Health Care Complaints Commission v Sallam

Health Care Complaints Commission v Sallam - [2018] NSWCATOD 161 - NSWCATOD 2018 case summary — Zoe

[3]

Complaint No. 1

The first complaint alleges that the respondent is guilty of unsatisfactory professional conduct under s 139B (1) (a) and/or (l) of the National Law, in that the practitioner has engaged in conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience; and/or has engaged in improper or unethical conduct relating to the practice of medicine. The complaint alleges that each of the particulars relied upon justifies a finding of unsatisfactory professional conduct or in the alternative if taken together, constitute unsatisfactory professional conduct.
The particulars relied upon relate to 19 patients who are identified in the complaint. In respect of each patient, it is alleged that the practitioner, in separate periods has prescribed Schedule 8 drugs to the relevant provisions of the Poisons and Therapeutic Goods Regulation 2008 (the PTG Reg); and contrary to sections of the Poisons and Therapeutic Goods Act 1966 (NSW) (the PTG Act), in circumstances where the practitioner had formed or reasonably had formed the opinion that the relevant patient was a drug dependent person.
The particulars in respect of each complaint allege that the practitioner prescribed drugs to 19 patients in circumstances which did not accord with clause 37 of the PTG Regulation in that the practitioner held no authority to prescribe such drugs. It is further alleged with respect to some of the 19 patients that the practitioner prescribed drugs of addiction to a drug dependent person within the meaning of s 27 of the PTG Act.
The specific allegations against each patient are described in the Schedule attached to the end of this decision. Since there is some variation between the particulars alleged, it is necessary to repeat the particulars for each of the 19 patients concerned. However, subject to the allegations in respect of particular 7 (b) relating to Patient D (which was not resolved by the evidence) and particular 9 (b) to Patient F (which was not pressed), all other particulars in Complaint 1 are admitted.

[9]

Practitioner's explanation

The practitioner states that he takes full responsibility for his inappropriate prescribing, and offers the following explanation: "During the time I practised in Egypt in general practice I did not prescribe the drugs listed in Schedule 8 or Schedule 4. They were not prescribed in general practice in Egypt. Paracetamol; ibuprofen or aspirin can be obtained over the counter at pharmacies. A GP cannot prescribe any stronger analgesics as they are not available in Egypt. During the time I spent in the Australian hospital system - August 2004 to April 2008, I did not receive any training or education about the regulatory system concerning the prescribing of Schedule 8 drugs. Nor did I encounter the issue during my studies for College Fellowship. Consequently I had little experience or knowledge of Schedule 8 and Schedule 4 medications when I commenced practising in Taree. I have never really received any specific education in relation to schedule 8 medications. I only needed 1 year of supervised general practice experience in Australia to be eligible to sit the Fellowship exams. As an IMG, I was subject to the 10 year moratorium in respect of my provider number from Medicare which meant I needed to work in an area of need supervised position in a rural area. Dr Nguyen was my supervisor and mentor. He has been before a Tribunal for inappropriate prescribing of Schedule 8 medications and is subject to a decision dated 30 May 2018. Whilst this is not an excuse for my conduct, it is the context in which it occurred. I first became aware of the need to apply for authorities when I was interviewed in February 2015 by Mr Batty and Mr Smith from the Pharmaceutical Services Unit. I stopped prescribing Schedule 8 drugs on 10 April 2015. When I appeared before the s 150 delegates on 10 April 2015, I instructed my counsel to inform the delegates that I was willing to surrender my rights to do so. The delegates made an order in those terms and I surrendered my prescribing rights to the PSU later that day. My approach to Schedule 8 drugs was that if a patient was being prescribed drugs by another general practitioner or specialist I would continue to do so. I naïvely believed that the treating medical practitioners work together as a team and that I could rely on what previous treating practitioners had done."

