• the respondent had inappropriately prescribed medication to patients exposing them to risk; failed to obtain informed consent from patients before prescribing medication which was experimental or not approved by the Therapeutic Goods Administration; failed to keep adequate records; and, in addition, breached the relevant Code of Conduct; and
• a period of suspension is not necessary as the protection of the public and the maintenance of public confidence in the profession will be achieved by the other sanctions proposed by the Board.

Health practitioners - Complaint by the Medical Board of Australia - Professional misconduct - Inappropriate prescribing, failure to obtain informed consent and inadequate record-keeping - Conditions imposed on registration, fine imposed, and reprimand

Health Practitioner Regulation National Law (South Australia) Act 2010 ss 193, 196

Medical Board of Australia v Singh [2017] WASAT 33 (S)

Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545

Pursuant to s 60 of the South Australian Civil and Administrative Tribunal Act 2013 (SA) the publication of the names of, or anything tending to identify, patients referred to in this decision have been prohibited.

Order Imposing a Condition on Practitioner's Registration

Made under the Health Practitioner Regulation National Law (South Australia) Act 2010

Made under the Health Practitioner Regulation National Law (South Australia) Act 2010

1. This is the determination of a complaint filed with the Tribunal on 23 August 2019 by the Medical Board of Australia (the Board) pursuant to s 193 of Schedule 2 to the Health Practitioner Regulation National Law (South Australia) Act 2010 (the National Law), concerning Dr Mario Marzola.
2. The complaint alleged that Dr Marzola had engaged in professional misconduct by prescribing medication where there was no evidence of therapeutic benefit; that put the health of patients at risk; and without the informed consent of patients where the medication had not been approved by the Therapeutic Goods Administration. These allegations were made in relation to the treatment of eight patients who Dr Marzola had treated over different periods, all between 2005-July 2017. Two of these complaints were not pursued at the hearing of this matter in relation to two patients (identified as KO and PM).
3. Dr Marzola's initial response acknowledged professional misconduct, but stated that he had believed there was therapeutic benefit in the prescribing of the medication in each case; that the prescribing had not placed the health of any patients at risk; and that there had been no reports of any adverse outcome. In addition, Dr Marzola believed he had informed consent in each case, and he had not been aware that the medications prescribed had not been approved by the Therapeutic Goods Administration or that they were regarded as experimental.
4. Dr Marzola subsequently accepted that he had not maintained adequate records, and that he had not sufficiently informed himself concerning the prescribed medication. He advised he had stopped prescribing the medication in issue between March 2013 and March 2016.
5. At the hearing of this complaint, the Tribunal had before it an Agreed Statement of Facts, two hearing books, a reflective letter from Dr Marzola dated 1 September 2020, and two reports from an expert witness, Professor Wittert, dated 18 July 2018 and 24 June 2020. The Tribunal takes all these documents into account, as well as others tendered at the hearing and written and oral submissions on behalf of both parties. There was no oral evidence given at the hearing.

