Medical Tribunal New South Wales Medium Neutral Citation: Balafas v Medical Council of NSW [2013] NSWMT 4 Hearing dates: 18 and 19 March 2013 Decision date: 19 April 2013 Jurisdiction: Civil Before: Levy SC DCJ Dr E Kok Dr B Westmore Ms D Robinson Decision: See paragraphs [107] - [111] for orders. Catchwords: MEDICAL TRIBUNAL - application for review of earlier deregistration orders - whether case for reinstatement has been made out Legislation Cited: Medical Practice Act 1994, s 66 Health Practitioner Regulation National Law (NSW), s 125, s 126, s 127, s 163(2), s 163A and s 163B Cases Cited: Dinakar v Medical Council of NSW, unreported, 12 December 2012 HCCC v Balafas, unreported, 18 June 2010 Re Mansour Haider Zaidi [2006] NSWMT 6 Category: Principal judgment Parties: Mr John Andrew Balafas (Applicant) Medical Council (Respondent) Representation: Mr E Pike (Applicant) Ms K Richardson (Respondent) Browns (Applicant) IV Knight, Crown Solicitor (Respondent) File Number(s): 40023/12 Publication restriction: No REASONS FOR DECISION Table of Contents Application for reinstatement as a medical practitioner [1] - [3] Reasons for applicant's deregistration on 18 June 2010 [4] - [7] Issues [8] - [10] Principles to be applied on an application for reinstatement [11] - [12] Applicant's medical training and work history [13] - [17] Summary of events leading to applicant's deregistration [18] - [23] Disciplinary history leading to 2010 Medical Tribunal hearing [24] - [29] Complaints arising after deregistration [30] Overview of applicant's pursuit of rehabilitation [31] - [36] Evidence in support of application [37] - [88] Mr John Balafas - applicant [38] - [42] Dr Keith Roberts - treating psychiatrist [43] - [48] Dr Alex Wodak - treating addiction specialist [49] - [63] Dr Michel Diamond - consultant psychiatrist [64] - [82] Associate Prof Stephen Jurd - psychiatrist [83] - [85] Applicant's wife [86] - [88] Consideration of the issues [89] - [106] Orders [107] - [108] Practice conditions [109] Health conditions [110] Review conditions [111] Application for reinstatement as a medical practitioner 1This Tribunal was convened to consider an application for review and reinstatement pursuant to s 163(2), s 163A and s 163B of the Health Practitioner Regulation National Law (NSW) ["the National Law"], by Mr John Andrew Balafas, a former general medical practitioner, who was deregistered on 18 June 2010 by order of a differently constituted Medical Tribunal. 2The applicant's registration history, and the chronology of the conditions that were imposed on his practice, before he was deregistered, are fully set out in the Annexure to these reasons in the form of an evidentiary certificate of the applicant's registration history issued by the Medical Council of NSW ["the Council"] pursuant to s 244A of the National Law. 3In the present application, the Council took the position that it neither consented to nor opposed reinstatement of the applicant, but in the event of the present Tribunal making an order recommending reinstatement, it sought that stringent conditions be applied to the applicant's future practice arrangements. Reasons for deregistration of applicant on 18 June 2010 4At the time the formerly constituted Tribunal ordered that the applicant be deregistered, it also ordered that there be no application by him for the review of that order until a minimum period of 2 years had elapsed from the time when that order was made. In making those orders, the former Tribunal made a series of adverse findings against the applicant. Those findings may be essentially summarised as follows. 5The former Tribunal did not accept the applicant as a reliable witness regarding the explanations surrounding his illicit use of Pethidine and Fentanyl whilst he was addicted to those substances. The former Tribunal also concluded that the applicant had given some differing and irreconcilable accounts of his level of his use of alcohol since 2007, and therefore did not accept his evidence in that regard. The former Tribunal also concluded that the applicant had given an untruthful explanation concerning his use of the drug Stilnox. The former Tribunal also noted that it considered the applicant to have given the Medical Board non-genuine assurances concerning the management of his addiction and his addictive behaviour. 6In the reasons for its decision, the former Tribunal set out in some detail the chronology of the circumstances of the applicant's deceptive behaviours that led to his deregistration. In these reasons it is not necessary to reiterate the full detail of that chronology, which is on the public record: HCCC v Balafas, unreported, 18 June 2010 [http://www.mcnsw.org.au/page/doctors--performance--conduct---health/professional-conduct-/hearings-and-decisions/decisions/medical-tribunal-decisions-index/medical-tribunal-decisions-2010/; pages 3 -14]. 7In ordering deregistration of the applicant, the former Tribunal determined that it did not place much weight on the applicant's proffered expressions of remorse for his conduct that was then in question. It concluded he was an unreliable witness. The former Tribunal went on to record the finding that the applicant had failed to provide a fully frank and honest account of relevant events. For those reasons, the former Tribunal concluded that at the time of its decision, the applicant was not fit to practise the profession of medicine. Issues 8In his present application before this Tribunal, the applicant has accepted the correctness of the findings arrived at by the former Tribunal. On behalf of the applicant it was acknowledged that in view of the adverse credit findings made against him by the former Tribunal, the applicant faced a high barrier to reinstatement. 9The essential question is whether the conduct the former Tribunal described as "acts of grave dishonesty" perpetrated by the applicant, and which led to his deregistration in 2010, have been overcome by a shift in his character sufficient to justify the conclusion that those defects in character are no longer suffered by the applicant. 10The Tribunal, as presently constituted, is required to determine whether, on the evidence before it, the applicant has discharged the heavy onus that an applicant carries in such circumstances to demonstrate, accepting and notwithstanding the findings of the former Tribunal, that he now has sufficient insight into his former addictions to drugs and alcohol and related behaviours, and has sufficiently reformed his character to enable this Tribunal to reasonably conclude, with the paramount consideration of the protection of the public in mind, that he could be safely permitted to be reinstated as a medical practitioner. Principles to be applied on an application for reinstatement 11The principles to be applied in an application for reinstatement have been identified in numerous decisions in the Medical Tribunal, for example, Re Mansour Haider Zaidi [2006] NSWMT 6, and more recently in Dinakar v Medical Council of NSW, unreported, 12 December 2012 [http://www.mcnsw.org.au/resources/1309/Dinakar,%20Rajesh%20121212.pdf]. 12Essentially, these principles provide that an applicant for reinstatement must demonstrate a reformation of character such that patients and colleagues can confidently expect that if reinstated, the practitioner would resume the position of trust expected of a medical practitioner as a member of an honourable profession by demonstration of the characteristics of a fit and proper person currently entitled to membership of that profession: Zaidi, at [42]. Applicant's medical training and work history 13The applicant is presently aged 39 years. He graduated from the University of Sydney in 2000 with the degrees MBBS BSc(Med). Significantly, in the view of this Tribunal, in his early post-graduate years of training, he did not pursue work in the traditional pathways that young medical graduates commonly undertook for training in preparation for general practice. 14Between 2000 to 2001 the applicant fulfilled the formal requirements of his internship and residency training years at Bankstown and Royal Prince Alfred Hospitals. Subsequently, through his employment with the company Oz Locums, he carried out contract work in the accident and emergency departments at Hornsby, Ryde and Mona Vale Hospitals. In 2002 he worked for an after hours medical service, making house calls in the eastern suburbs of Sydney. 15Between 2003 to 2004 the applicant worked for a clinic described as Total Health Screening ["THS"] in Bondi Junction. That clinic offered non-therapeutic elective screening services and CT scanning services. Between 2004 to 2009 he worked for a company known as Advanced Medical Institute ["AMI"], in the field of men's health, providing advice and treatment for erectile dysfunction. Neither of those employment situations involved general medical practice in the traditional and commonly accepted sense. 