Medical Practitioner, Dr E New Zealand Men's Clinic - Health and ...

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Health and Disability Commissioner and a vascular surgery referral may have been warranted. In addition, although I accept that there was discussion about the intended treatment, the consent forms were not signed. Dr E’s treatment of Mr A shows signs of having been superficial. Mr A’s description of the consultation having been brief seems convincing, and is supported by the limited documentation. By providing a cursory assessment, Dr E failed to provide Mr A services with reasonable care and skill, and breached Right 4(1) of the Code. By failing to document his care in relation to Mr A, in particular the failure to ensure that consent forms were signed, Dr E breached Right 4(2) of the Code. Mr B Mr B is a healthy young man (aged 21) who sought treatment for premature ejaculation. It is clear that Dr E’s assessment of Mr B was superficial. Although a physical examination may not have been necessary, given Mr B’s age and health background, he should have been asked questions about his sexual functioning, and should have received “psychosexual advice and education in addition to any treatments on offer” (in the words of Dr Tiller). Dr Wright notes that “while these psychosocial aspects would certainly have added to the history, they would have had no bearing on the case management at all. They are quite simply irrelevant in a case of premature ejaculation in a young healthy male with no erectile difficulty.” However, Dr Wright’s opinion illustrates his lack of familiarity with the patient-centred approach that is expected under New Zealand’s Code. Right 6 of the Code affirms a patient’s right to the information that a reasonable patient, in that patient’s circumstances, would expect to receive about his condition (including any contributing factors). As Dr E has pointed out, men attend the Clinic because they do not always feel comfortable discussing sexual dysfunction with their GP. Good information is all the more important in such “one-off” consultations, when a patient may not return for further advice. Dr E acknowledged that “psychosexual counselling forms a fundamental part of a successful outcome” of a patient’s consultation. However, Mr B describes a rushed consultation without “counselling” of any sort. In my view, Dr E’s assessment was deficient. I also note that Dr E prescribed an approved medicine for use in an unapproved manner. Although this is permissible in some circumstances, a medical practitioner should advise the patient that the proposed use is unapproved. Dr E did not do so in Mr B’s case. By providing a cursory assessment, Dr E failed to provide Mr B services with reasonable care and skill, and breached Right 4(1) of the Code. By failing to advise Mr B of the unapproved use of an approved drug, Dr E did not provide Mr B 18 December 2008 16 Names have been removed (except the NZ Men’s Clinic) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
Opinion 08HDC02899, 08HDC05986, 08HDC07100, 08HDC09984 information that was legally required, and therefore breached Right 6(1)(e) of the Code. Mr C Mr C (aged 75) had a significant cardiac history, including two major operations (a coronary artery bypass and an aortic valve repair), when he attended the Clinic. Despite this history, and the fact that he was taking a number of cardiac medications, Dr E performed no clinical examination on Mr C and recorded no clinical observations. Dr E clarified that he prescribed only apomorphine, and not phentolamine. He described the error as a typographical mistake. It resulted in subsequent reviewers (Drs Tiller and Wright) being unsure what drugs were actually prescribed. This is a good example of why clinical records need to be accurate. I also note that the dosage of the medication was not recorded. Dr Tiller advised that, prior to the prescription of the two documented medications (apomorphine and phentolamine), a cardiology consultation was required because of the potential effect of the medications, particularly phentolamine, which is contraindicated in patients with known coronary artery disease. While Dr Wright commented that such a referral was not “mandatory” in this case, and I accept that phentolamine was not dispensed, he added that a referral would have been warranted “if there were concerns on a clinical basis”. In this case, Dr E made no clinical assessment, and therefore he had no such basis on which to conclude whether a cardiac referral was warranted. Dr Wright considered “[Dr E’s] history taking, note taking and examination to be inadequate” in this case. I note that the use of apomorphine as a nasal spray is not approved by Medsafe, and Mr C was not advised of this. Dr Wright advised that apomorphine should not have been prescribed in this case, and “its use in unstable coronary disease is not recommended”. It is not known for certain what caused Mr C’s collapse following his use of the nasal spray. However, the collapse occurred immediately after his use of apomorphine (which is contraindicated for patients with a cardiac history), having been taken nasally (which would result in quick action). I am surprised by Dr E’s subsequent comment that he cannot explain what caused Mr C’s collapse, and that Dr E has not considered the possibility that the collapse was caused by the medication he had prescribed. By performing a cursory assessment, Dr E failed to provide Mr C services with reasonable care and skill, and breached Right 4(1) of the Code. By failing to advise Mr C of the risks associated with prescribing apomorphine, Dr E failed to provide an assessment of the expected risks, and breached Right 6(1)(b) of the Code. By failing to advise Mr C of the unapproved use of an approved medication, Dr E breached Right 6(1)(e) of the Code. 18 December 2008 17 Names have been removed (except the NZ Men’s Clinic) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
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