1. The parties provided the Tribunal with a detailed and extensive Statement of Agreed Facts, and the Tribunal adopts these.
2. A brief summary of these Agreed Facts is as follows:
   • Dr Marzola has been a registered medical practitioner since January 1967, and at all material times practiced in cosmetic and anti-aging medicine.
   • Details and definitions of certain drugs are set out in the Agreed Facts. These are CJC-1295, a synthetic peptide and growth releasing hormone; GRHP2, a synthetic peptide; GHRP-6, a synthetic hexapeptide; AOD-9604, a 16 amino acid peptide; Ipamorelin, a synthetic peptide; Testosterone, an anabolic androgenic steroid, used for the management of pathological hypogonadism, delayed puberty and impotence; Dehydroepiandrosterone (DHEA), an endogenous adrenal androgenic steroid; and Human Growth Hormone (HGH), a hormone approved for patients with severe growth hormone deficiency. In relation to each of these substances, it was agreed that inappropriate use, in terms of high dosage and/or extended duration, might have adverse effects on the health of a patient, and that Dr Marzola was aware of this.
   • Details concerning eight patients treated by Dr Marzola were also set out.
   • It was agreed that in relation to each of these patients Dr Marzola had inappropriately prescribed one or more of these medications such that the patients were, in each case, exposed to a risk of harm, and despite his belief at the time that there were indications for such prescribing, prescribing the medication for the purpose he did so was not appropriate and/or for an approved indication.
   • Following these agreed circumstances, it was agreed by Dr Marzola that he had engaged in professional misconduct, being conduct substantially below the standard reasonably expected of a registered medical practitioner of his level of training or experience.
3. In a reflective letter dated 1 September 2020 which was tendered by consent to the Tribunal, Dr Marzola explained his position concerning his professional practice and the complaint of professional misconduct. Dr Marzola states that he commenced his medical practice in general practice and developed an interest in procedural aspects of this practice, and became particularly interested in hair transplant procedures from about 1977. He began to concentrate in this area from 1982 and attended numerous conferences and other professional groups concerning this practice from that time. This interest, promoted by his desire to "help patients feel better about themselves", extended further into cosmetic surgery, and "the wider issues of aging", and he became aware hormone replacement therapy was a commonly accepted means of treatment in relation to these issues. Anti Aging Medicine Conferences which he attended in pursuit of these professional interests also introduced him to male hormone replacement treatment, Human Growth Hormone and Peptides, which he saw as products which could assist patients.
4. Dr Marzola states that he is able to appreciate how he came to engage in the conduct he now recognises as professional misconduct. He states he was attracted to the messages of anti-aging medicine in their asserted benefits to patients: the presentations were ostensibly credible; and he met other medical practitioners at these conferences who were similarly prescribing and promoting these products and this supported the use of these products. He acknowledges he did not do his own research but relied on information which he now recognises as not expert or disinterested.
5. Dr Marzola states that he subsequently became aware of concerns expressed by regulators and that colleagues had stopped prescribing peptides and he ceased being confident in his own knowledge of peptides, and he ceased prescribing them in 2016. He also began to refer patients seeking testosterone to endocrinologists.
6. Dr Marzola states that he has now had reference to the reports of Professor Wittert and other cases determined in various medical tribunals dealing with complaints concerning similar prescribing. Dr Marzola states that the opinions and information contained in that material have assisted him in appreciating "how wrong my patient treatments had been", and that he should not have engaged in such prescribing as this may have exposed his patients to harm. He now appreciates that when he moved outside his areas of established interest and expertise, namely hair loss and cosmetic medicine, he should not have relied on the promoters of substances for information concerning them, nor accepted their statements at face value.
7. Dr Marzola reports that he has changed his practices as a result of these new understandings. He has improved his record keeping and has developed a better documented consent process. Circumstances in 2020 including COVID-19 restrictions have significantly limited both his hair transplant surgery practice and his cosmetic medical practice, and he states that in the past 3-4 years he has been planning an exit strategy from his intensive medical practice, and his practice has become more limited. He no longer performs major abdominoplasties, facelifts or liposuctions. He has changed the scope of his insurance from July 2020 to six identified specific areas of procedures and will only work within these procedures.
8. Dr Marzola expresses the view that he has been embarrassed at the recognition of his errors and that he may have exposed his patients to risk, and that his recognition of his errors "has been long and haunting". He says he is "embarrassed, regretful and apologetic ... Most of all I remain troubled that my efforts to help patients might have exposed them to some harm".

