Psychiatrist reprimanded over long-term prescribing for non-psychiatric conditions

Doctors are expected to recognise and work within the limits of their competence, skills and experience. Doctors who prescribe for conditions outside their specialty or expertise, except in an emergency or in consultation with appropriately qualified colleagues, may find themselves subject to a complaint, as one psychiatrist discovered.

A psychiatrist, Dr V, diagnosed Ms A in 1980 with anorexia nervosa, major depressive disorder with pervasive suicidal ideation and an obsessive compulsive disorder. He continued to treat her for 40 years, making home visits on a weekly or fortnightly basis.

Sometimes when Dr V was visiting, Ms A would ask him to prescribe medications for non-psychiatric conditions including hypertension, cholesterol, gastro-oesophageal reflux disorder (GORD), cardiac conditions, skin conditions, pneumonia and back pain. Dr V provided multiple prescriptions for Schedule 3 and Schedule 4 medications.

In 2020, an anonymous complaint was made about Dr V’s prescribing and the matter was investigated.

Responsibilities when prescribing

Ms A was also seeing a GP who was treating her for a range of chronic conditions including chronic thrombocytosis, type 2 diabetes mellitus, osteoporosis, hypertrophic cardiomyopathy, and GORD.

Dr V was aware that Ms A had a treating GP, but said he had been unable to persuade her to consult the GP.

The regulator alleged Dr V had:

• prescribed medications that were not for the treatment of her psychiatric condition and were not for purposes within the scope of his practice, and
• failed to inform or communicate with Ms A’s treating GP about his prescribing.

Dr V said he had generally provided repeat prescriptions, however he had sometimes initiated antibiotics and analgesia. He admitted he had no recent training in drug interactions and had not communicated with Ms A’s GP about his prescribing.

Dr V acknowledged he now understood the RANZCP Code of Ethics required him to recognise the limits of his expertise and consult with other colleagues as necessary.

The tribunal accepted expert evidence that Dr V lacked appropriate expertise to prescribe for physical illnesses — except possibly as a one-off and in consultation with Ms A’s treating GP.

Even if Ms A’s psychiatric condition had made her initially reluctant to consult a GP, at the time Dr V was prescribing he was aware she had a treating GP. His ongoing prescribing without consulting the GP was significantly below the standard expected.

Medical records

It was also alleged that Dr V had failed to keep adequate records of his assessments, prescribing, and treatment plans.

Dr V claimed that at their initial consultation, Ms A refused to continue unless he agreed not to make any notes of her sessions or report to her GP.

The tribunal considered even if Dr V had been justified initially in agreeing to see Ms A without making notes while she was in crisis, he ought to have revisited the issue when her mental state improved. Other treating practitioners were able to keep records for her.

Failing to keep medical records at any time in the 40-year treating relationship constituted a significant departure from expected standards.

While acknowledging Dr V’s care had significantly improved Ms A’s quality of life, the tribunal found his errors had put Ms A’s health at risk and constituted unsatisfactory professional conduct.

Dr V was reprimanded and registration conditions were imposed. Dr V was to practise under supervision and submit to a practice audit.

Only prescribe for conditions within your area of expertise, unless in exceptional situations or as part of a treatment team in consultation with an appropriately qualified colleague.

If a patient requests a prescription outside your prescribing knowledge and expertise, consider this carefully. Often the most appropriate response will be to refer the patient to their usual treating doctor for that condition or an appropriate specialist. In some circumstances, you may be able to prescribe after you consult with a colleague who is familiar with the medication and its indications.

If you do consider you need to provide an informal or one-off prescription, communicate any treatment or advice given to the patients to their other treating practitioners.

Always keep a medical record of any treatment provided and arrange follow-up if required.

Avant factsheet – Prescribing safely

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