Application pursuant to s.71 of Health Professions Registration Act 2005 to review decision of Professional Standards Panel

Orchard v Medical Practitioners Board of Victoria (Occupational and Business Regulation) [2010] VCAT 1135

1. Pursuant to s.103(3) & (4) of the Victorian Civil & Administrative Tribunal Act 1998, and until any further order is made by the Tribunal, any information that might enable a person to identify the notifier, or identify a patient of any medical practitioner being a medical practitioner who has given evidence or made a witness statement in these proceedings, is not to be published or made available to any person other than the notifier and the parties to the proceedings or their legal representatives.
2. Pursuant to s.146(4)(b) of the Victorian Civil & Administrative Tribunal Act 1998, and until any further order is made by the Tribunal, the file kept by the principal registrar, and all documents filed at the Tribunal by the parties to the proceedings, are not to be inspected or made available to any person other than the notifier and the parties to the proceedings or their legal representatives.

1. The Tribunal finds that the applicant's communication with his patient, the notifier, amounted to unprofessional conduct on the part of the applicant.
2. The Tribunal finds that the professional performance of the applicant has been unsatisfactory.
3. The principal registrar is to appoint a time, date and place for the resumption of this hearing, to enable the parties to make submissions as to any further order to be made consequent upon the findings of the Tribunal.

1. Dr. Orchard is a psychiatrist. He applied to VCAT to review a decision of a Professional Standards Panel appointed by the Medical Practitioners Board of Victoria ("the Board").

THE DOCUMENTS ADMITTED INTO EVIDENCE BEFORE THE TRIBUNAL:

1. Section 49(1) of the Victorian Civil & Administrative Tribunal Act 1998 requires the maker of a decision to lodge with the Tribunal the decision under review, and "every other document in the decision-maker's possession that the decision maker considers is relevant to the review".
2. The Board lodged a Tribunal Book. Volume 1 comprised documents prepared or received by the Board before Dr. Orchard lodged his present application to the Tribunal. Volume 2 comprised witness statements bearing dates subsequent to the date upon which Dr. Orchard lodged his application. The Tribunal Book came into evidence without objection.
3. Three additional documents were tendered on behalf of Dr. Orchard, and accepted into evidence. They included a witness statement signed by Dr. Orchard, which was the only witness statement not included in Volume 2 of the Tribunal Book.
4. Five additional documents were tendered on behalf of the Board, and accepted into evidence.

[All references to sections are references to sections in the Health Professions Registration Act 2005, unless there is reference to another Act.]

1. Dr. William Orchard is a "health practitioner" for the purposes of the Health Professions Registration Act 2005, in that he practises in a profession regulated by the Medical Practitioners Board of Victoria: see Schedule 1 to the Act and the definition of "health practitioner" in s.3.
2. Ms P became a patient of Dr. Orchard when she consulted him on 29 August 2007. She subsequently notified the Board of matters relating to Dr. Orchard ("the notification"), as she was entitled to do by s.42(1).
3. The Board was obliged to investigate the notification: s.45(1). The Board appointed a person to conduct an investigation ("the investigator"), and delegated its power to conduct an investigation to the investigator. In taking those steps, the Board acted in accordance with s.45(3). The investigator gave notice of the investigation to Dr. Orchard, as required by s.48(1).
4. The investigator asked Dr. Orchard to undergo a performance assessment. The investigator was entitled to make that request: s.49(b). Dr. Orchard did not agree to undergo a performance assessment. As required by s.57(1), the investigator reported to the Board that Dr. Orchard did not agree to undergo a performance assessment.
5. The Board then referred the matter to a hearing by a Professional Standards Panel ("PSP"), a course open to the Board under s.57(2). The Board appointed members to the PSP, acting in accordance with s.61(1).
6. The PSP required Dr. Orchard to undergo a performance assessment by two health practitioners appointed by the panel. In making that requirement, the PSP acted in accordance with s.58(1). The health practitioners appointed to carry out the performance assessment were Professor Isaac Schweitzer and Dr. Peter McArdle.
7. Professor Schweitzer and Dr. McArdle carried out a performance assessment. They prepared a report of their assessment, and gave the report to the PSP, as required by s.58(3).
8. The PSP discussed the report with Dr. Orchard, a course open to the panel under s.58(4).
9. The PSP conducted a hearing on 22 January 2009 and 19 November 2009. The performance assessment took place between those dates. On 3 December 2009, the PSP made two findings of unprofessional conduct and one finding that Dr. Orchard's professional performance has been unsatisfactory. The power of the PSP to make such findings is set out in s.63(1).
10. Having made those findings, the PSP then made several of the determinations that it had power to make pursuant to s.63(2).
11. Dr. Orchard was dissatisfied with the findings and the determinations of the PSP. On 17 December 2009, he lodged an application to VCAT to have the findings and the determinations of the PSP reviewed. He was entitled to make the application pursuant to s.71.
12. Counsel for the Board submitted that the review should proceed as a re-hearing, a submission with which counsel for Dr. Orchard concurred. The Tribunal accepted the submission, and the review proceeded as a re-hearing.
13. The Tribunal is "obliged to conduct the review without any presumption as to the correctness of the decision under review": McDonald v Guardianship Board [1993] VicRp 36; [1993] 1 VR 521 @ 530. It is appropriate for the Tribunal to consider the evidence before the PSP and any fresh evidence relied upon by the parties: Storti v Medical Practitioners Board [2005] VCAT 873 @ [25].
14. The Tribunal may make one or more of the findings that were open to the PSP under s.63(1). Depending upon those findings, the Tribunal then may make one or more of the determinations that were open to the PSP under s.63(2). The power of the Tribunal to make such findings and determinations is granted by s.51(1) of the Victorian Civil & Administrative Tribunal Act 1998.
15. These reasons lead only to the findings of the Tribunal. The Tribunal will resume to hear submissions as to any determination to be made by the Tribunal.

1. The Board received the notification, effectively a complaint, from Ms P on 19 October 2007. Ms P expressed her concern as follows:

"I have just relocated home to Melbourne after living in Sydney for the past 6 years. Whilst living in Sydney, I was diagnosed with ADHD and have been a patient of Dr Gojak since the diagnosis approximately 4 years ago. I have been stable and happy with the prescribed medication Dexamphetamine as prescribed by Dr Gojak.

Since relocating, my challenge was to find a psychiatrist who would treat ADHD and provide me with a prescription for the same medication.

After an initial consultation with Dr Orchard on 29 August 2007, he very swiftly and carelessly diagnosed me as having a form of bi-polar disorder (hypomania) and recommended that I increase my current medication (Dexamphetamine) from 2 per day to 10 per day and commence taking lithium carbonate immediately. He proceeded to tell me what 'amazingly vivid' dreams I would have. His rash diagnosis was not only extremely confronting for me, but extremely dangerous."

