1. The respondent's registration is to be cancelled for one year commencing on 1 July 2013 and he is disqualified from applying for registration for a period of one (1) year pursuant to s.45A(2)(h) and (i) of the MP Act and s.77(4)(h) and (o) of the HPR Act..
2. Pursuant to s.45A(2)(c) of the MP Act and s.77(4)(c ) of the HPR Act the respondent is reprimanded.

1. Findings in this matter were set out in the reasons for decision delivered on 7 December 2012. The Tribunal has now heard and received the parties' submissions on determination.
2. As set out in our reasons, the events on which findings were based occurred over a period involving three different legislative enactments. The first of these was the Medical Practice Act 1994 which remained in force until its repeal on 30 June 2007. On 1 July 2007 the Health Professions Registration Act 2005 came into effect and remained in force until its repeal on 30 June 2010. On 1 July 2010 the Health Practitioner Regulation National Law (Victoria) 2009 came into force and remains to date. Although it is expressed to be a "national law" there are substantive differences on a state-by-state basis. The enabling legislation was passed in the Queensland parliament and then adopted with various modifications by some but not all of the states. Because the parties have referred the Tribunal to a number of New South Wales cases, it is important to note that New South Wales did not adopt Part 8 of the Queensland legislation (Victoria did) declaring in s.6 of its adoption of national law legislation that New South Wales "was not participating in the health, performance and conduct process provided by Divisions 3-12 of Part 8 of the Health Practitioner Regulation National Law". New South Wales also omitted from its law a raft of definitions including, relevantly, "unprofessional conduct" and "professional misconduct" preferring instead to its own definitions of "professional misconduct" and "unsatisfactory professional conduct"(our underlining). It follows that where necessary we have taken note of the definitional differences which affect the available determination; in particular we have noted that, in general terms, cancellation or suspension is not available on a finding of unsatisfactory professional conduct unless it is of a serious nature.

1. We should deal first with the references submitted to the Tribunal on behalf of the respondent. Many of the referees gave viva voce evidence, ranging from patients, their relatives, other practitioners and a number of assorted professionals. Generally the references might be described as stellar although not all of the referees knew of the nature of Dr Schulberg's prescribing practices. That said, it is clear he is held in high regard and admired for his empathetic approach to patients, friends and colleagues alike.
2. Mr Grace (for Dr Schulberg) emphasised the following matters:
   • Dr Schulberg had cooperated fully with the investigation since its instigation. Indeed throughout the hearing he made many admissions against interest.
   • He had exhibited significant remorse and contrition and was embarrassed and bruised by his lack of judgment and insight and the subsequent effect this has had on his patients, his family and his friends.
   • Since the hearing he has undertaken a variety of extra training in appropriately related areas, the better to understand the nature of addiction patients and perhaps better to understand his past shortcomings.
   • He has continued to comply (without fail) with the undertaking he gave to the Board in May 2010.
   • Dr Schulberg who is 58, has only had one vocation, that is, the practice of medicine.
   • He has no desire ever again to treat patients with substance abuse problems.
   • He conceded that his education relating to aggressive and addicted patients and addiction medicine generally was less than thorough. Counsel reminded the Tribunal of the evidence of Drs Sungaila and Pearce about the degree of difficulty, and the number of, the particular cohort of the doctor's patients.

1. Mr Grace made a number of submissions about the possibility of

"bifurcating" Dr Schulberg's practice responsibilities to quarantine his contractual arrangements with the Marie Stopes Clinic in the event negative determinations were imposed. His work at that clinic is not the subject of any complaint before this Tribunal. In relation to this issue he called evidence from a range of witnesses, chief among whom was Ms Deveson Crabbe. She is the vice-president of Marie Stopes International and chief executive officer of its Australian operation. 2. Marie Stopes International (MSI) is a global not-for-profit sexual and reproductive healthcare provider. It delivers contraception, safe abortion and mother and baby care and has done so for over 30 years, working in 42 countries around the world. In Australia, MSI runs a network of sexual and reproductive healthcare clinics and has been providing pregnancy termination services at these clinics since 2000 and currently sees about 28,000 women a year for this service. 3. The clinic where Dr Schulberg provides termination services was formerly owned by him and the sale to MSI was completed in March 2012. Ms Deveson Crabbe told the Tribunal that were Dr Schulberg unable to practise, the clinic would find itself in a very parlous state. According to her evidence (which on this point is not contested) there are few doctors available to perform terminations generally and a very real paucity of those available for post-16 week terminations. The impact on MSI was set out by Ms Deveson Crabbe as follows:

Dr Mark Schulberg is a unique practitioner in the field of pregnancy termination. He is the only provider in Victoria who offers surgical termination beyond 16 weeks gestation. Victorian law states that "a registered medical practitioner may perform an abortion on a woman who is not more than 24 weeks pregnant". Dr Schulberg is the only provider currently offering services to 24 weeks.

