attention. The framework is doctrinally important because it forecloses an argument that technology has changed the standard of care to permit reduced direct observation. The standard of care continues to require the anesthesiologist to be present, alert, and engaged with the patient.
The chart falsification / record alteration as DDU framework. Where a physician alters electronic medical records after an adverse outcome to conceal the actual clinical events, the conduct constitutes a particularly serious form of professional misconduct. The framework is grounded in the foundational role of the medical record. Sharma is the principal cluster authority on the framework. The framework is doctrinally important because it identifies an emerging category of misconduct that is enabled by electronic record systems but is also detectable through the audit trail that those systems maintain.
The “back to the patient” positional evidence pattern. The nurses’ observations that Dr. Sharma was at the computer with his back to the patient at both critical events provided concrete evidence of inattention. The framework is generalizable: where the clinical evidence of inattention is supported by positional observations from other clinical team members, the standard of care analysis becomes more straightforward.
The sequential adverse outcome pattern. The second incident occurred only five days after the first. The temporal proximity of the two events strengthens the inference that the conduct represents a pattern rather than an isolated lapse. The framework supports the regulatory intervention because the pattern indicates that voluntary correction did not occur even after the first event drew clinical attention from the nurse and endoscopist.
The OHIP billing as DDU framework. Systematic billing irregularities can support a DDU finding even where any individual event might be characterized as an honest mistake. The framework operates on the cumulative pattern rather than any single event. Sharma joins CPSO v Li (parking permit billing) as the second cluster authority on OHIP billing misconduct as DDU.
The three-domain misconduct pattern. Where the misconduct alleged spans clinical, documentation, and fiscal domains, the regulatory response is typically more serious than where the misconduct is confined to one domain. The framework reflects the structure of professional duty: a physician who breaches multiple categories of duty has shown a more fundamental departure from the expectations of the profession.
The audit-trail electronic record framework. The electronic record systems in modern hospital practice retain audit trails of changes made to records. The audit trail captures the original automatically recorded data, the time at which it was entered, the identity of the user who entered it, and any subsequent modifications. Where a physician alters a record, the audit trail typically preserves the evidence of the alteration. The framework is doctrinally important because it means that record falsification is increasingly detectable in the modern electronic environment.
Why this case matters
For patients and families. The case is a public articulation of three different categories of professional misconduct that can occur in clinical practice. For patients and families seeking to understand what regulatory discipline addresses, the case provides a clean illustration.
Some practical observations:
The standard of practice goes beyond the technical procedure. A physician’s duty to patients includes not just the technical conduct of treatment but also the documentation of that treatment and the integrity of the underlying clinical observations. A breach in any of these can lead to professional consequences.
Electronic records preserve evidence of alteration. Where a physician modifies a record after the fact, the modification is typically captured by the audit trail. The integrity of the underlying contemporaneous data is preserved even when the visible record is altered. The framework operates as a check on after-the-fact record adjustments.
Regulatory discipline is independent of civil litigation. A finding of professional misconduct by the OPSDT is a regulatory matter and does not by itself establish civil liability. Where the underlying conduct also harmed a patient, a civil malpractice action may proceed independently. The two proceedings can occur in parallel or sequentially. The standard of proof and the available remedies differ.
Concerns about a physician’s conduct can be raised with the CPSO. Where a patient or family member has concerns about a physician’s clinical conduct, documentation, or billing, the CPSO complaints process is available. For more on the framework, see A Patient’s Guide to Making Complaints About Health Care in Ontario and CPSO: Should I Make a Formal Complaint Against my Doctor?.
For physicians and clinical teams. A few practical observations:
Vigilance is not a documentation requirement; it is a clinical requirement. The CAS Guidelines describe physician presence and attention as the indispensable monitor. The framework cannot be satisfied by completing a properly formatted record after the fact. The clinical conduct itself is what is at stake.
The audit trail captures retrospective alteration. Modifications to electronic medical records are tracked by the underlying systems. Where a physician alters a record after an adverse outcome, the alteration is captured. The framework does not permit the alteration to displace the original data; it captures both, and the discrepancy itself can become evidence of misconduct.
Documentation should reflect what actually happened. Where an adverse event occurs, the documentation should reflect the actual clinical course, including the adverse event itself. The framework is consistent with the broader principles of contemporaneous documentation. Modifying the record to make the events appear more favourable than they were not only fails to satisfy the documentation framework but creates a new and more serious category of misconduct.
OHIP billing accuracy is part of the practice. Systematic billing irregularities can attract regulatory attention even where any individual event might be characterized as an oversight. The framework treats billing accuracy as part of the broader professional duty. The Ministry of Health and the CPSO can both review billing patterns.
Cluster integration
This is a regulatory discipline decision, joining the broader CPSO discipline cluster. The substantive doctrinal anchors are now well-developed.
For other recent CPSO discipline cases, see the related case comments on CPSO v Trozzi, CPSO v Luchkiw, CPSO v Li, CPSO v Thirlwell, and CPSO v Nahvi.
Decision Date: March 3, 2025
Jurisdiction: Ontario Physicians and Surgeons Discipline Tribunal
Citation: College of Physicians and Surgeons of Ontario v Sharma, 2025 ONPSDT 5 (CanLII)
Outcome: Ten-month suspension of medical licence followed by a period of clinical supervision. The Tribunal found that the respondent had committed three categories of professional misconduct: (1) failure to meet the standard of practice of the profession in his care of two patients during procedures in March 2023, principally through a lack of vigilance during sedation that contributed to the failure to recognize desaturation events in a 74-year-old patient and a hypoxia/hypotension/bradycardia cascade in an 83-year-old patient who subsequently died; (2) manual alteration of electronically recorded oxygen saturation values in both patients’ anesthetic records after the adverse outcomes, with the altered values showing higher oxygen saturation than the automatically recorded data; and (3) inappropriate OHIP billing in approximately 80 percent of audited patient charts across two batches reviewed, including the use of fee codes inconsistent with the services provided, billing of MRP-only codes by a non-MRP physician, and pre-anaesthetic evaluations billed as consultations.
Key authorities: Canadian Anesthesiologists’ Society Guidelines to the Practice of Anesthesia (the vigilance framework); Medicine Act, 1991, SO 1991, c 30 and O Reg 856/93, s 1(1)33 (the DDU statutory standard); Regulated Health Professions Act, 1991, SO 1991, c 18 and the Health Professions Procedural Code (the broader regulatory framework).
