New South Wales Medical Tribunal CITATION : Re Dr Swapan Chowdhury [2010] NSWMT 13 revised - 13/12/2010 TRIBUNAL: Medical Tribunal PARTIES : The Health Care Complaints Commission Swapan Chowdhury FILE NUMBER(S) : 40017 of 2010 CORAM: Kok, Dr E - Abouyanni, Dr G - Glass, Assoc Prof A - Murrell, SC DCJ CATCHWORDS: Contravention of registration conditions - professional misconduct or unsatisfactory professional conduct - appropriate response to conduct LEGISLATION CITED: Medical Practice Act 1992 Health Care Complaints Commission v Karalasingham [2007] NSWCA 267; Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630; CASES CITED: Pillai v Messiter (No 2) (1989) 16 NSWLR 197; Prakash v Health Care Complaints Commission [2006] NSWCA153; Qidwai v Brown (1984) 1 NSWLR 100 DATES OF HEARING: 27-28 September 2010 DATE OF JUDGMENT: 20 October 2010 LEGAL REPRESENTATIVES: M G Furness of Senior Counsel for the Health Care Complaints Commission Mr P Blacket of Senior Counsel for the Doctor ORDERS: The complaint is established; (1) The Tribunal finds the respondent guilty of professional misconduct; (2) The respondent is reprimanded; (3) When he is registered, the conditions in Annexure 2 are to be imposed on the respondent's registration; (4) The respondent is to pay the complainant's costs. JUDGMENT: The Complaint 1 Between 2000 and 2007, the respondent was a registered practitioner with the New South Wales Medical Board, registered under the Medical Practice Act 1992. 2 The Health Care Complaints Commission ('the complainant') asserts that the respondent is guilty of unsatisfactory professional conduct and/or professional misconduct in that, between 19 July 2005 and 19 September 2006, he contravened registration conditions imposed by a Performance Review Panel in April 2005. The conditions required the respondent to undertake a mentoring program with an experienced general practitioner approved by the Board and complete three educational programs: the Annual Revision Seminar held by the RACGP, the Clinical Communication Program conducted by the Cognitive Institute, and the Interactive Risk Management Program provided by the respondent's indemnity provider, MDASA. The respondent's professional performance was to be reassessed after 12 months. In July 2005, the respondent was notified of the conditions. 3 The conditions are Annexure 1 to these reasons. 4 The respondent admits the breaches of condition and concedes that he is guilty of unsatisfactory professional conduct. Issues (1) Does the respondent's conduct constitute professional misconduct or is it simply unsatisfactory professional conduct? (2) In what manner should the Tribunal respond to the respondent's conduct? Background 5 In October 2004, the Board undertook a performance assessment and found that the respondent performed "just below an acceptable standard" but had the ability to improve (Exhibit A, tab 4). 6 In April 2005 a Performance Review Panel found that the respondent's professional performance remained unsatisfactory (Exhibit A, tab 5). The Panel imposed the conditions that are the subject of these proceedings. The Panel concluded that: "Dr Chowdhury's basic clinical skills, diagnostic/problem-solving skills, patient management skills, interaction/communication with patience and record-keeping are not of the standard reasonably expected of a practitioner of an equivalent level of training or experience. … It is not clear to the Panel whether the deficiencies in Dr Chowdhury's diagnostic clinical and patient management skills indicate an inherent lack of skill in these areas, or a lack of attention to, or awareness of expected standards. … It is the Panel's view that, if Dr Chowdhury is to continue to practice, he requires mentoring, monitoring and training in particular areas of skill, knowledge and practice to ensure his practice of medicine is at the standard reasonably expected of a general practitioner of an equivalent level of training or experience. … The (conditions imposed) reflect the practice areas that the Panel considers require remedial action on the part of Dr Choudhury." 7 Between July 2006 and August 2007, the Board investigated impairment issues affecting the respondent. On 19 September 2006 there was an inquiry under s 66 of the Medical Practice Act 1992 into whether, having regard to his psychological condition, the respondent should be suspended from practice. The respondent was required to attend for assessment by Dr Westmore, a psychiatrist nominated by the Board. The matter was referred to an Impaired Registrants Panel (IRP). In February 2007, the IRP imposed health conditions on the respondent's registration (Exhibit A, tab 20). In May 2007, the respondent's psychological condition was reviewed (Exhibit A, tab 21). His health had improved. However, the Review Panel recommended that the respondent's registration remain subject to health conditions. 