Dec 2015 Statement on Urine, street drugs and termination

On April 28, 2014, while [the doctor] was with me in his office, renewing my prescriptions, he became unreasonable and informed me, first, that the next time I got my prescriptions renewed I would have to take a urine test “for street drugs,” he said. He was in the process of refilling the prescription for Tylenol 2 for me, consisting of two tablets per day, which I take for pain from a previously broken ankle with tissue and ligament damage, and which also helps with the arthritis. I had been started off in 2009 with Oxycodone, having broken my ankle, and got myself down to Tylenol 3 despite continuing pain due to tissue and ligament damage. Later, in London, I  was prescribed the lower strength, Tylenol 2, starting in March 2013, with [the doctor].

At the appointment, the doctor changed his mind within a few minutes, demanding that I take a urine test then and there. And then he changed his mind again, saying that in future I would only be able to have a renewal prescription for the Tylenol 2 for a period of one month and would have to take a urine test for “street drugs” each time I came to have it renewed. At the same time he was asking me once again, as he had two three times before, on other occasions while I was there for an appointment with him, if had I found a new doctor yet.

I said I would get him the sample, and picked up a jar at the front desk and continued on to the washroom. Once there, I changed my mind. I was rapidly becoming even more untrusting of the doctor than I had been, and when I saw that the empty jar for the sample had no name on it, that was the deciding factor. I left the washroom with the jar unfilled and took it back to the front desk and gave it to the receptionist. I understand that the reason the jar did not yet have my name on it was because the decision to have me take the test for street drugs had only been made minutes beforehand, but still, it didn’t seem like a good idea to hand in a sample of urine to a doctor who was behaving irrationally and who I no longer trusted and expect that it would be properly labelled and sent off.

When I came out of the washroom I was standing across the waiting room from him, and tried to explain to the receptionist and him that I would not be providing a urine sample. I did leave at that point, but returned just as I got into my car, to ask for a form so I could take the urine test at a lab. The receptionist and the doctor ignored me at that point so once again, I left.   April 28, 2014 was the last appointment I had with [the doctor] as my family doctor.

Two days later, on April 30, I submitted a letter to LDAM (London and District Academy of Medicine) to try to enlist their help in resolving the situation.

A week or so later I developed symptoms which, along with the typical shingles rash, led me to try to make an appointment with him, on May 12, but was told on calling the office only that he was booked up and that I could go there and wait, which I did. Two hours later, and still waiting, although it was by now the doctor’s lunch break, the receptionist informed me that I was a walk-in patient now and no longer a patient of the doctor’s. I had not formally been notified and hadn’t known. I think I was expected to leave at that point but I realized I needed the anti-viral prescription for shingles, so explained my situation. I managed to get the prescription for the anti-viral medication I needed from him and left, with no followup for the condition. I did eventually receive a letter of termination from the doctor, dated April 28, although postmarked May 20, 2014.

Following that, in June, I received a response to my complaint from LDAM, advising me to find a different doctor.

Effect of Urine sample, “street drugs,” and termination

This incident, occurring at the finish of the physician patient relationship, although I didn’t know it at the time, not only put me under a lot of stress, very likely having something to do with the episode of shingles that came about soon after, but has made me think a great deal about the inadequacies of the medical system, including the lack of transparency and the huge amount of power that the doctor wields over his patients. The doctor’s slurs against me, and his unprofessional behaviour, did harm to me – to my sense of well-being and to how others perceive me. Furthermore, not having a doctor familiar with my health concerns and needs, esepcially at my age, and willing to see I get what I need, is an obstacle to being as healthy as I can be and to my ability to maintain a healthy life. Where was the dignity in this?

I found [the doctor]’s language disconcerting, to say the least.  I have never used illegal drugs, only two or three times taking marijuana while at university, together with other people. I didn’t know why he was suggesting that I take such a test, and found it odd that he must have thought I used such drugs, and stranger still that he referred to them as “street drugs,” which implies that the person must be getting them on the street and possibly using them in back alleys. So I felt quite hurt, and appalled, that he would think this way of me, that he appeared to have so little respect for me and so little understanding of how I live my life. I don’t go out much, although swimming is one activity I try to keep up with, but I am most certainly not out on the street passing time.

It was a stressful ordeal, having to contend with a doctor who was being so disrespectful of me and treating me so badly, demanding that I  - me – take a urine test for street drugs, and not only that I  take a test that day but take one each time I come in, for 1 month’s worth of Tylenol 2, to deal with the pain of the ligament and tissue damage in my ankle, as well as arthritis.

