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

A GP was reprimanded for prescribing testosterone without therapeutic indication, to 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

One patient had started a new job as a bodybuilding assistant at a local gym. The patient asked the 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, the patient continued to ask the doctor for the prescription. The doctor relented, prescribing testosterone on at least eight occasions over a six-year period. The doctor admitted the complexity of the patient’s domestic and personal problems had blurred his clinical judgement.

Another long-standing patient of the doctor was an amateur body builder who asked 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 it was inappropriate to prescribe testosterone to the patients.

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.

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 patient 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 conditions placed on his registration preventing the prescribing of anabolic steroids and ordering him 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 or inappropriate expectations about their treatment, it is worth spending some time identifying why they want a specific treatment and to reinforce a more realistic understanding.

A good approach can be to explain the clinical reasons why the medication is not clinically indicated, and if further tests or referrals are necessary before a definitive diagnosis can be reached or treatment determined.

Clinical guidelines can also be used as another point of reference to explain to patients that prescribing this medication, in their clinical circumstances, does not align with recommended best clinical practice and is potentially harmful.

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, view 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. 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 indicated, then explain the reasons why this is the case.
• 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.

More information

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

Useful resources

eLearning course: Prescribing principles: Part one - general prescribing issues.

Factsheet: Managing patient expectations.

Webinar: Managing difficult patients.