16In 2008, the applicant obtained his Fellowship of the Royal Australian College of General Practitioners by passing an entrance examination and on the basis of his accumulated work experience with THS and AMI to that time. 17Between 2009 and 2010, until he was deregistered, the applicant worked as a general practitioner at the Bondi Medical Centre, a practice that he owned and currently still owns. Since becoming deregistered, he has worked as the Practice Manager in that practice, which presently employs up to 5 general practitioners. There is no suggestion that this practice is other than properly managed. Summary of events leading to applicant's deregistration 18The events that led to the applicant's deregistration are set out in detail in the reasons for decision of the previously constituted Medical Tribunal. The brief summary that follows is sufficient for present purposes. 19In 2004, the applicant started along the path of inappropriate personal use of Pethidine and then alcohol, and he then proceeded to conceal such activities. That course initially involved impulse on his part, but later developed into a compulsion to continue, and involved some elaborate planning on his part. 20The applicant's hindsight explanations for those events traversed matters such as a stressful upbringing where significant family pressures were brought to bear on him to achieve material success at an early stage. He found his residency period, which involved much night shift work, very difficult. For example, at one time he had worked 20 nights in a row. He felt that his time as a resident medical officer had left him without a clear sense of career direction. He was initially unsuccessful in gaining a place in the training scheme to become a general practitioner. This led him to take on even more night shift work in locum positions in public hospitals. His long working hours led to him becoming lonely and socially isolated. 21After moving to employment with THS and AMI, an opportunity arose for the applicant to invest as a financial partner in a general practice in Bondi. He took on large debts in order to do so. At that time he concurrently worked 5 days per week at AMI and he also spent nights and weekends over a period of about 6 weeks working with his father, a builder, in fitting out the premises for the Bondi practice. He found that in this period he had become physically and mentally debilitated. 22In a misguided endeavour to cope with those stresses, the applicant showed poor judgment by commencing the illicit use of Pethidine, which he inappropriately obtained from his doctor's bag. Surrounding those events, he also encountered difficulties in his business partnership. In order to try and resolve those difficulties he incurred further financial liabilities when he found that it had become necessary for him to buy out the interests of his business partner. These events proved to be very stressful for him. In that period he immersed himself in work to try and accumulate as much in the way of funds as he could in order to try and manage his situation. In these events he gave himself little or no time to reflect upon how he should develop his professional career. These circumstances fuelled his drug abuse. 23Between 2004 and 2005 the applicant ill-advisedly commenced writing prescriptions for Pethidine for his own use. He did so in a period when he was continuing to labour under heavy financial obligations in connection with his Bondi practice. This involved him working extra hours for AMI. His actions concerning the inappropriate prescriptions for Pethidine, were inevitably discovered by the Pharmaceutical Services Branch of the Department of Health (as it was then known), and this led to a chain of adverse disciplinary consequences for him, including from the evolving circumstances in which he sought to conceal his illicit use of prescription drugs. Disciplinary history leading to 2010 Medical Tribunal hearing 24After the applicant's illicit use of Pethidine was discovered, his licence to prescribe Schedule 8 drugs was withdrawn and the Medical Board then referred him to the Impaired Registrant's Programme. Despite the considerable supports afforded to him by that programme, in May 2005, he resumed abusing Pethidine. This resulted in a disciplinary hearing being convened under s 66 of the former Medical Practice Act 1994. That hearing resulted in the applicant's suspension from practice between 31 May and 1 August 2005. The applicant blames the relapse which led to that suspension on his pressured financial and working circumstances that then prevailed. 25After his initial suspension was lifted, on resuming practice on 2 August 2005, the applicant was subject to a number of stringently imposed practice and health conditions which are fully set out in the Annexure to these reasons. Those conditions, which related to the applicant's prescribing authority for Schedule 8 drugs, his need for supervision, his working conditions, his need for ongoing drug testing and treatment for recovery from his addictions, were imposed to assist him with his rehabilitation, but were primarily aimed at protecting the public. 26In the context of difficulties with compliance with those conditions, and as a result of various determinations made by the Board, in the period 2 August 2006 to 20 March 2008, those conditions were from time to time varied. 27On 20 March 2008 the applicant was again suspended from practice, this time for one month, due to problematic compliance with practice conditions. On 8 April 2008 his registration was again reinstated subject to the second tranche of stringent conditions set out in the Annexure which related to his reinstatement at that time. Those conditions were also subsequently varied by the Board from time to time up until the previous Medical Tribunal hearing which ultimately resulted in the applicant's deregistration from practice on 18 June 2010. 28In explaining his acknowledged past conduct lapses, the applicant stated that he had fully intended to cease his use of Pethidine but he had relapsed from his partial recovery at that earlier time. He said he started using Pethidine again because of his stressful working circumstances and financial pressures, which included the significant stress of financially subsidising a not yet financially viable practice. He had worked without adequate breaks. At the same time he was planning a major home renovation and had overloaded himself with tasks and responsibilities without giving proper attention to focussing and working upon his recovery. His judgment as to his welfare and responsibilities had become seriously clouded by his addictive behaviours, which by then, related to the hazardous use of both drugs and alcohol. 29All of these factors impacted on the applicant's judgment and upon the furtherance of his misguided addictive behaviours which inevitably led to his deregistration. Complaints arising after deregistration 30In accordance with the Council's obligations arising under s 163C(3) of the National Law, the Council tendered a bundle of material relating to a number of other complaints against the applicant that had come to light relating to the period 18 April 2007 and 18 January 2010: Exhibit "3". An examination of that exhibit revealed that a number of those matters were either discontinued as complaints or were not proceeded with. On evaluating that material it was plain that the requirements of procedural fairness and the timing of those complaints, which pre-dated the applicant's deregistration on 18 June 2010, indicate diminished weight and little probative value should be given to the bundle of material comprising Exhibit "3". Overview of applicant's pursuit of rehabilitation 31Deregistration has had a salutary effect on the applicant. The circumstances imposed on him by his deregistration forced him to undertake a reassessment of his life's circumstances. He ceased drinking alcohol as he recognised this was the key to his recovery from addiction. 32Before ceasing to take alcohol he had been using it sporadically. This involved him consuming up to one bottle of wine late at night, which he acknowledged had placed his patients at risk the day following such use. 33He attended regular consultations with Dr Wodak and Dr Roberts at approximately 6 week intervals. He has also attended weekly meetings of a group called Doctors in Recovery at the Northside Clinic. He also attended weekly meetings of Alcoholics Anonymous. During 2011 and 2012, he also assisted in setting up a group called Nurses in Recovery aimed at assisting health professionals other than medical practitioners, to deal with their addictions. 34The applicant has also sought out a sponsor who is a medical practitioner with a background of training in mental health, and he has maintained a close contact with that doctor for several years. This has assisted his motivation to maintain recovery from his addictions. He consults this sponsor as a mentor to discuss personal decisions of importance. He has also become a sponsor to another participant in the recovery group. 