8 In mid-2007, the respondent failed to pay his registration fees. Consequently, on 20 June 2007 his name was removed from the roll of medical practitioners. 9 On 4 July 2007, the respondent sought re-registration. In August 2007, Dr Westmore reassessed the respondent (Exhibit A, tab 23). Subsequently, pursuant to Schedule 1 of the Act, the Board held an inquiry into the respondent's eligibility for registration (Exhibit A, tab 24). The respondent's application for re-registration was refused, inter alia because of the respondent's history of non-compliance with registration conditions. 10 In October 2007, the HCCC made two complaints against the respondent. The first alleged a failure to maintain proper professional boundaries with a patient, and the second alleged a breach of registration conditions. The current complaint reflects the second complaint. In 2009, the Medical Tribunal dismissed the first complaint. In relation to the second complaint (the current complaint), the Tribunal found the respondent guilty of professional misconduct, directed that he be deregistered and ordered that there be no application for review of the deregistration for two years (in effect, that there be no application for re-registration before February 2011). The respondent appealed to the Court of Appeal. In March 2010, the appeal was allowed and the matter was remitted to the Tribunal (differently constituted) for determination. Characterisation of the Respondent's Conduct 11 Unsatisfactory professional conduct is defined in s 36 of the Act to include: "(c) Contravention of conditions of registration Any contravention by the practitioner (whether by act or omission) of a condition to which his or her registration is subject." Professional misconduct is defined in s 37 of the Act as follows: "For the purposes of this Act, professional misconduct of a registered medical practitioner means: (a) unsatisfactory professional conduct, or (b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct, of a sufficiently serious nature to justify suspension of the practitioner from practising medicine or the removal of the practitioner's name from the Register." (emphasis added) 12 The issue is whether, when the respondent's contraventions are considered as a whole, they are of "a sufficiently serious nature to justify" suspension or deregistration. Characterisation is not to be determined by backward reasoning, first determining the appropriate outcome and then characterising the conduct based on the outcome. The definition of professional misconduct is focused on the nature of the conduct, which must have the capacity to justify such an order, whether or not such an order should be made in particular circumstances: Health Care Complaints Commission v Karalasingham [2007] NSWCA 267 per Basten JA at [67]. Whereas the characterisation of conduct depends upon the "seriousness" of the conduct, additional considerations are relevant to determining outcome, principally the need to protect the health and safety of the public: s 2A (3) of the Act. 13 The "seriousness" of unsatisfactory professional conduct is to be measured by the extent to which it departs from proper standards: Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 638. "Misconduct in a professional respect" means conduct that incurs the strong reprobation of colleagues of good repute and competence. Frequently, such conduct involves "moral turpitude", but it need not do so: Qidwai v Brown (1984) 1 NSWLR 100, per Preistley JA at 104. For example, conduct that is not a deliberate departure from accepted standards but which portrays indifference and an abuse of the privileges associated with registration as a medical practitioner may constitute "misconduct in a professional respect": Pillai v Messiter (No 2) (1989) 16 NSWLR 197 per Kirby P at 200. 14 Dr Westmore gave evidence that medical practitioners would view a fourteen-month non-compliance with the subject conditions as "extremely serious" because it is critical that practitioners acknowledge the authority of the Board (now the Council) in monitoring and supervising practitioners, its entitlement to impose conditions for the purpose of protecting the public, and the associated risk that failure to comply with conditions may endanger the public (Transcript 28 September 2010, page 8). 