1. The investigator interviewed Ms P on 3 December 2007. A summary of the interview, prepared by the investigator, is in evidence. The summary purports to record statements made by Ms P during the interview. In the witness statement that she adopted as her evidence in chief, Ms P said that the summary of interview generally reflected what she said during the interview. We will set out some of the statements as recorded, as they supplement the notification made by Ms P:

"Dr. Gojak has sent a copy of my records to Dr Orchard.

... Dr Orchard gave me information regarding bipolar disorder. He warned me not to be alarmed about Bipolar Disorder. He told me to have a read of the information he provided and gave me a prescription for Dexamphetamine tablets 5 mg with instructions to start with one tablet four times per day and slowly increase to ten tablets per day in four divided doses five hours apart. Dr Orchard also prescribed Lithium. I had gone simply seeking a repeat of my Dexamphetamine that Dr Gojak had prescribed. I did not ask for nor want to increase my medication.

Dr Orchard prescribed this medication after a short time. He told me he has many patients who have been diagnosed with ADHD but what they really suffer from is Bipolar Disorder.

I left the consultation in tears. I was distressed at being diagnosed with Bipolar Disorder and at the excessive prescribing. I telephoned Dr Gojak and told him what had happened. ... He suggested that I see someone else for another opinion.

I only filled the prescription for Dexamphetamine but not the Lithium. I did not take the doses prescribed by Dr Orchard."

1. A letter from Dr. Gojak to Dr. Orchard, dated 27 August 2007, provided Dr. Orchard with the following information:

"[Ms P] has been a patient under my care since April 2002. I have seen her infrequently in dealing with her adult ADHD and background depression and relationship problems.

Her childhood was characterised by difficulties sustaining attention in class, distractibility and talking over the top of others. This continued into adulthood with impatience, difficulty completing tasks, impulsiveness, poor short term memory and poor attention.

She has derived significant benefit from stimulant medication in the form of Dexamphetamine, 2 daily and has managed to keep a job that requires a relatively high degree of focus.

She also has a history of depression, bulimia, and anorexia but has been fairly stable on those fronts on a low dose of Zoloft 25mg."

1. A copy of the prescription for dexamphetamine is exhibited to Ms P's witness statement. The prescription is signed by Dr. Orchard and dated 29 August 2007. The dosage directions are "Up to 10/day in 4 divided doses 5 hours apart. Start ONE 4 times/day & slowly increase". The quantity prescribed is 300 with five repeats.
2. The Tribunal will deal immediately with the statement that Dr. Orchard also prescribed lithium. When she gave evidence before the Tribunal, Ms P said that she tore up the prescription for lithium on the day that she received it. Dr. Orchard gave evidence that he did not prescribe lithium. Lithium is not mentioned in his clinical notes. The Tribunal is not satisfied that Dr. Orchard prescribed lithium, and no further mention will be made of a prescription for lithium.
3. We turn next to the written information provided by Dr. Orchard to Ms P at the conclusion of their consultation.
4. The first document is entitled 'Comments About The Clinical Diagnosis & Management Of ADHD In Adults'. It is a paper prepared by Dr. Orchard which appears to be directed at medical practitioners. It sets out details of Dr. Orchard's experience in diagnosing and treating ADHD and bipolar spectrum disorder. It mentions a large number of symptoms detected by Dr. Orchard, and contends that ADHD is under-diagnosed and frequently co-morbid with bipolar spectrum disorder.
5. The second document is entitled 'Patient Notes On Dexamphetamine'. It is directed at patients generally, not at a particular patient. It encourages patients to adjust the dosage as they see fit. It includes the following passage:

"Please take your dexamphetamine tablets in 4 divided doses approximately 5 hours apart. It is suggested you initially have 1 tablet on awakening, 1 after 5 hours, 1 after another 5 hours and 1 on retiring to bed. Patients may then adjust dosage higher or lower but keeping to 4 dosages a day. The maximum legal dose is 12 a day but 4 to 8 tablets is the most usual range. ... Please take as high a dose as you can without developing the stimulant effect of these tablets eg. anxiety, palpitations."

1. The notes set out side effects of dexamphetamine, and inform patients that they can stop taking tablets at any time without suffering any ill effects.
2. The third document is entitled ' "Masked" Bipolar Illness' and states that it is based upon an address given by Dr. Orchard to "Family Practitioners". There is a long and detailed analysis of bipolar illness in the paper. It concludes by saying "Today, I am recommending that you experience a similar sea change, a change of attitude, and make bipolar illness your diagnosis of first choice in the every day patient with psychiatric symptoms, rather than depression".
3. The fourth document is entitled 'The Amen Clinic ADD Type Questionnaire'. It asks the patient to complete a questionnaire about 71 symptoms of ADD.
4. The fifth document is entitled '50 Tips on the Management of Adult Attention Deficit Disorder', written by Drs. E.M. Hallowell & J.J. Ratey. The paper is directed at patients, rather than medical practitioners.
5. The sixth documents is entitled 'Time to Take the 'Disorder' out of ADD', written by Robert Tym & Tania Lioulios. The paper appears to be directed at medical practitioners. It is written at a level that would confuse many patients.
6. The six documents run to 44 pages, most of which are single spaced and in small font.

THE PERFORMANCE ASSESSMENT REPORT PREPARED BY PROFESSOR SCHWEITZER AND DR. MCARDLE:

1. Professor Schweitzer and Dr. McArdle met with Dr. Orchard on 12 & 21 August 2009. They prepared a report which is undated, but which was received by the Board on 14 September 2009.
2. It must be said at the outset that Professor Schweitzer and Dr. McArdle did not refer to Dr. Orchard's treatment of Ms P in their performance assessment report. The report was prepared in general terms, save that the report set out information concerning one patient who was identified by initials (not Ms P). The report dealt with medical matters and record keeping matters.
3. The medical matters mainly concerned Dr. Orchard's diagnosis and treatment of adult Attention Deficit and Hyperactivity Disorder ("ADHD") and co-morbid conditions, particularly Bipolar Spectrum Disorder ("BSD"). The report included the following passages:

"Over recent years he [Dr. Orchard] had become increasingly interested in Adult Attention Deficit Disorder (ADHD), and as other doctors had learnt of this interest, he had been receiving increasing numbers of referrals of patients suffering from this condition.