35Since September 2010, the applicant has undertaken thrice weekly urine drug testing at an accredited pathology laboratory which adheres to Medical Council protocols for such tests. He also attends the same pathology laboratory for monthly blood tests for Carbohydrate Deficient Transferrin ["CDT"] aimed at detecting hazardous use of alcohol. These tests have also been carried out with strict adherence to Medical Council protocols. The results of those tests over an extended period of over 2 years indicate that there have been no detected lapses in compliance with the testing protocols and no detected substance use or abuse. 36The applicant has also sought out appropriate advice and mentorship, and he has utilised opportunities to attend conferences, academic days and other occasions aimed at assisting in dealing with drug and alcohol addiction. Evidence in support of the application 37In support of his application for reinstatement, in addition to his own evidence, the applicant relied upon evidence from Dr Keith Roberts, his treating psychiatrist, Dr Alex Wodak a specialist in drug and alcohol issues, and Dr Michael Diamond, a consultant psychiatrist who has examined him on a number of occasions at the request of the Medical Council. In addition to the tender of some testimonials, the applicant also relied upon a letter from Associate Professor Stephen Jurd, a consultant psychiatrist in the field of drug and alcohol medicine. That evidence was augmented by the serial and extensive results of objective pathology testing. A statement from the applicant's wife, Ms Kate Klunder, was also tendered. In the paragraphs that follow, we review that opinion and factual evidence, none of which was challenged. Evidence of Mr John Balafas - the applicant 38In these proceedings, the applicant expressed his shame at his former behaviours whilst addicted to drugs and alcohol. He also acknowledged the depths of planning, lies and deceptions to which he had resorted in order to conceal his pursuit of those former behaviours. He also acknowledged that as a result of those former addictions and the related perpetuating behaviours, he has lost many things valuable to him, both tangible and intangible, including his credibility as a person, and as a member of a respected profession. 39The applicant has had to endure the public humiliation of having his evidence tested by embarrassing questions about his past conduct that had led to his deregistration. He acknowledged having abused his professional position in 2007 by obtaining Pethidine from a wholesale source, and of having manipulated his circumstances, also in 2007, to obtain access to Stilnox, and having taken steps to evade detection of his use of Stilnox. 40In accepting and coming to terms with the previous findings made against him in 2010, the applicant has put himself forward as a much changed and reformed person from his former ways that brought him to adverse attention and deregistration. He now claims his personal values are very different, and he wants not only to conduct himself in the right way, but to restore his credibility and to resume a position of professional usefulness in society. He claims that he is no longer subject to the stresses and pressures, including family pressures that led to his former addictive behaviours and misconduct. 41The applicant also accepts that his recovery from his "very, very severe dependency" nevertheless continues to carry with it the risk of relapse, especially in the face of stressful circumstances. He points to a claimed change in his character and a change in how he now conducts himself, with humility, openness, frankness and honesty. He argued that the risk of a relapse into his former addictions is remote in his new circumstances. In this regard, he points to a different and healthier relationship he has with his parents, the fact that his wife will be running the business side of the practice which he owns, his now stable circumstances, and the absence of other family involvement in his practice, taken together with his pattern of pathology testing showing he is free from drug use. He also points to his pattern of attendance at appropriate professional consultations and supportive recovery groups as indications of the unlikelihood of relapse on his part. He has stated that he intends never to take alcohol again. 42The applicant claims he now has appropriate insight into his former circumstances and claims he has achieved a state of fitness to practise. He recognises that if he were to be reinstated, he would have to abide by a pattern of stringent practice and health conditions. He also indicated an acceptance of the guidance offered by such conditions as he is dedicated to returning to the practise of medicine and to helping others. He feels his period of deregistration, and the resultant events he has gone through in the ensuing period, will make him a better and more compassionate doctor. Evidence of Dr Keith Roberts - treating psychiatrist 43The applicant tendered a report dated 26 March 2012 from his treating psychiatrist, Dr Keith Roberts, whom he had been seeing at approximately monthly intervals since 2004. In his opinion, Dr Roberts concluded that since his deregistration, the applicant appeared to have been taking the requirements of the Medical Board far more seriously and in greater detail than had been the case in previous years. 44That statement by Dr Roberts was something of a misnomer, because the Board, and its successor, the Medical Council, had no formal requirements of the applicant once he was deregistered on 18 June 2010. Any such matters pursued by the applicant since his deregistration were therefore necessarily voluntarily self-imposed requirements, albeit in compliance with Council protocols, and undoubtedly aimed at obtaining evidence to secure a finding of fitness to practise. 45Dr Roberts made reference to the applicant's prior dishonest conduct where, in previous years, the applicant had succeeded in his efforts at misleading Dr Roberts and other doctors with regard to the nature and extent of his abuse of drugs and alcohol. 46In contrast to that conduct, on his review of the applicant's circumstances, Dr Roberts concluded that he was of the opinion the applicant had undergone a significant level of rehabilitation. At the time of writing his report, he stated that the applicant was physically and mentally well, without any psychiatric condition being evident. Dr Roberts was of the view that the applicant had also shown a greater level of insight into the problems that had led to his deregistration, and had shown remorse for his previous unacceptable behaviour. Dr Roberts recorded that the applicant had acknowledged to him, that he had previously exhibited poor professional judgment, in that his prior behaviours had transgressed the required medical and ethical codes. 47Against that background, with a significant qualification, Dr Roberts expressed the opinion that the applicant had achieved a reformation of his character to a degree such that it would be appropriate that he be returned to the Medical Register. The qualification expressed by Dr Roberts was that the applicant and his doctors should not be complacent about the future of the applicant's situation, and that the applicant would require continuing assessments for a period of time, including by himself as the treating psychiatrist, Dr Wodak or his successor, and a Council nominated psychiatrist. 48Dr Roberts was not required for cross-examination on the content of his opinions. His opinions remained unchallenged albeit that they were expressed as at 26 February 2012. No adverse comment was made by the Medical Council concerning the fact that there were no further reports from Dr Roberts covering the 12 month period between March 2012 and March 2013. Evidence of Dr Alex Wodak - treating drug and alcohol addiction specialist 49The applicant tendered and relied upon a report dated 6 August 2012 from Dr Alex Wodak, an eminent consultant in Drug and Alcohol Medicine. Dr Wodak also gave oral evidence in which he explained aspects of his report. 50The applicant has been a patient of Dr Wodak from 2005 until the present time for treatment of his drug and alcohol problems. His appointments with Dr Wodak have been at intervals of approximately 6 weeks. Dr Wodak has monitored the applicant's progress over that time and has given him encouragement and support in overcoming the difficulties he has encountered with his addictions. 51Dr Wodak recorded the applicant's expressions of shame and remorse at having in the past been untruthful and deceitful concerning his disclosures of the nature and extent, and his lack of control, of his addictions. He also expressed the opinion that since his deregistration, the applicant has now achieved good insight into his problems in that regard. 