18th January 2019, Volume 132 Number 1488

Katharine A Wallis, Susie Middleton

Little is known about disciplinary cases in New Zealand involving doctors and drugs of dependence.1,2 Disciplinary charges against doctors are heard by the Health Practitioners Disciplinary Tribunal (HPDT), and prior to 2004 by the Medical Practitioners Disciplinary Tribunal (MPDT). A doctor may be found guilty of professional misconduct because of “any act or omission that, in the judgment of the Tribunal, amounts to malpractice or negligence … or … has brought or was likely to bring discredit to the profession”.3 The purpose of the disciplinary process is to “protect the health and safety of members of the public”, not to punish doctors.3 Nevertheless, it is generally accepted that most doctors perceive the process as punishing, and the process can have punitive consequences. Penalties can include removing the doctor from the register, suspending the doctor for a period up to three years, imposing conditions on practice, costs, and a fine up to $30,000.

Drug dependence is recognised as a disease, not a crime.4 Drug dependence can have dire consequences for a doctor’s personal and professional life, although when treated the prospects of return to work can be good.4,5 Regular attendance at meetings and ongoing monitoring are encouraged to minimise the risk of relapse.6

Drug-dependent doctors may be reluctant to seek help for fear of losing their licence to practice. Colleagues are required by law to notify the Medical Council if they believe a doctor “is unable to perform the functions required for the practice of his or her profession because of some mental or physical condition” (s.45), but colleagues may also be reluctant to report.3,7 The Medical Council manages most doctors with drug dependence through its Health Committee.8 Some doctors are referred for discipline, not for drug dependence but for offences such as inappropriate prescribing, falsification of the clinical record and forging a colleague’s signature.

The role of discipline in drug dependence is not clear. We sought to describe disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand, with a view to understanding risk factors and outcomes.

Methods

Data source

In New Zealand, all written decisions for medical practitioner disciplinary proceedings are published on the websites of the Disciplinary Tribunals (MPDT and HPDT).9,10 Our data came from the MPDT website 1997–2005, and the HPDT website 2004–2016. Available data included the full texts of the decisions, barring redacted names and identifying details in cases where the doctor was granted name suppression, including the charge, evidence submitted by prosecution and defence, the Tribunal’s decision and penalties imposed.

Data collection

SM examined all decisions on the websites to identify cases where the alleged misconduct included inappropriate prescribing of drugs of dependence. SM collected data from these decisions, including the characteristics of the doctor (sex, specialty, years since qualification, prior knowledge by authorities) and characteristics of the case (setting, drugs, means of detection, disciplinary proceeding outcomes). Missing demographic data on named doctors was supplemented with data from the Medical Council of New Zealand’s website, where available.11

Data analysis

The analytical approach to these data was mainly descriptive as we aimed to determine the content of the decisions and their ability to inform about risk factors and outcomes.

Results

Over the 20 years 1997 to 2016, there were 236 disciplinary cases against doctors, 25 of which included inappropriate prescribing of drugs of dependence (11%). Over the eight years 1997–2005 the MPDT heard 143 charges against doctors (18 per year on average), five involving inappropriate prescribing (3%); and over the 12 years 2004–2016 the HPDT heard 93 cases (eight per year on average), 20 involving inappropriate prescribing (22%). In all cases the doctor was found guilty of professional misconduct (100%).

Characteristics of cases

The alleged misconduct was diverse and often involved misconduct in addition to inappropriate prescribing, including sexual relations with patients and forging a colleague’s signature. It was not always clear in the decision for whom the inappropriately prescribed drugs were intended, although in some cases it was clear the drugs were not for self-use. The prescriptions were usually made out for patients, family or self. The prescribed drugs included opioids (17;68%) (pethidine (8), codeine (7), morphine (4), dextropropoxyphene, oxycodone, tramadol and fentanyl); benzodiazepines (12;48%); pseudoephedrine (2); and sibutramine (1).

Pharmacists were the most common source of notification to the authorities (6;24%), followed by reporting from medical colleagues (4;16%). Other sources of notification were the patient or family (3), patient’s caregiver (1), police (2) and patient death (1). It was not possible to determine the source of notification in eight cases (32%). In some decisions it was clear the doctor was already known to the authorities: in seven cases (involving six doctors) the doctor was being monitored by the Medical Council’s Health Committee (28%); in one case the doctor had previously appeared before two separate tribunals for unrelated matters (HPDT 05/27D; 06/32D; 10/145P); and in another a doctor had previously been cautioned by the Medical Council for prescribing to those close to her but not disciplined (16/348P). One doctor faced two separate charges for inappropriate prescribing of drugs of dependence six years apart (MPDT 00/63C; HPDT 06/29P).