Dr O expressed his opinion that Adult ADHD was an extremely prevalent disorder and in his opinion it affected 1 in 10 in the general community. He also believed it was generally under diagnosed by mainstream psychiatrists in Melbourne. On questioning about his approach to assessment, he stated that he now felt able to make a diagnosis at interview, and generally at the first interview and that he would usually start treatment, often as a combination of sodium valproate and dexamphetamine. He based this mainly on the interview he gained from the patient, but when questioned, said that he encouraged people to bring a spouse or significant other to corroborate the history if possible.

Dr O also went on to speak of his belief that many of these patients have "Bipolar spectrum disorder", which he believed was more prevalent that unipolar depression and that this was present in up to 50% of cases co-morbid with ADHD. Thus it was his practice to prescribe Epilim in conjunction with dexamphetamine, which he outlines in a patient information leaflet he provided us with dated October 2008.

He went on to state his conviction that angry outbursts, over activity, mood swings, poor response to high dose antidepressants are also diagnostic features of Bipolar Disorder. ..... He did not appear to differentiate between affect change and mood change and was dismissive of the diagnosis of Borderline Personality Disorder.

We went on to explore further how Dr O went about managing his patients. He told us he would often give those patients who he suspected of suffering from ADHD, a treatment trial. He would commence dexamphetamine 5mg qid and reassess the patient's response within a week. Where patients felt calmer and were more clear-headed and relaxed, he considered this was diagnostic of ADHD. He would then usually increase the dose of dexamphetamine. He provided us with a printed leaflet that gave detailed information for patients and how they should take the Dexamphetamine.

He went on to state that he thought antisocial or angry patients and again patients with personality disorders such as Borderline Personality Disorder, actually had a Bipolar Spectrum Disorder and were best treated with a biological therapy such as sodium valproate.

We suggested to him that he may at times lack scepticism when diagnosing ADHD or that he was unconcerned that he might be over diagnosing ADHD because of his strong convictions about its prevalence and the benefits of dexamphetamine. His response to this was that he was at the cutting edge of diagnosis and that academic psychiatry had a long way to catch up.

We both formed the impression that patients he would see had the diagnoses of ADHD and Bipolar Spectrum Disorder until proven otherwise.

We had particular concerns regarding his management of those patients who have co-morbid substance abuse disorder and ADHD. Dr O indicated that if patients had an active substance abuse disorder, he would not treat them unless they were attending a general practitioner with an interest in addiction medicine or an addiction specialist. He also noted that he would specify on his prescriptions for patients for whom there were concerns that they were to collect their Dexamphetamine with their Methadone, on a daily basis from the pharmacy. He also indicated that he requires regular and frequent follow up, within a week, and that he is available on the phone.

We discussed in greater detail the "AMEN" classification of ADHD. ..... There are six subtypes of ADHD according to this system. This system, which is not in general use by the psychiatric community, is much broader than either of the conventional systems of classification, that is, DSM IVTR or ICD 10. Of concern was Dr O's broad application of this system. The AMEN system suggests that there may be a spectrum of conditions related to the more traditional ADHD of the conventional classificatory systems. The AMEN approach however does not advocate the use of Psycho-stimulants for all the subtypes whereas it became clear from our discussions that either Dr O disagreed with this or had not fully understood this. Dr O indicated that he was much more inclined to use Dexamphetamine, no matter the subtype. It was evident from this discussion that Dr O uses a rather broad definition of ADHD, much broader than conventional criteria, which he sees as rather narrow. He felt that his practice was light years ahead of other psychiatrists."

1. The report then made several observations by way of summary, including the following:

"Dr O impressed as being a caring clinician who sincerely believes in the work that he does.

His practice has become more and more specialised over recent years and he increasing attracts referrals of patients who have possible ADHD.

Many patients, if not most, are treated with the same medication combination of dexamphetamine and sodium valproate.

Dr O appears to use very broad, if not loose criteria, for diagnosis of both ADHD and Bipolar Spectrum Disorder and these criteria do not concur with either of the conventional diagnostic systems DSM IVTR or ICD 10. His diagnosis is based more on his personal views and experience. They are idiosyncratic and his reading appears to be confined and limited rather than referring to the broader evidence based literature."

1. So far as record keeping is concerned, the report included the following passages:

"He observed that he sometimes felt overwhelmed by the number of referrals. He admitted that he had been unable to keep up writing reports and responses to his referring GPs and felt rather inundated with court reports.

... we reviewed approximately 8 sets of case notes each. These were written on a small card and were rather difficult to read. Amongst these 16 cases records, there was only one letter to the referring GP.

We both found the card system for his case records as cumbersome, outdated and difficult for another clinician to follow. The history and examination on the cards were not set out in a way that made it easy to follow Dr. Orchard's clinical thinking, and how he formed the diagnosis.

We consider that this level of documentation leaves Dr. Orchard vulnerable to litigation and criticism. ... It also would make it difficult for another clinician to take over management of his cases, if that became necessary.

He acknowledged that he needed to improve his medical notes and that they would be difficult for other clinicians to read. He recognised he had become too busy to maintain his written communications with his referring doctors."

1. The summary in the report included an observation that "his card system for patient records is not adequate for contemporary practice and contains insufficient detail of the full psychiatric history, mental state examination, formulation and follow up entries".
2. The report concluded with eight recommendations. However, the Tribunal will make findings, and give the parties an opportunity to make submissions, before considering the recommendations.

1. As we have mentioned, the PSP conducted a hearing on 22 January 2009 and 19 November 2009. The performance assessment took place between those dates. The PSP made its decision on 3 December 2009, being the decision under review.
2. The Tribunal will set out, in full, the findings of fact made by the PSP:

"The Panel found that Dr Orchard failed to adequately assess [Ms P] during a consultation on 29 August 2007. The Panel found that Dr Orchard did not contact Dr Gojak, [Ms P's] previous treating psychiatrist, when it was relevant and prudent to do so.

Dr Orchard communicated a diagnosis to [Ms P] that was at odds with that of her previous treating psychiatrist. [Ms P] had been very satisfied with her management by Dr Gojak so she was somewhat shocked to hear the new diagnosis. Dr Orchard handed her a 'massive document' on BPSD but did not explain the reason for a new diagnosis. The Panel found that Dr Orchard did not adequately explain his diagnosis or provide [Ms P] with adequate instructions regarding the dose of dexamphetamine which he prescribed.

At its hearing on 22 January 2009, the Panel found that Dr Orchard had refused to undergo a performance assessment as requested by the Board.

On reconvening following receipt of the performance assessment, the Panel found that the performance assessment conducted by Professor Schweitzer and Dr McArdle was considered, comprehensive and well reasoned. Based on this assessment and Dr Orchard's response to it, the Panel found that Dr Orchard's performance was inadequate. The Panel found the recommendations in the report to be reasonable and that, if implemented, would be likely to lead to an improvement in Dr Orchard's performance."