52Dr Wodak expressed the opinion that the applicant had overcome his problems with addiction by changing his life and his values such that he is now a much changed person, including in his general outlook. Dr Wodak described the applicant as now being more thoughtful, serious and mature individual compared to his former situation. Although Dr Wodak acknowledged that the applicant's problems with addiction involved what is accepted and understood to be a relapsing-remitting condition, he said he did not expect any further relapses or problems in that regard. He confidently considered that the risk of relapse by the applicant was now very low. 53Dr Wodak considered that the personal, professional, community, and family resources that had been engaged in order to effect a change in the applicant's former behaviours and outlook have resulted in the applicant, slowly but surely, coming to grips with his former addiction behaviour difficulties. He concluded that the applicant had learned from the salutary experience of his deregistration, and now had a prognosis for being an excellent and safe doctor. 54Given that the applicant had in the past succeeded in manipulating and deceiving his doctors, including Dr Wodak, as to the true status of his addictions, the Tribunal initially viewed the optimism expressed in Dr Wodak's report with some caution. However, on weighing the relevant considerations, the Tribunal is of the view those misgivings have been adequately addressed in the form of the objective results of pathology tests which have confirmed that the applicant has continued to abstain from the use of mood altering drugs and alcohol, and through the additional matters raised by Dr Wodak in his explanatory oral evidence, which is reviewed as follows. 55In his oral evidence, Dr Wodak expanded upon some of the more cautiously expressed remarks that he had set out in his report as summarised above. The Tribunal found Dr Wodak's oral evidence persuasive. 56In that evidence, Dr Wodak acknowledged that a fundamental question concerning the fitness of the applicant to practise, after the question of character, was whether the applicant was likely to be a safe doctor. 57In that regard, he observed what he described as the occurrence of a complete and astonishing change in the applicant's outlook. He also observed that in his view, the risk of the applicant having a relapse to his prior behaviours has receded considerably with the passage of time as the applicant's past illicit attachment to the use of drugs and alcohol has continued to remain absent over the years that have passed since his deregistration. 58Dr Wodak was asked to consider the character-related question of whether, given the applicant's past dishonest conduct in misleading and deceiving his treating and assessing doctors, including Dr Wodak himself, that such deceptive behaviours could possibly be a continuing phenomenon, as an extension of the previously misleading behaviours that had been exposed. In that regard, Dr Wodak was of the opinion that the contrary proposition was compelling. 59The factors which Dr Wodak drew upon for the view that the applicant is a much changed individual were first, the consistency of the pattern of negative blood results and the results of the urinalysis of samples taken under appropriate supervision over two and-a-half years, secondly, the applicant's pursuit of further studies in the nature of professional development, thirdly, his diligence in other areas, which included voluntary activity in the community amongst the disadvantaged, fourthly, the realisation of how damaging alcohol and drug problems can be, fifthly, the setting up by the applicant of a clinic for drug and alcohol dependent nurses, sixthly, his active involvement in Alcoholics Anonymous and Narcotics Anonymous groups, and seventhly, the applicant's active participation in a recovery group for impaired doctors. Dr Wodak also pointed to the significant positive impact of the applicant's marriage subsequent to his deregistration, and the ongoing positive influence on him of his wife, as further important factors. 60Dr Wodak was of the view that when those matters were considered as a whole, together with the applicant's realisation of the significant monetary and other losses that have flowed from his deregistration in 2010, this provided him with compelling evidence that the applicant was a much changed individual compared to how he had formerly conducted himself, including the observation that previously, the applicant had been at near psychological breaking point. 61The expanded explanations within Dr Wodak's oral evidence have provided the Tribunal with a helpful and objective guide to the assessment of the applicant's evidence as to his changed ways. We accept his evidence concerning the matters upon which he has expressed opinions. 62Dr Wodak pointed to the truism that drug and alcohol dependent persons with severe substance dependence were commonly untruthful about relating the detail of such matters. Significantly, he also pointed to the commonly accepted view that the longer the duration of the interval of time over which the individual was free of such dependencies, the more truthful they were likely to be about their past behaviours. On the strength of Dr Wodak's evidence, when taken together with the opinions of the other psychiatrists whose reports were tendered, the Tribunal is comfortably satisfied that this is now the position with regard to the applicant's present circumstances. 63However, those matters accepted, Dr Wodak emphasised that if the applicant were to be reinstated, there would be a need for appropriate conditions to be imposed on the applicant's future practice and conduct. Evidence of Dr Michael Diamond - consultant psychiatrist 64Over the period between 3 June 2005 and 18 June 2010, the applicant was assessed on a number of occasions by Dr Michael Diamond, a consultant psychiatrist appointed by the Medical Board, and its successor the Medical Council. On those occasions Dr Diamond saw the applicant in his capacity as the Board-nominated psychiatrist. Dr Diamond had periodically forwarded his reports to the Medical Board following his assessments of the applicant in respect of those reviews. In these proceedings, neither party sought to tender any of Dr Diamond's sequential historical reports that arose from that process. However, Dr Diamond obviously drew upon that material in preparing his opinion which was tendered in these proceedings. 65On 19 October 2012, for the purposes of obtaining Dr Diamond's evidence to be placed before the Tribunal in respect of this application, and as a prelude to the preparation of his report dated 7 November 2012, the respondent arranged for Dr Diamond to reassess the applicant. 66On behalf of the respondent, Dr Diamond was asked to review the material assembled by and on behalf of the applicant in support of his present application. In his report, Dr Diamond summed up the applicant's pre-application status in the following terms: "After graduating MBBS from the University of NSW in 2000, he was granted full registration in NSW on 14 February 2001. By March 2004 he was known to be abusing pethidine and by May 2005 he was suspended from practising medicine because of his ongoing, untreated substance abuse disorder. From that date until the Tribunal's decision of 18 June 2010 when he was deregistered, he was either suspended from practising, or practising with conditions upon his registration. In a relatively brief medical career, Mr Balafas has practised medicine with an obvious need for supervision, accountability and review by the registration body. I refer to comments in my report to the New South Wales Medical Board of 26 February 2008 (which formed part of the body of evidence at the Medical Tribunal of 2010). On page 2 of the report, I commented as follows: "We spoke about his medical career generally and how he had come to be working in this particular way. It was apparent that he made these decisions without any advice or mentoring about his career. His experiences as an intern at a major teaching hospital were unsatisfactory overall. He discovered that he could work better hours, in a more conducive environment, by doing shifts at emergency rooms rather than working fully within the hospital system. From there he went into a medical practice doing general screening of patients and thereafter to AMI. He found that his work at AMI provided him with a pathway to Fellowship of the RACGP and he persevered in that environment." These comments are relevant in that Mr Balafas has practised medicine in an unusual manner during his relatively short medical career. His concepts about professional responsibility, professional standards and professional ethics were undeveloped. What supervision he has had was within the context of an unusually narrow range of general practice activities (men's sexual health clinic) and sometimes by individuals who have worked as employees in the medical centre that he owns. More recently, Mr Balafas has completed his Fellowship of the Royal Australian College of General Practitioners. He has also in the latter part of his career to date, broadened the scope of his medical practice. Overall, Mr Balafas is a medical practitioner who is not well integrated into a peer cohort. His predicament is affected by a number of important factors. The first of these has to do with long term anxiety within a peer group. Over the years he has spoken about anxiety in social situations. He has described feeling vulnerable when he compares himself to his medical peers and to his friends socially. He has evidence of low self esteem that underpins a former need to boost his social standing. The experience of deregistration accompanied by deep feelings of shame and humiliation have affected him adversely. He is self-conscious amongst his colleagues generally. He is very keen to feel accepted and to be free of feelings of shame and guilt. This emerged in the course of my interview with him, as will be described later. My knowledge of these psychological vulnerabilities existed before I saw him most recently." 