Allegations regarding appropriateness of prescribing methods

Section 59 of the Guide to Professional Conduct and Ethics for Registered Medical Practitioners provides guidance to practitioners in respect of the best approach to be adopted in relation to prescribing practices. Of particular note is the guidance provided to practitioners in relation to treating patients with drug dependency or abuse problems. The Guide advises practitioners that they should ensure that they have appropriate training, facilities and support before treating patients with drug dependency or abuse problems and that they should refer patients to other services and supports where this is in the patient’s best interests. The Guide further advises that practitioners must be aware of the dangers of drug dependency when prescribing benzodiazepines, opiates and other drugs with addictive potential. The Guide counsels against practitioners undertaking treatment of opiate dependency patients unless they have been approved under the Methadone Treatment Protocol.

The Medical Council has received complaints from patients, family members and other health care providers regarding the prescribing methods of practitioners in relation to controlled drugs, namely benzodiazepines.

In one such case a practitioner was referred to an inquiry before the Fitness to Practise Committee (FTPC) on the basis of allegations regarding the appropriateness of his prescribing methods. Among the allegations were that the practitioner prescribed drugs in inappropriate quantities and strengths and that he failed to prescribe the most appropriate medicine to suit his patient’s condition and/or best interests. It was also alleged that the practitioner placed undue reliance on the prescribing of drugs and further that he prescribed drugs in an irresponsible manner. It was submitted that the practitioner failed to make any or adequate enquiries as to whether the patient was being treated by another general and/or specialist substance misuse practitioner and that he failed to arrange for the patient to be referred to a specialist substance misuse practitioner. The practitioner had continued to prescribe the drugs in certain quantities and strengths notwithstanding the concerns expressed by a pharmacist and he failed to ensure that he had received adequate training before treating some or all of the specified patients.

Having considered all of the evidence, the role of the FTPC is to decide whether the facts have been proved beyond reasonable doubt and, if so, whether the facts as proved amount to either professional misconduct, poor professional performance or other grounds as may have been set out in the notice of inquiry.

Professional misconduct is defined in paragraph 2.1 of the Ethical Guide as:
a) Conduct which doctors of experience, competence and good repute consider disgraceful or dishonourable; and/ or
b) Conduct connected with his or her profession in which the doctor concerned has seriously fallen short by omission or commission of the standards of conduct expected among doctors. Poor professional performance is defined by the Medical Practitioners Act 2007:

‘Poor professional performance, in relation to a medical practitioner, means a failure by the practitioner to meet the standards of competence (whether in knowledge and skill or the application of knowledge and skill or both) that can reasonably be expected of medical practitioners practising medicine of any kind practised by the practitioner.’(1)

In the above case the FTPC found the doctor to be guilty of professional misconduct and poor professional performance. Any sanction to be imposed on a doctor’s registration is a matter for the Medical Council. The FTPC therefore referred its report to the Council which decided to sanction the practitioner and impose conditions on his registration pursuant to section 71(b) and (c) of the Medical Practitioners Act, 2007. Among the conditions imposed on the practitioner were the following;

That the practitioner work with a nominated person acceptable to the Medical Council to formulate a professional development plan which would specifically include areas of deficiency in the following areas of the Practitioner’s practice, as identified by the expert reports;

a) Benzodiazepine prescribing;
b) Management of patients with addictions;
c) Approved clinical records systems in an Irish healthcare setting and compliant with data protection legislation and other applicable legislation;
d) Familiarisation of care and referral patterns for patients in an Irish healthcare system.

The above case highlights the need for practitioners to ensure that they have the appropriate training in the area of drug dependency prior to implementing a course of treatment for a patient. The case also emphasises the need for practitioners to have an awareness of their own expertise and knowledge in the area of prescribing and to make reasonable efforts to ensure patients with drug dependency are not inappropriately obtaining drugs from multiple sources. In this respect practitioners should engage with colleagues and pharmacists in relation to the patient’s interests. Finally the case underlines the need for practitioners to display a willingness to refer patients to other support services were this would be more beneficial for the long term treatment plan of the patient.

(1) Poor professional performance was introduced by Ministerial Order on 3rd July, 2008.