1. Having made those findings as to the facts, the PSP proceeded to make two findings of unprofessional conduct and one finding that Dr Orchard's professional performance was below the standard of performance expected of a reasonable medical practitioner.
2. The first finding of unprofessional conduct was that "Dr Orchard failed to adequately communicate with [Ms P] causing her considerable distress".
3. The second finding of unprofessional conduct was that Dr Orchard "refused to undergo a performance assessment at the request of the Board".
4. The finding that "Dr Orchard's performance was below that expected of a reasonable medical practitioner" was based upon the acceptance by the panel of the performance assessment report. The PSP identified the areas of "particular concern" in the report as record keeping; inadequate correspondence with referring practitioners; inadequate assessment of patients and failure to seek a second opinion from peers; treatment of most patients with the same combination of medication; use of loose diagnostic criteria and lack of reference to a broad evidence base; and lack of involvement with peer or interest groups.

THE FINDING OF THE PSP THAT DR. ORCHARD REFUSED TO UNDERGO A PERFORMANCE ASSESSMENT AT THE REQUEST OF THE BOARD:

1. The Tribunal is unable to accept the second finding of the PSP, namely that Dr. Orchard "refused to undergo a performance assessment at the request of the Board". The Tribunal will deal with that finding immediately.
2. The request was made by the investigator. On 4 September 2008, the investigator wrote a letter to Dr. Orchard, which stated that "pursuant to Section 49 of the Health Professions Registration Act 2005 I now request that you advise me within 28 days of the date of this letter whether you are prepared to undergo a performance assessment".
3. The relevant part of s.49 provides that "An investigator may ... ask the health practitioner ... to undergo a ... performance assessment within 28 days".
4. Dr. Orchard responded by letter dated 8 September 2008. His response, so far as is relevant, was that "After consulting with my Medical Insurer I will endeavour to get back to you within 28 days" and that "barring a remarkable event, I will not accept your request and rather put my trust in legal process".
5. Dr. Orchard provided an unequivocal response on 1 October 2008, when he replied that "I write to inform you that I decline to accept your request ... that I agree to a Performance Assessment".
6. The response of Dr. Orchard brought s.57(1) into operation. It provides that "If a registered health practitioner who is subject to an investigation ... does not agree to undergo a performance assessment ... the investigator must report on the matter to the responsible board together with any recommendations". This is followed by s.57(2), which provides that "After receiving a report from an investigator under subsection (1), the responsible board may refer the matter to a hearing by a professional standards panel or to VCAT for a Tribunal hearing".
7. The word 'ask' in s.49, and the words 'does not agree' in s.57(1) make it apparent that Dr. Orchard was not obliged to undergo a performance assessment at the request of the investigator.
8. Of course, Dr. Orchard did undergo a performance assessment when required to do so by the PSP pursuant to s.58(1). It is significant that the PSP was entitled to require Dr. Orchard to undergo a performance assessment, and that the investigator was entitled to ask Dr. Orchard to undergo an assessment: compare sections 49(b) and 58(1).

1. The witness statement adopted by Ms P accorded with her notification and the summary of her interview with the investigator, subject to a few minor adjustments. We will set out significant passages in her witness statement:

"I told him [Dr Orchard] about my current medication (Dexamphetamine) and the dosage prescribed by Dr Gojak. I told Dr Orchard that I was happy with my current treatment regime. [paragraph 23]

... Dr Orchard gave me a wad of printed material regarding bipolar spectrum disorder. He told me not to be put off by what I was about to read. ... This occurred approximately five minutes before the end of the consultation. Dr Orchard told me that he believed that I had bipolar spectrum disorder. [paragraph 28]

Dr Orchard did not express his diagnosis regarding bipolar disorder as a provisional or tentative diagnosis. [paragraph 30]

At the end of the consultation, Dr Orchard prescribed a significant increase in my Dexamphetamine medication. Dr Orchard did not give me any indication at all as to why he increased the Dexamphetamine dose so sharply. This is why I was so shocked by his prescription. [paragraph 29]

Ultimately, I told Dr Orchard that I was not going to take the cocktail of drugs he was proposing, and I said that I would take the Dexamphetamine as per my previous prescriptions from Dr Gojak ..." [paragraph 32]

1. In cross-examination, Ms P acknowledged that Dr. Orchard told her that mood swings and an overactive mind were indicative of bipolar spectrum disorder. She also acknowledged that Dr. Orchard explained to her that she had something different to bipolar. She said that she read the written material provided by Dr. Orchard, and that she could follow it. She also said that, after her consultation with Dr. Orchard, she continued to take two dexamphetamine tablets each morning, and two in the afternoon if required.
2. Ms P was asked questions by Tribunal members. She said that she told Dr. Orchard that she might increase her dosage of dexamphetamine, but not to ten tablets per day. She said that Dr. Orchard did not explain the difference between bipolar and bipolar spectrum disorder. She acknowledged that Dr. Orchard asked her to return within seven to ten days.
3. The Tribunal found Ms P to be an impressive witness. She gave a consistent version of events from the time that she made the notification until the time that she gave oral evidence.

