A DOCTOR’S DECEPTION

A month later, another of Shuen’s patients arrived at the hospital from his clinic, again on a Saturday and again in rapid labour. This time, a nurse named Lindsay Bruer performed a vaginal exam on the woman and found the remnants of a little white pill. There was no mention of it on her chart. Whatever this pill was, it had been given to Shuen’s patient without her knowledge or consent, and it had sent her into a violent labour. Bruer pulled off her latex glove, with the pill on the tip of its finger, turned it inside out and threw it in the trash. She went to the nursing station and told her colleague Karen Yu. This wasn’t the first time something like this had happened: similar pills had been found in Shuen’s patients twice before, in 2013 and 2015. Together, the nurses decided that Bruer should retrieve her glove from the garbage and put it in a specimen bag. They were going to test it and find out what it was.

The first time hospital staff found a mysterious white pill in one of Paul Shuen’s patients,  the evidence was discarded

The scandalous truth about Paul Shuen’s practice would come to shock the clubby world of Toronto medicine, where Shuen had distinguished himself over three decades. He came to Toronto in 1987 with his wife, a Chinese-Canadian woman named Piera Ip. He secured a gig at North York General, the hospital where he’d spend his entire career, and quickly became known as an excellent surgeon and ob-gyn. In 1988, he was appointed a lecturer at the University of Toronto and taught two generations of physicians. He developed a sterling reputation for serving his community honorably and diligently. By late middle age, he was still youthful and slim, with a full head of salt-and-pepper hair.

As Shuen’s practice and reputation grew, so did his ego. Over time, he became increasingly cavalier about a core tenet of medicine: consent. One patient who experienced this first-hand was a pregnant marketing professional named Kerry George. During a checkup three and a half weeks before her due date in 2008, her ob-gyn, Modupe Tunde-Byass, told George her amniotic fluid was low and recommended induction. On the night of January 31, George and her husband went to North York General. Labour was slow, and 10 hours after being induced, George was only one centimeter dilated. She received an epidural, which eliminated her pain, but by mid-morning, labor still hadn’t progressed. When Tunde-Byass finished her shift, she left George with Shuen, the doctor on call.

George first met Shuen when he came to check on her. He was annoyed, she remembers because she was still only one centimeter dilated. He was also gruff, abrupt and disrespectful toward the nurses. “Who said she could have an epidural?” he barked. He mumbled some orders and hurried off.

Finally, by late afternoon, the nurses told her she could try pushing. Shuen re-entered the room, fulminating. “We need to hurry this up,” George remembers him saying. “I have a scheduled Caesarean section to get to.” His irritation peaking, Shuen said her baby was in distress and he’d need to deliver by C-section. A nurse disagreed, pointing out that the fetal heart monitor had slipped and the baby was fine.

The 1996 Health Care Consent Act requires physicians to secure consent for any medical intervention, to walk patients through the nature of the treatment and the various risks and benefits, and to let patients know they have the right to refuse treatment. But Shuen had lost patience. Without informing George or seeking her consent, he performed an episiotomy, a surgical incision to enlarge the vaginal opening. But as George kept pushing, she began to tear, and because she’d had an epidural, she couldn’t feel anything from the waist down. She was shearing with each push. She ended up with a third-degree tear of the perineum. “I was torn everywhere, everywhere,” she says.

Finally, the baby—a tiny, perfect boy—was born. “Wow,” George recalls a medical resident saying. “That was the roughest birth I’ve ever seen.” Shuen hurriedly stitched up the deep wound George didn’t even know she had. She was discharged the next day, swollen and sore. It wasn’t until three days later that she realized the extent of her injuries. “The plumbing wasn’t working how it was supposed to,” she says. The situation was so bad that she eventually went to the ER at Trillium Urgent Care Centre. The doctor referred her back to Tunde-Byass, who said she hadn’t seen that kind of trauma outside of a third-world country, and told George she’d need surgery to repair the damage. Tunde-Byass notified the chief of surgery at North York General then spoke to Shuen directly, who she says was apologetic.

George waited eight excruciating months for surgery. It wasn’t right, she decided. Shuen shouldn’t get away with this. In August 2008, she lodged a formal complaint against him with the College of Physicians and Surgeons of Ontario, the governing body meant to regulate the province’s doctors. Shuen was cagey in a letter defending himself, saying he had no recollection of the delivery but also disputing George’s version of the facts: “I cannot agree with her allegation,” he wrote by email. “Perhaps at the time, with the fetal heart rate dropping, and the fetal head crowning, and Ms. George pushing hard, she might not have heard me advising her that I had to do an episiotomy.”