15 The Tribunal agrees with Dr Westmore's opinion that the respondent's non-compliance was extremely serious. The conditions that were notified in July 2005 were not narrow in focus. They were designed to address a variety of fundamental concerns about the respondent's clinical competence. Although the respondent did spend some time observing a practitioner who specialised in cosmetic work, that practitioner was not a Board-approved general practitioner. The respondent did not comply or substantially comply with any condition. There was little acknowledgement of the Board's authority. Non-compliance continued for a period of 14 months. Such a substantial departure from proper standards must be characterised as professional misconduct. Outcome 16 Section 60 of the Act recognizes that, once a complaint is proved, the Tribunal " may exercise any power or combination of powers conferred on it by (Division 4)" (emphasis added). In the case of a finding of professional misconduct, the Tribunal retains a discretion as to whether or not to make an order suspending or deregistering the respondent: Prakash v Health Care Complaints Commission [2006] NSWCA153 per Stantow JA at [59]. 17 In determining the appropriate outcome, the paramount consideration is the protection of the health and safety of the public: s 2 A (3) of the Act. Other relevant (and related) considerations include specific and general deterrence, the maintenance of high standards within the medical profession and the maintenance of public confidence in the profession. 18 Before and during the breach period, the respondent was suffering from depression. In 2004 - 2005, his family was under financial pressure. The respondent had two jobs and was working up to 16 hours a day. His wife observed a dramatic change in the respondent's behaviour. He changed from a happy, loving and a motivated person to someone who was irritable, argumentative and lethargic. In July 2006, the respondent realised that he needed help. He approached Dr Benjamin, a consultant psychiatrist. 19 Dr Benjamin diagnosed the respondent as suffering from a moderate to severe adjustment disorder with depressed mood (Exhibit A, tab 15). He prescribed Lexapro, an antidepressant, and noticed a significant improvement within two weeks (Exhibit A, tab 16). In September 2006, Dr Westmore considered that the respondent may have suffered a major depressive illness in the past but agreed that the principle differential diagnosis was a moderate to severe adjustment disorder with depressed mood (Exhibit A, tab 18). However, in August 2007, Dr Westmore revised his opinion, stating that the respondent probably had suffered from a major depressive illness (Exhibit A, tab 23). In mid 2007, the respondent was prescribed Fluoxetine, which proved to be more effective than Lexapro. From July 2007 to May 2008, Dr Menzies, a psychiatrist, provided relationship counselling to the respondent and his wife. Dr Menzies reported that the respondent may have suffered from an adjustment disorder with anxiety and depressive features (treated) (Exhibit 1, tab 5). In 2010, the respondent's medication was changed to Duloxetine. The respondent finds that Duloxetine is more efficacious than Fluoxetine. In August 2010, Dr Selwyn Smith, a psychiatrist, stated that, between April 2005 and September 2006, the respondent probably had suffered from an adjustment disorder with depressed and anxious mood, but the condition was in remission (Exhibit 1, tab 3). 20 The complainant and the respondent agree that the respondent's non-compliance with registration conditions is not adequately explained by the depression from which he suffered. There was a significant component of "wilfulness". The respondent himself describes his behaviour as "passive-aggressive". 21 Dr Westmore opined that both depression and personality factors contributed to the respondent's non-compliant conduct (T 28 September 2010, pp 6-7). Had depression been the sole cause of the respondent's behaviour, it is likely that the respondent would have become more compliant as his depression began to resolve (T 28 September 2010, p 4). Dr Westmore did note the qualification that maladaptive behaviour may continue after depression has resolved because the maladaptive behaviour has "gathered its own momentum" (T 28 September 2010, p 9). 22 In the Tribunal's view, during the breach period of July 2005 to September 2006, personality factors did contribute to the respondent's non-compliant behaviour. However, during that period, depression was the dominant factor influencing the respondent's behaviour. It was only towards the end of the period that the respondent's condition was diagnosed and he began to receive treatment. When, in early August 2006, Dr Benjamin reported that the respondent's condition had "significantly improved" over the preceding two-week period, Dr Benjamin meant that the respondent had ceased being "unfit to attend court or give clear instructions to his solicitor" (which was the case on 27 July 2006) and had become "capable of responding" to allegations (Exhibit A, tabs 15 and 16). It was not until September 2006 that the respondent confided to his wife that he was receiving psychiatric treatment. The Tribunal accepts the evidence of the respondent's wife (who was an impressive witness) that the respondent's attitude and behaviour did not greatly improve until after his antidepressant medication was changed to Fluxetine in 2007, and that there was a further and very significant improvement following the introduction of Duloxetine in 2010. 