Josef Krop Misconduct
|Discipline Committee Decisions 2000|
The Notice of Hearing contained the following allegations of professional misconduct:
Dr. Krop trained in Poland as a paediatrician. After arriving in Canada and obtaining full licensure in the mid-1970ís, he practised family medicine. Since the early 1980ís, however, he has confined his practice to what he characterized as environmental medicine. His patients are roughly equally divided between adults and children.
SUMMARY OF EVIDENCE
First, the Committee wishes to emphasize that the focus of this hearing was the practice of Dr. Krop as it related to his management of the six patients whose charts were entered in evidence. "Environmental medicine" was not the issue being deliberated. Indeed, in the course of the hearing it became apparent that Dr. Krop's methods differ significantly from the majority of the practitioners tendered by the defence as knowledgeable in environmental medicine.
The central role of Vega testing in Dr. Krop's practice appears to be unusual. It was claimed by Dr. Krop that the Vega machine -one electrode of which was held by a patient while the other electrode was applied to the patientís toe - assisted him in arriving at diagnoses. He used the Vega apparatus to screen for a broad range of sensitivities (as the only method of evaluation in at least one patient), as an integral part of the provocation/neutralization procedure in a number of patients, and as a means of adjusting previously prescribed treatment sera.
The six patients whose records were the focus of this hearing presented with a wide variety of complaints: chronic dry and cracking skin, recurring respiratory infections, bloating and diarrhea, skin rashes, headaches, stomach aches, chronic fatigue, cognitive difficulties, flu-like symptoms, recurrent rhinitis, urinary tract infections, chronic groin pain, and depression. Despite the wide range of symptoms, the patientsí assessments were remarkably similar. All completed exhaustive "environmental" and "food sensitivity" questionnaires, all charts contained the same physical examination check-list, and virtually all received the same battery of tests. All were "screened" with Vega testing. Intracutaneous testing with serial dilution end-point titration was foregone only in the case of the child and an adult, in the latter instance because of cost. All but one underwent provocation/neutralization sublingual testing. All underwent extensive conventional hematologic and biochemical testing, the results of which were uniformly unremarkable. In a number of patients, subsequent treatment was modified by repeat Vega testing.
Treatments prescribed or recommended were similarly formulaic. Injectable sera for a variety of inhalants, including fungi, were prescribed in three patients. Some were given sublingual drops. All were given or recommended oral antifungals and three received the systemic antifungal ketoconazole. The rotary/elimination diet was recommended in all but one. In addition, a yeast-free diet and acidophilus supplements were recommended to several, as were vitamin and mineral supplements, organically-grown food, evening primrose oil, Vitamin E, and bottled water.
In the Committeeís view, the testing techniques and treatment approaches employed by Dr. Krop have in common a lack of scientific validation. This judgment includes, in particular, the Vega machine which Dr. Krop additionally used to assess a wide variety of putative stressors, to screen for occult disease, and to adjust treatments which in themselves are questionable. Our conclusion also includes the diagnostic/therapeutic technique known as provocation/neutralization, hair analysis, the rotary diet, the use of staph lysate, autogenous vaccines made from serum and sputum, "thymus extract" injections, repeated high dose parenteral Vitamin C infusions, and sauna therapy. It includes the diagnosis of "candida-related complex" and thus the treatment that flows from that diagnosis.
The experts called by the College reviewed each of these diagnostic and therapeutic modalities. All condemned their use. Two expert witnesses stated that Dr. Krop's use of these techniques in the six patients in question constituted a failure to meet the standard of practice.
The Committee accepted the evidence of the College experts in preference to that of the experts called by the defence. The Committee did not view the latterís evidence as worthy of equal weight in that it lacked the authority of acceptable scientific evidence.
The Committee, therefore, finds Dr. Krop guilty of professional misconduct in that he failed to maintain the standard of practice of the profession in the care of the patients in question in that he:
THE ISSUE OF ABUSE OF PROCESS
The issue of abuse of process was raised by the defence both at the commencement of the hearing and in final argument.
At the outset, a voir dire was held regarding the admissibility of the patient records to be tendered as evidence in the proceeding. This in turn led to a review of the manner in which Dr. Krop's practice came to be investigated and in which the resulting referral to the Discipline Committee was made. The Committee held at the conclusion of the voir dire that the investigation into the practice of Dr. Krop was carried out with the authority of, and in compliance with, Section 64 of the Health Disciplines Act. It further found that Dr. Krop and his position was dealt with by the College with the degree of fairness that was appropriate at each stage of the investigation and referral process. The process by which patient records were selected did not breach the privacy rights of the patients involved nor did it constitute unreasonable search and seizure.
PENALTY AND REASONS FOR PENALTY
Counsel for Dr. Krop called six witnesses, all patients of Dr. Krop. Two were among those patients whose office records had been the focus of this hearing; the third witness was the mother of a child whose medical records had also been entered in evidence. All testified to their satisfaction with the care provided by Dr. Krop, and to his good reputation among those who know of his work. Counsel further submitted three volumes of testimonial letters from satisfied patients, and read from a number of them.
Counsel for the College proposed a penalty that would include a recorded reprimand and the imposition of a number of conditions on Dr. Krop's certificate of registration. These would require Dr. Krop to adhere to the specified recommendations of the Report of the Ad Hoc Committee on Complementary Medicine of the College of Physicians and Surgeons.