Shuen’s apparent amnesia didn’t convince his interlocutors. “We are not satisfied,” they wrote, “that Dr. Shuen obtained Ms. George’s consent to perform the episiotomy during the course of her delivery, and as such we are extremely concerned with his approach.” They ordered Shuen to appear at the college, where he’d receive an oral caution that would both remonstrate him and instruct him on how to improve his professional behavior to avoid complaints about consent in the future.

There was no public record of what Shuen had done to George. Today, the college maintains web pages for all its member physicians, logging the status of their license to practice medicine and tallying any previous oral cautions, but in 2009, there was no public notice of the college’s cautions against doctors, leaving patients in the dark about doctors’ misdeeds. It would be another six years before those records would be made public.

Shuen’s flagrant disregard for consent was motivated not by malice but by greed. He was taking advantage of peculiarities in OHIP’s billing system, which encourage all sorts of chicanery that, while not always illegal, can tempt doctors into bending the rules. There’s a practice sometimes called “one visit, one concern,” where a doctor will only deal with one malady per appointment. So if you’ve got a lung infection and a sprained ankle, your doctor might ask that you book two appointments so he or she can bill OHIP twice. Patients who have been stable on medications for a decade might receive 60-day prescriptions from opportunistic physicians who want to cash in on additional appointment fees. Even when the government plays catch-up, tweaking the system to prevent misuse, each reform brings a new way to exploit the system, an endless game of whack-a-mole between a sluggish bureaucracy and clever physicians.

As Shuen’s practice and reputation grew, so did his ego. Over time, he became cavalier about a core tenet of medicine: patient consent

Shuen’s brush with professional ruin did little to chasten him. He had a volcanic temper, a priggish attitude with patients and nurses, and a childish vindictive streak. If Shuen couldn’t find a patient’s chart, he would retaliate against the nurses by hiding other charts, to teach them a lesson about what it’s like to have to search for one. His boss, Adrian Brown, then chief of obstetrics and gynecology at North York General, pulled Shuen into one of the back rooms of the labor and delivery ward so they’d be out of earshot of patients and nurses. As discreetly as he could, Brown told Shuen that his behavior amounted to harassment and that his anger was out of control. “I’m not as bad as I was,” Shuen replied.

By the summer of 2012, his marriage had ended. He moved out of the house but got to keep their dogs. According to Shuen, the divorce settlement left him strapped for cash, so he did the only thing he could do to reverse his fortunes: he worked. He was 65 but still in good health, and despite his bedside manner, he was in high demand. Even when he failed to save the lives of his oncology patients, their family members thought enough of him to thank him in their loved ones’ obituaries. A birth notice from one of his patients, announcing the arrival of their twins, singled Shuen out for praise. And he’d earned a reputation among Ontario’s midwives for being progressive when it came to breech births, allowing mothers to deliver vaginally instead of by C-section.

By 2014, however, Shuen was again in trouble. He’d seen a patient who had a lesion on her left labium, little white spots that turned out to be caused by Paget’s disease, a rare malignancy. Shuen recommended a partial vulvectomy. The patient was confused and scared but agreed to book the surgery if that’s what he thought was best. In the meantime, he suggested she google Paget’s disease. When she went home, she looked it up and found that it might be treated simply with a topical cream. At her next appointment, she told Shuen she wanted to cancel the surgery, which was still a month away. He told her that the cream was not an appropriate treatment for her condition, and she’d have to pay a $100 cancellation fee if she backed out of the surgery. Feeling pressured, she decided to proceed.

She had no idea what the surgery would entail, and post-op, she was shocked to discover that Shuen had cut off her left labium and her clitoris. Devastated, she complained to the College of Physicians and Surgeons. The complaints committee found that although there was nothing wrong with Shuen’s surgical technique, he’d used the threat of a $100 cancellation fee to press a vulnerable woman into a surgery she wasn’t sure about and didn’t understand. A fee is appropriate for a surgery canceled the day before, the committee said, but not a month prior. The committee issued Shuen another caution about obtaining informed consent, but there was still no public record of his censure, no way for potential patients to know how he might behave if they fell into his care. Shuen, still recovering financially from his divorce, went back to work.