23 The complainant submitted that, given the respondent's long history of deliberate non-compliance with registration conditions, the Tribunal could not be confident that the respondent would comply with any conditions that were imposed. Consequently, it was impossible to fashion conditions that would adequately protect public health and safety. The complainant submitted that the Tribunal should order deregistration, i.e. that the respondent not be re-registered: s 64(2) of the Act. Alternatively, pursuant to section 61(3) of the Act, the Tribunal should make a "critical compliance order", such that any contravention of post-registration conditions will result in automatic deregistration. 24 In determining the appropriate outcome in a case involving a breach of registration conditions, the Tribunal would usually consider the circumstances that resulted in the imposition of the conditions and the substance of the conditions (including the problem to which the conditions were directed and the related public interest), the seriousness of the breach and the circumstances that caused the breach, and the respondent's current circumstances (in the context of protecting public health and safety). 25 In 2005, the subject conditions were imposed on the respondent's registration because his clinical skills were deficient. Whatever the cause of clinical deficiency, it was a serious problem that was a potential danger to public health and safety. 26 With the benefit of hindsight, it is apparent that the respondent was depressed by 2004/ 2005. Even in the case of a clinician with high clinical skills, depression is likely to impair those skills, particularly in the area of patient communication: Dr Westmore (T 28 September 2010, p 6). 27 The respondent's non-compliance with registration conditions was governed by two factors: his underlying psychological condition and personality factors. The factors are not entirely independent. Depression may exaggerate a pre-morbid tendency to passive-aggressive behaviour: Dr Westmore (T 28 September 2010 pp 5 and 8). 28 On the evidence before the Tribunal, the underlying psychological condition has resolved with treatment. The respondent cannot change his fundamental personality. He is likely to remain proud and somewhat inflexible, reluctant to display "weakness" by accepting help, and inclined to resist direction. However, the respondent has gained significant insight into his personality and has expressed a changed attitude towards the subject registration conditions. He now understands that his behaviour was inappropriate. He appreciates that the Board (Council) is there to help and support practitioners. He acknowledges that it is "very appropriate" that he should attend courses designed to improve and update his clinical skills. He wants to undertake mentorship. 29 The Tribunal is moderately confident that the respondent will make a real effort to comply with any registration conditions. The Tribunal hopes that the respondent will be proactive, approaching the Council and proposing sensible amendments to any conditions with which it is difficult to comply. At the same time, the Tribunal cautions the respondent that he must accept the authority of the Council and quell any desire to dictate his own terms. 30 When the respondent seeks re-registration, the Council will need to consider the issues of psychological impairment and adequacy of clinical skills: s 13 of the Act. The evidence before the Tribunal is to the effect that the respondent is no longer psychologically impaired. However, the Tribunal has not thoroughly enquired into the respondent's current psychological condition. Nor has the Tribunal enquired into the respondent's current clinical skills. In addition to the concerns about clinical skills that resulted in the 2005 conditions, there is an issue about loss of clinical skills associated with three years of non-registration. The Council is the body best equipped to consider the respondent's current psychological condition and current clinical skills. It is not appropriate to make a full assessment of those matters until the respondent applies for re-registration. The Tribunal has no desire to usurp the role of the Council in considering those matters when the respondent applies for re-registration. 