No More. It Ends Here.
A Report on the Complaints Process
Let’s talk about the path you will likely see from any complaint to AHPRA
1. A complaint is lodged. It will take months to travel the circuitous path to your mail box. All you can do is wait even if you know what is in the making. Your legal representatives will tell you to “do nothing” against the patient (to make them withdraw the complaint). Such an action can be construed as obstructing justice. Such an action is illegal. AHPRA themselves will look with disfavour oh your actions and use this as a defacto admission of guilt.
2. A letter arrives to you, usually by Email these days up to nine months after a complaint. You are usually given two weeks to respond. This makes it difficult to get medical defence advice or to give medical defence a briefing. Your medical defence solicitor can ask for an extension of time to reply. These are usually granted but AHPRA gives itself as much time as it wants whether you like it or not.
I think there are legislated requirements for notification of complaints, but AHPRA feels it can safely ignore these.
3. Generally, for a body like AHPRA, where there is evidence rebutting aspects of the complaint, the item should be discounted. AHPRA however has a particular skillset to ignore your evidence, to ignore its own evidence where this supports your complaint and to make judgements that suit itself or its aims, (remember that AHPRA acts as if every doctor against whom a complaint is made is guilty). Your notes can always as a last resort, be found to be deficient.
4. You are invited to object.
5. Whatever you say can be conveniently ignored.
6. AHPRA sends you its judgement and its justification for its actions.
7. If you decide to appeal, AHPRA really relaxes. Your medical defence organisation abandons you. Every action you take is now at your own personal expense. Some solicitors are excellent but some look at you as if you are a mobile food source. The judges are generally in favour of the big honest impartial organisation- though I’ve never seen this organisation in my experience. AHPRA essentially laughs at you as there is no prospect of a successful appeal.
8. Having said that, one of my acquaintances, actually won a court appeal against AHPRA, using QCAT criteria and having a judgement made that the medical records were not deficient as part of the settlement.
9. Easy says AHPRA. Let's just attack the idiot another way. There is no appeal to AHPRA launching an investigation into a complaint it generates itself for the sole purpose of convicting you.
Send in two hired guns to assess the medical records- Which of course can never be good enough even though the practice/ doctor has passed accreditation using the same medical records criteria 3-7 timers already. The medical records are judged to be deficient.
As AHPRA says, a medical records audit is a chance for your organisation/ medical practice to shine. You are guilty no matter how much you shine or how hard you may try though.
10. An interview is held to talk to you about the result of the medical records audit. It turns out that AHPRA is not going to tell you anything, just ignore everything you said and then say that you failed to challenge any of the findings of the audit.
(As a basic guideline, always get the names of the patients assessed. If you want to challenge AHPRA you will need to contradict the basic findings that make your records noncompliant. E.g. find the social history. Challenge the facts, not your heart. You should probably be given an assistant by medical defence or someone to work through the deluge of material that needs to be challenged and any of which can be given “critical;” status by AHPRA at its whim.
The Jurors @ Runnymede.
I think personally that if any practitioner or practice is found to have deficient records, if accreditation has been passed, AHPRA should be required to justify all of the findings to an independent court of peers: at AHPRA expense. After all, the accreditation process has already said that the practitioner and practice is OK multiple times. AHPRA should be required to substantiate why its findings are different to Accreditation audits.
11. If you decide to appeal this. Guess what? Your medical defence organisation abandons you. Every action you take is now at your own personal expense. The argument is no longer about the “complaint” and the original complaint becomes irrelevant to the new action undertaken by AHPRA. And to really top it off, you are effectively unable to contest AHPRA’s decisions. You will lose.
12. What does a typical enforcement action look like : ( see Below)
My opinion- Impossible to read and follow with so many restrictions that it almost impossible to understand or follow.
13. Now it gets interesting. The actual judgement is a “lie”. The medical education takes more time than stated and is banally stupid to anyone with more than 1-2 years of medical experience. The mentoring costs you about 30-60K: depending on whether you are counting direct or indirect/ inferred costs. It also takes approximately 30 hours, not 10 hours.