But there was a problem: he could only work so much. The hospital has a policy that ob-gyns are only allowed to deliver a certain number of babies each month. The cap is based on funds allocated by the government, so to stay within the hospital’s budget, the quota is distributed among North York’s ob-gyns. Doctors like Shuen aren’t salaried from those funds—they’re more like high-powered freelancers, billing OHIP for each birth. Shuen was capped at 50 deliveries, which could present a major problem for his bank account.

So he ignored it. The volume of his deliveries alarmed his boss. Brown thought Shuen’s numbers could be contributing to potentially unsafe conditions in the labor and delivery ward. And then Shuen heard a rumor that there was a plan afoot to financially penalize doctors who were exceeding their delivery cap. He asked to speak to Brown and apologized to his boss for roaring past his quota. He admitted that he’d done it for financial reasons, maintaining his frenzied pace to make up for what he’d lost in his divorce, and agreed not to do more than 45 per month.

But if he could only deliver 45 babies a month, he’d have to make as much money as possible on each one. Being born has a price tag, and the billable amount for a delivery varies by the day of the week. For a vaginal delivery on a weekday, a doctor can bill OHIP $498.70; on a weekend, when hospitals are generally short-handed, he or she can charge $748.05. So how do you get pregnant women to give birth on Saturdays and Sundays? Shuen had a plan. He’d found a way to secretly induce his patients, causing them to go into labour on weekends.

The first time North York General nurses found a mysterious white pill in one of Shuen’s patients, they alerted Brown, but the evidence was discarded. (Brown didn’t respond to interview requests for this story.) Two years later, in August 2015, it happened again. This time, staff kept the tablet. Both times, the patients were in precipitous labor. When the second pill was discovered, Brown warned Shuen: if he was inducing patients without their knowledge, it was grounds for revocation of his hospital privileges. Worse still, it could lead to criminal charges. Shuen feigned ignorance. At a department meeting in August 2015, the hospital reminded staff that using medications to induce labor in an office setting would likely result in revocation of hospital privileges. In the face of Shuen’s denial, they figured, there was nothing else they could do.

A statistically improbable 46 percent of Shuen’s deliveries occurred on the weekend when he could bill OHIP a higher rate

In the summer of 2016, after finding yet another unknown substance in one of Shuen’s patients, Karen Yu and Lindsay Bruer decided they had to act. Nurses had been suspicious for some time, and they finally had the evidence they needed to figure out what Shuen was up to. After collecting the glove from the trash, they informed Brown, who sent the pill off to be tested by their lab, along with the one that had been found in a different patient a year earlier.

The results were conclusive: it was misoprostol. Originally developed to treat stomach ulcers, misoprostol also softens the cervix and can cause contractions. Today, it’s half the recipe for a medical abortion (the other ingredient is usually mifepristone). Disturbingly, some doctors, like Shuen, use it to induce labor, which is against North York General policy, and it’s the subject of a Food and Drug Administration black-box label warning for pregnancy induction. The FDA cautions doctors that they have no scientific proof that misoprostol is safe and effective, and offers a list of serious side effects, including a torn uterus, which might lead to severe bleeding, the need for a hysterectomy, or the death of the mother or baby. The warning goes on: “UTERINE RUPTURE HAS BEEN REPORTED WHEN ADMINISTERED TO PREGNANT WOMEN TO INDUCE LABOR.”

Shuen had put the lives of every woman he’d surreptitiously induced, and the lives of their babies, in mortal danger. On August 18, he was summoned into a meeting with senior officials from North York General, including one of its vice-presidents and Brown, who was all too familiar with Shuen’s autocratic ways. They confronted Shuen about the white powdery pill. Did he know anything about it, they asked him, and had he ever given induction medication to a patient in his office? Absolutely not, he said.

Brown and his team had looked over the delivery numbers and cross-referenced them by day of the week. The data shocked them. In the 2015–16 fiscal year, Shuen delivered 696 babies—more than anyone else at the hospital. At an average of 58 per month, he’d violated the hospital’s delivery cap. But what was far more alarming was that a statistically improbable 46 percent of Shuen’s deliveries occurred on a weekend, when he could bill OHIP the higher rate.