At the Royal Women's Hospital, Melbourne women can currently access a surgical termination up to 16 weeks. Beyond this, termination is only provided in the case of foetal abnormality as assessed by a panel or ethics committee at the hospital. The process for patients who proceed is feticide and induced labour which, for some women, is an unbearable ordeal. Other private providers in Victoria have the ability to provide terminations up to 13-16 weeks depending on the provider.

175 women a year in Victoria who require a termination between 16-24 weeks gestation depend on the services of Dr Schulberg (based on 2012 figures). If he were no longer able to practise, women up to 20 weeks would have to fly to NSW, QLD or WA incurring significant additional costs of up to 212% as well as personal trauma. Women over 20 weeks would be left without another option at all.

Nationally Dr Schulberg is the only practitioner offering surgical termination beyond 20 weeks. Beyond this, women interstate are again only able to access a termination in the case of foetal abnormalities.

77 women a year who require a termination between 16-24 weeks gestation, travel interstate to access Dr Schulberg's services (based on 2012 figures). If he were no longer able to practise, these women would have no other option than to proceed with their unwanted pregnancy.

1. Ms Deveson Crabbe spoke about succession planning and told the Tribunal that as Australia's largest single provider, MSI is clearly aware of the shortage of doctors who are able to provide termination services.
2. She stated that Dr Schulberg currently provides some 3,884 terminations per year under sixteen weeks in the Victorian clinics and presently it does not have a doctor able to replace these services. As a result, she stated, if Dr Schulberg were no longer able to practise, these women may well start to experience waiting lists for procedures thereby increasing their gestation and potentially the cost of their procedure. Aware of this impediment, MSI has been working to develop plans for an abortion training curriculum. The Tribunal was advised that the first stage, which is RANZCOG endorsed, is an on-line training programme for medical practitioners wishing to prescribe mifepristone for early medical abortion. That programme is complete and freely available. MSI is in discussion with various training organisations to develop a surgical termination training curriculum. A vital aspect of this would be training in surgical termination post sixteen and post twenty weeks to expand the gestational capabilities in both existing and new providers. It was her evidence that if Dr Schulberg were not able to continue to practise, none of the other proceduralists presently utilised by them would be able to 'take up the slack'. She agreed there would be some ad hoc opportunities but the existing proceduralists are already at capacity. She confirmed that Dr Schulberg was the only provider in Victoria offering surgical termination beyond sixteen weeks except for the very limited capacity at Royal Women's Hospital which, due to its many limitations, constantly refers patients to MIS.
3. She was asked whether there were other doctors who were able to provide the approximately 4,000 termination procedures presently conducted by Dr Schulberg pre-sixteen weeks and responded that there was a serious shortage of doctors in Victoria who will provide terminations at all.
4. When cross-examined by Mr Moloney she conceded that this difficulty was largely due to a lack of will, rather than a lack of skill because, as she put it, 'abortion is a stigmatised area and because there is personal security and professional risk involved'.
5. When questioned by Dr Reddy she agreed that it was a valid point of view that training of future practitioners would be better performed by an obstetrician and gynaecologist, and agreed that to provide the service safely and proficiently in a private environment in accordance with Victorian Law would require at least 18 to 24 months of training.