You are of course pressured on your “reflection” to say something acquiescing to your punishment to avoid further punishment.
Weighing Souls:
Egyptian God of Justice Ma'at
The audits have engendered changes in your practice that make you stop thinking about what you are doing and making you concentrate on the “recoding” of what you are doing, not the doing.
Perhaps AHPRA should reflect on exactly how standards of care are improved by distracting doctors from doing their work. And that’s what this whole process does. It distracts doctors from work and forces them to spend time performing tasks that make you less able to do the work and less able to commit to the work. The medical records have become very comprehensive in the era of macros, but heaven forbid you actually attempting to extract any useful information from them. The main findings and events are now embedded in verbiage that creates the need for a lot of energy and CPU cycles to process the buried information – as opposed to seeing the information immediately when the record is viewed.
14. Good luck. AHPRA will make sure you won’t get it.
EXAMPLE: Undertake education
1. The Practitioner must undertake and successfully complete a program of education, approved by the Medical Board of Australia (the Board) and including a reflective practice report, in relation to:
a. Medical record keeping; and
b. Communication with patients, with an emphasis on:
i. The management of complex and complicated management;
ii. Dealing with difficult patients, such as those suffering from drug dependence and/or drug seeking patients; and
iii. Medical professionalism, namely the values and skills that the profession and society expect of general practitioners in Australia.
2. Within 21 days of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN24), nominate for approval by the Board an education course, assessment or program (the education) addressing the topics required. The Practitioner must ensure:
a. The nomination includes a copy of the curriculum of the education.
b. The education consists of a minimum of 10 hours of education in relation to the topics identified in condition 1 above.
3. The Practitioner must provide evidence to AHPRA of the successful completion of the education within three (3) months of the notice of the Board's approval of the education.
4. Within 28 days of the completion of the education, the Practitioner is to provide:
a. Evidence of successful completion of the education.
b. A report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to this condition requiring they undertake education and how the Practitioner has incorporated the lessons learnt in the education into the Practitioner’s practice.
Attend for mentoring
5. The Practitioner must be mentored by another registered medical practitioner (General Practitioner) in relation to medical record keeping and communication with patients.
For the purposes of this condition, 'mentoring' is defined as a relationship in which a skilled registered medical practitioner (the mentor) helps to guide the professional development of another practitioner.
6. The mentoring must comprise a minimum of 10 sessions with each session being of one (1) hour in duration occurring each month over a 10-month period, and should cover the following topics:
a. Appropriate medical record keeping in a general practice setting.
b. Managing and treating complex patients.
c. Appropriate communication with complex, difficult and demanding patients.
d. How to diffuse difficult situations in practice, such as drug seeking patients.
e. Expected professional behavior when communicating with patients.
7. Within 21 days of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN16), nominate a person(s) to be approved by the Board to act as mentor. The Practitioner must ensure that the nomination is accompanied by acknowledgement, on the approved form (HPNA16), from the nominated person.
8. Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to AHPRA, on the approved form (HP16), acknowledgement that AHPRA may seek reports from the approved mentor on any or all of the following occasions:
a. On a monthly basis;
b. at the conclusion of the mentoring relationship in order to confirm the outcomes of the mentoring;
c. whenever the mentor has a concern or becomes aware of a concern regarding the Practitioner’s conduct or professional performance; and
d. When otherwise requested by AHPRA or the Board.
9. In the event an approved mentor is no longer willing or able to provide the mentoring required the Practitioner is to provide a new nomination in the same terms as previous nominations. Such nomination must be made by the Practitioner within 21 days of becoming aware of the termination of the mentoring relationship.
10. Within 28 days of the conclusion of the mentoring the Practitioner must provide a report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to the condition requiring they attend for mentoring and outlining how the Practitioner has incorporated the lessons learnt in the mentoring into their practice.
11. Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to AHPRA, on the approved form (HPC), the contact details of a senior person, such as the Director of Medical Services, Senior Practice Manager, Senior Manager, Senior Partner, Proprietor, Owner, or equivalent (the senior person) at each current place of practice. In providing this form, the practitioner acknowledges that AHPRA will contact the senior person and provide them with a copy of the conditions on the practitioner’s registration or confirm that the senior person has received a copy of the conditions from the practitioner.
The practitioner will be required to provide the same form:
A. within seven (7) days of the commencement of practice at each subsequent place of practice, and
B. within seven (7) days of each and every notice of any subsequent alteration of these conditions, Undertake an audit of practice
12. The Practitioner must submit to an audit of their practice (the audit), including any supporting records, within 28 days of the completion of the education conditions (conditions 1 – 4) and thereafter on a three-monthly basis, by permitting an auditor (the auditor) approved by the Board to attend any and all places of practice (public and private) for the purpose of the audit and by permitting the auditor to provide a report in relation to the findings of the audit.
The audit and the audit report are to focus on:
a. medical record keeping including progress notes;
b. the assessment of patients including diagnoses, management plans, medication monitoring and comprehensive care for chronic diseases; and
c. Include, at a minimum, 25 randomly selected current patients.
13. Within 21 days of the notice of the imposition of these conditions, the Practitioner must provide to AHPRA:
a. nomination, on the approved form (HPN12), of an auditor(s) to be approved by the Board
b. acknowledgement, on the approved form (HPN12), that AHPRA will seek reports from the approved auditor at the conclusion of each audit, and
c. Acknowledgement, on the approved form (HPNA12), from the nominated auditor.
14. Within 21 days of the notice of the approval of the nominated auditor, the Practitioner is to provide a written audit plan, from the approved auditor, outlining the form the audit(s) will take and how the area of concerns for the Board will be addressed. The audit(s) will take the form determined by the auditor.
15. In the event an approved auditor is no longer willing or able to provide the audit required, the Practitioner must notify AHPRA within fourteen days of becoming aware of this and provide a new nomination of a proposed auditor(s) to the Board in the same terms as the previous nomination of auditor(s).
16. All costs associated with compliance with the conditions on their registration are at the Practitioner’s own expense.
Text on public register
The details of the above conditions are recorded on the public register.
Review period
The review period is 12 months.
Australian Health Practitioner Regulation Agency
National Boards
GPO Box 9958 Darwin NT 0800 Ahpra.gov.au 1300 419 495
AHPRA and the National Boards regulate these registered health professions: Aboriginal and Torres Strait Islander
health practice, Chinese medicine, chiropractic, dental, medical, medical radiation practice, midwifery, nursing,
occupational therapy, optometry, osteopathy, paramedicine, pharmacy, physiotherapy, podiatry and psychology.
A Reflection from a Battered Bruised Individual,
Lucky not to have Suicided
following an AHPRA investigation and Treatment Process.
Introduction
Although l have already written a report - which was found to be inadequate by AHPRA's clerks - I have been reflecting on my professional behaviour every day for the past forty five years - this line of work demands it. I have been careful to document sufficiently in order to rationalise my clinical assessments, and have done so more thoroughly since the very start of this, frankly, traumatic ordeal two and a half years ago.
Since the beginning of this drawn-out shaking down, I have reflected on what I had done wrong, how I could have provided better care and have continuously thought "What could I do differently that could have helped these patients more?" I am instead condemned to spend many hours reading, reflecting, writing workbooks as well as 11 hours of face-to-face discussion of these readings and writing in detail with a tutor and facilitator present. As per the Australian Health Practitioner Regulation Agency's reflective report template, I will write according to its requirements.