67When Dr Diamond examined the applicant in October 2012 he reviewed the applicant's general history, his work, his other activities, and his professional and personal relationships that had developed since he had been deregistered. In his review, Dr Diamond observed that the applicant had in the past failed to address his problems in sufficient depth, which had led to issues of compliance with his conditions of practice, and which in turn had led to his deregistration. Dr Diamond reviewed a number of factors that were influential on the maintenance of the applicant's former problematic circumstances. 68Those former circumstances concerned the applicant involving himself deeply in social activities, attending clubs and licensed premises, drinking alcohol to excess, and being hyper-focussed on financial and material success. He acknowledged this was in part due to the work ethic of his Greek family background, including his need for parental approval by being seen to have been successful, and where his parents, and particularly his mother's intrusiveness and insistence, had dominated his own opinions. 69Those background forces had blindsided the applicant to the significance of his participation in aspects of the AMI practice which he now concedes to have been not good medical practice, notwithstanding that hindsight has revealed, those practices to have been taken into account for the purposes of the applicant obtaining RACGP accreditation. 70Dr Diamond was satisfied that the applicant now recognised the problematic nature of those circumstances, and that he had now substantially changed his attitudes and now realised that success and wealth was not the central focus, and that his own happiness and having happy relationships was more important for him. These realisations had made him focus less on his own insecurities and made him feel less socially uncomfortable, compared to his previous circumstances. 71In his most recent examination of the applicant, Dr Diamond took him to the following crucial matters: "I asked him to comment about the role of alcohol in his life currently. He said he no longer drank at all. He referred to his CDT testing and the fact that all of the results were below the cut-off level. I commented that this was a test to identify hazardous drinking rather than abstinence from alcohol. He accepted that that was the case. I asked him whether the alcohol was in any way tied into his patterns of narcotic abuse. He said the abuse of alcohol was quite separate from his narcotic abuse. The alcohol assisted him to feel more comfortable when he was socialising. The role of alcohol was more important for him within the particular lifestyle. He commented that his life was now quite different. His social relationships currently were with people who accepted him as an addict in recovery. He no longer had to keep up with a peer group who intimidated him. I took him through the detail of the Medical Tribunal Judgment of June 2010. He was distressed to have to face up to the extent of his misconduct. The judgment forced him to look at his misconduct in its totality. I questioned him about his credibility in the face of the Tribunal Judgment that systematically outlined the extent of his deception and lies to treating practitioners, to the Medical Board at the time and its representatives, which included me. We spoke about the destruction of his credibility and the implications that this had when forming a view about his character. His response was notable. It appeared to me that he had not addressed these issues in sufficient depth previously. He appeared taken aback by the line of questioning. It appeared that he was not able to reflect on these matters in depth." 72In his oral evidence, at T112.30 to T113.5, Dr Diamond clarified the last cited comments in the preceding extract and he explained that comment as being descriptive of past events, indicating that the applicant had been slow to appreciate the damage that he had been doing to his own credibility. 73Dr Diamond's examination of the applicant's mental state revealed no matters of concern. He remarked that there was no evidence of disturbed perception or disordered thought processes. He presented as an intelligent and competent individual with a normal and appropriate affect, ranging from a normal level of anxiety about the process of the interview, to tearfulness at times, and to also showing a sense of humour. Importantly, in the view of Dr Diamond, the applicant had demonstrated a basic understanding of his predicament. Dr Diamond was satisfied that the serial results of urinary drug screening tests demonstrated that the applicant was not using prohibited substances. 74Dr Diamond was asked to address the crucial question of whether the applicant has gained genuine insight into the inappropriate nature of his conduct which resulted in his deregistration, including his past attempts to lie to and to deceive others about his drug and alcohol use. In response to this question, Dr Diamond stated: "This is a complex question consisting of a number of points that require comment individually. As a general comment, the gaining of insight occurs progressively in its depth and in its meaning. For Mr Balafas, his insight arises primarily because of the consequences that have followed his misconduct. In this way, he has had to face the full extent of his misconduct and has had to confront the full implication of deregistration that is different from his previous experiences of suspension from practice and of having to practise with conditions on his registration. The time period of his deregistration has forced him to confront practical realities impacting directly upon his financial responsibilities, his fears of losing his ability to maintain his home ownership and to ensure that his business remained viable. On a personal level, he was confronted by the severe and unequivocal comments about him in the Tribunal Judgment. He is aware that the Judgment is on the public record. He has experienced shame, humiliation and regret. This has occurred at many levels such as when patients had visited the medical centre and asked him why he is unable to practise, it has occurred when he has attempted to attend medical meetings and sees people who know him, and it has occurred more generally in the course of his relationships with family members and with others in social settings. The insight gained as a result of facing up to consequences of his misconduct has evolved because it was inescapable. Mr Balafas has further gained insight into his understanding of the extent of his drug and alcohol use. Once again this has occurred primarily as a result of having to face the full extent of his addiction and substance abuse as it was exposed in toto in the Medical Tribunal proceedings. This insight is in contrast with degrees of denial, rationalisation and compartmentalisation processes that, precluded him from acknowledging and accepting the full implication of his addiction and substance abuse in the past. A further relevant aspect of insight concerns his increasing awareness of his underlying psychological vulnerabilities that, in my opinion, form a significant part to the development of his addiction and substance abuse disorders. These vulnerabilities concern his longstanding low self-esteem and social anxiety. He is gaining a deeper understanding of the overriding needs he had in the past to attempt to keep up with and impress a peer group, to try to live out the expectations of his parents and to set himself difficult or even impossible goals with regard to personal and career achievements. He has developed insight and clarity into these issues over the years. It appears to me that he is uncomfortable to acknowledge or to address these issues directly but he now has awareness of their relevance in driving him to conduct himself in dysfunctional and aberrant ways that have been part of the evolution of his addiction and substance abuse in the past. In my view, this process still has some way to go in terms of a need for ongoing treatment and therapy. My reason for making this point is that these "vulnerabilities are the likely underpinnings to the unacceptable and dysfunctional conduct that was evidenced in his dishonest, deceptive and destructive conduct that has resulted in destruction of his credibility before the Medical Tribunal. These elements of his values and conduct underpin the significant impairment of character that was so clearly commented upon in the Judgment of the Medical Tribunal. When I saw him most recently, it was the superficiality of his understanding and acknowledgment of these features that demonstrated to me the need for ongoing development of "genuine insight into the inappropriate nature of his conduct which resulted in him being deregistered". I have provided a detailed answer to this complex question. It is my attempt to highlight the different aspects to the development of insight and hopefully to assist the Tribunal in coming to a view as to the extent of the insight shown by Mr Balafas sufficient for him to be seen as a man whose character has changed sufficient for him to be considered for registration as a medical practitioner. In my view, Mr Balafas has developed incomplete but sufficient insight for him to be considered for registration as a medical practitioner." 