GP’s registration on the line after conforming to patient demands

23 October 2019 | Megan Prideaux, BA (Hons), LLB, GDLP, Grad Dip Health and Medical Law, Senior Solicitor, Avant Law, SA

A GP has been reprimanded for prescribing testosterone without therapeutic indication, to two patients who wanted the medication for bodybuilding purposes.

The decision highlights the danger of prescribing unnecessary medication at the insistence of patients, that may put them at risk of adverse side effects.

Patient pressure

In one reported case, a patient who had started a new job as a bodybuilding assistant at a local gym, asked a doctor for a prescription for testosterone. The patient had experienced a prolonged period of unemployment and felt embarrassed about his physique in comparison to some of his clients. The doctor offered the patient a blood test to check his testosterone levels, but he declined.

Suffering anxiety and worried about his ongoing employment at the gym, he continued to pester the doctor for the prescription. The doctor relented, prescribing testosterone on at least eight occasions over a six-year period. He admitted the conundrum of the patient’s domestic and personal problems had blurred his judgement.

Another long-standing patient was an amateur body builder who asked the doctor for a prescription for testosterone for body building. Over a decade, the doctor prescribed testosterone to the patient on 16 occasions.

Insistent patients are no excuse

The Medical Board of Australia referred the case to the state’s tribunal, where the doctor admitted the allegations and realised his error in prescribing testosterone to the two patients. At the time, he said he believed it was permissible to prescribe testosterone as a private prescription.

The tribunal highlighted that doctors are afforded the right and authority to prescribe medications and this comes with a duty and expectation to exercise that right in a proper and evidence-based manner.

In this case, the tribunal found there was no therapeutic justification to prescribe the testosterone to these patients, which exposed them to the risk of serious side effects and harm.

The doctor had conformed to his patients’ demands, rather than exercising his professional judgement, the tribunal said.

“Insistent patients can be challenging but that is no excuse to act otherwise in accordance with accepted clinical practice,” the tribunal said.

The doctor was found guilty of professional misconduct and a condition placed on his registration preventing him from prescribing anabolic steroids. He was also ordered to complete education on dealing with assertive patients inappropriately seeking medication.

Managing unrealistic expectations

While handling insistent or drug-seeking patients can be a challenge, this case reinforces the importance of maintaining your professional judgement and only prescribing medications that are therapeutically indicated.

An important part of your role when planning a patient’s care is to determine expectations and discuss them with the patient. If you become aware a patient has unrealistic expectations about their treatment, it is worth spending some time identifying why they want a specific treatment and gently reinforce a more realistic understanding.

A good approach can be to explain the clinical reasons why further tests or referrals are necessary before a definitive diagnosis can be reached or treatment determined.

Another helpful strategy can be to explain, early on, that you cannot meet a patient’s request in terms of practice policy, so the patient understands it is not personal to them. For example, “It is against our practice policy to prescribe testosterone for you in such circumstances.”

Patient expectations not met

If it is clear after a discussion with the patient, they have an expectation you cannot or choose not to meet, you have a few options:

  • Try to further educate the patient by giving them information to read and ask them to come back for a second appointment.
  • Depending on the situation, it may be appropriate to recommend the patient seek a second opinion.
  • As a last resort, you can decline to treat the patient. You should discuss the reasons why with the patient in person and then follow up the discussion with a formal letter. 

All discussions should be documented in the patient’s medical record. If their concerns escalate to a formal complaint, correspondence regarding this should be kept separate from their medical record. For more information, download our factsheet, Responding to direct patient complaints.

Key lessons

  • Only prescribe medications that are therapeutically indicated.
  • If a patient has unrealistic expectations about their treatment, identify why they want a specific treatment. Gently reinforce a more realistic understanding and explain why you will not be able to meet the request.
  • If a patient requests a prescription for a medication that is, in your opinion, not clinically warranted, then explain the reasons why further tests or referrals are necessary before a diagnosis can be reached or treatment determined.
  • Recommend the patient seek a second opinion if appropriate.
  • As a last resort, you can decline to treat the patient.

Being coerced by a patient into providing treatment you believe is inappropriate is generally not accepted as a defence if a claim or complaint is made.

For more information, view our eLearning course, Prescribing principles and practices.

For medico-legal advice please contact us on nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.

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