31 In determining an appropriate outcome, the Tribunal must have regard to the protection of the health and safety of the public as the paramount consideration: s 2A (3) of the Act. In the unusual circumstances of this case, there is no direct risk to public health or safety because the respondent is not registered and the Council will only re-register him if he is competent to practise medicine: s 13 of the Act. However, by upholding the authority of the Board (Council) and mandating compliance with conditions, the Tribunal can indirectly protect the health and safety of the public. If practitioners fail to respect registration conditions, public health and safety will be jeopardised, standards will be compromised and the public will lose confidence in the profession. Consequently, the Tribunal has decided to require that the respondent comply with registration conditions that are equivalent to the original conditions. 32 The Tribunal has considered the imposition of pre-registration conditions. However, the Tribunal has decided that its principal concerns of upholding the Council's authority and enforcing compliance will be better served by reinstating the original conditions as post-registration conditions. There was no direct relationship between the respondent's non-compliance and the loss of registration. Prior to re-registration, it may be difficult for the respondent to obtain a mentoring situation and he may be ineligible for clinical skills programs. Further, as a result of the 2009 Tribunal proceedings, the respondent was eligible for review of de-registration in February 2011. 33 The Tribunal acknowledges that some of the 2005 conditions may no longer be appropriate. For example, a nominated program may no longer be offered. Some of the conditions may become otiose. For example, prior to applying for registration, the respondent may choose to attend an equivalent program for the purpose of updating his clinical skills. The Council may consider that the reassessment condition is inappropriate. Such contingencies are addressed through the condition that enables the Council to amend or delete any condition. 34 The Tribunal has considered whether it should make any condition one of "critical compliance" under s 61(3). Section 61 (3) is commonly invoked as a "last resort". Given the respondent's improved psychological condition and apparent change of attitude, there is no obvious need for a "last resort". Further, a minor non-compliance should not automatically result in deregistration. 35 The respondent's counsel conceded that it was appropriate that the respondent pay the complainant's costs. 36 The respondent's story is a salutary tale of the tragic consequences that may flow when a practitioner suffers from depression that does not receive early diagnosis and treatment. If the respondent's depression had been recognised and treated early, his 2004/2005 clinical performance may have been acceptable. It may have been unnecessary to impose registration conditions. Had early treatment effected a remission of the respondent's depression by 2005/ 2006, the respondent may have made a real attempt to comply with registration conditions. Unfortunately, by the time that the respondent consulted a psychiatrist in July 2006, the Board was pressing for compliance and the respondent's condition had deteriorated to the extent that he was unable to provide his solicitor with clear instructions. 37 The complaint is established. (1) The Tribunal finds the respondent guilty of professional misconduct. (2) The respondent is reprimanded. (3) When he is registered, the conditions in Annexure 2 are to be imposed on the respondent's registration. (4) The respondent is to pay the complainant's costs. Annexure 1 2005 Conditions 1. That Dr Chowdhury spend a total of 10 sessions as an obsever with an experienced general practitioner. A session is defined as a block of at least 4 hours. (a) within 2 months of this decision, Dr Chowdhury is to nominate to the Board for the purpose of approval, an experienced general practitioner. (b) That within 3 months of Board approval of the experienced general practitioner, Dr Chowdhury is to spend a total of 10 sessions as an observer with his practitioner. (c) Dr Chowdhury is to provide a report detailing the dates when he attended, what he learnt and his plans for implementing changes to his practice based on his observations during the placement. Dr Chowdhury should make specific reference to the issues that were found by the Performance Review Panel to be below the standard reasonably expected of a practitioner of equivalent level of training or experience, but he should not restrict his report to addressing those issues. The specific issues are as follows: i Basic Clinical Skills ii Diagnostic/Problem-Solving Skills iii Patient Management Skills iv Interaction/Communication