75Dr Diamond was of the opinion that the applicant had, by the time of his most recent reviews, developed strategies to overcome his addiction that are consistent with the recovery process. He was of the view that the applicant's recovery has been achieved with the assistance of the expert treatment he had received. This was a reference to the applicant's treatment by Dr Wodak and Dr Roberts. 76Dr Diamond also concluded that the many changes in the applicant's psychosocial environment (including the positive effects on him of marriage, and the more settled relationship he has with his parents, the less competitive peer environment, and the applicant's former and related pursuit of material assets) are likely to enhance the chances of the applicant maintaining his recovery from his addictions. 77Dr Diamond agreed with the view expressed by Dr Wodak to the effect that the identified conditions of drug and alcohol abuse are essentially relapsing conditions. He stated that notwithstanding the history of the applicant's stormy and unduly prolonged introductory phase of the recovery process, the consensus amongst those who have treated the applicant was that the applicant has in fact achieved the point where the recovery process has been consolidated. 78Dr Diamond also referred to previous untrue statements made by the applicant concerning his drug and alcohol abuse. In that context he noted that the currently expressed view was that the applicant had reached a state of recovery and this was supported by credible objective evidence comprising urinary drug screening to exclude illicit drug use, and blood screening to exclude hazardous drinking patterns. On balance, Dr Diamond therefore accepted that there was support for the views held by the treating practitioners that the applicant has achieved a state of recovery. 79Dr Diamond expressed his conclusions in the following terms: "A return to practice for Mr Balafas would, in my opinion, be likely to lessen the risk and stressors that operate on him at present. His key vulnerabilities are those that arise because of his inability to practise and assert himself as a medical practitioner. They arise because of his financial stress and his inability to use his skills to provide for himself and his family adequately. He is further stressed by the public shame and humiliation that accompany his current predicament. By returning to medical practice, my view is that Mr Balafas would be in a more settled and composed state. I hold this view with some reservation, however. My reservation concerns the requirement for Mr Balafas to practise medicine in a properly supported environment. This will require total compliance with practice conditions that are described below. In essence, Mr Balafas should not be exposed to unconventional, inappropriate or narrow forms of medical practice that could place him under additional stress. He would benefit from a collegiate environment. He requires supervision of the quality of his practice as a relatively inexperienced medical practitioner, albeit as a Fellow of the Royal Australian College of General Practitioners. In addition he would benefit from mentorship from a recognized established senior general practitioner who could help him make up for the obvious deficiencies he has demonstrated to date with regard to his understanding of medical responsibilities, medical ethics, scope of medical practice as a general practitioner and development of sound work-lifestyle balance principles. It is these features of his previous attempts at successful practice that may well have underpinned the emotional stressors that contributed to the development of addictive illness so early in his medical career." 80In his oral evidence, Dr Diamond addressed the question of whether the applicant's expression of apology to him for his past deceptions were considered by him to have been sincere and indicative of the applicant having faced up to his prior shortcomings. Dr Diamond accepted that those apologies were sincere. 81In his oral evidence, Dr Diamond emphasised that the applicant had taken longer than it should have taken for him to have reached a point of recognition that he should have previously complied with practice and personal conduct conditions that the Medical Board had imposed upon him. However, Dr Diamond was of the view that the point has now been reached where the applicant had achieved and met the requisite degree of insight into his past behaviours. 82In expressing the above views, Dr Diamond also addressed some practical matters as to the appropriate conditions that he considered should apply if the Tribunal considered that the applicant should be permitted to return to practise. The Tribunal has been strongly influenced by Dr Diamond's persuasive views in that regard. Evidence of Associate Professor Stephen Jurd - psychiatrist 83The applicant tendered a letter dated 2 October 2012 from Clinical Associate Professor Stephen Jurd, who is a specialist psychiatrist with expertise in the management and treatment of drug and alcohol addiction. In his letter, Prof Jurd acknowledged his awareness of the former Tribunal's findings concerning the applicant's previous elaborate levels of deception in order to illicitly obtain access to drugs and to deny his use of drugs, and the applicant's attempts to avoid the consequences of that behaviour. 84Prof Jurd gave consideration to the applicant's increasing level of commitment to his involvement with the group Doctors in Recovery. He described the applicant as having engaged in the process of commitment to membership of that group by sharing his shame with others, increasing his honesty, and receiving the benefit of reinforcing feedback. In this regard he stated: "I am aware that the Medical Tribunal found that Mr Balafas developed a "very elaborate web of deception'' to obtain drugs, to deny he used them and to avoid consequences. Over the last five years Mr Balafas has, through his 12-Step membership, been engaged in a process of sharing his shame, increasing his honesty, and receiving feedback. Over the last several years I have noticed that Mr Balafas' attitude has improved, recognizing his own faults and taking responsibility for improving his life. He has tearfully expressed his remorse to me and expressed his understanding of the deep personal pain he has caused to his family. He is more aware of his ethical infringements in the time of his drug use. On return to medical practice, Mr Balafas should have the support of the impaired Registrants Program to monitor his health through interviews, urine and blood samples, and compulsory treatment of his addiction. Mr Balafas is committed to the provision of high quality medical care, as evidenced by his attaining the FRACGP and his continued engagement as a manager in a medical practice. I understand that Mr Balafas has engaged in charity work as a demonstration of his urge to assist the community." 85The above observations and comments of Prof Jurd were not challenged and the Tribunal accepts them as evidence of the applicant's commitment to the process of recovery from his addictions. Evidence of the applicant's wife 86In June 2011 the applicant met Ms Kate Klunder. They married in October 2012. Ms Klunder provided a statement dated 15 October 2012 in which she described the development of the relationship. She has operated a successful domestic aged care agency business in Sydney since 2001. That business is currently operated from within the premises of the medical practice owned by the applicant. 87In her statement, Ms Klunder outlined her impressions of the applicant's significant efforts at maintaining abstinence from the use of drugs and alcohol. In this regard, her descriptions included her observations of the applicant's commitment to recovery by his attendances at thrice weekly urine drug screening tests, monthly CDT blood pathology testing, regular meetings with Alcoholics Anonymous and weekly meetings of Doctors in Recovery at the Northside Clinic. 