I don’t know how he could have got the ideas he had about me, or why he thought it was okay to talk to me in that manner. Had he overheard informal talk about me, people telling untruths in an attempt to put me in a bad light – and believed them?  If someone had said something about drug use, they were mistaken – or worse yet, lying!  If anyone has been spreading lies about me, I would like to know. Or was he making assumptions about me based on my family status and the fact I am female?  If a woman isn’t a good wife and mother, and never had a career, what else is there left for her to be? Did he discriminate against me on the grounds of my being female, and my family and marital status – and age, of course - for reasons that, in the wider context, could have something to do with the state of the health care system in Ontario? I came to see that indeed he was.

I understand that [the doctor] has now instituted a policy that his patients must adhere to, that if they are taking opioids, which I gather includes narcotics such as Tylenol 2, that they must sign up for, agreeing to submit to urine tests if the doctor decides they should, whether it be on a mere whim or for some logical aim in mind. But just because a patient has been taking Tylenol 2, which is mostly acetaminophen with caffeine together with 15 mg codeine per tablet, for longterm pain associated with an ankle injury, doesn’t mean they have been abusing it. Neither does it mean they have been cooking it down to extract the codeine, as one CPSO investigator informed me some people do, as though she thought I might be doing that - doing that and presumably selling it on the street. I admit, I am handy in the kitchen, and still prepare all my own meals, but on no account would I go so far as to do what she suggested, or be able to put in that attention required, on my feet.

But at the time, on April 28, 2014, that policy had not been formalized and I had not been asked to sign anything.  And yet he had then told me I would have to take a urine test each time – every month – if I wished to have the Tylenol 2 renewed. As I mentioned, within two weeks of that last formal appointment I developed the shingles rash and returned to his office in the hope it would be seen to.

Since that time, I have had to go as a walk-in patient to walk-in clinics for my health needs, with mixed results, and for prescription renewals, although I no longer am able to be prescribed Tylenol 2 as walk in clinics apparently don’t prescribe them, I was told. I receive no pain relief for my arthritis and painful ankle, other than Tylenol 1 that I can buy over the counter. I would prefer Tylenol 2 with codeine, although it may have been possible to discuss marijuana as an option, but I believe it could interfere with the functioning of the brain. And the acetaminophen, that comes with every Tylenol 1 in large amounts, is dangerous for my kidneys.  So I take the bare necessity, and live with pain daily, as I have no family doctor to assist in diagnoses or referrals, or trustworthy advice on my health needs, or who will provide consistent treatment and checkups. I don’t know how to go about getting a family doctor when the last time I got one turned out to be such a disaster and the process for getting one seems so problematic - sign up and then meet the doctor. And after writing this it may be even less of a probability in my life. Other doctors have asked me, “Why do you no longer have a family doctor”, and I have no response to that. If I did tell them there were unresolveable problems, would they be more likely to think the problem lay with me, because he is a doctor, and I am just an old woman alone with no husband or family around?

Discrimination on the grounds of sex

When [the doctor] suddenly demanded that I take a urine test for "street drugs,"on April 28, 2014, as far as I know there was no policy governing how narcotics were to be prescribed and regulated in doctors’ practices. I had been prescribed Tylenol 2 by [the doctor] for a year, since March, 2013. Before that, I had been taking Tylenol 3 and before that, I was prescribed oxycodone following fracturing my ankle in 2009.

I did not sign any opioid contract because no one had asked me to. I didn’t even know, until I read the letter, that Tylenol 2 is considered to be an opioid, or that there was a contract. While getting my prescriptions renewed on April 28, 2014, and getting my blood pressure medication changed back to what it had been when I first started with the doctor, he suddenly declared that I had to take a urine test – for street drugs. This was outside my realm of experience, and I wondered why I was being ordered to do so. Not everyone has to, even when they have signed such a contract. So I am wondering why me?

I questioned to myself the term "street drugs," as used by [the doctor], as it carries a connotation of "being on the street," which for women carries the connotation of prostitution. I am not and never have been that, either, but the point is that I found the use of that term disturbing. I was shocked and appalled by his language and his unprofessional behaviour!

I can’t imagine that moms with kids, or women with careers, who have a painful injury or medical condition get called upon to submit to a urine test for "street drugs," even if he used another name for them, without there being a very good reason why. But we don’t know because in many areas of the health care system there is little or no transparency, including this area, as far as I know. On what basis do patients get selected to have their urine tested for street drugs? While we’re all women (the ones I mentioned), I would suggest we don’t all get treated the same.

If there are no checks on this kind of decision-making, how do patients know whether they have been singled out and had this imposed upon them unfairly, because they are female?

I believe I was discriminated against by [the doctor] on the grounds of sex, and that he ended the physician patient relationship on those grounds, because I wasn’t the stereotypical kind of woman that he wanted in his practice, that he could treat respectfully, but thought I was the kind of woman he could treat disrespectfully, providing only substandard treatment.