[12]

PATIENT B 2. Between 6 February 2014 and 16 October 2014, the practitioner prescribed the schedule 8 drug Alprazolam to Patient B in the quantities set out in the schedule attached and marked B: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals for specialist assistance in relation to Patient B's long-term benzodiazepine use; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in thecircumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe a type B drug of addiction incircumstances where the period of prescribing exceeded two months,contrary to section 28(2) of the PTG Act; e. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient B was a drug dependant [sic] person; and f. without recognising and responding appropriately to Patient B's drug- seeking behaviour. 3. Between 11 July 2012 and 16 October 2014, the practitioner prescribed the schedule 4D drugs Temazepam and Diazepam to Patient B in the quantities set out in the schedule attached and marked B: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referral for specialist assistance in relation to Patient B's long-term benzodiazepine use; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in thecircumstances, contrary to clause 34 of the PTG Reg; d. without recognising and responding appropriately to Patient B's drug-seeking behaviour; and e. in an inappropriate combination with Alprazolam, a schedule 8 drug of addiction, as set out in the schedule attached and marked B .

Patient B: Expert Opinion: no record of assessment; had a history of schizoaffective disorder but no letter of referral from practitioner to a psychiatrist requesting opinion about appropriate management; incorrect prescribing in respect of appropriate therapeutic purpose; large quantity of medication provided over a long period of time and potentially inconsistent medication which could result in increased sedation and overdose; failure to understand drug dependence including legal issues and convictions notes do not refer to any consideration of interaction between alprazolam and temazepam, nor between these benzodiazepines with other medications particularly method and that the patient was receiving through an opiates treatment program; no documentation of a satisfactory history or physical examination; referral to psychiatrist who found no psychiatric issues; temazepam and alprazolam were prescribed regularly in the period from 16 October 2012 to 16 October 2014 and diazepam intermittently;

[13]

PATIENT C 4. Between 14 August 2014 and 20 February 2015, the practitioner prescribed the schedule 8 drugs Buprenorphine, Fentanyl, to Patient C in the quantities set out in the schedule attached and marked C: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; g. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; b. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed theopinion that Patient C was a drug dependant [sic] person; and c. without recognising and responding appropriately to Patient C's drug-seeking behaviour. 5. Between 1 December 2014 and 20 February 2015, the practitioner prescribed the schedule 8 drugs Codeine Phosphate, Codeine Phosphate Linctus and Oxycodone to Patient C in the quantities set out in the schedule attached and marked C: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; c. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient C was a drug dependant [sic] person; and d. without recognising and responding appropriately to Patient C's drug- seeking behaviour. 6. Between 29 August 2014 and 11 February 2015, the practitioner prescribed the schedule 4D drugs Temazepam and Diazepam to Patient C in the quantities set out in the schedule attached and marked C: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate follow up after specialist referral; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in thecircumstances, contrary to clause 34 of the PTG Reg; d. without recognising and responding appropriately to Patient C's drug-seeking behaviour; and e. in an inappropriate combination with schedule 8 drugs of addiction, as set out in the schedule attached and marked C.

Patient C: Expert Opinion: no documentation of assessment to justify continued medications; complex medical issues but little detail in notes concerning assessment of each drug prescribed and whether it met the therapeutic purpose; scripts provided too frequently and dosage was excessive.

[28]

PATIENT R 22. Between 26 May 2010 and 23 February 2015, the practitioner prescribed the schedule 8 drug Pethidine Hydrochloride to Patient R in the quantities set out in the schedule attached and marked R: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals to a neurologist drug and alcohol services; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without an authority to prescribe a type B drug of addiction in circumstances where the period of prescribing exceeded two months, contrary to section 28(2) of the PTG Act; e. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient R was a drug dependant [sic] person; and f. without recognising and responding appropriately to Patient R's drug-seeking behaviour. 23. Between 26 May 2010 and 23 April 2014, the practitioner prescribed the schedule 4D drug Diazepam to Patient R in the quantities set out in the schedule attached and marked R: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. without appropriate referrals for specialist assistance; c. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; d. without recognising and responding appropriately to Patient R's drug- seeking behaviour; and e. in an inappropriate combination with schedule 8 drugs of addiction, set out in the schedule attached and marked R .