88Ms Klunder's statements concerning what she sees as being the applicant's total commitment to recovery, and his continuing abstinence from the use of drugs and alcohol were not challenged. She was not required for cross-examination. The Tribunal accepts her evidence and is comfortably satisfied that the applicant has had, and is likely to continue to have, the benefit of the active support and insightful encouragement of his wife in his ongoing efforts at maintaining his recovery from his addictions regarding his former use of drugs and alcohol. Consideration 89In view of the demonstrated and acknowledged instances of the applicant's past deceptive conduct concerning his substance abuse, the Tribunal has looked to objective evidence of his abstinence from the use of illicit drugs and abstinence from the hazardous drinking of alcohol. The evidence in the form of pathology test results, taken together with the observations of Dr Roberts, Dr Wodak, Dr Diamond and Associate Prof Jurd has persuaded the Tribunal that the evidence of the applicant concerning his abstinence from use of mood altering substances should be accepted. 90On considering the evidence we have reviewed in these reasons, the Tribunal is satisfied that the applicant has demonstrated a shift or change in his character sufficient for the Tribunal to be persuaded he no longer suffers from the formerly evident defects in his character that led to his deregistration. For the reasons that follow, the Tribunal is satisfied that the applicant has made out a case for a recommendation that he be reinstated as a medical practitioner. 91The Tribunal is satisfied that the applicant has acquired a deeper understanding and insight into the personal weaknesses that formerly impaired his judgment and allowed him to use Pethidine and other psychoactive substances, and to then deceive others as to the truth concerning those activities, and to conceal his involvement in those activities. 92The Tribunal is satisfied that the applicant has demonstrated a change in his awareness and immaturity of outlook concerning these matters. The Tribunal is satisfied that the applicant has acquired a realisation of his earlier wrongdoings and that he has properly acknowledged these matters. Those honest and sincere acknowledgments, together with the objective results of testing for substance abuse, provide evidence of the applicant's successful albeit continuing journey along the rehabilitation pathway. 93Through the applicant's involvement in the described rehabilitative activities he has stated that he has had the opportunity to honestly discuss and evaluate the history of his use of drugs and alcohol, his past relapses from his attempts at recovery, and the harm he has done to himself and to his career. On reviewing the evidence, the Tribunal is satisfied that this evidence should be accepted. 94It appears that the applicant's efforts at rehabilitation have led him to set more realistic expectations of himself. Following the disastrous consequences for him of his deregistration, his parents have ceased to apply pressure to him, as he explained was previously the case. Those circumstances had formerly led to him pursuing unrealistic personal and financial objectives. His recent marriage has provided him with a strong and supportive relationship and with strong motivation to maintain his recovery and sobriety. He has appropriately identified his goals as wishing to maintain good fitness and health, to maintain good relationships, and to be honest and forthright in his conduct and in dealings with others. 95The applicant's time in the role as practice manager in the practice he owns has allowed him time to reflect upon and to pursue professional development objectives and to keep his medical knowledge updated in the hope that if he were permitted to be reinstated, he would have maintained an appropriate skills set. 96In that regard the applicant has studied the RACGP standards for general practice, the Medical Board of Australia code of conduct Good Medical Practice and other Medical Board Guidelines. The applicant's statement in that regard went on to state: "26. As the result of all these steps I believe I am a totally different person now. I made the conscious choice to completely immerse myself in the treatment and support programs that could enable me to return to professional life. The program that I have undertaken has become a part of my daily life, and is the basis of a new way of life for me. A core part of this is the many AA and doctors in recovery meetings I have attended and the many specialist appointments where I have been involved in psychotherapy, and the support of my family and friends." 97The Tribunal is satisfied that the applicant has broadened his life experience by performing volunteer work at the Wayside Chapel and has drawn upon those experiences as a confrontational reminder of the adverse outcomes of drug and alcohol addiction. He now sees his deregistration as a catalyst for having to face his problems and get his life back on track by personal growth in recovery from his former addictions. 98The applicant now conducts himself with more humility and with a respectful state of mind, including with a greater awareness of the people around him. He has achieved greater insight into the importance of maintaining his sobriety and in being a properly functioning and honest member of society. He draws upon the stepped approach embodied within Alcoholics Anonymous principles and methods in order to maintain that state of mind, aided by what he has learnt in psychotherapy, with the assistance of the supportive network provided to him by the Doctors in Recovery network. 99The applicant has sought to reinforce those life changing activities by making time to maintain physical fitness, by pursuing meditation for relaxation and pursuing hobbies and recreations to balance his life and to cope with stress. He has also obtained satisfaction from performing voluntary work for some of his wife's elderly and needy clients such as taking them shopping and to doctors appointments or outings when a need has arisen for such assistance. He also attends a general practitioner for his own health issues, which lessens the risk of relapse to his former addictive behaviours. 100The picture painted by the applicant's evidence and by the evidence called on his behalf is one of a much changed and now honest individual, compared to the one adversely described in the reasons of the former Tribunal on 18 June 2010, including him having in the past resorted to engaging in lying and deceitful conduct in order to mask his illicit drug use. 101The applicant has given assurances that if he were to be permitted to return to medical practice, there would be no repetition of his former professional misconduct, which resulted in his deregistration. In this regard, he has stated that he has fully committed himself to maintain a comprehensive programme of rehabilitation in order to achieve and maintain a change in his life and in his moral compass. He understands and accepts that if he were to be permitted the privilege of returning to practice, this would be at the price of having to assiduously adhere to stringent conditions for as long as the Council thought appropriate. 102The conditions the Tribunal has in mind to set are not intended to be punitive of the applicant. They are required to be put in place as a necessary surveillance and reinforcement measure in order to protect the public from the risk of harm through possible future misconduct if the applicant were to unfortunately relapse into his former ways that led to his deregistration. 103Given the applicant's limited practical training and experience in broad general practice, the Tribunal considers his return to practice should be subject to structured mentoring, and supervision in a broad general practice, initially other than his own, and not limited by narrowly focussed areas of practice. Such practice should preclude Schedule 8 and Schedule 4D drugs. The Tribunal is also of the view that the applicant's future mentors, supervisors and employers should be given copies of the reasons for decision of the Tribunal which deregistered him, and the reasons for decision of the Tribunal as presently constituted. 104This Tribunal considers that health conditions should be imposed on the applicant to ensure he maintains a supportive environment in which to continue his rehabilitation. Those health conditions should be structured to provide for the applicant's own health care needs from time to time, and for him to be appropriately reviewed on behalf of the Council. The Tribunal also considers that until the Council may direct otherwise, there should be continued pathology testing of the applicant's blood and urine in accordance with the Council's protocols, as has been the case until the present time. 105The Tribunal recognises the onerous nature of compliance with the conditions that are proposed but is nevertheless of the view that they are necessary in the short to medium term until the Council, as the appropriate review body for those conditions, is satisfied in the public interest, that the applicant has made a successful integration into practice. The applicant himself recognises that such reintegration would involve taking one step at a time and that each step may involve a period of time. The Council is in the best position, at least initially, to assess the applicant's progress in that regard. 