Discrimination on the grounds of family and marital status

By imposing upon me the requirement of having to submit to a urine test as a matter of routine, for the purpose of what he referred to as testing for "street drugs" (not even calling them ‘illegal drugs’), based on his new policy which he had not yet instituted as of April 28, 2014, [the doctor] discriminated against me on the grounds of family status, as a single person, alone and lacking a husband or the close family caring connections in this city that might well have enabled me to be seen as a worthwhile person.

This kind of action is damaging to my reputation and sense of well-being, as it implies very strongly that I use illegal drugs or have used them in the past. I have never used illegal drugs, unless smoking marijuana a few times while a university student counts. But I have never used any other kind of illegal drugs, and in fact have not abused the pain relief medication that I was prescribed in 2009 after breaking my ankle, and which I gradually got down to Tylenol 3, myself. [The doctor] became my doctor in September, 2012, when he advertised for patients for his new practice. The dosage of the narcotic pain relief that I was on originally, when I came here, was lowered further by [the doctor], for no apparent reason.

Somehow he got the idea that I was a drug user – on the streets of the city – seeking out drugs. That’s the impression his language conveys. At the end, he pushed me out of his practice into being a user of walk-in clinics, starting with his own clinic, when I returned 2 weeks later with a case of shingles, not realizing he was no longer my gp. I felt I had been pushed down to the lowest level of society – that of user of "street drugs," walk-in clinics, and whatever else was implied by that.

He attempted to force me to submit to a test that was unecessary and for which I was singled out. He did not behave reasonably or fairly when he made his demands – to take the urine test and then, to find a new doctor. Finally, he decided to terminate the physician patient relationship, which apparently was his right, according to the CPSO’s policy (Ending the Physician Patient Relationship, CPSO, ),

As stated in the Ontario Human Rights Commission’s Policies and Guidelines,
"The Code provides explicit protection against discrimination for specific relationships, through prohibitions on discrimination because of marital status and family status.
Section 10(1) of the Code broadly defines the ground of marital status as follows:
"marital status" means the status of being married, single, widowed, divorced or separated and includes the status of living in a conjugal relationship with a person outside of marriage" ( p 8. Code Definitions (I), Code Protections for Relationships (III), POLICY AND GUIDELINES ON DISCRIMINATION BECAUSE OF FAMILY STATUS, OHRC. March 28, 2007. retr March 22, 2015. ,

" . . . discrimination based on family status may be described as any distinction, conduct or action, whether intentional or not, but based on a person’s family status, which has the effect of either imposing burdens on an individual or group that are not imposed upon others, or withholding or limiting access to opportunity, benefits, and advantages available to other members of society (Defining Discrimination Based on Family Status, OHRC Policies etc on family status. Retr. Jan 25, 2015)

I believe [the doctor] discriminated against me on the grounds of family status including marital status (intersecting with the grounds of sex), for being a single woman alone and not closely associated with family, as well as not in a caring role for an aging husband at home, the kind of role members of the health professions seem keen to endorse. And what he did was, first of all, demand I submit a urine sample on that day and each future date I wished to have my prescription for Tylenol 2 renewed, and secondly, ended the physician patient relationship altogether.

Discrimination on the grounds of age

In our society, at the present time, there seems to be a common understanding that if a woman has not had a career, or has not achieved success in life it is due to some personal failing. This way of thinking has come about since feminism encouraged women to enter the work force in greater numbers, though it used to apply largely to men. Many women of earlier cohorts were stay-at-home mothers, as I was, working only part-time when I was able to fit it in with the raising and caring of the children, taking care of the home, back yard, and garden, and just being there when the man of the house came home.

Thus, while some may view older individuals as a drain on the system, especially when they have not contributed through having a career, and if, because they did not have a career and have no husband, they are seen as less respectable and unworthy of decent health care, then this is a case of discrimination on the basis of age. Even older citizens who had careers may find themselves treated as less worthy once they have retired and are seen as no longer contributing to the community. I believe [the doctor] discriminated against me on the grounds of age, seeing me as a less worthy human being. As stated in the pages of the Law Commission of Ontario,

´. . . ageism also functions as older persons’ invisibility, marginalization, and social exclusion. This is because the “other age” (persons who are not old) are treated as the norm and the more valued group. To the extent to which older people do not fit the perceived social norm, they are treated as “less”, which may include less valued and less visible. They become relegated to a second class status; their needs and their lives are treated as if they do not matter as much” (Ageism: Concepts and Theories, Law Commission of Ontario [LCO]. 2009. Retr Jan 20, 2015.  ).

Furthermore, the article goes on to describe a “socially useful” understanding of aging, concluding that

“Ageism is also the perpetuation of the belief that individuals by themselves can achieve this “successful aging”, or that by individual effort and sufficient willpower they can undo all the social inequities that have led up to their later years or the inequities that arise in later life” (Calasanti in Ageism: Concepts and Theories, 2009).