with patients v Medical Records (d) That within four weeks of the completion of the placement this report is then sent to the Board. (e) That Chowdhury give a copy of his report referred to in c. above to the approved practitioner. The approved practitioner is to write a report describing Dr Chowdhury's progress during this period of the observation period and to make written comments on the authenticity of the observations and observation dates recorded in Dr Chowdhury's report. (f) Dr Chowdhury is to authorise the approved practitioner to forward the approved practitioner's report to the Board within four weeks of the completion of the placement. (g) Dr Chowdhury is responsible for any costs incurred in relation to the period of observation and any subsequent report. 2. Thereafter, for a period of 6 months, Dr Chowdhury is to meet with the general practitioner referred to in condition 1 for at least one hour on a monthly basis ar Dr Chowdhury's practice. Those meetings should include, but not limited to, discussion of clinical issues relating to patient consultations that have occurred in the previous month. The record of these consultations should also be reviewed and discussed. Discussion should be in regard to the following: i Basic Clinical Skills ii Diagnostic/Problem-Solving Skills iii Patient Management Skills iv Interaction/Communication with patients v Medical Records (a) At each meeting the approved practitioner is required to complete a record of matters discussed at the meeting in a format which is approved by the Board. (b) Dr Chowdhury is to authorise the approved practitioner to forward to the Board, a report and copies of the records of each meeting. This is to occur at the end of the first three months and then again at the end of the second three month period. The report should describe Dr Chowdhury's overall clinical performance and is to be in a format approved by the NSW Medical Board. (c) Dr Chowdhury is responsible for any costs incurred in the monthly meetings, and any subsequent report. 3. That Dr Chowdhury attends all sessions of the Annual revision Seminar in February 2006 held by the RACGP, NSW Faculty, and within 2 months of the Seminar provides the Board with proof of his attendance. Dr Chowdhury is responsible for any costs incurred. 4. That Dr Chowdhury undertakes and completes all components of the Clinical Communication Program conducted by the Cognitive Instituted. Dr Chowdhury is to focus on having a two-way interaction by listening to all patients concerns and also is to focus on how he can better relay appropriate information to the patient. The Clinical Communication Program is conducted over six months and comprises three phases. Phase 1: Preparation and Goal-Setting to occur in the six weeks prior to Phase 2. Phase 2: Attend and participate in all sessions of the three-day residential workshop to be held 30 September 2005 – 2 October 2005 in Brisbane Queensland. Phase 3: Implementation and Mentoring. Dr Chowdhury is required to supply to the NSW Medical Board the following: i) Copy of the letter from Cognitive Institute confirming registration within two weeks of this decision. ii) Copy of Cognitive Institute Phase 1 and Workshop Progress Statements within one week of receipt. iii) Copy of Cognitive Institute Certificate detailing successful completion or otherwise of all program components within one week of receipt. Dr Chowdhury is responsible for ay costs incurred in participating in the Clinical Communication Program. 5. That Dr Chowdhury is to undertake and satisfactorily complete the Interactive Risk Management Program provided by his indemnity provider MDASA. (a) As part of this program Dr Chowdhury attend and successfully complete the Group Workshops being held in Sydney 8 October 2005. These workshops are 'Medical Notes', 'Failure to diagnose Medical-Legal issues' and 'dealing with Difficult Client Interactions'. (b) Within two weeks of this decision Dr Chowdhury is to supply to the Board a copy of a letter from his indemity provider acknowledging his registration in the program. (c) Within two weeks of completing the program Cr Chowdhury is to provide documentary evidence to the Medical Board that he has satisfactorily completed the program. (d) Dr Chowdhury is responsible for any costs incurred. 6. Pursuant to section 86O of the Act, no sooner than twelve months after the date of this decision, Dr Chowdhury's professional performance is to be reassessed. The form of the reassessment is at the discretion of the Performance Committee. 