1. The Board sought the following sanctions against Dr Marzola:
   • A finding that he had engaged in professional misconduct;
   • An order that he be reprimanded;
   • An order that his registration be suspended for a period of nine months from the date of the Tribunal's order;
   • That certain conditions be imposed on Dr Marzola's registration prohibiting him from accessing and prescribing the medication in issue in this matter; that he undergo audits conducted quarterly by a Board approved auditor to ensure compliance with the condition concerning prescribing, and enabling access to information concerning his medical practice, and an acknowledgment that the Board and AHPRA may seek and obtain data from relevant government or other agencies; and with a review of these conditions in 12 months. All costs associated with compliance with these conditions to be at the practitioner's own expense; and
   • That Dr Marzola pay the Board's costs in this matter.
2. Dr Marzola did not oppose the sanctions proposed by the Board in relation to a finding of professional misconduct, the issue of a reprimand, the conditions on registration proposed by the Board, or the payment of the Board's costs. However, he submitted that as an alternative to a period of suspension, an additional condition be imposed expressly restricting his medical practice to five specified discrete areas, as well as the imposition of a fine of $15,000, or that any suspension be for a period shorter than nine months.

1. Mr Forbes for the Board told the Tribunal that the facts in this matter were essentially agreed, as well as that a finding of professional misconduct was justified by the agreed facts.
2. Mr Forbes said that initially, and until April 2020, Dr Marzola had taken the position that he believed there was evidence of therapeutic benefit of the medications prescribed, and denied patients had been exposed to risk, and that he had, in each case, the informed consent of the patients. He had asserted he was unaware the medications prescribed were not approved by the Therapeutic Goods Agency, and that their use in these circumstances was experimental. It was only much more recently and closer to the hearing of this matter that he had conceded that this was not the case and that his practice in these respects constituted professional misconduct.
3. Mr Forbes said the Board's position was that there was no therapeutic basis for the prescribing at the relevant times, and Dr Marzola now concedes this. He now also concedes that he should not have formed the belief that the patients had provided their informed consent to the prescribing.
4. Mr Forbes referred the Tribunal to the uncontested expert opinion of Professor Wittert set out in his reports of 18 July 2018 and 24 June 2020. Professor Wittert asserted that with respect to the drugs prescribed by Dr Marzola ... there is either no established therapeutic indication (CJC-1295, GHRP-6, AOD 9604) or no appropriate therapeutic indication (Testosterone) established by Dr Marzola as applicable to the patients for whom these were prescribed.
5. Mr Forbes told the Tribunal that the Board's view was that Dr Marzola's conduct fell within the definition of professional misconduct as set out in clause 5 of schedule 2 of the National Law. This was agreed by Dr Marzola, and Mr Forbes submitted that Dr Marzola's conduct fell within each of the examples given in the definition.
6. In relation to determining an appropriate sanction, Mr Forbes referred to the consideration of this issue set out in Medical Board of Australia v Singh [2017] WASAT 33 (S) ('Singh'), where the WA State Administrative Tribunal determined that the appropriate sanction is to be considered at the time of the making of the sanction rather than the time of the unprofessional acts; the tribunal should choose the sanction which maximises the protection of the public as the dominant purpose of the sanction is the protection of the public; the impact of the penalty on the practitioner, and any personal hardship to the practitioner are secondary considerations; and there may be circumstances where a "global" approach to sanction may be more appropriate than imposing a separate sanction for each unprofessional act. In Singh, the Tribunal also identified 12 matters relevant to considering an appropriate sanction, and Mr Forbes referred to each of these criteria in relation to an assessment of an appropriate sanction to be applied to Dr Marzola.
7. Mr Forbes referred the Tribunal to numerous cases where appropriate sanctions have been considered and applied, and he summarised a number of factors arising from those decisions which he submitted supported the imposition of more significant sanctions. These factors were as follows:
   • Where there has been inappropriate prescribing to a number of patients;
   • Over a significant period of time;
   • Of multiple medications where the inappropriate prescribing may have caused harm to the patients;
   • Where the practitioner has sought to rationalise or justify their conduct;
   • Where there has been a failure to obtain informed consent or to warn patients of potential risk; and
   • Where the practitioner has failed to keep appropriate records.