Counsel for Dr. Krop proposed that no penalty be imposed. He stated that there was at least some support for just about everything Dr. Krop did, that no physical harm had befallen any patient, that Dr. Krop should not be penalized for the tactics employed by his former legal counsel, that Dr. Krop had demonstrated in the care of his patients both considerable effort and compassion, and that the decade-long period of investigation and hearing had taken a toll on both Dr. Krop and his family. He stated that patients have a right to choose based on informed consent, and that there was no evidence that Dr. Krop does not follow the principles espoused by the Report of the Ad Hoc Committee on Complementary Medicine.
The Committee, however, found that Dr. Krop did not provide the six patients who were the focus of this hearing with the information upon which they, in turn, could give him truly informed consent for the diagnostic tests and treatments he used. The Committee, in its decision, stated that it must be made clear to the patient where scientific evidence exists ó and by extension where it does not ó for both diagnostic methods and treatment recommendations.
It is important to add that the principle of informed consent extends to the naming of diagnoses. "Systemic candidiasis" and "multiple chemical sensitivity syndrome" are controversial labels. The former lacks any credible scientific support as a diagnosis. In the case of the latter, while there are generally acceptable epidemiologic definitions to identify it as a syndrome, there are no known scientifically acceptable means to either diagnose or treat it in a specific individual.
It is with these findings in mind that the Committee firmly rejects the proposal and rationale put forward by Dr. Krop's counsel, and accepts the penalty recommendation of College counsel.
The Committee has no doubt that Dr. Krop is sincere, hard-working, and devoted to the well-being of his patients. It is clear that, as was stated in the course of the hearing, many of his patients believe he is the "physician of last resort", the individual to whom they have turned because they have been unable to find relief from conventional physicians. His caring approach undoubtedly plays a major role in their healing.
Nevertheless, Dr. Krop owes a debt of honesty to his patients. While he may hold strong beliefs in the appropriateness of his diagnostic methods, his diagnostic conclusions, and his methods of treatment, he must make it clear to his patients that they are simply that ó beliefs. He must be candid in stating that they are unsupported by scientifically acceptable evidence.
The Committee believes that Dr. Krop would be of even more help to his patients, and to society at large, if he would subject his beliefs to the same level of scientific scrutiny expected of any innovation in the field of medicine today. Given the size of his practice and the current climate of openness to alternative methods of treatment, he has had ó and with this decision still has ó an opportunity to do just that.
Unfortunately, Dr. Krop apparently continues to believe that his approach to diagnosis and treatment has been scientifically validated and that he does provide his patients with the basis of truly informed consent. Because of this, Dr. Krop must hear in no uncertain terms that he has failed to meet the standard of practice.
In reviewing the penalty proposal put forward by the College, the Committee notes that Dr. Krop's primary obligation is to approach each patient in accordance with the standard of practice. To paraphrase the Report of the Ad Hoc Committee on Complementary Medicine, he is to carry out a history and physical examination relevant to the presenting complaint, investigate utilizing generally accepted modalities pertinent to the problem at hand, reach a conclusion that a reasonable physician would reach, supported by the data, and advise the patient of the usual and conventional treatment options. The Committee believes that Dr. Krop would be wise to document this in the patient record.
The penalty does not forbid Dr. Krop from going beyond this, nor does it prohibit his employment of any of the testing procedures, diagnostic labels, or treatments referred to in the foregoing. If Dr. Krop chooses to do so, however, he has an obligation to provide each patient with the basis upon which truly informed consent can be given and paraphrasing the Report of the Ad Hoc Committee on Complementary Medicine, Dr. Krop is obliged to ensure that his patients are told the degree to which tests, treatments or remedies have been evaluated, and the degree of certainty and predictability that exists about their efficacy and safety.
In order to reassure the College that Dr. Krop has understood and acted upon the particulars of this decision, the Committee has a number of recommendations it wishes to urge upon Dr. Krop. While these are recommendations and not requirements, the Committee believes they are both prudent and consistent with our Order:
This Committee is aware that some of the areas in which Dr. Krop has failed to meet the standard of practice will undoubtedly evolve. The Report of the Ad Hoc Committee on Complementary Medicine makes a final recommendation, one which urges those who enter into "areas of less well proven efficacy" to "collaborate in the collection of information that can be appraised qualitatively or quantitatively, so that new knowledge is created, to be shared with, and critically appraised by, the profession." Dr. Krop, should he choose to do so, could make a significant contribution in this area. The penalty recommendation envisions such a possibility.
The Committee therefore orders that:
1) A reprimand, with the fact of the reprimand to be recorded on the Register;
2) Dr. Krop's certificate of registration is to be subject to the following conditions:
(a) Dr. Krop is required to adhere to the recommendations with respect to members, from the Report of the Ad Hoc Committee on Complementary Medicine, for assessing patients, treating patients and advancing knowledge;
(b) In addition, prior to any use of Vega testing, provocation/neutralization testing, serial dilution end-point titration testing for non-inhalant sensitivities including candida-related sensitivity, and hair analysis when not used in the diagnosis of heavy metal toxicity or essential element deficiency, Dr. Krop:
The following recommendations from the Report of the Ad Hoc Committee on Complementary Medicine to the Council of the College of Physicians and Surgeons of Ontario are modified to refer specifically to Dr. Krop:
In assessing patients, Dr. Krop should henceforth be expected to:
In treating patients, Dr. Krop should henceforth be expected to: