Junior doctor reprimanded for prescribing without clinical justification

31 Oct 2018

The Victorian Civil and Administrative Tribunal (VCAT) finds junior doctor guilty of unprofessional conduct for prescribing testosterone and human growth hormone without clinical justification.

Dr Bassam Abi Haila was a junior doctor, three years into his four-year general practitioner training, working one day per week at an anti-aging clinic. The Board alleged that between 2013 and 2014, Dr Abi Haila prescribed testosterone and human growth hormone to adult male patients at the clinic without clinical justification.

The clinic was owned by a dietician and a personal trainer who referred patients to Dr Abi Haila. By the time Dr Abil Haila saw them, they had had an initial consultation, completed a questionnaire and blood test results had been obtained. In most cases, the blood tests showed hormone levels within the normal range. In all but one case, the patient was under 50. Dr Abi Haila did not order repeat blood tests before prescribing and did not obtain specialist opinion from an endocrinologist or andrologist.

Testosterone and hGH are both schedule 4 poisons and must not be prescribed by a medical practitioner unless he or she has taken all reasonable steps to establish that therapeutic need exists.

The Medical Board of Australia alleged that Dr Abi Haila had engaged in unprofessional conduct and/or professional misconduct by:

• prescribing testosterone to four patients without clinical justification
• prescribing hGH Somatropin to six patients without proper clinical justification
• failing to adequately record his medical treatment of six patients, and
• failing to appropriately clinically manage certain patients, in particular failing to obtain the opinion of a suitably qualified specialist before initiating treatment.

Dr Abi Haila acknowledged that the patients referred to him were seeking hormone treatment and that while working at the clinic, he felt under increasing pressure to prescribe, leading to his decision to stop working there. However, he maintained that his prescribing was appropriate and that he would not have done anything differently. He argued that his prescribing was clinically justified in the circumstances because they were male patients going through ‘andropause’ (the hormonal changes which occur in men as they age). He held the view that, although this is a controversial area of medicine in Australia, andropause is an emerging field of endocrinology.

The tribunal, in making its decision, noted that it was not a question around the diagnosis of andropause but rather whether Dr Abi Haila had behaved in a way that constitutes unprofessional conduct. Relevantly Dr Abi Haila did not record a diagnosis of andropause for any of his patients and, in any event, it was the opinion of all three expert witnesses that andropause has not been accepted as a medically valid concept and that none of them would have prescribed testosterone or hGH in the particular circumstances.

In making its decision, the tribunal noted that it was relevant that Dr Abi Haila was at the time a junior doctor still in training. Taking into account his level of training and experience, it found that his conduct was not at the extreme end of irresponsible prescribing: he did not prescribe without seeing patients, he had blood tests, although had not repeated the tests, took care to ensure the absence of any contraindications, apparently refused to prescribe to seven patients despite pressure to do so and had chosen to leave the clinic because of the increasing pressure to prescribe.

The tribunal found that it was evident that Dr Abi Haila was clearly out of his depth and that the case highlighted the risks for medical practitioners, particularly junior medical practitioners, in working in ‘such clinics at the fringe of medical practice, and where the medical practitioner is likely to come under intense pressure to prescribe’.

The tribunal found that Dr Abi Haila had engaged in conduct that is of a lesser standard than which may reasonably be expected of a health practitioner by the public or the practitioner’s professional peers. He had prescribed Schedule 4 poisons without proper clinical justification and failed to appropriately clinically manage some of his patients. However, it stopped short of a finding of professional misconduct principally because the definition of the National Law refers to standards reasonably expected of a registered health practitioner of an equivalent level of training and experience.

The tribunal ordered that Dr Abi Haila be reprimanded and conditions be imposed on his registration requiring him to undertake further education and a period of mentoring.

The decisions are published on the Austlii website:

www.austlii.edu.au/cgi-bin/viewdoc/au/cases/vic/VCAT/2017/1627.html

www.austlii.edu.au/cgi-bin/viewdoc/au/cases/vic/VCAT//2018/196.html

In each case, he said, the patients were fully informed of the risks and benefits and gave informed consent. He prescribed low starting doses and short term prescriptions. He had prescribed testosterone and/or hGH to 14 patients in total but had refused to prescribe to seven patients.