In the face of Shuen’s lies, the executives advanced inexorably on him. They had tested the tablet, they said, and they knew it was misoprostol. They had also interviewed the most recent patient, who said she’d never consented to induction. Shuen knew he’d been caught. Still, he denied everything. Nervously, he said he’d have to check his notes. Now was the time, to be honest, they told him.

This all seemed a little dramatic, Shuen said, given all his years of honorable service. He asked what would happen if he apologized and promised never to do it again. Finally, he admitted the truth: okay, yes, he had induced women with misoprostol, and he’d been doing it for years. But it was safe, he said, and in fact, he was responsible for more healthy births than his colleagues. It wasn’t harming anyone. It was helping women, even. He says he even trained another doctor to do it. “Why don’t you go after him?” he asked. “Everyone knows that I do it,” he added, though he later retracted that comment.

Brown thanked Shuen for admitting what he’d done. But, he said, it was impossible to know that Shuen’s patients hadn’t been hurt by his actions because Shuen didn’t keep any records of the outcomes of his illicit inductions or even which patients had been induced. I spoke to a detective about the criminal liability Shuen could face. There’s criminal negligence, assault, assault causing bodily harm, administration of a noxious substance and even homicide if one of the mothers or babies in Shuen’s care had died during or after childbirth.

The hospital revoked Shuen’s privileges, made him hand over his ID badge and forbade him from contacting any of his patients. It referred Shuen to the discipline committee of the College of Physicians and Surgeons, which had sweeping powers to investigate him, apply for search warrants and even end his medical practice.

Three days later, Shuen emailed Brown. “I have done a great deal of soul-searching since Thursday and can now see the seriousness of my mistakes,” he wrote. “So I write in a spirit of sincere remorse and full responsibility for what I have done. You were right to warn me before, and I do not blame you for calling the disciplinary hearing, which I deserved. I have no desire or intention to fight the hospital’s ruling.” He asked for six months to care for his current load of patients, promising to stop taking on new ones and to retire when the period was up. “If you sense that there might be such a possibility, for the sake of my patients and maybe in recognition of the good I have done over the years in spite of my mistakes, please let me know how I might proceed.”

Brown refused Shuen’s offer, and the next day, Shuen resigned from the hospital that had been his home since 1987. He framed it as a retirement, and U of T’s ob-gyn newsletter wrote up a sweet valediction for him. “After a long and prestigious career in ob-gyn and gyn-oncology, Dr. Paul Shuen retired from active staff at NYGH at the end of 2016. His surgical training of residents was exemplary, and dozens have benefited from his tips and techniques over the years.” The note didn’t mention that he was under investigation by the College of Physicians and Surgeons’ discipline committee, which had empowered 16 investigators to pore over every aspect of Shuen’s disgraced practice.

The lead medical inspector was Jon Barrett, a top obstetrician at Sunnybrook Hospital whose resumé runs 33 pages. A devout Jew who frequents the meditation and prayer room at Sunnybrook, Barrett still thinks of each birth as a genuine miracle. He interviewed Shuen on April 3, 2017, in the sixth-floor boardroom at the college’s headquarters on College Street.

Barrett began with a note of humility and deference. “I just want to start off saying this is difficult for me because of the respect that I have for you—of your history in the city; it’s well known. And I just wanted to put that out front at the beginning.”

Then Barrett unraveled Shuen. He asked him how long he’d been using the misoprostol on patients without their consent, and Shuen admitted that it was for quite a few years. Misoprostol hadn’t been around that long, though, Barrett noted. Had he used anything else before that? Yeah, Shuen said. Before that he used prostaglandin. How did he determine the dosage? He only used a little bit of each pill, Shuen said, to make sure it was safe. So he cut the pill in half, along the groove, then he cut it again, where there isn’t any groove, and then, eyeballing it, he scratched it down until he decided the dosage was safe. Why do you think you did this, Barrett asked. “Okay. It’s—it’s because I want to—I wanted to bypass the hospital; that’s basically it.” It was a way to cut through all that Canadian health care red tape. If you booked a patient for induction, sometimes they’d have to delay it or cancel it outright, because the hospital was too busy. He was doing them a favor.

Barrett wasn’t buying it. He sent a report to the college in June 2017. He could only prove that Shuen had given the drug to two women, the ones from whom the pills were recovered and tested. By not keeping a record of the misoprostol on the patient’s chart, Shuen effectively kept his actions not only from his patients and colleagues but also from any future investigators, like Barrett.

Nevertheless, Barrett decided that what he found bordered on assault. “It is my unfortunate conclusion,” he wrote, “that Dr. Shuen fell below the standard of care in his practice of obstetrics by inserting induction agents into patients who had no indication for induction, in an outpatient setting, without their knowledge or consent. As a result of his actions, harm was likely being caused to his patients, either in the form of unnecessary Caesarean section, or perhaps worse. The extent of the harm it caused is difficult [to determine] due to the lack of record-keeping and difficulty in knowing exactly which patients were affected.”

As to why Shuen did it, Barrett decided: “I cannot conclusively know the reason for Dr. Shuen’s actions; however, the practice of inducing labor on the night that he is on call for pecuniary reward remains high in my suspicion. The cluster of deliveries during Dr. Shuen’s shift, in my opinion, defies coincidence.”

Shuen had gambled with so many lives, risked his own legacy and lost everything. And he did it all for the money—a couple of hundred bucks more per birth. On June 25, 2018, the College of Physicians and Surgeons ordered Shuen to pay more than $40,000 in costs and revoked his license to practice medicine in Ontario. For the first time, they posted a notice that Shuen was a danger to the public, on the very day he could no longer do any harm. A brief summary of the committee’s findings and their admonishment went live on Shuen’s page on the college’s website. “It would be an understatement to say how disappointed this committee is with the totality of your professional misconduct,” the discipline committee wrote in a public reprimand. “We speak for the public and the profession in stating that your actions were self-serving, damaging to the public and the profession, and were dishonest and distasteful….Your conduct during the investigation by the hospital and the college was disgraceful, dishonorable and unprofessional….You acted as though you were above the law.”

I was assigned this story not long after that first—and last—public warning against Shuen went live. I read the brief summary of Shuen’s misdeeds, but I wanted to see more than just the verdict, so I asked the college for access to the supporting documents that were entered into evidence against Shuen. I do this all the time in the civil and criminal cases I cover. It’s the only way to know what happened and whether justice was served.

A very odd disclosure process ensued, unlike anything I’ve ever seen from a court. Toronto Life had to bring a formal legal motion before the college to see the documents. In civil and criminal courts, all you have to do is ring up the court office. Not so with doctors. Two weeks after we filed the motion, Shuen’s lawyers filed a response on his behalf. Naturally, they sought to block our access to the material. The lawyer for the college also got to weigh in; she opposed allowing us access to several exhibits, including Shuen’s interview with Barrett, Shuen’s delivery statistics and even an excerpt from the Regulated Health Professions Act, the legislation that empowers the college (which is freely available on the Internet).

It turns out that it’s easier to see the evidence against a murderer than the evidence against a doctor in Toronto. Toronto Life’s lawyer then had to file a formal response to Shuen’s lawyers, arguing that the open court principle should apply to the College of Physicians and Surgeons’ discipline committee hearings. The magazine spent thousands on legal fees to find out exactly what Shuen had done. As the fight dragged on, I asked North York General if they were undertaking any larger investigation into the potentially hundreds, maybe even thousands, of mothers and babies whose lives Shuen had gambled on, like human roulette wheels. All they’d say is this: “The hospital also reviewed clinical documentation from 2011 to 2016 and did not find evidence of adverse maternal or neonatal outcomes.” I reached out to Shuen, who declined interview requests through his lawyer. And I asked the Ministry of Health and Long-Term Care if there was any fraud investigation related to Shuen’s billing. One of their communications representatives said the ministry couldn’t share details about the review of any individual physician. Eight weeks after we’d filed our formal motion with the college, yet another lawyer, an independent legal counsel, weighed in on our request, and it was finally granted. We were allowed to find out what Shuen had done.

Among the details released to us, we learned that Shuen had been abusing his access to prescription medication. Looking for the source of the misoprostol, the college obtained the records of everything Shuen had prescribed for himself from the Shoppers Drug Mart on the ground floor of his office building, under the pretense of it being “for office use only.” The list included something for a sour stomach and something for acid reflux and something else for irritable bowel syndrome, and then something much stronger for anxiety, for depression. And he needed sedatives, maybe to help him close his eyes and quiet his brain and turn off that restless part of himself that he might still dare call his conscience. It must have been so hard for him to sleep.