1. Returning to Mr Grace's submissions, he referred us to a number of cases, which he submitted were on all fours with the matter before us and in which reprimands, conditions and fines had been the resulting determinations. We will refer to some of them in chronological order.
2. In MPBV v Dr John Gyorki [2004] MPBV 21 the Panel reprimanded Dr Gyorki and imposed conditions on his continued registration after making findings that he had engaged in "unprofessional conduct" of a serious nature. The complaint related to the doctor's treatment of a patient identified as Mr LZ over a period between October 1996 and April 2001. The complaint related to his inappropriate prescribing of benzodiazepines and opiate analgesics, prescribing large quantities of drugs of dependence (sedative medications), poor recording keeping and a range of related matters.
3. In coming to its conclusion the Panel accepted a submission that the doctor's conduct "must not be judged solely in hindsight, but should be based on standard of medical behaviour and procedure appropriate at the time, e.g. the practice and purpose of note taking in 1996 was perceived by medical practitioners to be quite different to the practice in 2004"
4. It accepted the dilemma in which the doctor found himself faced with a demanding patient complaining of severe and uncontrollable pain for which the doctor believed there was an organic basis, all being managed in a psychosocial context of anxiety, depression and work and marital breakdown. The Panel concluded the doctor was compassionate but risked harming the patient in the process although it acknowledged that the patient in question was manipulative and at times misleading.
5. In MPBV v Dr Christopher Watts [2005] MPBV 13 the practitioner was involved in prescribing excessive amounts of Temazepam to a patient over a period ranging between mid-2001 and July 2004. This too involved a challenging patient with complex problems who had been addicted to benzodiazepines for approximately 5 years. The Panel in this case considered that the practitioner's conduct did not fall within the definition of "professional misconduct" but constituted "unprofessional conduct" of a serious nature. He was cautioned and reprimanded and ordered to undergo specific education programmes and a supervisory condition was placed on his registration for a period of 12 months.
6. Dr Peter Tisdall was a country general practitioner who was found to have engaged in unprofessional conduct of a serious nature in relation to poor record keeping and the prescription of Pethidine on some 241 occasions between July 1997 and March 2003 (MPBV v Tisdall [2007] MPBV 5). He was reprimanded and cautioned and ordered to complete relevant education within the ensuing 12 month period.
7. In MPBV v Dr Parmjit Kaur [2010] VCAT 374, the practitioner had inappropriately prescribed Morphine, Valium and Pethidine over a period of years between 2001 and 2006 as a treatment of chronic pain ostensibly caused by ovarian cancer. It transpired that the patient did not have ovarian cancer at all. Dr Kaur had come to the notice of the Medical Board on three earlier occasions and on this occasion the Tribunal found she had engaged in unprofessional conduct of a serious nature and professional misconduct. Her registration was cancelled and she was disqualified from reapplying for a period of two years.
8. In Health Care Complaints Commission v Dr Jones [2012] NSWMT 19 the Medical Tribunal of New South Wales made findings of professional misconduct under the New South Wales law in relation to Dr Jones' treatment of seven patients. The complaints related to indiscriminate prescribing of benzodiazepines in the years 2008 and 2009. The decision of the Tribunal was that the practitioner be reprimanded in respect of both complaints, fined $10,000.00, ordered to pay the complainant's costs and stringent conditions were placed on his registration. The Tribunal took into account that the doctor's failings in relation to Schedules 8 and 4D drugs had been removed, his glowing references, the need for doctors in the Central Coast area and the fact that conditions could be tailored to reduce the risk of re-offending.
9. HCCC v Dr Leslie [2013] NSWMT 1 is another analogous case. The complaints related to the prescribing of 2,115 scripts for miscellaneous benzodiazepines and narcotics to 23 patients between 2004 and 2008. The doctor practised in a country area and has done so since 1987. The Tribunal took into account the admissions made by the doctor which shortened the hearing, noted his compassion and decided that his was not a case meriting suspension or cancellation. Rather it considered his newly acquired skills about which evidence had been given, his insight and understanding that he had been a soft touch, his attendance on a clinical psychologist for cognitive behavioural therapy and an acceptance that the doctor had now developed an ability to be more assertive in the face of challenging patients. He was reprimanded and a number of conditions were placed on his registration, including a condition that precluded his prescription of Schedules 4 and 8 drugs.
10. Mr Grace referred us to other cases such as MPBV v Dr John Mackellar [2009] MPBV14, MPBV v Crilly [2009] MPBV 2, MPBV v Jansz [2011] VCAT 1226 and an earlier appearance before the Medical Board by Dr Schulberg when he was reprimanded for a failure to obtain proper consent to perform a particular medical procedure. We have not attempted a detailed analysis of all the cases put before us by Mr Grace because, notwithstanding this Tribunal's desire to strive for consistency of decision-making, there is no such thing as a tariff in these disciplinary matters and each hearing turns on it own particular facts. We are mindful (as VCAT said in the Kaur case) that dispositions "must not vary according to the personal traits of tribunal or panel members much less the whims of the day." We are also mindful that some of these cases appear, at first blush, to be strikingly similar to the matter presently before us.
11. Mr Grace summarised his position as follows:

My submission is that there ought not to be a period of suspension or cancellation, but if there is, a bifurcation of practice is available and is certainly within the powers of this Tribunal. The relevant requirements for determination as considered at length in Jansz and in other cases would allow for such a result. It would allow for the appropriate degree of censure. It would allow for the appropriate degree of sending a message. It would allow for the appropriate degree of protecting the public.