Mr Forbes submitted all these factors applied in Dr Marzola's case and this should be taken into account by the Tribunal in considering the appropriate sanction. He submitted that the sanctions proposed by Dr Marzola, and in particular that no suspension be applied, would not address either future risk or general deterrence. He submitted that Dr Marzola's proposals for the appropriate sanction invited the Tribunal to fit its decision concerning the appropriate sanction around the way in which he has now organised his medical practice.

1. Mr Forbes referred to an undertaking made by Dr Marzola in August 2018 not to prescribe many of the medications in issue in this proceeding. He acknowledged that Dr Marzola had ceased prescribing peptides in 2017 prior to this undertaking, but Mr Forbes said that as early as February 2016 Dr Marzola had included in one patient's records that "it may be best to stop peptides", noting he had become aware of Department of Health "scrutiny". Mr Forbes submitted this indicated Dr Marzola was certainly aware at that time that prescribing of peptides was a controversial matter, as was also attested by widespread discussion in the popular media.
2. Mr Forbes noted that Dr Marzola's admissions had come late in these proceedings, and he had initially denied many of the key allegations despite Professor Wittert's report and assessment.
3. Mr Forbes also referred to other matters which he submitted represented aggravating features. These were that Dr Marzola had prescribed a range of inappropriate medication, to most patients over an extended period; that his prescribing of peptides was more extensive than initially conceded; that he had prescribed multiple peptides and steroids, and combinations of these; and that his prescribing of peptides occurred after it was widely publicised that such prescribing was controversial.
4. Mr Forbes submitted that these factors all suggested that there was a need for specific deterrence, especially given the seriousness of the conduct and that Dr Marzola was slow to acknowledge the misconduct. He also submitted the prescribing of peptide and steroid medication is accepted as a significant departure from accepted standards, and the sanction should include a significant period of suspension of registration.

1. Mr Cox QC told the Tribunal that Dr Marzola accepts that his conduct was wrong, admits professional misconduct, and has cooperated in these proceedings, leading to the Statement of Agreed Facts.
2. Nevertheless, he told the Tribunal that although Dr Marzola accepted that his medical practices had departed from accepted professional standards, this had occurred in the broader context of his cosmetic medical practice where he had explored treatment which was innovative, but which he had wrongly believed was credible, for the purpose of aiding his patients. The sanction applied needed to be proportionate to these circumstances.
3. Mr Cox QC described Dr Marzola's medical practice. Dr Marzola has been in medical practice since 1968, initially in general practice. He developed an interest in hair transplant surgery in 1977 and set up a dedicated practice focussing on hair transplant surgery in 1982, and maintains this practice, which presently operates in Adelaide and Melbourne, with other practitioners. This practice later extended to interest and practice in the field of cosmetic surgery, including liposuction, and in anti-aging surgery in general. From the 1990s his practice as a general practitioner became very limited and virtually ceased. He had considerable training and professional interactions in relation to hair replacement therapy and cosmetic practice and developed a significant positive reputation and leadership in these areas, but concedes that his interest in anti-aging medicine was without adequate or sufficient inquiry of its merits, and this has given rise to the conduct in issue in this matter. His interest and participation in anti-aging medicine exposed him to an awareness of human growth hormones and peptides, and the prescribing of those medications in his practice.
4. Dr Marzola first prescribed human growth hormone to a patient (AC) in 2008 and commenced prescribing peptides to all eight relevant patients identified in the Agreed Facts in 2013. His final prescription of peptides was in 2016, by which time he had come to the conclusion he should not be prescribing peptides. This was significantly prior to Dr Marzola being notified of an investigation into his prescribing of peptides by AHPRA, in October 2017, which has led to these proceedings.
5. Dr Marzola also prescribed testosterone over the period 2013-2015, to five patients, as an aspect of his anti-aging practice. He ceased this prescribing in March 2017 and gave an undertaking to the Board in August 2018 that he would no longer prescribe Testosterone.
6. Mr Cox QC told the Tribunal that Dr Marzola had believed at the time that he was helping his patients, and this belief, which he now recognises as mistaken, was reinforced by their claims of positive effects from the prescribing of these medications. He believed he was acting in the interests of his patients, and that he was doing so safely. He arranged for blood tests and other assessments prior to the prescribing, and he undertook research on the internet and relied on advice from colleagues and other practitioners working in the area of anti-aging.
7. He submitted that Dr Marzola has now obtained significant insight into his conduct and its difficulties. He now understood the nature of his conduct and appreciated why that conduct amounted to professional misconduct. Dr Marzola had now changed and significantly limited his medical practice and is greatly concerned with the risk of harm to which he may have exposed his patients. He has demonstrated that he is willing to identify the risk factors in his practice and has changed his behaviour and medical practices significantly since 2016. He has formally approached his insurers from April 2020 limiting his insurance to reflect his now significantly limited medical practice in which he practices only in his well-established areas of expertise, namely hair restoration therapy and some minor cosmetic procedures.
8. Mr Cox QC submitted that Dr Marzola is now no longer practicing in any areas presenting risk in terms of the issues of prescribing before the Tribunal, and under these circumstances a suspension period is unnecessary to address any issue of public risk.
9. Mr Cox QC submitted that Dr Marzola's case lacked many of the objective features of other cases where sanctions have been imposed for inappropriate prescribing, and he differentiated the circumstances of Dr Marzola's prescribing. He emphasised that Dr Marzola had not prescribed drugs of addiction, and there was no suggestion of self-prescription, or exchange for money or other favours, and he had not prescribed contrary to other specialist advice. He said Dr Marzola had an honest but wrong belief that he was helping his patients, and although it was accepted that the prescribing could have exposed patients to a risk of harm, there was no actual harm. The patients did not present as vulnerable, and as he had almost no general practice any risk was very limited. In addition, he submitted that Dr Marzola had demonstrated insight, and had made voluntary changes to his medical practice.
10. Mr Cox QC told the Tribunal that Dr Marzola had admitted there was no proper therapeutic basis for his prescribing of the relevant medications, but any future risk had been immediately ameliorated by his ceasing to prescribe peptides in 2016 (prior to the notification); his assurance to the Board concerning testosterone prescribing in 2018; and by his own limiting of his practice, in particular illustrated by the limited insurance cover he had established from June 2020, whereby his medical practice was limited to 6 areas, namely hair restoration treatment (medical and surgical); laser resurfacing of the skin; injections of fillers and neurotoxins; minor skin excisions; ear lobe repair; and lipodissolve.
11. Taking these considerations into account Mr Cox QC submitted that the Tribunal ought to exercise its discretion to impose sanctions but not including a suspension. Dr Marzola agreed to the sanctions proposed by the Board in respect of a finding of professional misconduct, the issuing of a reprimand, the imposition of various conditions on his registration, and that he pay the Board's costs. However, Mr Cox QC proposed that rather than suspending his practice, it was appropriate to impose a further condition on Dr Marzola's registration, expressly restricting his medical practice to the areas identified above and imposing a fine of $15,000 on Dr Marzola. Mr Cox QC proposed these sanctions represented a reasonably proportionate response to protect the public, as it significantly restricted Dr Marzola's future practice to his core area of skill. No issues concerning his expertise and competence in that area have been raised. In addition, the conditions proposed provide for external oversight of Dr Marzola's practice, and the relevant costs of compliance are imposed on him. Alternatively, Mr Cox QC suggested that a more limited suspension, such as a period of 4 months, would be more appropriate.

1. Section 196 of the National Law governs the Tribunal's determination in this matter. There are two matters to be determined: the characterisation of Dr Marzola's conduct; and the appropriate disciplinary sanction to be imposed.
2. Section 196(1)(b) of the National Law empowers the Tribunal to decide one or more of the following as the appropriate characterisation of the practitioner's conduct:

(i) the practitioner has behaved in a way that constitutes unsatisfactory professional performance;

(ii) the practitioner has behaved in a way that constitutes unprofessional conduct;

(iii) the practitioner has behaved in a way that constitutes professional misconduct;

...

1. Professional misconduct is defined in clause 5 of schedule 2 of the National Law as follows:

professional misconduct, of a registered health practitioner, includes -

(a) unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(b) more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(c) conduct of the practitioner, whether occurring in connection with the practice of the health practitioner's profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.

1. The Tribunal notes Dr Marzola was a registered health practitioner within the meaning of the National Law at all relevant times, and that he has agreed his conduct amounts to "professional misconduct" within the meaning of this definition. Taking into account all the material before it, the Tribunal is satisfied this is the case, and finds that Dr Marzola has engaged in conduct amounting to professional misconduct.
2. The remaining issue before the Tribunal is the appropriate sanction to apply to Dr Marzola's conduct. Dr Marzola has agreed to some of the sanctions proposed by the Board, and the disagreement relates to whether he should have a period of suspension imposed, and if so, what period. Despite the agreement on some aspects of the proposed sanction, it is for the Tribunal to consider and determine the appropriate sanction to be applied. The central issue in this respect is an assessment of the risk to the public.
3. In considering the appropriate sanction to apply the Tribunal must bear in mind the purpose of such sanctions under the National Law. These general principles are set out in the judgement of Doyle CJ in Craig v Medical Board of South Australia [2001] SASC 169; (2001) 79 SASR 545 at 553:

The purpose of a disciplinary sanction is to protect the public and not to punish a practitioner in the sense in which punishment is administered pursuant to the criminal law. A disciplinary tribunal protects the public by making orders that will prevent persons who are unfit to practice from practising, or by making orders that will secure the maintenance of proper professional standards. A disciplinary tribunal will also consider the protection of the public, and of the relevant profession, by making orders that will assure the public that appropriate standards are being maintained within the relevant profession.

At the same time, the disciplinary action must be proportional and appropriate to all the circumstances of the case.

1. These principles are widely accepted and applied in the case law, recognising that the purpose of disciplinary proceedings is to protect the public, maintain proper professional standards, and assure the public that proper standards are being maintained in the relevant profession. A disciplinary sanction also assists in upholding the public trust and confidence in the profession, bringing home to the practitioner the seriousness of their conduct, deterring the practitioner from any future departures from appropriate standards, deterring other members of the profession from acting in a similar manner, and imposing restrictions on the practitioner's right to practice so as to ensure the public is protected.
2. The Tribunal notes that the parties have agreed some of the sanctions proposed to be applied to Dr Marzola in this matter. Such agreement between the Board and the practitioner obviously is useful for the Tribunal to take into account in considering an appropriate sanction as it demonstrates the sanction that the Board considers appropriate to effectively address the objects of the National Law to protect the public and maintain professional standards and confidence in the profession, as well as demonstrating that the practitioner recognises and appreciates the deficiencies in his conduct and its inappropriate nature and is taking responsibility for it.
3. Nevertheless, the Tribunal is not bound to adopt the sanctions proposed and agreed by the parties and must satisfy itself as to the appropriate sanctions to apply to achieve these ends in the particular case before it. Accordingly, to adopt the sanctions proposed and agreed by the parties, the Tribunal must be satisfied they address the concerns of the National Law, of protecting the public, and maintaining professional standards and confidence in the profession.
4. In making an assessment of the risk Dr Marzola's future medical practice might pose in respect of these concerns, both parties directed the Tribunal to the 12 points identified in Singh as relevant in determining the issue of risk. The Tribunal adopts these considerations as appropriate in this matter.
5. These factors are as follows:
   • Any need to protect the public against further misconduct by the practitioner.
   • The need to protect the public through general deterrence of other practitioners from similar conduct.
   • The need to protect the public and maintain public confidence in the profession ... [including] an emphatic indication of ... disapproval.
   • In the case of conduct involving misleading conduct, including dishonesty, whether the public and fellow practitioners can place reliance on the word of the practitioner.
   • Whether the practitioner has breached any (a) Act; (b) Regulations; (c) Guidelines or Code of Conduct...; and (d) whether the practitioner has done so knowingly.
   • Whether the practitioner's conduct demonstrated incompetence.
   • Whether or not the incident was isolated.
   • The practitioner's disciplinary history.
   • Whether or not the practitioner understands the error of his ways, including an assessment of any remorse and insight (or lack thereof).
   • The practitioner's personal circumstances at the time of the conduct and at the time of imposing the sanction.
   • ... other matters relevant to the practitioner's fitness to practice and other matters which may be regarded as aggravating the conduct or mitigating its seriousness.
6. In considering these factors in relation to Dr Marzola, the Tribunal notes that there is clearly a need to protect the public against any further misconduct by Dr Marzola, but in this context also notes that Dr Marzola has significantly limited his medical practice in a manner which effectively excludes the impugned and unprofessional prescribing, and has in addition given an undertaking concerning the prescribing of testosterone. Dr Marzola has also accepted the conditions proposed on his registration, which are designed to provide protection to the public by significantly limiting his medical practice. A reprimand, along with the imposition of a fine (as proposed by Dr Marzola) and the payment of the Board's costs, in the Tribunal's view operate as emphatic indications of disapproval supporting public confidence in the profession, and also provide significant deterrence to other practitioners as well as Dr Marzola. In terms of Dr Marzola's own conduct, the Tribunal notes his professional misconduct occurred over some years and in relation to a number of patients, but also notes that no other disciplinary history has been brought to our attention; Dr Marzola ceased prescribing peptides having become aware of controversy and concerns relating to this medication but well before the AHPRA notification, and further, the Tribunal accepts that he has come to appreciate the professional misconduct involved in his prescribing, and that he has experienced considerable remorse and concern about the consequences of his professional misconduct, including the risk to which his patients were exposed and the consequential loss of confidence in the profession.
7. The sanctions to which both parties agreed are as follows:
   • A finding of professional misconduct.
   • A reprimand.
   • A condition that Dr Marzola's registration be subject to a prohibition from in any way accessing and prescribing any of the medication the subject of these proceedings.
   • A condition that Dr Marzola's registration be subject to a requirement that he undergo quarterly audits by a Board approved auditor with a focus to ensure compliance with the condition concerning medications prescribing, and enabling access to relevant information including that held by Government Departments and agencies; and that Dr Marzola bears the costs of the audits of these conditions.
   • That there be a 12-month review period for these conditions.
   • That Dr Marzola pay the Board's costs.
8. The Board also proposed a period of suspension of Dr Marzola's registration for a period of 12 months. Dr Marzola opposed any suspension of his registration, proposing, as well as these sanctions but instead of a suspension of registration, an additional condition be imposed on his registration, namely that his medical practice be expressly restricted to the six areas he identified, and in addition that he would pay a fine of $15,000. Alternatively, he proposed a shorter period of any suspension.
9. Taking into account all the material and the submissions before us, including the Agreed Statement of Facts, the Tribunal is satisfied that Dr Marzola engaged in professional misconduct within the meaning of clause 5 (a), (b) and (c) of schedule 2 of the National Law, in the inappropriate prescription of medication to patients in circumstances where there was an absence of evidence to support a therapeutic benefit and which exposed his patients to risk; in failing to obtain informed consent from patients before prescribing medication which was experimental or not approved by the Therapeutic Goods Administration; by failing to keep adequate records; and in addition, breaching the relevant Code of Conduct, Good Medical Practice: A Code of Conduct for Doctors in Australia (March 2014).
10. Taking into account this finding, the Tribunal is satisfied it is appropriate to issue a reprimand to Dr Marzola.
11. The Tribunal is satisfied that Dr Marzola has recognised the nature and cause of his professional misconduct and has made significant changes to his medical practice as an indication of his commitment to avoid exposing himself, his practice or his patients to any such unprofessional conduct in the future. These changes include ceasing to prescribe peptides, including at the request of patients, from June 2016, and his undertaking to the Board of August 2018 concerning access to and prescribing of testosterone. In addition the Tribunal notes Dr Marzola has voluntarily restricted his practice to the six areas of clinical activity set out, which do not include his past practices of anti-aging medicine in relation to which the relevant prescribing occurred, and which relate only to his long established areas of expertise in hair restoration therapy and cosmetic medicine, in relation to which there have not been concerns expressed. The Tribunal also notes these areas of practice do not entail any general practice, so limiting a wider possibility of risk. Dr Marzola has also accepted and agreed to the conditions on his registration proposed by the Board. The Tribunal accepts that these undertakings demonstrate Dr Marzola's commitment to avoiding his professional misconduct of the past and ensuring his patients are not exposed to any similar risk of harm in his future practice.
12. The focus of the sanctions to be imposed in respect of any finding of professional misconduct is the protection of the public, and the maintenance of professional standards and confidence in the medical profession. These concerns are not necessarily addressed by imposing punitive sanctions on the practitioner: the purpose of the sanction is not to punish the practitioner, but to protect the public, deter the practitioner from repeating the professional misconduct as well as deter other practitioners from engaging in similar conduct, and to ensure that public confidence in the medical profession is maintained and not undermined.
13. The Tribunal has formed the view that these outcomes will be achieved by issuing a reprimand to Dr Marzola; and the imposition of the following conditions on Dr Marzola's registration, namely:
    • Prohibiting him from in any way accessing and prescribing any of the medication the subject of these proceedings;
    • That his practice be subject to quarterly audits by a Board approved auditor; and
    • That his medical practice be restricted to specified areas of clinical activity, namely hair restoration treatment (medical and surgical); laser resurfacing of the skin; injections of fillers and neurotoxins; minor skin excisions; ear lobe repair; and lipodissolve,

with these conditions subject to a 12 month review by the Board, and for Dr Mazola to pay all the costs associated with compliance with the conditions of his registration; that Dr Marzola pay a fine of $15,000; and that Dr Marzola pay the Board's costs in this matter.

1. The Tribunal's view is that these sanctions sufficiently and proportionately address the consequences of Dr Marzola's professional misconduct, and in particular appropriately protect the public by managing any future risk in Dr Marzola's practice through limitation, oversight and review; constitute a deterrence to both Dr Marzola and other practitioners through the limitation of his practice and the costs imposed on him; and address the issue of public confidence in the profession by these means and the reprimand issued.
2. Accordingly, the Tribunal will make orders reflecting these findings and incorporating these sanctions.

1. The Tribunal makes the following orders in relation to this application:
   1. The respondent is reprimanded.
   2. The following conditions are placed on the respondent's registration as a medical practitioner:
      • He is prohibited from in any way accessing or prescribing any of the medication that has been the subject of these proceedings;
      • That he undergo audits conducted quarterly by a Board approved auditor with a focus of ensuring compliance with the requirement not to prescribe the medications that have been the subject of these proceedings, and enabling access to information such as clinical billing and appointment records and enabling the Board to seek and obtain data from relevant government departments and agencies;
      • That his medical practice be confined to the following areas, namely hair restoration treatment (medical and surgical); laser resurfacing of the skin; injections of fillers and neurotoxins; minor skin excisions; ear lobe repair; and lipodissolve.
   3. That there be a 12-month review period for the conditions set out in order 2 above.
   4. That all costs associated with compliance with the conditions of his registration set out in order 2 above are at the expense of the respondent.
   5. That the respondent pay a fine of $15,000 to the Board.
   6. The respondent pay the Board's costs of and incidental to the proceedings as agreed with the Board or, failing agreement, as determined by the Tribunal.