Patient R: Expert Opinion: practitioner prescribing Pethidine Hydrochloride and diazepam from May 2010 to February 2015; record of long history of migraines only responsive to Pethidine and Valium IM; no detail of any assessment in subsequent notes but rather regularly recorded "repeat scripts filled"; no apparent consideration to the fact that the patient was already on opiates and benzodiazepines; referral to neurophysiologist to assess management of migraines but nothing directly addresses the prescribing of pethidine or diazepam; dosage excessive; no authority for S8 medication prescriptions; notes inadequate containing few details of history, examination findings, opinions, diagnoses, management advice, medication instructions, treatment goals or plans.

[29]

PATIENT S 24. Between 4 November 2012 and 25 March 2014, the practitioner prescribed the schedule 8 drugs Fentanyl and Oxycodone to Patient S in the quantities set out in the schedule attached and marked S: a. in an inappropriate quantity that did not accord with the recognized therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; b. without an authority to prescribe drugs of addiction to a drug dependant [sic] person, contrary to section 28(3) of the PTG Act, in circumstances where the practitioner had formed, or ought reasonably to have formed the opinion that Patient S was a drug dependant [sic] person; and c. without recognising and responding appropriately to Patient S's drug- seeking behaviour. 25. Between 21 January 2013 and 31 October 2014, the practitioner prescribed the schedule 4B and 4D drugs Testosterone and Mesterolone and the schedule 4 drugs Tamoxifen and Human Chorionic Gonadotrophin to Patient S in the quantities set out in the schedule attached and marked S: a. without performing an appropriate and adequate medical assessment prior to issuing the prescriptions; b. in an inappropriate quantity and for a purpose that did not accord with the recognised therapeutic standard of what is appropriate in the circumstances, contrary to clause 79 of the PTG Reg; and c. without recognising and responding appropriately to Patient S's drug-seeking behaviour.

Patient S: Expert Opinion: from January 2013 to 31 October 2014 the practitioner prescribed anabolic steroids and restricted substance to patient on 38 occasions; history of patient taking anabolic steroids for bodybuilding purposes; following motor vehicle accident on 30 July 2013, practitioner commenced to regularly prescribe oxycodone and on one occasion, fentanyl; length of time for such prescriptions fell below appropriate standards; dosage of oxycodone was high and continued longer than recommended; no authority; notes brief containing few details of history, examination findings, opinions, diagnoses, management advice, medication instructions, treatment goals or plans especially relating to the monitoring of the effects of anabolic steroids. The practitioner ceased the oxycodone medication in March 2014 but continued to prescribe steroids until October 2014.
The practitioner was subjected to extensive cross examination over two days. As a result of that cross examination, and of the material provided to the Tribunal, the Tribunal concurs with the opinion of Dr Eldridge that in virtually every instance, the conduct of the practitioner fell significantly below the standards of acceptable practice for a medical practitioner.

[30]