And I repeat what I've said earlier and tried to stress earlier, that there has been nothing untoward suggested to attach to Dr Schulberg's practice in medicine where the normal practice in terms of prescribing or otherwise in any other aspect of general practice since the time when he ceased prescribing these substances. And in effect the evidence...and also the character and written testimonials not only of friends and associates, but also of patients, the very people....the very people are saying the opposite. They want him.

....So there needs to be a balancing exercise. It's accepted there has to be appropriate determinations imposed. But there is ample provision within those types of determinations that are open to the Tribunal to cater for all the competing requirements and disposition of this case.

1. Counsel for the applicant provided written submissions with relevant case law. The applicant seeks a determination that the respondent's registration be cancelled, that he be disqualified from applying for registration for a period of 2 years, that he be reprimanded and that there be a range of conditions placed on any future grant of registration. This submission was made bearing in mind the objective of determinations is that they should not in any sense be punitive and should not be constituted in such a way, or be so harsh as in reality to be punitive or retributive.
2. He reminded the Tribunal that the objectives of determination can be achieved by specific deterrence, ie the deterrence of the person concerned from further inappropriate conduct, and general deterrence, ie the deterrence of other practitioners minded to engage in similar conduct and by facilitation of rehabilitation on the part of the practitioner.
3. Counsel confirmed the various matters for consideration in making a determination - the protection of the public, the maintenance of professional standards in the medical profession, the nature and gravity of the conduct and the requirement for general and specific deterrence. Counsel submits the first two are the prime objectives.
4. Part and parcel of those aims, he submitted the following matters for the Tribunal's consideration.

An assessment of the ongoing risk posed by the practitioner, and the likelihood of repetition is of central importance to the imposition of a determination.

Personal matters such as personal embarrassment and financial detriment have no relevance to the appropriate sanction except that this may be considered as part of the matrix for specific deterrence of the practitioner.

The acquiescence of insight into his or her found conduct is of potential relevance to the determination in that it goes to the continuing risk posed by the practitioner. In context, this "insight" might be reflected in a variety of ways, such as an understanding of the nature of the conduct, an acceptance that the conduct was wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and/or a willingness to take measures to identify risk factors and to do that which is necessary to avoid further transgressions.

Whilst there are some circumstances in which it is appropriate for regard to be had to the consequences to a patient community if a practitioner is suspended or deregistered, the public interest in the practitioner remaining in practice must be weighed against the main elements of a sanction, namely, public interest in protecting patients against any repetition of the conduct, the gravity of the conduct and the protection of the profession, and all those matters are involved in the deliberative processes of the Tribunal.

1. The choices available to us include reprimand, caution, suspension, cancellation, the imposition of specific requirements, a fine or a combination of these coupled with conditions. This is so whether we are deciding on determinations available under the MP Act, the HPR Act or the National Law. We have given considerable thought to the outcome of this matter and the requirement that it is essential for public confidence in the medical profession to be maintained. In Honey v Medical Practitioners Board of Victoria [2007[ VCAT 526, the practitioner was found guilty of three counts of serious unprofessional conduct. Judge Harbison and Associate Professor Davis stated at paragraph 51 that -

It is necessary to look at the conduct overall and to ascertain whether the protection of the public requires a strong message to be sent to other medical practitioners that the conduct in question is reprehensible, and to other patients that they will be protected from that conduct. This is so even if there is no risk at all of repetition of the offending conduct.

1. In Craig v Medical Board of South Australia (2001) 79 SASR the South Australian Full Court considered an appeal from a decision of the District Court (Medical Practitioners Professional Conduct Tribunal). In deciding whether or not a suspension of the practitioner for 6 months was excessive, Doyle CJ found that the order was not excessive and at p.557 stated -

I consider that Dr Craig's conduct was conduct of a kind that might well shake the public confidence in the profession of psychiatry, were it not dealt with firmly. It was conduct which called for an emphatic indication of the Tribunal's disapproval, and of the profession's disapproval. Although Dr Craig's acknowledgment of wrongdoing was accepted as genuine, and there was no need to deter him from repeating his conduct, it was appropriate for the Tribunal to emphasise to Dr Craig the seriousness of his conduct

1. Dr Schulberg's conduct occurred over a number of years and was in regard to a number of patients. It cannot be said to be isolated and of course it must be viewed through the spectrum of contemporary knowledge. Community concern about the incidence and over-use of prescription drugs has most likely never been higher and for that reason the reputation of the profession as a whole is at stake. In our view it is necessary to send a strong message to the profession that the type of prescribing that occurred in this case is wholly unacceptable. Given the prevalence of benzodiazepine prescribing, the patient cohort involved as well as the highly unusual prescribing of Tramadol and MS Contin, this message is of utmost importance.
2. The findings did not arise episodically or occasionally. The findings of professional misconduct (and these were not incidental) constituted as counsel put it, "the most serious and gravest form of lapse of professional standards". The particular findings relating to the prescribing of benzodiazepines indicated the conduct occurred extensively and over a long period. Counsel submitted this formed a pattern and he went on to submit that -

The extensive prescribing of Xanax, for example, was the subject of special criticism by Dr Sungaila. Its addictive nature was explained [by her]. It of itself creates dependency, a withdrawal syndrome and is highly questionable treatment of depression and anxiety. When coupled with heroin addiction, cardiorespiratory collapse is a present risk. This style of treatment ought be severely publicly condemned and in the manner submitted.

1. As the applicant's counsel put it, the extensive prescribing of benzodiazepines - whether Xanax, Diazepam, Ducene, Valium, Flunitrazepam, Oxazepam or Temazepam was massive. It spanned a period from April 2000 (JP) through to December 2009 (DG) and the charts made available to the Tribunal at the hearing showed in graphic detail the volumes and frequency in which they were provided. Without having regard to particular doses of any of the drugs, at first glance one can see that, over the period, in excess of 25,000 Xanax tablets were prescribed to the cohort of patients, nearly 9000 Valium along with some thousands of others.
2. In support of his submission for censure at the upper end, the applicant's counsel referred back to the evidence of Dr Sungaila relating to the length of time over which benzodiazepines were prescribed and her evidence that this either created or perpetuated a dependence on the drugs. She stated how serious such dependence was.
3. Mr Moloney cited cases where cancellation for two years had been determined in less serious circumstances. In Medical Board of Australia v Christian [2012] VCAT 1647, the relevant prescribing involved Dexamphetamine, Codeine, MS Contin, Oxycontin and Sustanon to four patients. This resulted in a two year cancellation. Likewise in Dr Robert Molnar v Medical Practice Board of Victoria (2009) MPBV 4 a two year cancellation was ordered in respect of prescribing MS Contin and Dilaudid. We reiterate the remarks we made in paragraph 22.
4. Other submissions made by the applicant's counsel include the following:
   • The prescribing of MS Contin, which was found to constitute professional misconduct, was to patients with illicit drug problems and warrants censure of a high degree. A similar position exists with regard to the prescribing of steroids;
   • The pattern of prescribing Tramadol as a form of opiate substitution was profoundly disturbing given the cardiovascular risks and its addictive qualities;
5. A particular response to the "bifurcation" issue was put by the Board's counsel as follows:

[Mr Grace's submission] overlooks the necessity of the maintenance of proper standards in the practice of medicine. It overlooks the necessity of general deterrence. It overlooks the benefit of the public statement that is made by the condemnation of the treatment and prescribing in this case. It completely distorts the element of discretion constituted by the principle that a sanction is not to be punitive. It is as illogical as submitting that a doctor who has committed boundary violations and sexual indiscretions with female patients, may still be permitted to treat male patients. Such a submission is a complete non sequitur.

1. We have given consideration to the parties' submissions and have come to the conclusion that this case is one meriting the strongest response from this Tribunal. Indeed as Doyle CJ stated in _Craig'_s case Dr Schulberg's conduct "calls for an emphatic indication of the tribunal's disapproval and of the profession's disapproval."
2. We are mindful of Dr Schulberg's admissions on the day (which shortened the hearing), of his obvious remorse, that he has undertaken further study in relation to drug misuse and mental health co-morbidity, that he has meticulously abided by his prescribing restrictions ever since they were imposed and of course his very impressive references speaking as they did to his empathy and concern and to his good works.
3. Without wishing to labour the point, the function of our determination is protective, not punitive and the public interest in the practitioner continuing to practise must be weighed against the public interest in protecting patients from any repetition of like conduct. In weighing up these matters it is important that any determination stands to deter both the particular practitioner and others from similar conduct. In Honey v Medical Practitioners Board of Victoria [2007] VCAT 526 the Tribunal summarised the position thus -

It is of prime importance in assessing the appropriate sanction that we bear in mind that the purpose of the determination is not to punish [the practitioner]. Rather, the purpose is to protect the public, by preventing persons who are unfit to practise from practising as medical practitioners, and by maintaining proper professional standards.

1. We have formed the view that cancellation is the appropriate order. The findings set out in the addendum to the reasons for decision show the gravity and range of offending. We agree with the Board's counsel that the findings were of a kind that constitute the most serious and grave lapse of professional standards.
2. His conduct was consistent poor practice, it endangered the patients, it continued over a number of years and we viewed the pattern of prescribing as reckless. It was not an isolated lapse of judgment but a systemic pattern occurring over a number of years. Although the doctor expressed the view that he had thought it better that his patients continue to be treated by him than perhaps turning to crime to sustain their habit, we did not consider that to be mitigation but rather signified a lack of insight about his patients' wellbeing.
3. We have accepted the Board's submission that cancellation is the appropriate determination although we have not agreed with their suggested term of cancellation; we considered two years unduly harsh. In our view Dr Schulberg's registration should be cancelled for one year commencing on 1 July 2013 and that he be disqualified from applying for registration for a period of one (1) year pursuant to s.45A(2)(h) and (i) of the MP Act and s.77(4)(h) and (o) of the HPR Act..
4. We have also determined that pursuant to s.45A(2)(c) of the MP Act and s.77(4)(c) of the HPR Act Dr Schulberg is to be reprimanded.
5. We have not imposed any educational requirements linked to any future registration leaving that in the hands of the Board to consider if and when such an application is made.
6. The other matter for consideration is the bifurcation submission put by counsel for the applicant. It will be obvious from the determinations above that we have rejected that submission. Counsel for the Board vehemently objected to this submission and although we agree with the thrust of his objections, we have perhaps arrived at our decision from a slightly different angle. The bifurcation issue was raised by the doctor's counsel during the determinations hearing and was not seriously flagged before then. Evidence was adduced on that day from Ms Deveson Crabbe and from the Director of Nursing at MSI.
7. The Tribunal understands there are some 18,000 medical practitioners in Victoria. The evidence given by Ms Deveson Crabbe was to the effect that Dr Schulberg is the only medical practitioner in Victoria offering and performing a surgical termination beyond 16 weeks and up to 24 weeks gestation. According to her there are no specialist obstetricians or gynaecologists in Victoria offering this service.
8. We took the liberty of looking at the Royal Australian and New Zealand College of Obstetrics and Gynaecology's policy statement on termination of pregnancy published in November 2012 but first endorsed in 2005 before the Abortion Law Reform Act 2008 authorised the performance of an abortion on a woman who is not more than 24 weeks pregnant.
9. The College policy states "termination of pregnancy becomes more complex in the presence of late recognition of pregnancy, advanced gestational age, fetal abnormality and pre-existing maternal disease."
10. With that in mind we are concerned that the risks arising from this increased complexity might be a significant factor in the reluctance of medical practitioners to perform late term abortions. The Tribunal heard evidence that Dr Schulberg currently performs these in a day procedure centre (presumably without the benefit of a High Dependency Unit or an Intensive Care Unit) and without a specialist anaesthetist. Dr Lebranksi, described as a GP Sedationist with some 30 years experience, performs that service at MSI.
11. What we found concerning was that the evidence of Ms Deveson Crabbe made it clear there was no audit of morbidity at the clinic beyond the day of the procedure. In the circumstances of this hearing there was no opportunity to hear from the relevant professional college by way of response to her evidence about the absence of other available practitioners or from any specialist obstetricians or gynaecologists to give us comfort in the accuracy of the present state in Victoria or to comment on the appropriateness of allowing the doctor to continue. It follows that we cannot agree on the material before us that Dr Schulberg's practice be divided such that he might be disqualified from general medical practice for a period but be permitted to practise in an area in which there was an absence of relevant professional evidence to justify continuation of the practice.