1. Professor Schweitzer is the Healthscope Professor of Psychiatry at the University of Melbourne, and the Medical Director of The Melbourne Clinic. He is a highly credentialed psychiatrist.
2. His witness statement adopted the performance assessment report prepared by himself and Dr. McArdle.
3. Professor Schweitzer said that he currently spends about 30% of his time performing clinical work, and that about 30% to 40% of that work relates to mood disorders. He encounters ADHD "occasionally". He said that he regularly provides second opinions for colleagues.
4. Professor Schweitzer also gave evidence that the Australian and New Zealand Journal of Psychiatry is a peer review journal, and is the pre-eminent journal relating to psychiatry in Australia. He said that he would expect Dr. Orchard to be familiar with a journal article on ADHD.
5. In cross-examination, Professor Schweitzer agreed that ADHD had been under-diagnosed in the past. He said that ADHD previously had been seen as a childhood condition, but was now seen as persisting in adulthood. Professor Schweitzer agreed that completion of the AMEN questionnaire by a patient was a "useful tool"; however, the AMEN classification was not referred to in any of Dr. Barclay's publications.
6. He said that Dr. Orchard has a broad view of mood swings which leads him to regularly make a diagnosis of bipolar spectrum disorder. Professor Schweitzer was asked whether he would inform a patient immediately of a diagnosis that was different to a diagnosis made in the past. He said that he might immediately raise the suggestion with the patient that some symptoms suggest another condition, start an explanation of the new diagnosis, ask the patient to keep a daily log book as to mood, provide literature, and ask to meet with a family member who might be able to provide corroborative evidence to support the additional diagnosis.
7. It was put to Professor Schweitzer that ADHD and bipolar spectrum disorder can be treated together. Professor Schweitzer said that he was not of that view. He said that a provisional diagnosis should be made, and that the main condition should be treated before the other. He said that ADHD would have been present since childhood, so treatment usually was not urgent. He said that bipolar spectrum disorder, or any mood disorder, if present, usually should be treated first. This would allow the doctor to better manage any side effects that arose from the medication being trialled and it would also reduce confusion around side effects and drug interactions if any occurred.
8. Professor Schweitzer said that it was now generally accepted that 8% of children in the population had a diagnosis of ADHD and data presently being submitted considers 4% of the adult population also had this diagnosis (Professor Barclay in the US acknowledges this to be so in his publications).
9. Professor Schweitzer was asked questions by Tribunal members. He said that not all patients with ADHD needed treatment with drugs; psychological strategies and cognitive behaviour therapy should also be considered. He said there ought to be concern when prescribing dexamphetamine as it was "potentially a drug of dependence". He said that Dr. Orchard did not appear to refer patients to psychologists or other therapists.
10. Professor Schweitzer acknowledged that many psychiatrists prescribe doses above recommended levels, as standard doses do not affect some patients. In that situation, he said that he raises the dose of medication slowly, incrementally, with supervision, and gives each dose for two or three weeks to observe the response before he considers raising the dose again. He also said that in these cases he probably would seek a second opinion to receive confirmation of his assessment and provisional diagnosis.
11. Professor Schweitzer was asked about the protocol surrounding communicating with peers when a new and unusual line of treatment was being trialled. He said that, if you thought you were the only specialist in the country treating patients in a particular way, the protocol would be to confer with your peers and colleagues, present the data at peer review meetings or at College meetings or publish the data in the College magazine. He said that he was surprised that Dr. Orchard had not presented his clinical findings, diagnosis and plan of management at any meetings or submitted any papers about his treatment of patients with a diagnosis of ADHD who were on increased dosages of dexamphetamine. He said that it would have been useful for Dr. Orchard to raise the matter for discussion at the College [The Royal Australian & New Zealand College of Psychiatrists]. He said that peer review groups are formed through the College, and meet frequently.

1. Dr. McArdle is a consultant psychiatrist at The Alfred Road Clinic. He said that he spends about 90% of his time performing clinical work. He said that he encounters ADHD occasionally. If he diagnoses ADHD, he refers the patient to a colleague at his clinic.
2. His witness statement adopted the performance assessment report prepared by Professor Schweitzer and himself.
3. Dr. McArdle said that Dr. Orchard gave the impression that he sees ADHD and bipolar spectrum disorder commonly together. Dr. McArdle said that a dual diagnosis required a mood stabiliser and a stimulant; these drugs were very different to each other. Dr. McArdle said that he was concerned about drug interactions.
4. A Tribunal member asked Dr. McArdle whether he thought that Dr. Orchard "accelerated diagnosis". Dr. McArdle said that Dr. Orchard claimed to be able to make a diagnosis in one interview. Dr. McArdle said that diagnosis by Dr. Orchard appeared in some cases to be "rather rapid". Dr. McArdle said that further consultations were required "to firm up data". In further cross-examination relating to the question asked by the Tribunal member, Dr. McArdle agreed that an experienced psychiatrist could formulate a diagnosis within one hour if a good history was available, and if a family member provided corroborative evidence that supported the diagnosis.
5. Dr. McArdle said it was important to prescribe medication for one condition and then commence treatment for the second condition later to avoid problems with side effects or drug interactions.

1. In 2008, the investigator sought a report from Professor Philip Mitchell, then the Professor and Head of the School of Psychiatry at the University of NSW.
2. Professor Mitchell provided a report dated 21 July 2008, and it is among the documents admitted into evidence as part of the Tribunal Book. Professor Mitchell did not give evidence before the Tribunal.
3. The PSP stated in the decision under review that it "had regard to" Professor Mitchell's report. We will set out some relevant parts of his report:

"... my relevant expertise is in bipolar disorder and depression.

... I have not assessed [Ms P] myself. The opinions stated below are based on the documentation provided to me.

I was surprised at the brevity of the case notes for a one-hour initial assessment of a new patient.

There appears from the various documents to be reasonable evidence of childhood onset ADHD that had persisted into [Ms P's] adulthood.

The diagnosis of bipolar spectrum disorder. ... this is an unorthodox and contentious diagnosis. It would appear from all the documentation ... that Dr. Orchard works to the assumption that most adult ADHD patients also suffer from bipolar spectrum disorder. ... While there is good evidence that ADHD is comorbid with the orthodox bipolar disorder syndrome more frequently than due to chance (Kessler et al, 2005), I would consider his belief that ADHD is associated with bipolar spectrum disorder in 90% of cases ... to be idiosyncratic.

Accepting that this is so [that the maximum legal dose of dexamphetamine allowed in Victoria is 12 tablets daily, namely 60mg], it is still extraordinary that Dr. Orchard recommended that [Ms P] increase the dose from 10mg to 50mg (albeit with the caveat of "slowly") in a woman who claimed (interview of 3 December 2007) that her condition was stable and that she "wanted to keep to same treatment regime".

The concept of "bipolar spectrum disorder" is not recognized in the main standard international or national psychiatric classificatory systems for example, (DSM-IV and ICD-10). It is regarded as controversial.

The use of this term "bipolar spectrum disorder" in the limited sense of describing subsyndromal bipolar disorder has gained credence in recent years, with formal studies of its prevalence in the US appearing recently in the leading psychiatry journal Archives of General Psychiatry (Merikangas et al, 2007).

... the "commonly" comorbid manifestations of bipolar spectrum disorder as described by Dr. Orchard (in his document on "masked" bipolar illness) includes features not described by Akiskal or others.

I agree with Dr. Orchard ... that an experienced psychiatrist is able to make an informed provisional diagnosis on the basis of a single assessment.

There have been no randomised controlled studies of medications or non-pharmacological treatments for patients diagnosed with "bipolar spectrum disorder" - neither in the narrow sense of subsyndromal presentations, nor in the broader sense as appears to be used by Dr. Orchard.

None of the major national clinical practice guidelines on the management of bipolar disorder (US, UK or Australia; APA 2002; Goodwin et al 2003; RANZCP 2004) detail treatment recommendations for "bipolar spectrum disorder".

In other words, there are no validated treatments for this "condition" no matter how it is defined."

1. We will refer to one matter only. Ms P consulted another psychiatrist Dr. Manjula O'Connor because she was dissatisfied with Dr. Orchard. Dr. O'Connor wrote a letter to the investigator on 24 January 2008 in which she stated that "[Ms P] was managing well in NSW on 10mg of Dexamphetamine. I continued the same dosage and she has managed to maintain her wellbeing on a low dose of Dexamphetamine".