FINDINGS

The practitioner failed to demonstrate and apply appropriate clinical acumen in respect of the patients who are the subject of this enquiry. This is evident, for example, from the fact that the practitioner took guidance from a patient, who was relaying advice from the patient's personal trainer. The practitioner accepted the direction of the patient and on this basis, the practitioner provided prescriptions for anabolic steroids, hormonal and other treatments for non-therapeutic purposes. On some occasions, such drugs were administered to the patient. On other occasions, the practitioner permitted the patient to administer the substances themselves.
On many occasions, the practitioner was prepared to prescribe medication solely on the basis that a previous practitioner had provided such treatment. The practitioner did not appear to bring any independent decision-making as to the appropriateness of the treatment.
The practitioner demonstrated that he frequently accepted, without question, complaints of pain or discomfort from patients and was willing to prescribe painkilling medication, oftentimes in high doses and quantities.
The records maintained by the practitioner do not disclose that he carried out comprehensive and appropriate clinical assessments of his patients.
The practitioner's naïveté in the role of prescription medication in substance use disorders was evident in the majority of the patients who were the subject of these proceedings and were under his care. The practitioner was unable to discern drug seeking behaviour in circumstances which should have triggered a high degree of suspicion. The practitioner was unaware that the drugs he prescribed could have been diverted into the illicit drug market. The practitioner displayed a poor knowledge of the opiate treatment program, believing it to be a self-referral system only, and that the program did not apply to prescription medication abuse.
Whilst the practitioner appears to now have an improved knowledge of opiate pharmacology, it remains imperfect. For example, he displayed an inadequate understanding of opiate cross-tolerance. Further, the practitioner prescribed pethidine when such medication was already considered an inappropriate practice. Several patients were also permitted to take away from the practice large quantities of opiates for injection by themselves or by their partner.
The practitioner displayed an ignorance in the prescription of more common medications, in their indication, dosage and monitoring. For example he prescribed Lasix for side effects related to the administration of anabolic steroids, without consideration of that drug's potential for adverse effects, and at a dosage higher than would have been appropriate.
The practitioner's medical records of his patients were inadequate, in that they failed to provide a comprehensive history of the patient and of the patient's medical condition, and did not disclose any management plan. Often the patient records provided no indication that the practitioner had provided an appropriate physical examination.
The practitioner failed, when referring patients to a specialist, to provide the necessary detail in the referral sufficient to describe the patient's background, condition and especially medication history. Failure to provide a comprehensive background potentially exposed other medical practitioners to the risk of harm. For example, the failure to disclose that a patient had a history of drug abuse and was therefore at risk of hepatitis C and HIV might have exposed health workers to risk.
Whilst demonstrating a capacity to recognise suicide risk, in some cases, the practitioner displayed an unsound and potentially dangerous prescribing habit; specifically in patient H, who had a number of risk factors for completed suicide. The practitioner provided a prescription of a potentially lethal quantity of oxycodone (OxyContin).
The practitioner demonstrated that he possessed a wholly inadequate knowledge of the regulatory requirements for the prescription of Schedule 8 drugs and of Schedule 4 medications.
In relation to the practitioner's clinical notes pertaining to Patient B, there was discussion regarding the practitioner's prescription of alprazolam for panic. The practitioner indicated that pharmacotherapy was the mainstay of his treatment for panic which the Tribunal considered inadequate and failed to meet appropriate standards.

[32]

CONSIDERATION

The jurisdiction exercised by the Tribunal is protective. Section 3A of the National Law requires that the "protection of the health and safety of the public must be the paramount consideration" when considering an application to practise medicine. Inherent in such a requirement is that the applicant must be considered to be a "fit and proper person" to practise. In Australian Broadcasting Tribunal v Bond (1990) 94 ALR 11 at [56] (Toohey and Gaudron JJ), when speaking of the risk of a possible recurrence of a failure to observe the standards, said: "The question may be whether it can be assumed that it will not occur, or whether the general community will have confidence that it will not occur. The decision stated that there may be sufficient ground to make a finding that a person 'is not fit and proper to undertake the activities in question'."
For other examples, confirming the protective nature of the jurisdiction, see for example Health Care Complaints Commission v Do [2014] NSWCA 307 at [35] where Meagher JA said: "The objective of protecting the health and safety of the public is not confined to protecting the patients or potential patients of a particular practitioner from the continuing risk of his or her malpractice or incompetence. It includes protecting the public from the similar misconduct or incompetence of other practitioners and upholding public confidence in the standards of the profession. That objective is achieved by setting and maintaining those standards and, where appropriate, by cancelling the registration of practitioners who are not competent or otherwise not fit to practise, including those who have been guilty of serious misconduct. Denouncing such misconduct operates both as a deterrent to the individual concerned, as well as to the general body of practitioners. It also maintains public confidence by signalling that those whose conduct does not meet the required standards will not be permitted to practise."
The Tribunal considers that in this instance the repeated prescription of drugs of addiction, especially without authority, is serious, constituting not only unsatisfactory professional conduct but also professional misconduct. The observations of the Tribunal in Health Care Complaints Commission v Chen [2016] NSWCATOD 144, at [137], are pertinent, when the Tribunal said (inter alia): "Medical practitioners are in a unique position in enabling members of the public to have access to drugs of addiction and the community is entitled to rely on the integrity and professional expertise of medical practitioners to avoid creating drug addicts and to avoid feeding the habits of drug addicts. This is not necessarily an easy task, but there are well-recognised protocols for the administration of drugs of addiction and well-recognised resources to assist medical practitioners in treating their patients. The respondent clearly failed in all of these areas and did not display any initiative or insight in meeting the challenge which she says she perceived she had when dealing with this cohort of patients. This is a most serious matter and calls into question the ability of the respondent generally to practice [sic] medicine safely."
Unsatisfactory professional conduct of a practitioner can extend to professional misconduct, as such term was considered by the NSW Court of Appeal in Chen v Health Care Complaints Commission [2017] NSWCA 186, especially at [19]-[20], [23], and [75]. See also Health Care Complaints Commission v Karalasingham [2007] NSWCA 267; Sabag v Health Care Complaints Commission [2001] NSWCA 411 at [42].
For other instances of conditions concerning the need to protect the public: see Health Care Complaints Commission v Litchfield (1997) 41 NSWLR-630 and for the maintenance of standards: see Gayed v Walton [1997] NSWSC 297; Prakash v Health Care Complaints Commission [2006] NSWCA 153 at [91]; Health Care Complaints Commission v Howe [2010] NSWMT 12 at [113]; Health Care Complaints Commission v Iskander [2015] NSWCATOD 30.
In instances of improper prescription of drugs, the following discussion in Spicer v NSW Medical Council (unreported, NSWCA, 19 February 1981) is relevant: "In my opinion, it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard for the law, it cannot be said that he is fitted at such a time to be a medical practitioner. In my opinion, the view expressed by the Tribunal has implicit in it that not merely was he presently unfitted to treat those addicted or habituated to drugs but that unfitness in itself demonstrated his present unfitness to be a medical practitioner."
Taking these considerations into account, the Tribunal must determine what measures must be taken to protect potential patients should it determine that, contrary to the submissions made by the applicant; the practitioner is permitted to practise under conditions.
The practitioner has urged the Tribunal to reinstate his right to practise subject to conditions similar to those imposed by the Medical Council, which effectively restricted his prescribing of opiates.
The practitioner states that whilst he was in the Australian hospital system from August 2004 to April 2006 he received no training or education concerning the prescribing of Schedule 8 drugs and that he had little experience or knowledge of Schedule 8 and of Schedule 4 medications when he commenced practising in Taree. The practitioner obtained his Fellowship through the Practice Pathway program and did not have the benefit of the training provided through the GP registrar training program. His statement continues: "I have never really received any specific education in relation to schedule 8 medications. I only needed 1 year of supervised general practice experience in Australia to be eligible to sit the Fellowship exams. As an IMG, I was subject to the 10 year moratorium in respect of my provider number from Medicare which meant I needed to work in an area of need supervised position in a rural area. Dr Nguyen was my supervisor and mentor. He has been before a Tribunal for inappropriate prescribing of schedule 8 medications and is subject to a decision dated 30 May 2018. Whilst this is not an excuse for my conduct, it is the context in which it occurred. I first became aware of the need to apply for authorities when I was interviewed in February 2015 by Mr Batty [sic] Battye and Mr Smith from the Pharmaceutical Services Unit. I stopped prescribing Schedule 8 drugs on 10 April 2015. When I appeared before the s150 delegates on 10 April 2015, I instructed my counsel to inform the delegates that I was willing to surrender my rights to do so. The delegates made an order in those terms and I surrendered my prescribing rights to the PSU later that day."

[33]

CONCLUSION

The Tribunal is satisfied that the conduct of the practitioner, referred to in Complaint One and Complaint Two constitutes professional misconduct as alleged in Complaint Three. The Tribunal finds the explanation of the practitioner that he was unaware of the need to have authorisation to prescribe Schedule 8 drugs to be credible, despite his considerable experience in Australia. Irrespective of such finding the circumstances demonstrate a gross failure on the part of the practitioner to inform himself of the requirements for prescribing Schedule 8 drugs and Schedule 4 medications.
As a consequence, there has been a flagrant breach of the National Law. The Tribunal acknowledges that such conduct was not performed with illegal intent: the practitioner was simply oblivious to the statutory requirements. But the practitioner should have known them, and the ignorance of the practitioner reflects very adversely upon his competence to practise medicine.
Further, the Tribunal is satisfied that the practitioner's approach to his patients was deficient, in that no comprehensive clinical assessments appear to have been made prior to prescribing medication and repeats the findings already made concerning the inadequacy of his approach to treatment of patients, especially those with drug seeking habits. These matters in themselves constitute unsatisfactory professional conduct.
In Pillai v Messiter (No.2) (1989) 16 NSWLR 197, Kirby P at 200 said: "Departures from elementary and generally accepted standards, of which a medical practitioner could scarcely be heard to say that he or she was ignorant could amount to such professional misconduct. But the statutory test is not met by mere professional incompetence or by deficiencies in the practice of the profession. Something more is required. It includes a deliberate departure from accepted standards or such serious negligence as, although not deliberate, to portray indifference and an abuse of privileges which accompany registration as a medical practitioner."
At 201 Kirby P said: "The public needs to be protected from delinquents and wrong-doers within professions. It also needs to be protected from seriously incompetent professional people were ignorant of basic rules or indifferent as to rudimentary professional requirements. Such people should be removed from the register or from the relevant roller practitioners, at least until they can demonstrate that their disqualifying imperfections have been removed."
The Tribunal considers that the observations of Kirby P are entirely appropriate and applicable in the complaints now before it.

[34]