That’s simply not the case, as we know. It’s more like a downward spiral, difficult to pull out of, especially when some people seem determined to keep pushing us down.

The CPSO addresses the subject of patient care in general from the perspective of a physician’s duties, saying:

“Collaboration with an individual patient is essential to providing good medical care. The physician must work with the patient in order to understand the patient’s health care needs, to formulate treatment plans that are optimal for the patient, to ensure that the patient remains informed about his or her care, and to address patient questions and concerns” (Collaborating with Patients and Others,  Duties: To the Patient. Principles of Practice and Duties of Physicians. CPSO Policies and Publications. Retrieved March 26, 2015. )

In this case, the doctor didn’t see me as worth treating with respect, and in the end, not worth keeping as a patient at all. I believe [the doctor] discriminated against me by making unreasonable demands to submit a urine sample and pushing me out of his practice, not only on the basis of my age, but also on the basis of my sex, and family and marital status, seeing me as a woman alone, without family or support.

In a letter he wrote to me, that I received weeks later, after the last appointment on April 28, 2014, the doctor blamed me for the end of the physician patient relationship, saying there had been a breakdown of trust, but implying I was the cause of the loss of trust in the relationship. I have described here what the consequences might have been, when I did trust him as my family doctor, in my explanation of the uneccessary pelvic renal ultrasound incident, which could have turned out so disastrously – a situation of misplaced trust. Just because it didn’t result in a disaster doesn’t mean there was no harm done.  I wanted to be part of the decision-making process, and to be involved in my own health care, and not simply ‘managed’ by the doctor.

Conclusion for each of the incidents, the ‘Pelvic Renal’ and the ‘Urine sample, “street drugs” and termination’

The provision of treatment or diagnoses that had been appropriate does not take away from the fact that there was inappropriate treatment, unnecessary tests (as in the situation of the pelvic-renal ultrasound) and changes in medications made, and a general lack of thought and committment put into the patient/physician relationship by [the doctor]. A person may well be an upstanding citizen but still have flaws in his personality or cultural beliefs that affect decision-making and the way he interacts in his daily life, as well as affecting the lives of the people he encounters in negative ways.

The doctor took a situation of needed pain medication due to a previous injury and blew it out of all proportion, finally, at the last official appointment I had with him, demanding I take a urine test for “street drugs:” This was the last straw and it affected me deeply, to be reduced to the status of someone who, according to him, required routine monitoring for suspected drug activity on the streets of London. He may well have people with drug problems on his roster, but I am not one of them. Nor am I out there, on the streets or attempting to get enough money to buy them. Nor did I shout at him or his staff, not ever, as he has tried to claim.  

I am a 69 year old woman, living alone and trying to make ends meet, not active in the community, in part due to mobility problems including pain on a daily basis. But I am not the kind of person he has tried to make me out to be.

I have no doubt that his preconceived notions about me influenced the way he treated me.  His language and attitude towards me, at other times and not just during these two situations, indicate that he thought I wasn’t worth bothering with. Greeting me with “You’re smiling; you must be okay,” surely isn’t the best way to greet a patient, who generally is there due to an illness, injury, or other health concern. It trivializes their concerns. Perhaps that perception is due to a cultural difference. In some countries, women and even men may express emotions in order to get across how they are feeling, unlike western countries in which women have been taught to smile, no matter what. In like manner, announcing “The report’s back - you’re okay,” is a conversation-ender rather than the chance to discuss further what the problem could be.

Having to make an appointment to have prescriptions renewed in person, rather than use the pharmacist’s faxable form, doesn’t even make sense. He surely doesn’t require his patients who go on extended holidays to have to do that. One wonders why one patient gets treated one way, another, a different way.

These may not seem to be instances of discrimination, but if they reflect the doctor’s attitude on the basis of age, or sex, or marital status, they may well be.

Because I was an older woman, was not married and did not have a family nearby and lived alone, it apparently seemed to him that I was abusing or at risk of prescription drugs and possibly “street drugs” too, and should be required to submit to a urine test on a regular basis – for a prescription for Tylenol 2. I don’t know what other reason there was.

He is a physician, who has the power to dictate who will get tested for drugs and who he will allow to take narcotics without being tested at all – even if they do sign the required form to say they will, if asked. If not all patients in Ontario are being tested routinely for narcotics in their urine, (and obviously not all patients are or the results would surely stop them from getting prescribed it again and again),  perhaps it is time to consider doing just that, and not allowing Ontario’s doctors to concentrate their efforts on only some patients, for reasons more to do with social circumstances than legitimate concerns, on those who do not have the power and connections to object and be heard. I don’t take narcotics or other illegal drugs and never have (aside from trying marijuana), except for the pain of a broken ankle with ligament damage and the arthritis that often comes as one grows older, and I object strongly to the manner in which this doctor treated me throughout the time I was his patient.

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