1. Dr. Orchard adopted a witness statement dated 5 April 2010. It included the following passages relating to Ms P:

"She had been treated for ADHD for four years in Sydney and I received an excellent and courteous letter from her psychiatrist in Sydney recounting the four years of treatment that she had received there.

She described that she only took two Dexamphetamine tablets per day and at the time I thought that she was taking one in the morning and one in the evening but since then it has been revealed that she was taking both tablets in the morning a quite inappropriate regime in my extensive experience. Her history included that she largely worked meeting people and had her appointments in the morning but was "not on the ball in the afternoon".

In view of what she told me about her inability to work in the afternoon, I explained to her at the end of the appointment that Dexamphetamine had a clinical effect of only four to six hours and that accepted best practice was to take Dexamphetamine four times per day and she was started on Dexamphetamine four times a day as written on her history card and she was encouraged to return and see me in another ten days.

I explained to her that most patients in Victoria whom I treat are given a trial of Dexamphetamine up to eight to ten per day and that once they have tried this dosage they can then become their own doctors and work out whichever dosage they preferred. She was told that if she was to take more than four per day, in view of the fact that ADHD regularly has associated psychiatric reactions with it, she would probably later need to take mood stabilizing medication in order to be able to sleep and I told her that the medication was Sodium Valproate and that she would possibly be put on that at her second appointment.

Ms P did not telephone in and arrange her next appointment in ten to fourteen days as agreed.

Patients that I have seen from NSW regularly come on a dose that I regard as under treatment."

1. In that part of his evidence in chief given orally, Dr. Orchard said that he read Dr. Gojak's report prior to his interview with Ms P. Dr. Orchard said that he made provisional diagnoses of ADHD and Bipolar Spectrum Disorder at the end of the interview. He said that he informed Ms P that he agreed with the diagnosis of ADHD made by Dr. Gojak. He said that he asked Ms P to take four dexamphetamine tablets per day, five hours apart, and that at her next appointment he might give her a higher dose.
2. Dr. Orchard also said that he informed Ms P that she had Bipolar Spectrum Disorder in a muted form that might require treatment. He said that he intended to give Ms P sodium valproate at her next interview. Dr. Orchard said that he gave four documents to Ms P to read.
3. In cross-examination, Dr. Orchard agreed that he had been informed by Dr. Gojak that Ms P was happy with her present medication. Dr. Orchard acknowledged that he did not tell Ms P that dexamphetamine was an addictive drug, or warn her of the possible effects of an increase in its use.
4. Dr. Orchard also agreed that Dr. Gojak had not informed him at that stage that Ms P had bipolar symptoms. Dr. Orchard said that he discussed bipolar spectrum disorder with Ms P during the last five minutes of the consultation. He did not tell her that his diagnosis of bipolar spectrum disorder was provisional. He explained that her symptoms did not indicate bipolar illness, but rather bipolar spectrum disorder. He said that, with the advantage of hindsight, he gave Ms P too much written material.
5. As far as professional performance is concerned, Dr. Orchard's witness statement included the following passages:

"Over the last ten years I have become particularly interested in the area of what is sometimes referred to as Bipolar Spectrum Disorder (muted forms of bipolar illness) ...

... to the best of my knowledge there are only approximately fourteen psychiatrists in Victoria who are interested to diagnose and to treat ADHD in adults.

... I would estimate that last year, I treated over 500 patients with ADHD.

... I claim to be on the cutting edge of innovative medical practice in Melbourne with respect to the diagnosis and treatment of ADHD in adults and have no doubt that this will be recognized in another few years when the DSMV, the American classification of psychiatric illnesses is published ...

Probably the most venerable person in the world in the field of ADHD in adulthood is a psychologist Dr Russell Barkley. ... Dr Barclay's latest view [is] that ADHD in adulthood may have the same frequency as ADHD in childhood, that it is a gravely under diagnosed condition and may have a frequency as high as 9% of the population. ... I agree with Barkley's assessment ...

There is a paradigm shift occurring in psychiatry and a recognition that ADHD is the generative condition which creates the anxiety which leads to an enormous amount of social pathology, comorbid psychiatric illnesses, and psychosomatic illnesses.

Patients with ADHD develop what is described as a paradoxical response to Dexamphetamine and Methylphenidate and find that the tablets do not have a "go fast" effect but a calming effect upon them and help them to keep their focus, help them to comprehend what they read and helps them to listen to other people ....

Ignorance about ADHD in adulthood is extensive in Victoria and reflects on academic psychiatry, the Royal Australian and New Zealand College of Psychiatry and the Medical Practitioners Board of Victoria, in my view.

I have become very impressed at the advantages that people gain from taking Dexamphetamine up to 8 to 12 per day. ... Insomnia is a regular problem in ADHD patients and I consider that it is due to the fact that they have a subclinical form of hypomania and an overly active mind which prevents them from sleeping. If they take Sodium Valproate and/or an atypical antipsychotic drug such as Olanzepine, they can usually take up to 8 to 12 tablets per day and find that they develop a marked capacity to sleep very soundly.

ADHD in adults is almost invariably a comorbid illness, that is, the patient regularly has other diagnoses as well, such as ADHD plus bipolar spectrum disorder plus substance abuse disorder (alcoholism) plus oppositional defiant personality disorder.

The reason that ADHD is such an important diagnosis is that it is the generative illness significantly determining the other illnesses; simply treating the other illnesses regularly is ineffective unless the ADHD is tackled.

The fears about the dangers of Dexamphetamine within the medical community of Melbourne are quite unfounded.

What has not been appreciated by most medicos in Victoria is the massive destructiveness of undiagnosed and untreated ADHD, its everyday frequency, (it is as common as the common cold) and that its effective treatments regularly improves comorbid somatic illnesses, not previously recognized as being associated with ADHD."