Description
A pharmacist was misinformed about my treatment of a patient with chronic non-cancer pain with opiates. What followed was an audit of all of the drugs of dependence I had prescribed over the previous year. I realised I was being investigated as early as February 2019. No serious breach of the regulations was found, with the exception of one case where I had failed to report the treatment of a patient prescribed opiates for longer than two months. It is worth mentioning this regulation was dropped in 2019 and carried almost the equivalent weight of a parking ticket. No irregularity was found during this audit.
The board at that time had found that my treatment of this exceedingly difficult patient was entirely appropriate. I might also add that she is taking the same reduced amount of opiates that she took in 2018 and 2019 except for a period when I had seriously contemplated retirement and was not practicing. I was exceptionally careful to document all prescriptions of opiates and benzodiazepines according to the instructions given at pain seminars, particularly that of Dr. "Pain Specialist of Brisbane".
As far as I can tell, the initial complaint was from a pharmacist who was completely uninformed, did not know this patient's diagnosis and formed an opinion not based in fact, but in their own predisposed ideas. This unjustified event was the catalyst for this 'journey' that has spanned more than two years now. In primary care we cannot apply a one-size-fits-all approach, and each patient presents its own challenges. We must be ready to respond individually to each one. What followed was this patient suffering unnecessarily and her quality of life trending downward quickly. Only one of the parties involved - that is, between myself and the pharmacist - was adequately informed to make any decision regarding my patient's treatment.
There was then a vexatious complaint from the girl with a dreadful mouth who said I had offered her oxycodone for her teeth when in actuality it was doxycycline, after which there was some scrutiny regarding my "inappropriate" prescription. I have been prescribing doxycycline for around 35 years as my go-to antibiotic and have never witnessed the entire list of the side-effects that are listed in the American literature. I would have rarely seen an adverse effect in perhaps more than 30,000 prescriptions.
Additionally, I had listed concerns regarding her mental health in the notes. Regarding the prescription for nitrazepam for this particular patient, there was nothing wrong nor inappropriate to be found. I attach a copy of a recent leading article from the British Journal of psychiatry by nine eminent American Psychiatrists regarding Benzodiazepines and the science about their use for the information of Board Members. The outcome was as above - there was nothing to worry about in the treatment of the index patient. Regardless, the Board then decided to select four other patients to check if they were being properly treated.
Using my paranoia and diligence in documenting every visit for every patient, I adhered to the 6 A's:
- Analgesia
- Adverse effects
- Activity
- Affect
- Aberrant behaviour
The five of which constitute Adequate notes. This was an absolute minimum for every visit.
The board had found that, in one circumstance, I had not communicated with other colleagues when in actuality l had done so, and furthermore, referred the patients for investigation and specialist opinions.
Another circumstance included an accusation that I had failed to communicate with a Psychiatrist to whom I had written two letters - he had answered the first with "I leave it in your hands." He completely ignored the second letter.
Feelings and Response
In the following months I continuously and repeatedly questioned my own abilities while at all time trying to put the health of my patients first. What followed still was what I can only describe as a convoluted torrent of emails from Compliance Monitoring bureaucrats, containing many similarly numbered designed forms. At this point my frustration had peaked.
Finally, I decided to take a week off - and further decided to not return. This situation had really broken me down. I had dark thoughts; my self-esteem was lowered; I drank more; I slept less; I thought I should retire. I felt I no longer had enough to offer and, to my regret, turned my back on my patients. I felt like a criminal on parole. I had advised Multiple Restriction Compliance that it was all just too much.
Thankfully, a colleague took me aside and talked me down and assured me I could not let this darkening cloud overshadow what to him was a 'stellar career' and to rethink my decision. After a collegiate lunch I was offered the opportunity to replace a doctor who was moving interstate in his practice.
It was at this point that I, for lack of a better phrase, 'rolled over' and engaged Morrison Consulting to provide me with the education which had been approved by the board.
I have spent countless hours reading and filling out workbooks as defined by Ms. Morrison. I have actively engaged, completed and responded to all the tasks set forth for me. I have engaged in the Zoom meeting for up to three hours at a time. I have read all the regulations and am compliant with all the rules and regulations. I
was directed repeatedly to things like lapses and how people get into trouble with QCAT and the Board.
I understand all of the rules, and I live within them. I do not think my notes were inferior. Compared with my colleagues, my notes are quite good. I do not engage electronically generated bogus notes, as it is not my style. I have gone through all of the assessments and all of the patients. The fact is that in the practice I was in for about 6 years, I felt compelled to clean up the practice which was notorious for benzodiazepines and got rid of the vagabonds who were all passed to me as a consequence of the principal having been investigated.
Because of this he would not deal with anxious or depressed patients and they all fell to me for care.
Thankfully, in my new practice, the vast majority of the vagabonds - who also deserve care attend one particular practitioner.
I thought that I should do this education and give it my full attention, and I did. I believe ail education is valuable, and I understood it with that in mind. I engaged fully with the educator for 11 hours - face to face, over four sessions. It was structured as outlined in the initial submission and we followed through all of the steps. Each hour was preceded by a minimum of three hours of reading and research as if for an examination. As I reflect on it, it was simply a refresher course on all the rules and regulations that apply to us. The structure of the workbooks was such that you could not but read and reflect on the
I thought that it was more important to concentrate on the patient rather than the actual narrative and cunning ways to write copious useless notes that are not relevant to the situation at hand. Patients find it intrusive to ask them their family history when they present for something straightforward like a renewal of a prescription.
I think now that no matter how good the notes, at least in my case, they are never good enough. That said, I strive to write the best notes possible given the constraints of time. Mostly they are very concise.
Evaluation and Analysis
As previously stated, all education is of benefit. I have never in my professional career ceased searching for wisdom. I would personally have preferred 33 hours of CME education on any number and a variety of subjects I might find interesting. Because of yesterday's email I have now missed on another one and a half hours of Zoom from St. Andrew's Hospital on ENT updates. I have been thoroughly involved with this education every step of the way.
As for the material in question - I went through the pages about how the TGA works, how the board works and AHPRA's role as I filled out the workbooks.
I am finding it difficult to say what the most valuable part of it was, because I have been practicing for 45 years and see new things every day. The old adage could apply here; data are not information, information is not knowledge and knowledge is not wisdom.
This continued enquiry has made me significantly more attentive to the notes. I write things that are relevant such as reasoning behind some change or no action in a shorthand way. It must be remembered that some patients resent being quizzed and find it intrusive - all of which cannot be recorded or its notation might be considered offensive. 90% of what happens in consultation cannot be recorded. I make more effort with the notes and perhaps write them more explicitly.
Legal Fees of Justice
Conclusions and Change
Compared with the negative I strain to see many positives. The entirety of this ordeal has made me doubt myself, lowered my self-esteem, made me drink more and think more defensively. I cannot see anywhere that I would make a huge difference. I have been completely paranoid for over 30 months now. I am extremely careful. I give the best advice I can and document as best I can.
Were the events to occur again, I should go straight to QCAT. I cannot see how any of this process has benefited any one of the six patients that were trawled through - in any way. I understand the most powerful argument against this is that it is in the public's best interest - to which I respond: that would require at least one patient who benefitted from this prolonged investigative assault.
I have many times witnessed patients who were abused describe their feelings. I now completely understand their feelings, as this all feels to me like coercive control and in no way helps my patients or myself.
I have agreed to this entire process. I have another 12 hours of face-to-face Zoom meetings and have submitted the resume of someone who has agreed to audit my notes. I am getting on with all of the processes that AHPRA has put in place and most of this, to my estimation, amounts to harassment.
If AHPRA's mantra is to help the public, then treating honest and ethical practitioners in this unjust way cannot help the public - quite the contrary. In my opinion this systematic harassment has diverted my attention from my patients to fighting this baseless and unending fight.
I am taking all of the steps recommended by the board and am complying with every requirements. My notes are better than ever, will continue to get better, and I further understand the regulations within which I must practice.
Sincerely,
