Roman Hasil and the Whanganui DHB - Health and Disability ...

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Health and Disability Commissioner It is only Dr A from the management team who is specifically under investigation. The reason for singling him out for investigation is that he was personally responsible for supervising Dr Hasil. A supervisor has a duty to provide supervision with reasonable care and skill and in accordance with professional standards. This duty is recognised at common law. 40 The duty of a supervisor has been considered in several major HDC reports, including Southland District Health Board Mental Health Services February– March 2001. 41 Definition of supervision Supervision is a broad and somewhat fluid concept. In practice, it varies in nature and degree. 42 Supervision can be both formal and informal. 43 It is important to distinguish between the different types of supervision in a medical context. One type of supervision is regulatory supervision. The Medical Council may require that a doctor practise under supervision and that the supervisor assess and report on the performance of the supervised doctor. 44 Regulatory supervision is supervision provided at the request of the Medical Council for doctors who are provisionally registered, such as an international medical graduate (IMG) new to the country. 45 Regulatory supervision does not necessarily take place within the same clinical team. Offsite regulatory supervision — where the supervisor works somewhere else — is permitted in certain cases, particularly in provincial or rural settings. The supervisor is an agent of the Medical Council. The Medical Council provides guidance on the supervision of new doctors in New Zealand. 46 The more familiar type of supervision in medicine is when a more senior doctor supervises a more junior doctor within a clinical team (eg, a senior doctor of a registrar or medical officer; a registrar of a house surgeon). 47 This is clinical supervision. 48 A basic principle of clinical supervision is that the supervisor may delegate care to the 40 McKenzie v Medical Practitioners Disciplinary Tribunal [2004] NZAR 47 (HC), paras 24–25. 41 Health and Disability Commissioner, October 2002; accessible at www.hdc.org.nz/publications/reports. 42 The Medical Council defines supervision as “the provision of guidance and feedback on matters of personal, professional and educational development in the context of a doctor’s experience of providing safe and appropriate patient care”. Whanganui DHB has a supervision policy that provides that supervision is a process in which the supervisor enables, guides and facilitates the supervisee in meeting certain organisational, professional and personal objectives. 43 Formal supervision involves regular protected time, specifically scheduled. Informal supervision involves regular communication and conversation providing advice, guidance or support as and when necessary. 44 Health Practitioners Competence Assurance Act 2003, section 23. 45 Professor John Campbell, “Supervision — why the concern?” New Zealand Doctor, 26 September 2007, 14. 46 Medical Council of New Zealand, Guidance for doctors working in supervised practice and their supervisors (August 2004), which has been replaced by Induction and supervision for newly registered doctors (October 2007). 47 R Paterson and M van Wyk, “Supervisory Responsibility of Specialists” (2002) 10 Journal of Law and Medicine 187, 190. 48 Professor John Campbell, “Supervision — why the concern?” New Zealand Doctor, 26 September 2007, 14. 74 February 2008
Opinion 07HDC03504 supervisee where he or she has good reason to believe that they are competent to carry out the delegated tasks. The supervisee should be encouraged to seek assistance if he or she feels out of their depth. The supervisor needs to be available to provide assistance as required. 49 A critical issue in cases involving clinical supervision is whether the supervisor acted reasonably in relying on the supervisee acting in the role assigned. In deciding this issue, several factors are considered, including the supervisee’s experience and the supervisor’s knowledge of their skills and experience. 50 One variant of clinical supervision is the supervision of a medical officer by a specialist within a service. 51 The supervisory relationship between a specialist/Clinical Director and a medical officer within a mental health service was discussed in Director of Proceedings v O’Flynn. 52 In considering the adequacy of the supervision, the Tribunal adopted the objective test referred to by Venning J in McKenzie v Medical Practitioners Disciplinary Tribunal. 53 The Tribunal indicated that specialist/clinical director Dr O’Flynn was not required to provide close supervision. In the absence of any specific knowledge of the medical officer’s shortcomings, the specialist/Clinical Director is entitled to expect the medical officer to conduct himself to a standard commensurate with his qualifications and experience as a senior member of the medical staff. If the person responsible for delegating clinical responsibilities in a service has worked closely with a medical officer, and is confident that the medical officer can act in the role assigned, it would usually be reasonable for the specialist to rely on the medical officer to act independently, in effect as a specialist. 54 I accept that there are medical officers who are well able to act independently, in effect as specialists. However, if a medical officer’s competence is in doubt, or not known to the supervisor, closer supervision is required. Effective clinical supervision is critical for safe health care. One of the essential checks within the system will be lost if the requirement for supervision is “watered down”. A 49 There has been a tremendous change in nature of the medical workforce and hospital medicine in the past 20 years, which is undermining the traditional model of supervision. The supervisors may not be familiar with the supervisee’s level of competence. Concomitantly, the supervisee may not recognise their own limitations due to their lack of experience. 50 McKenzie v Medical Practitioners Disciplinary Tribunal [2004] NZAR 47 (HC). 51 A medical officer, previously known as a medical officer special scale (MOSS), falls between the cracks in relation to the professional colleges. Professional colleges have a role in relation to their fellows and trainees. For example, there is generally a requirement for formal supervision as part of registrar training programmes. 52 Director of Proceedings v O’Flynn, Medical Practitioners Disciplinary Tribunal, 291/03/110D, 15 July 2004. 53 McKenzie v Medical Practitioners Disciplinary Tribunal [2004] NZAR 47 (HC), para 562–563. 54 Director of Proceedings v O’Flynn, Medical Practitioners Disciplinary Tribunal, 291/03/110D, 15 July 2004. February 2008 75
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