1. In that part of his evidence in chief given orally, Dr. Orchard said that his major interest is psychotherapy, and that he works five day a week and eleven hours a day.
2. He acknowledged that it is better to use one drug at a time, but said that he was satisfied by his experience that dexamphetamine could be used in conjunction with sodium valproate. He said that the combination did not produce adverse reactions.
3. In cross-examination, Dr. Orchard agreed that he often prescribes eight to ten dexamphetamine tablets per day. He said that he usually starts patients on four dexamphetamine tablets per day, and then increases the dosage to eight to ten tablets per day.
4. He said that he prescribes dexamphetamine and sodium valproate for about 80% of his patients. He said that the majority of his patients immediately are put on both drugs, because dexamphetamine alone causes insomnia.
5. In cross-examination, the attention of Dr. Orchard was drawn to the report of Professor Mitchell, and in particular to Professor Mitchell's reference to an article by Sachdev and Troller in the Australian and New Zealand Journal of Psychiatry in 2000. Professor Mitchell reported that the article, which is entitled How high a dose of stimulant medication in adult attention deficit hyperactivity disorder?, was to the effect that there was no evidence of any benefit in increasing the dose of dexamphetamine above 30mg for patients with adult ADHD. Dr. Orchard said that the report of Professor Mitchell had not caused him to read the article. Dr. Orchard said the article has no relevance in 2010, and that "I would have scant regard for it".
6. In response to questions asked by a member of the Tribunal, Dr. Orchard agreed that his treatment regime was to prescribe dexamphetamine and sodium valproate as a trial, and then to review treatment. He agreed that his treatment regime has not been reported anywhere. He said that his treatment regime was "unique to my practice". He agreed that he had not presented his treatment regime to the Journal as an extract, or to the College. However, Dr. Orchard said that his daughter, also a psychiatrist, comments upon his work. Dr. Orchard said that he speaks with another psychiatrist Dr. James Lees about twice a week, and that he goes to drug company seminars.
7. It was put to Dr. Orchard that in a letter to the Board dated 25 January 2008 he had stated "I am aware that patients with ADD regularly have a compulsion to go into a daydream when people talk to them and quite frequently have almost no recall of their medical interview after it is over". Dr. Orchard stated he had not recognised that Ms P was not attending to his verbal instructions and she could have misunderstood his instructions given that the written material and the prescription he had provided did not caution against raising the dose of dexamphetamine until after further consultation with him. He acknowledged it was mainly the clinician's responsibility to ensure that the patient has clearly understood how the medication was to be taken, problems regarding side effects and reviews, etc.
8. Dr. Orchard was then asked about procedures in his practice regarding follow up of patients who failed to make further appointments or failed to attend follow up appointments. Dr. Orchard said that he probably saw 11 new patients during the week that Ms P attended her first (and only) consultation with him. It was not his practice to follow up patients who failed to make or keep further appointments with him. He did not attempt to make any contact with them by telephone or letter, nor did he make any contact with the referring medical practitioner regarding their failure to attend or inform the referring doctor that he had provided the patient with a prescription for large doses of dexamphetamine.
9. Dr. Orchard addressed the concerns of Professor Schweitzer and Dr. McArdle about inadequate records and inadequate reporting. Dr. Orchard said "I fell down in reporting". Dr. Orchard said that he now allows one hour and a half for each initial consultation, thus allowing half an hour to prepare adequate records and a report to the referring doctor. He assured the Tribunal that he would write more extensive notes, and that his notes would allow another doctor to take over his practice.

1. Dr. Lees practises as a consultant psychiatrist. He adopted a witness statement dated 26 March 2010. It included the following passages:

"To my knowledge, a small group of medical practitioners, both psychiatrists and general practitioners manage and treat patients with a diagnosis of ADHD. In my opinion, patients with ADHD are substantially neglected by the rest of the medical profession.

I believe it is unlikely that Dr Orchard would overdiagnose ADHD in patients who consult him if he is using the Amen questionnaire. The questionnaire enquires of the core criteria in use in DSM-IV-R ("DSM")

The alleged bias of Dr Orchard to diagnose ADHD and BSD must be considered in the context of selective patient referrals and that the great majority of the medical profession neglect the diagnosis and treatments of the conditions.

Attention to subtle, so called subsyndromal evidence of bipolar affective disorder is clinically responsible and required.

BSD, or subsyndromal bipolar symptomology does not lend itself to conventional diagnostic criteria, if by that is meant the use of DSM"

1. In that part of his evidence in chief given orally, Dr. Lees said that he treats a lot of people with ADHD.
2. He said that he read the material provided by Dr. Gojak and Dr. O'Connor, the psychiatrists who treated Ms P before and after Dr. Orchard. Dr. Lees said that Dr. Orchard's diagnoses of ADHD and bipolar spectrum disorder relating to Ms P were "reasonable". Dr. Lees also said that Dr. Orchard's prescriptions for dexamphetamine and sodium valproate were "reasonable", although he added that he would have tended to handle the bipolar spectrum disorder psycho-therapeutically.
3. In response to questions asked by a member of the Tribunal, Dr. Lees acknowledged that information in Dr. O'Connor's clinical notes regarding Ms P's presentation could lead a clinician to consider a diagnosis of mood disorder, an anxiety disorder or a social anxiety disorder. The presentation as described in the notes did not specifically point to significant under treatment of ADHD or an untreated mood disorder. More history and assessment would be needed before a further diagnosis could be made.

THE OTHER EVIDENCE AND WITNESS STATEMENTS RELIED UPON BY DR. ORCHARD:

1. Mr. D gave evidence on behalf of Dr. Orchard. Both Mr. D and his wife became patients of Dr. Orchard in 2009.
2. In his witness statement Mr. D said that, at least since 1987, his wife had suffered from "symptoms that she was not able to come to terms with which significantly impacted her quality of life and ability to function consistently and without anxiety". His wife had been treated with a variety of anti-depressants until 2009. Dr. Orchard then diagnosed Attention Deficit Disorder, and prescribed dexamphetamine and Epilim [sodium valproate]. Mr. D said that his wife "has for the first time in many years been independent of anti-depressant medications and is learning to live a full life". When he gave oral evidence, Mr. D said that his wife now is a patient of Dr. Lees, and is taking 10 dexamphetamine tablets and one Epilim tablet each day.
3. Mr. D spoke highly of Dr. Orchard's interviewing technique, attention to the compilation of a detailed history, and professionalism.
4. Dr. Orchard also relied upon a witness statement made by Mr. R, another of his patients. Mr. R stated that he was diagnosed by Dr. Orchard as suffering from ADHD and a bipolar condition. He said that Dr. Orchard prescribed dexamphetamine and Epilim. Mr. R said that "It is as if Dr. Orchard has helped me turn on the light at the end of the tunnel. He has got me out of the hole in which I was living".
5. In another witness statement, Mrs. B stated that she has been a patient of Dr. Orchard since 2002. She was diagnosed with post traumatic stress disorder, which brought on ADHD and a bipolar disorder. She stated that she attended group therapy sessions at the suggestion of Dr. Orchard. She said "My medication and treatment by Dr. Orchard help me to cope with my everyday life".
6. Another witness statement was made by a country medical practitioner. He stated "I have seen many seriously ill psychiatric patients who had been seen by a number of other psychiatrists who had not been helped. ... Then I referred these patients to Dr. Orchard who has given them both dexamphetamine and Epilim - they then improved and did very well".
7. A further witness statement was made by a suburban medical practitioner. He said that he had referred many patients to Dr. Orchard, who often diagnosed ADHD. The practitioner stated that feedback from Dr. Orchard allowed him to "have a much better idea of whether the person is likely to be diagnosed with ADHD".
8. Another witness statement was made by a medical practitioner who described himself as a Family Physician. He stated that he has been clinically interested in ADHD for twenty years and has diagnosed and treated adults with ADHD for over ten years. He opined that "If diagnosis is limited to strict conventional criteria, many patients with ADHD would not be diagnosed and would be denied the benefit of treatment"

