A guide to performance management and support for general practitioners

Appendix A. Case studies

Last revised: 02 May 2020

The following cases are commonly occurring scenarios that would raise concern, necessitating investigation and requiring the GP to undergo some form of remedial intervention. They are scenarios for reflection from a personal and a practice perspective. They may also be used in clinical meetings to facilitate discussion on a range of topics having medico-legal repercussions, to encourage reflective practice and to improve capability and effectiveness at both the individual and practice level.

 


PA, the practice manager at practice X, has received several complaints from patients about Dr GA, one of their GPs. The complaints are that Dr GA does not listen, his practice is different from that of the other GPs in the clinic, and the patients do not want to see him again. PA decides to speak to SA, the practice principal. SA is surprised to hear these complaints because he believes Dr GA is a good doctor. SA wonders whether the problem may be due to language and communication skills because Dr GA is overseas-trained and speaks with an accent. PA mentions that patient bookings with Dr GA remain consistently low, even though he has been at the clinic for several years. SA and PA arrange a meeting with Dr GA, who is taken aback when he hears the complaints. He says that he is an experienced GP, has enjoyed working at practice X, has many regular patients who are happy with him and no one has ever complained about him before. He blames his colleagues’ patients who question him and make it difficult for him to do his job properly.

After some consideration, SA speaks to RM, a remediation expert, and requests a formal assessment of Dr GA’s communication skills. SA informs Dr GA of this decision and Dr GA agrees to the assessment.

On the day of the assessment, RM speaks first with Dr GA to obtain his perspective. RM then observes several of Dr GA’s consultations. RM identifies that Dr GA has no difficulties with use of language, reasonably good clinical skills, some knowledge deficits, and difficulty with being assertive and communicating effectively (understanding the patient agenda and providing information clearly). RM makes recommendations to Dr GA and the practice for addressing these issues.

Questions

  • Have assumptions been made? How does SA know that Dr GA is a good doctor? Is there bias in attributing the problem to language and communication skills?
  • What do others in the practice (colleagues and staff) know about the concerns?
  • Are the patient complaints new? If so, what has happened? If not, why weren’t they addressed earlier? How long has the practice known about these complaints?
  • What if Dr GA had refused to undergo the assessment? Can the practice compel him?
  • How is Dr GA being supported through this process? How does he continue working in light of what has happened?
  • What if Dr GA does not follow through on the recommendations? Is there anything else that can be done by the practice?
  • Would a period of supervision be helpful? If so, how would it be conducted?


Dr GB has been a GP for more than 20 years and runs a busy solo practice. He has not been accepting new patients for some time and he knows his patients quite well. Following a patient complaint that triggered an investigation by AHPRA, Dr GB’s standard of practice is found to be below what would be expected of his peers because he is not keeping up to date with current medical information and treatment guidelines.

While Dr GB has been maintaining his CPD requirements, specific concerns are identified regarding his clinical skills.

Observations and questions

Most, if not all, GPs attract a particular patient base over time and settle into a mode of practice that suits them. Familiarity, however, can be a double-edged sword.

  • What processes do individual GPs and practices have in place for ensuring the adequacy of their clinical skills? How can a GP:
    • be truly reflective as regards their clinical practice and identify their real learning needs?
    • keep abreast of change and maintain their general skills when they are working in an area of special interest or a specific patient base?
  • Would Dr GB benefit from having a mentor on an ongoing basis?

Dr GB is required by AHPRA to undertake an educational program on ‘staying up to date’. At the conclusion of the education, Dr GB says to the medical educator that he intends working as a solo GP until the day he dies. His father, he says, died while consulting at the age of 90.

  • What do you think of Dr GB’s plans to continue working for so long?
  • What advice would you give him?
  • Should Dr GB be encouraged not to continue working for so long? If so, at what age do you think he should stop and should he commence planning for retirement from now?

Case 3 – Dr GC (professional behaviour)

Dr GC was investigated by AHPRA following a patient complaint regarding his professional behaviour. In the process, Dr GC’s medical record keeping was found to be inadequate. He was ordered to undertake education in medical record keeping and undergo six-monthly audits of his medical records.


Case 4 – Dr GD (informed consent)

Dr GD was investigated by AHPRA following a patient complaint about a skin procedure that Dr GD had performed. The patient was unhappy with the outcome of the procedure and claimed that Dr GD had not informed her of the risks. The investigation found that Dr GD’s record keeping and processes for obtaining informed consent were inadequate. Dr GD was ordered to undertake education about informed consent and medical record keeping.


Case 5 – Dr GE (certificates)

Dr GE was investigated by AHPRA following a complaint by an educational institution that Dr GE was issuing inappropriate sickness certificates to students at examination times. Dr GE was ordered by AHPRA to undergo an audit of his medical records. Fortunately, Dr GE maintained good medical records from which it was possible to verify the appropriateness of the certificates.


Case 6 – Dr GF (prescribing)

Dr GF was investigated for inappropriately prescribing narcotics. During the investigation, Dr GF’s medical record keeping was found to be inadequate. Specifically, her medical records lacked considerable detail regarding the reasons for prescribing narcotic medication to several patients; the need for the ongoing use of narcotics; why doses were increased and multiple narcotics prescribed; and what other treatment measures were being used. Dr GF was ordered to undergo education about narcotic prescribing, drug-seeking behaviour and medical record keeping.


Observation and questions

These are not uncommon scenarios where, as part of an investigation, medical records are examined and documentation found to be inadequate.

  • What processes do individual GPs and practices have in place for assessing and ensuring the appropriateness of:
    • documentation?
    • certification?
    • informed consent?
    • prescribing practices?
    • billing practices?
  • Would consultation with an MDO, by the individual GP and the practice, be helpful in assessing risk?


Dr GG was investigated by AHPRA following a patient complaint. The patient had stated that Dr GG did not close the curtain around her while she undressed for a physical examination. This distressed her greatly and it was made worse when Dr GG made jokes while examining her. In reply, Dr GG said that he had not intended to be disrespectful towards the patient. He said he was on the computer recording notes and he had his back to the patient while she was undressing. He also said that he had made some lighthearted comments while examining the patient because she appeared very tense. Dr GG was ordered to undergo education about professional boundaries and working ethically with female and vulnerable patients. Dr GG was also required to participate in a mentoring program to reinforce what he had learnt in the education program. This entailed direct observation of Dr GG’s consultations, over several sessions, by a medical educator.

Observations and questions

Among other things, this case highlights the importance of good communication skills: what was said and what was not said by the doctor, his intent and the patient’s perceptions.

  • How often are patient complaints either partly or entirely about poor communication on the doctor’s part?
  • How do GPs know whether their communication skills are appropriate and effective?
  • How do practices address poor or ineffective communication by their GPs?


Dr GH was investigated by AHPRA for professional misconduct in examining female patients. He was ordered to have a chaperone in attendance when consulting with and examining female patients. He was also ordered to display a sign to this effect in his waiting room. Dr GH did put up a sign, but it was in such a position that it was obscured from view. This came to the attention of AHPRA and Dr GH was reprimanded. He was required to undergo education not only on professional boundaries, but also on professional behaviour and responsibilities.

Observation and questions

Dr GH was clearly embarrassed to display the sign and saw it as a significant blow to his professional standing. He was also very upset that AHPRA had not taken into consideration that he was a hard-working GP, often going beyond the call of duty for his patients. While his commitment might be laudable, his repeated protestations suggested some denial of wrongdoing. AHPRA investigations take their toll both professionally and personally, and it is also not unusual for GPs to react in anger and to believe that the system is against them.

  • How can the medical educator delivering the education engage with Dr GH and enable him to understand the issues?
  • How can Dr GH regain his self-respect and sense of commitment?
  • Does the medical educator have a role in counselling and supporting Dr GH?

Postscript

Dr GH completed the education on professional boundaries, behaviour and responsibilities. Not long after, he was under investigation again by AHPRA for professional misconduct over the same issues (‘inappropriate and unwanted physical contact of a sexual nature’ and ‘placing pressure on the patient not to complain about his behaviour’). Dr GH’s medical registration was cancelled. The basis for this decision was that Dr GH had not shown any insight into his behaviour and even though he had expressed remorse with the first patient, he had gone on to reoffend.


Dr GI was found by AHPRA to have engaged in professional misconduct in that he had entered into a personal and sexual relationship with a patient. His registration was suspended and he was ordered to first undertake an educational program on ‘the importance of professional and sexual boundaries’, followed by a mentoring program to ‘reinforce the importance of maintaining professional boundaries’.

Observation and questions

The mentoring task presents challenges for the mentor, namely:

  • engaging Dr GI in the mentoring, especially because this is a very sensitive and personal area
  • what to cover in each session
  • AHPRA’s concern that Dr GI does not reoffend, which would entail a behaviour change on Dr GI’s part
  • addressing issues of self-care and the development of resilience
  • assisting Dr GI with re-entry to practice.

Questions to consider:

  • Where should the line be drawn regarding relationships with patients?
  • What about patients who become friends? Can friends become patients?
  • What action can be taken when intimacy with a patient has developed? What are the early warning signs to developing intimacy with a patient?


Dr GJ, a GP, and surgeons Mr SB and Mr SC were found by the coroner to have been negligent when a patient under their care died from complications of cosmetic surgery that had been performed by Mr SB. All three doctors were either directly or indirectly involved in this patient’s post-operative care. The coroner determined that there had been poor communication and cooperation between the doctors as well as a failure in their duty of care. Following this unfortunate incident, the practice updated its management protocols, including having delineated responsibilities and clear lines of communication. Dr GJ decided to cease clinical practice because AHPRA’s investigation, the civil court case and the attendant media scrutiny had taken their toll on him and his family.

Questions

  • How do these doctors recover personally from such an incident?
  • How do these doctors retain their professional standing and continue working, especially when the incident and ensuing court case were widely reported in the media?
  • Can MDOs be of assistance to practices in preventing similar incidents from occurring?


Dr GK was investigated by AHPRA for inappropriate prescribing of drugs of addiction. The investigation was instigated when a patient made a complaint to AHPRA that Dr GK had turned him into a drug addict.

During the investigation it came to light that Dr GK had:

  • been prescribing drugs of addiction inappropriately to several patients
  • been inappropriately prescribing human growth hormone to patients and family members
  • a chronic medical condition for which he was self-prescribing.

Observations and questions

The patient who made the complaint to AHPRA was a drug-seeker and didn’t become drug addicted because of Dr GK’s prescribing. While this was a vexatious complaint, Dr GK did breach several prescribing regulations (regulations regarding drugs of addiction, self-prescribing, unsanctioned off-label prescribing).

  • Why do GPs self-treat? Why do GPs find it difficult to seek help?
  • Is ‘I’m just too busy’ a valid excuse when problems arise?
  • When a GP is experiencing health or personal problems, what duty of care is owed to that GP by their colleagues and the practice?

Drug-seeking behaviour has become more difficult to manage and requires a higher level of communication skills as well as behaviour management skills. When faced with problems that are outside one’s level of expertise, it is important to ask for help. The next step is to decide whether to continue managing these problems and if so, to obtain the required skill set.

  • What processes do practices have in place to assist GPs in managing difficult patient behaviour, including drug-seeking behaviour?

Off-label prescribing and medical practices that are not recognised as mainstream are fraught with medico-legal issues.

  • How do individual GPs monitor their practice, including prescribing, to ensure that they are practising safely?
  • What processes do practices have in place for supporting and ensuring that their GPs are practising safely?
  • How can a GP be more mindful of potential medico-legal issues?
  • Would a period of supervision be helpful for Dr GK? If so, how would it be conducted?


Dr GL is a GP of many years and well regarded by his colleagues. Lately, Dr GL has been having outbursts of anger, often directed at the practice nurse, NA. Last week, after yet another altercation with NA, he smashed her mobile phone on the floor. NA demands of PB, the practice manager, that something be done about Dr GL immediately, otherwise she will resign.

PB discusses the situation with the practice principal, SD. They arrange a meeting with Dr GL. Initially Dr GL denies that he is at fault but then becomes apologetic. He says that he is under a lot of stress and not coping because his marriage is breaking down. He requests time off so that he can get his life in order.

Dr GL returns after three weeks. At first, he appears to be much more settled, but before long the anger outbursts recommence. He is often late for work. There are occasions when he leaves part way through a session, without telling anyone, and doesn’t return. When questioned, he apologises and says that he is experiencing ‘horrendous migraines’. Some of his patients complain that he smells of alcohol and appears very detached. PB and SD are discussing what to do when one of the receptionists interrupts them. She says that there is a very angry woman at the front desk claiming that Dr GL groped her and tried to kiss her. At the same time, she saw Dr GL hurriedly leave the building and she is concerned that he might harm himself. She says that Dr GL has been confiding in her about his marital problems and how life is not worth living.

Observation and questions

This case highlights the importance of looking beyond the behavioural problem and exploring what underlies the behavioural change.

  • What should be done now?
  • Dr GL has not made any clinical errors. Should he be reported to AHPRA? What are the issues for Dr GL? For the practice?
  • What support/assistance might Dr GL need?
  • What issues need to be considered, by Dr GL and by the practice, when Dr GL returns to work? What is Dr GL’s responsibility with respect to self-care?
  • What would be an appropriate Remediation Plan for Dr GL?
  • Could this have been better dealt with earlier? When Dr GL requested time off ‘to get his life in order’, should he have been required to take longer time off?

There are individuals whose behaviour is more ingrained.

  • Does that mean that their behaviour can never change and that it shouldn’t be addressed?


 

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