DISCIPLINARY SANCTIONS

The Tribunal has received the practitioner's evidence concerning attempts that he has made to inform himself, and repeats the relevant portion of the practitioner's statement to the Tribunal as follows: In June 2017 my legal representatives forwarded my S40 response to the HCCC. On page 2 of that letter they listed a number of courses I had completed which had been offered by my insurer. They also listed some publications I had read which I found particularly helpful. As noted, I have completed: a) Avant's risk IQ course 'Doctor Shoppers, the law and addiction; prescribing drugs of dependence'; b) Avant's risk IQ course 'Gathering Diagnostic Information'; c) Avant's risk IQ course 'Prescribing perils: opioids, polypharmacy and medication errors'; d) Avant's risk IQ course 'Prescribing: principles and practices'; e) Avant's risk IQ course 'Consent: the key issues'; f) Avant's risk IQ course 'Common Medico-Legal Issues for General Practitioners'; g) Avant's risk IQ course 'On the record: medical records and documentation'; and h) Avant's risk IQ course 'Chaperones: intimate examinations and cultural sensitivities' and read: i) Prescribing Drugs of Dependence in General Practice, Part A and Part B, published by RACGP, Melbourne and edited by Dr Evan Ackermann (Chair, RACGP National Standing Committee for Quality Care; University Medical Centre, Southern Cross University, Queensland) published on the Royal Australian College of General Practitioners' website; and j) Opioid use in chronic non-cancer pain written by Dr Simon Holliday (GP in Taree and staff specialist Drug and Alcohol Clinical Services), Dr Chris Hayes (Director of Hunter Integrated Pain Service) and Dr Adrian Dunlop (Area Director and staff specialist Drug and Alcohol Clinical Services) Since that time I have undertaken the following educational activities: k) 'Over-The-Counter Codeine Use' through the Australian Doctor Education on 10 April 2018; l) 'Managing Knee Osteoarthritis - A Review Of Non-Surgical Options', mdBriefcase on 2 April 2018; m) 'The GP's Role In Maximising Quality Of Life For Patients With Chronic Non-Cancer Pain', mdBriefcase dated 2 April 2018; n) 'Optimising The Function Of Older Patients With Chronic Non-Cancer Pain: The Importance Of A Tailored Approach To Assessment And Treatment', mdBriefcase on 2 April 2018; o) 'Effective Management Of Low Back Pain With A Neuropathic Component', mdBriefcase on 31 March 2018; p) 'Codeine Rescheduling And Chronic Pain Management' by ThinkGP on 2 April 2018; q) 'Management Of Chronic Non-Cancer Pain In Older Patients' by ThinkGP on 31 March 2018; r) 'SPOT Clinical Audit: Safety Prescribing Opioid Treatment' by ThinkGP on 2 April 2018; and s) 'Wholistic Management of Chronic Non-Cancer Pain', General Practice Conference by GPCA on 19 and 20 May 2018."
The practitioner also states that he has undertaken online courses through Avant's Risk Advisory Service, namely: 'Doctor shoppers'; The Law and Addiction; Prescribing Drugs of Dependence; Prescribing Perils: Opioids, Polypharmacy and Medication Errors; Prescribing Perils Part 2: Drugs of Dependence; Prescribing: Principles and Practices. He has also completed the course entitled Gathering Diagnostic Information. All these courses were undertaken in October 2015.
Despite the courses undertaken, the Tribunal does not consider that they will provide the necessary educational standard required for the practitioner. The Tribunal notes that most of the courses recently undertaken by the practitioner were completed online. Whilst the practitioner professed to have an improved knowledge from the courses he has undertaken, the Tribunal was concerned that adequate learning was not reflected in his responses.. Rote learning and formulaic reponses which were displayed by the practitioner but there was no evidence to show that the practitioner was able to use the theoretical knowledge in his clinical practice.
A course which should be undertaken by the practitioner is the Vocational Training Program conducted by the Royal Australian College of General Practitioners or a similar course.
Furthermore the practitioner is in need of an experienced mentor to monitor and assist the practitioner in his daily practice. Such mentor should not be involved in the Medisense practice.
The practitioner should undertake intensive courses directed to mental health, addiction medicine, and pain management to improve his knowledge and practical skills at a higher level, and preferably where lectures and presentations are provided, and learning formally assessed. He may also benefit from the involvement of a psychologist (or other like professional) with the aim of improving his capacity to resist patients' inappropriate demands whilst maintaining an emphatic balance of clinically indicated assistance.
The issues raised in the above three paragraphs will be of critical importance in any future application by the practitioner for re-registration. He will need to be able to demonstrate that he has taken effective measures to overcome the deficiencies referred to in this decision. The proposals suggested by the Tribunal in the paragraphs above will be relevant to any future application.
The Tribunal considers that, whilst the practitioner sought a reprimand and that conditions be imposed on his right to practise, such sanctions would be inadequate for the protection of the public. The Tribunal is satisfied that nothing short of cancellation of the practitioner's registration is required.
These proceedings were clearly necessary, as is admitted by the practitioner. In these circumstances, the practitioner should be ordered to pay the applicant's costs of the proceedings: see Health Care Complaints Commission v Philipiah [2013] NSWCA 342 at [42].

At a glance

Court

Decision date

Before

Catchwords

Source

Catchwords

Judgment (36 paragraphs)

Parties

Legislation Cited (2)

Cases Cited (15)