1. Having considered the contents of the Tribunal Book, the oral evidence given by witnesses at this hearing, and the documents tendered when they gave evidence, the Tribunal makes the following findings:

1. Ms P was medically stable and satisfied with the medication prescribed by her previous psychiatrist Dr. Gojak, who had treated her albeit infrequently since April 2002.
2. In a letter dated 27 August 2007, Dr. Gojak informed Dr. Orchard that Ms P suffered from ADHD and depression and relationship problems, and that Ms P had derived significant benefit from two dexamphetamine tablets daily plus a low dose of Zoloft.
3. Ms P consulted Dr. Orchard on only one occasion, on 29 August 2007.
4. Dr. Orchard diagnosed Ms P as having ADHD and bipolar spectrum disorder. Dr. Orchard informed Ms P of those diagnoses without consulting Dr. Gojak as to the new diagnosis of bipolar spectrum disorder. Dr. Orchard did not give an adequate explanation to Ms P of the reasons for the new diagnosis.
5. Dr. Orchard prescribed up to ten dexamphetamine tablets per day, in four doses five hours apart, but starting on one tablet four times per day and slowly increasing. Dr. Orchard gave that prescription to Ms P without consulting Dr. Gojak as to the relatively large increase in the dosage of dexamphetamine. Dr. Orchard did not give an adequate explanation to Ms P of the reasons for the increased dosage, or inform Ms P of the possible effects of the increased dosage.
6. Dr. Orchard provided Ms P with 44 pages of written material, and asked her to take it away and read it. A large part of the material was directed at medical practitioners. The material was complex, excessive, and potentially confusing to a patient, but Ms P was "able to follow" the material.
7. Communication of the new diagnosis without an adequate explanation of the reasons for the new diagnosis, and the prescription of a relatively large increase in the dosage of dexamphetamine without an adequate explanation of the reasons for the increased dosage, caused distress to Ms P.
8. Ms P did not take the increased dosage prescribed by Dr. Orchard. Since her consultation with Dr. Orchard, Ms P has remained well on the lower doses of dexamphetamine prescribed before and after she consulted Dr. Orchard.
9. Dr. Orchard's communication with Ms P, involving inadequate explanation of the reasons for the new diagnosis, inadequate explanation of the reasons for the increased dosage of dexamphetamine, inadequate explanation of the instructions in the hand written prescription, and the provision of complex, excessive and potentially confusing written material amounted to unprofessional conduct on the part of Dr. Orchard.

1. Most of Dr. Orchard's patients are referred to him because they have, or may have, ADHD.
2. Dr. Orchard uses broad diagnostic criteria to diagnose ADHD. The criteria used by Dr. Orchard to make a diagnosis of ADHD do not concur with the conventional diagnostic systems DSM IVTR or ICD 10. Dr. Orchard regularly diagnoses ADHD.
3. Dr. Orchard uses broad diagnostic criteria to diagnose bipolar spectrum disorder. There are no major national clinical practice guidelines for the diagnosis of bipolar spectrum disorder, either in the narrow sense of subsyndromal presentations or in the broader sense of the criteria used by Dr. Orchard. Dr. Orchard believes that bipolar spectrum disorder is co-morbid with ADHD in about 50% of the cases where he diagnoses ADHD.
4. Dr. Orchard prescribes dexamphetamine for ADHD and sodium valproate for bipolar spectrum disorder for about 80% of his patients diagnosed with those conditions. The dosages of dexamphetamine prescribed for his patients often are higher than the dosages likely to be prescribed by other psychiatrists. Dr. Orchard generally directs patients to self select a dosage of dexamphetamine they are comfortable with after increasing the medication to these higher doses. He did not require the patients to seek further consultation with him or their referring doctors before adjusting the dose of medication.
5. Dr. Orchard's history taking sometimes is inadequate. He rarely seeks corroborative evidence. He is reluctant to use psychological strategies or cognitive behaviour therapy. He also is reluctant to seek a second opinion.
6. Dr. Orchard claims to be on the "cutting edge" of medical practice with respect to the diagnosis and treatment of ADHD, and maintains that he is in advance of academic psychiatry. He is convinced that there are advantages in patients taking up to eight or twelve dexamphetamine tablets per day.
7. Peer protocol for someone on the "cutting edge" of medical practice is to confer with peers and/or publish data. Dr. Orchard has not submitted an extract of his diagnostic and treatment regime to the Australian and New Zealand Journal of Psychiatry, or to the Royal Australian & New Zealand College of Psychiatrists. He has not submitted his diagnostic and treatment regime to any other peer groups.
8. Dr. Orchard does not follow up patients who fail to attend appointments, or notify referring doctors that their patients failed to attend appointments. His record keeping is deficient. He often does not provide a written report to referring doctors. It would be difficult in some cases for another psychiatrist to ascertain from Dr. Orchard's clinical notes how Dr. Orchard reached a particular diagnosis. It would be difficult for another psychiatrist to take over Dr. Orchard's practice or his patients.
9. Dr. Orchard's professional performance has been unsatisfactory, because:

(a) his history taking was inadequate, and he rarely sought corroborative evidence;

(b) he used broad and unconventional diagnostic criteria, for a period of years, to make a diagnosis of ADHD and/or bipolar spectrum disorder;

(c) he usually directed patients to increase the dose of medication and then select a dosage of dexamphetamine that they considered was most suitable for them to be taking. He did not require that they only adjust the dose after further consultation with him or their referring doctors;

(d) he failed to submit this unusual diagnostic and treatment regime for ADHD and/or bipolar spectrum disorder for review and comment by his peers;

(e) he rarely recommended therapies such as psychotherapy or cognitive behaviour therapy;

(g) he did not follow up patients who failed to attend appointments, or notify referring doctors that their patients had failed to attend appointments; and

(h) his record keeping was deficient, and his communication with referring doctors was inadequate on many occasions.

1. The principal registrar will appoint a time, date and place for the resumption of this hearing, to enable the parties to make submissions as to any further order to be made consequent upon these findings.