Patient harm or the potential for harm was mentioned in some decisions, usually as a consequence of inappropriate prescribing or inaccurate patient records (for example when a prescription was made out for but never intended for a patient). Other decisions documented that there was no patient harm or safety concerns.

Characteristics of doctors

Twenty-four doctors were involved in the 25 cases. Most doctors were male (19;79%). Most were working in general practice (19;79%); and there was one each in anaesthesia, internal medicine, registrar, medical officer, house officer and not available. Most doctors were on the general register (17;71%), and seven were on the vocational register (general practice 6; anaesthetics 1). Most doctors had been in practice a long time, with a mean of 24 years between qualification and discipline (range 2 to 36 years). The year of qualification was not available in seven cases.

Penalties

The diversity of misconduct is reflected in the diversity of penalties imposed by the tribunals, as set out in Table 1. Six doctors were removed from the register (24%); 11 doctors (44%) were suspended for between three and 24 months; and most of the remainder had conditions imposed on practice. Conditions included supervision (20); prescribing restrictions (12); drug urine or hair monitoring (8); counselling and/or being part of a support group (6); enrolling with a general practitioner (4); re-training, for example in record keeping (5); abstaining from drugs and/or alcohol (4); and practising in an approved practice (4) or a group practice (3). In nearly all cases the tribunal censured the doctor and imposed costs of 6% to 50%. In nearly half of cases the tribunal also fined the doctor, with fines varying from $5,000 to $20,000.

Table 1: Disciplinary decisions involving inappropriate prescribing of drugs of dependence in New Zealand, 1997–2016.

Case

Charge

Penalty

Registration

Conditions

Fine

Costs

MPDT 98/36C

White, Gen

Prescribing to patient; excessive triazolam

Cancelled

-

0

40%

MPDT 00/63C

Dr K, Voc, GP

Forged colleague’s personal stamp on prescriptions for pethidine, morphine

-

Y

0

45%

MPDT 01/74C

van Rhyn, Gen

Prescribing for self; zopiclone

-

Y

$5,000

25%

MPDT 05/127C

Dassanayake, Gen

Gave patient clonazepam and temazepam without a prescription; sexual relationship with patient

Cancelled

-

$5,000

0

MPDT 05/128C

Laubscher, Voc, Anaes

Forged signature on prescriptions for pethidine

-

Y

0

25%

HPDT 04/03P

Nuttall, Gen

Prescribing midazolam and dihydrocodeine to patient, in sexual relationship with patient

Cancelled

-

0

$10,000

HPDT 05/08P

Brock-Smith, Gen

Prescribing to restricted persons; diazepam and temazepam

-

Y

$7,000

30%

HPDT 06/29P

Keshvara, Voc, GP

Forged signature on prescriptions for dihydrocodeine

Suspended 12m

Y

0

33%

HPDT 06/36D

Patel, Voc, GP

Prescribed zopiclone to patient, in sexual relationship with patient

Suspension 24m

Y

$10,000

50%

HPDT 06/44P

Cullen, Voc, GP

Prescribing pseudoephedrine

 

Cancelled

-

$15,000

34%

HPDT 07/76D

Dr E, Voc, GP

Prescribed paradex to patient in de-facto relationship with

-

Y

$7,500

0

HPDT 07/80P

Aitcheson, Gen

Prescribed to patients for self; pethidine

Suspension 12m

Y

$10,000

40%

HPDT 08/102P

MacDonald, Voc, GP

Prescribing morphine to patient, in sexual relationship with patient

Suspension 9m

Y

0

47%

HPDT 10/145P

Wilson, Gen

Prescribing pseudoephedrine, alprazolam and paradex

Cancelled

-

$20,000

50%

HPDT 10/155P

Dr E, Gen

Forged prescriptions to get sibutramine for self

Suspension 3m

Y

0

10%

HPDT 11/197P

Dr S, Gen

Prescribing to patients with dependency; pethidine, morphine, codeine, diazepam, triazolam and nitrazepam

-

Y

0

30%

HPDT 11/201P

Wong, Gen

Prescribing to restricted persons; benzodiazepines

-

Y

$7,000

30%

HPDT 14/272P

Dr T, Gen

Prescribing to self, family, and patients; codeine, lorazepam, zopiclone

-

Y

0

15%

HPDT 15/310P

Dr Y, Gen

Prescribing to patients, collected for self; codeine

Suspension 3m

Y

0

30%

HPDT 15/315P

Hodgson, Gen

Prescribing to patients and family; dihydro-codeine, diazepam, zopiclone and triazolam

Suspension 3m

Y

0

15%

HPDT 15/320P

Thorne, Voc, GP

Prescribing to patients with history of dependence; oxycodone, morphine, tramadol, codeine, clonazepam, triazolam, clonazepam, zopiclone, dihydro-codeine, diazepam

Suspension 6m

Y

0

35%

HPDT 15/335P

Dr N, Gen

Forged signatures in controlled drug register to obtain pethidine, morphine and fentanyl

-

Y

$8,000

30%

HPDT 16/348P

Craig, Gen

Prescribing to patients, family and self; triazolam and zopiclone

-

Y

0

30%

HPDT 16/351P

Cooper, Gen

Prescribing to patients to stock practice

-

N

0

6%

HPDT 16/353P

Kleszcz, Gen

Prescribing to patient; pethidine, diazepam and nitrazepam

Cancelled

-

0

26%

In seven cases (28%) the doctor was given name suppression, one on appeal. The tribunals were not always consistent in their reasoning. For example, in White (MPDT 98/36C) the tribunal denied name suppression in part because there was already extensive publicity about the case, but in Dr K (MPDT 00/63C) the tribunal allowed name suppression in part because previous publicity reduced the need for further publicity to protect patient safety (but also to support Dr K’s rehabilitation). When Dr K faced a second disciplinary charge for inappropriate prescribing, he was denied name suppression since the previous suppression had failed to prevent relapse and reoffending (Keshvara HPDT 06/63P). In nine cases (36%) the doctor appealed all or part of the tribunal’s decision, in particular concerning name suppression or conditions on practice.

Discussion

We identified only 25 disciplinary decisions involving inappropriate prescribing of drugs of dependence over the 20 years 1997–2016. One of the 25 cases was for repeat offending by the same doctor. While the HPDT heard fewer cases per year than the MPDT,12 a greater proportion involved inappropriate prescribing. In all cases the doctor was found guilty of professional misconduct. The consequences were dire, often spelling the end of a doctor’s career. Most disciplined doctors were men, working in general practice, and had been in practice a long time. Patient harm was not a strong feature. It may be that drug-dependent doctors pose a greater risk to themselves than they do the health and safety of the public.

Few cases came to the attention of the authorities via notification from medical colleagues (16%). Doctors may be unaware of drug dependence in their midst, unaware of their duty to report, or unwilling to report. It may be that the threat of discipline acts more as a deterrent to reporting than to drug dependence.

Our findings are consistent with those reported elsewhere.13–15 The study provides an insight into the disciplinary consequences of inappropriate prescribing of drugs of dependence in New Zealand, but provides no indication of the extent of drug dependence in doctors. In some disciplinary decisions it was clear the drugs were not for self-use.

The paucity of disciplinary cases and diversity of misconduct mean it is not possible to generalise, but it appears that discipline is used as the last resort for dealing with drug-dependent doctors. Doctors with drug dependence should be encouraged to get help. The Medical Council’s Health Committee has an important role to play here. The role of discipline is unclear. Further work is needed to understand the barriers and enablers to reporting by colleagues, to understanding the extent of the problem in New Zealand, and to identifying systems that best manage drug dependence in doctors.

Summary

We reviewed disciplinary decisions in New Zealand 1997–2016 to describe cases involving doctors and the inappropriate prescribing of drugs of dependence. Drug dependence is recognised as a disease, not a crime. We identified 25 disciplinary cases involving 24 doctors. Most doctors were male, older and working in general practice. Few cases came to light through reporting by colleagues. The penalties were severe, often spelling the end of a doctor’s career.

Abstract

Aim

To describe disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand, 1997–2016.

Method

A retrospective analysis of disciplinary decisions to describe characteristics of cases (setting, drugs, outcome) and doctors (sex, specialty, years since qualification).

Results

There were 25 disciplinary decisions involving 24 doctors. Disciplined doctors were mostly male (19;76%), working in general practice (19;76%), and older (mean 24 years in practice). Pharmacists were the most common source of notification to the authorities (6;24%); medical colleagues reported only four (16%). The alleged misconduct often involved behaviour in addition to inappropriate prescribing. In all cases the doctor was found guilty of professional misconduct. Penalties were severe: six doctors were removed from practice, 11 were suspended, and of the remainder all but one had restrictions on practice imposed. In many decisions there was no patient harm documented.

Conclusion

Disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand are not common, but the consequences can be dire. The role of discipline in doctors with drug dependence is unclear.

Author Information

Katharine A Wallis, Senior Lecturer, Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, Auckland; 
Susie Middleton, Medical Student, University of Auckland, Auckland. 

Acknowledgements

University of Auckland Summer Research Scholarship.

Correspondence

Katharine Wallis, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland 1142.

Correspondence Email

k.wallis@auckland.ac.nz

Competing Interests

Nil.

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