7. These conditions may be amended at the discretion of the Board or its Performance Committee. Annexure 2 Conditions imposed by Tribunal 1. The respondent is to spend a total of 10 observer sessions with an experienced general practitioner. A session is a block of least four hours. (a) Within two months of registration, the respondent is to nominate an experienced general practitioner to the Council for the purpose of obtaining Council approval that the practitioner is suitably experienced. The nominated practitioner must be prepared to report to the Council in accordance with 1 (d) and 2 (b) below. By nominating the practitioner, the respondent authorises him/her to report to the Council in accordance with 1 (d) and 2 (b). (b) Within three months of the Council approving the practitioner, the respondent is to undertake the 10 observer sessions. (c) Within four weeks of completing the 10 sessions, the respondent is to provide the Council with a report setting out the session dates, the lessons learned and the respondent's plans for implementing practice changes based on observations made during the sessions. The report is to refer to: i basic clinical skills ii diagnostic/problem-solving skills iii patient management skills iv interaction/communication with patients v medical records vi other lessons learned and plans for change (d) At the same time as the report is provided to the Council, a copy is to be provided to the experienced general practitioner, enabling the practitioner to provide the Council with a report on the respondent's progress and the authenticity of the respondent's report. The practitioner will report to the Council within one week of receiving the respondent's report. (e) The respondent is to meet any costs incurred by the practitioner in connection with this condition. 2. (a) For a period of six months after the tenth session, the respondent is to meet with the practitioner at least once a month for a period of at least one hour for the purpose of discussing clinical issues that have arisen in the respondent's practice during the preceding month. In the monthly meeting, the practitioner and the respondent are to review and discuss consultation records relevant to those clinical issues. Each meeting is to address: i basic clinical skills ii diagnostic/problem-solving skills iii patient management skills iv interaction/communication with patients v medical records (b) At the commencement of the six-month period, the Council is to provide the practitioner with a reporting format that includes reference to the respondent's overall clinical performance. During each monthly meeting, the practitioner is to make a record of the meeting in the format provided. Within one week of the third monthly meeting and the six monthly meeting, the practitioner is to furnish the Council with the records of the three preceding meetings. (c) The respondent is to meet any costs incurred by the practitioner in connection with this condition. 3. Following registration, the respondent is to attend all sessions of the next Annual Revision Seminar held by the RACGP, NSW Faculty. Within two weeks of Seminar completion, the respondent is to furnish the Council with proof of attendance. The respondent is to meet any costs incurred in connection with Seminar participation 4. The respondent is to complete the Clinical Communication Program conducted by the Cognitive Institute. Within one week of Program registration and within one week of completing each phase of the Program, the respondent is to furnish the Council with proof of registration/completion. The respondent is to meet any costs incurred in connection with Program participation. 5.The respondent is to undertake the first available Interactive Risk Management Program conducted through his indemnity provider, or an equivalent program (inter alia, dealing with medical notes, failure to diagnose/medico legal issues and difficult clinical interactions) that has the prior approval of the Council. Within one week of Program registration and within one week of Program completion, the respondent is to furnish the Council with proof of registration/completion. The respondent is to meet any costs incurred in connection with Program participation. 6. No sooner than twelve months after registration, the respondent's professional performance is to be reassessed at the discretion of the Council 7. For the purpose of ensuring that the respondent is adequately trained and skilled in the areas mentioned above, the Council may vary or delete any condition. Inter alia, if requested by the respondent, the Council may approve alternative programs, including programs that encompass observation and mentoring. Note: The Council may consider that the GP Synergy Re-entry Program constitutes an acceptable alternative to some or all of the above programs/ observation and mentoring conditions. 8. The Council is the appropriate review body for the purpose of review of the conditions. DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated.