GP suspended for inadequate consent process, failure to follow guidelines and performing procedures beyond his clinical ability

Key messages from the case

A GP working long hours as a solo practitioner accepted that he had harmed patients by performing procedures beyond his clinical ability, failing to provide patients with sufficient information to make decisions about their treatment and performing procedures that were not clinically indicated.

For example, in one case, he failed to take a biopsy before performing extensive skin surgery in an office setting on an 88-year-old woman with co-morbidities who was taking Warfarin for atrial fibrillation. The lesion was benign and did not require treatment. In another case a patient formed a blood clot and died following a skin procedure.

This case illustrates the ways in which isolation and lack of professional peer input can lead to loss of perspective, over-reach and ultimately result in significant patient harm.

Details of the decision

The tribunal case involved 11 complaints of unsatisfactory professional conduct against Dr S relating to skin surgeries.

The regulator alleged Dr S had been operating beyond his clinical ability, performed procedures that were not clinically indicated, failed to follow guidelines, failed to refer patients for specialist or hospital care and failed to obtain informed consent.

It was also alleged that Dr S failed to keep appropriate records of the procedures and that he inappropriately billed Medicare.

Clinical competence

While Dr S claimed that he was trying to do the best for his patients, the tribunal found that he lacked the skill to perform the surgeries. He failed to recognise his own lack of skill and failed to refer high-risk patients for specialist care.

The accuracy of his clinical diagnosis was also insufficient. In a number of cases he failed to perform biopsies prior to surgery. He performed procedures that were not clinically indicated – in some cases conservative management was clinically indicated, in others topical or ablative therapies should have been considered and offered.

He also failed to perform procedures safely and allowed a patient to drive shortly after a procedure.

Informed consent

One criticism of Dr S’s care was that he failed to discuss alternatives to surgery, and that he failed to refer or offer referral to relevant specialists.

In several cases he failed to inform patients that procedures were not urgent and to allow them time to consider their options.

The regulator argued, and Dr S conceded, that in his over-confidence in his own abilities and expertise, he had deprived patients of the right to choose the best treatment for them. He had acted on his own views outside of relevant guidelines without informing patients of their options.

Medical records

Dr S was also criticised for lack of detail in his clinical records.

Many significant details were missing including details of the diagnosis, biopsy results, treatment plan, details of the procedure, plan for follow-up and details of any follow-up appointments.

He appeared to be using a basic template to record consent instead of signed consent forms or detailed individualised notes about highly invasive and risky procedures. This meant he failed to record appropriate details about consent discussions.

He agreed that he rarely took contemporaneous notes – usually recording them later in the day – sometimes later than that.

Medicare

Dr S also failed to record the time spent attending to patients or the time of the consultation when claiming for after-hours billing.

Boundaries and insight

Dr S was working long hours (12 – 15-hour days, 5½ days a week) and seemed to have had no professional support.

He agreed that he was over-zealous, over-ambitious and failed to observe boundaries by saying ‘no’ or conceding that an issue might be better treated elsewhere. He characterised this as due to his own lack of insight and desire to solve the problems of his patients.

The regulator alleged his motives were financial and that he had overtreated patients, failed to offer non-surgical options and failed to refer to other specialists in order to claim higher procedure fees.

The tribunal did not agree with this interpretation, and found that he lacked expertise and insight but was not motivated by greed.

Outcome

Dr S admitted the finding of professional misconduct.

The tribunal reprimanded Dr S and imposed a five-month suspension, plus conditions including supervision, practice audits, attending for treatment by GP and psychologist.

Dr S was prohibited from undertaking any skin treatments and from practising more than 5 days per week or seeing more than 30 patients in a day.

Key lessons

A patient has the right to make decisions about their own medical care. Your professional obligations include giving patients enough information to make the decision. This includes explaining the urgency of treatment, discussing alternatives, and clearly explaining the risks of a procedure.

Your professional obligations also require you to recognise and work within the limits of your competence and clinical ability. Where a treatment or procedure is outside your expertise you are expected to refer patients to another practitioner.

Good medical practice also means you must only recommend treatments where there is an identified therapeutic need and where the treatment is in the best interests of the patient.

You are also required to maintain accurate, up to date and legible records with appropriate detail which can be understood by other health practitioners.

Be particularly aware of the risks of isolation and lack of peer support which can lead to a loss of perspective and failure to recognise practice limitations and professional boundaries.

References and further reading

Avant eLearning – Consent: informed consent and more

Avant factsheet – Consent: the essentials

Avant factsheet - Medical records: the essentials

Avant factsheet – Medicare compliance

For more information or immediate medico-legal advice, call us on 1800 128 268, 24/7 in emergencies.