106As the applicant's name has never appeared on the register in place under the National Law that commenced on 1 July 2012, if the National Board accepts the recommendation of this Tribunal, then the applicant's name will appear on the National Register for the first time, with the appropriate notations commensurate with the orders this Tribunal makes. Orders 107The Tribunal concludes that the applicant has reached a sufficient state of insight and recovery from his prior addictions that would permit the Tribunal to make a reinstatement order under s 163B(1)(c) of the Health Practitioner Regulation National Law (NSW) No 86a, but subject to the applicant's compliance with stringent conditions on his future practice, including conditions concerning the monitoring of his health and provision for the review of those conditions, as summarised above. The Tribunal therefore makes the following orders: (a)The Tribunal makes a reinstatement order in respect of Mr John Balafas pursuant to s 163B(1)(c) of the Health Practitioner Regulation National Law (NSW) No 86a; (b)The Tribunal orders that pursuant to s 163B(4) of the above Act, Mr Balafas' registration be subject to the practice and health conditions set out in paragraphs [109] to [111] below; (c)The Tribunal orders that the applicant pay the costs of the Medical Council of NSW. 108The conditions set out in paragraphs [109] to [111] are undoubtedly onerous for the applicant, and may appear complex, and involve inconvenience for him in adhering to them. However, the Tribunal is nevertheless strongly of the view that in the short to medium term, the recommended conditions are a necessary mechanism for the protection of the public, and should only be varied after the applicant has demonstrated to the satisfaction of the Council as the appropriate review body, a significant and sustained period of compliance. Practice Conditions 109The Practice Conditions referred to in paragraph [107] above are as follows: (1)The practitioner is to practise only in a group general practice or practices, (but in no more than 2 practices), accredited as teaching practices by the Royal Australian College of General Practitioners and approved by the Council. The group practices must be comprised of a minimum of 4 doctors (full time equivalent). Those group practices must offer a broad range of general practice services not limited by emphasis on selected or narrowly focussed health issues; (2)The practitioner is not to prescribe, possess, supply, administer, handle or dispense any drug of addiction (Schedule 8 drugs) or any prescribed restricted substance (Schedule 4D drugs); (3)The practitioner is to treat no more than 100 patients in any one week during the first 6 months of resuming practice. That number may be increased at the direction of the Council, at the request of the applicant, but should not exceed 150, unless the Council directs otherwise; (4)The practitioner is to nominate a general practitioner in a senior position as a supervisor 14 days prior to commencing employment as a medical practitioner. The supervisor is to be approved by the Council, and is to monitor and review the practitioner's clinical practice and compliance with Public Conditions in accordance with Level 2 Supervision as contained in the Council's Supervision Policy. A "general practitioner in a senior position" is defined as a practitioner holding the Fellowship of the Royal Australian College of General Practitioners or Fellowship of the Australian College of Rural and Remote Medicine and with 5 years or more continuous post Fellowship experience in general practice. The supervisor is to be provided with a copy of the Council's Supervision Policy and a copy of this Decision and any reports the Council deems to be appropriate to the practitioner's circumstances; (5)The practitioner is not to work in a practice he either owns or in which he has a financial interest without the prior approval of the Council. The practitioner is not to seek such approval for a period of at least 2 years from the date of this Decision; (6)In the event that the Council gives approval for the practitioner to commence working as a medical practitioner in a medical practice in which he has either a direct or indirect financial interest, 14 days prior to commencing such employment, the practitioner is to nominate for the approval of the Council, a general practitioner in a senior position, as an additional supervisor. The supervisor approved by the Council is to monitor and review the practitioner's clinical practice and compliance with Public Conditions in accordance with Level 3 Supervision as contained in the Council's Supervision Policy. That supervisor is to be provided with a copy of the Council's Supervision Policy and a copy of this Decision and any reports the Council deems to be appropriate to the practitioner's circumstances; (7)All costs associated with the supervision arrangements specified in Practice Conditions (4), (5) and (6) above are to be borne by the practitioner. To facilitate compliance with these conditions the practitioner is to ensure that: (a)He and his approved supervisors meet on a weekly basis for at least one hour, the first meeting to occur within one fortnight of the practitioner being advised by the Council that his nominated supervisors have been approved; (b)At each meeting between the practitioner and his supervisors, the supervisors are to review the practitioner's work progress and address any relevant work-related, personal and professional matters; (c)At each meeting between the practitioner and his supervisors, the supervisors are to complete a record of matters discussed at the meeting in a format prescribed or approved by the Council; (d)The practitioner's supervisors are to forward to the Council, initially on a monthly basis and then subsequently at a frequency determined by the Council, a Supervision Report in a format prescribed or approved by the Council; (e)The practitioner's supervisors are to be authorised by him to inform the Council immediately if there is any concern in relation to the practitioner's compliance with these supervision requirements, compliance with other conditions of registration, clinical performance, health status, or if the supervisory relationship ceases; (f)In the event that an approved supervisor is no longer willing or able to provide the practitioner with the supervision required by these orders, details of a proposed replacement supervisor are to be forwarded for approval by the Council within 21 days of the cessation of the original supervisory relationship; (8)The practitioner is to, within 14 days of commencing clinical practice, provide for approval by the Council, the name and professional address of a registered general practitioner in a senior position who has agreed to act as his professional mentor. The nature and frequency of contact with the mentor is to be determined by the mentor in accordance with the Council's Guidelines for Mentors. The mentor is to be provided with a copy of the Council's Guidelines for Mentors, a copy of the Tribunal decision dated 18 June 2010 together with a copy of this Decision, and copies of any reports the Council deems to be appropriate to the practitioner's circumstances. To facilitate compliance with this condition, the practitioner is to: (a)Authorise the mentor to report, in an approved format, to the Council every three months, about the fact of mentor contact, and to inform the Council if there is any concern held by the mentor about the practitioner's professional conduct, health or personal wellbeing; (b)Meet with the mentor every 3 months for an initial period of 12 months from the date of the first consultation, and thereafter for such period as the Council may determine; (c)Authorise the mentor to notify the Council of any failure to attend, termination of the mentoring relationship against the advice of the mentor, or any other matter the mentor considers appropriate; (d)In the event that the approved mentor is no longer willing or able to continue as mentor to the practitioner, he is to nominate another mentor for approval by the Council within 28 days of the cessation of the original mentor relationship; (e)Be responsible for any costs associated with the mentoring process; (f)Ensure that the practitioner's initial meeting with the mentor should include discussion of the issues highlighted in this Decision and, as and when they arise, any personal and/or medical practice issues, and his personal and professional development as a registered medical practitioner; (9)The practitioner is to obtain the approval of the Council prior to changing the nature or place of his practice; (10)The practitioner is to authorise and consent to the exchange of information between the Council, Medicare Australia and the Pharmaceutical Services Unit of the NSW Department of Health, for the purpose of monitoring compliance with these conditions; (11)Unless otherwise directed by the Council, the practitioner is to provide copies of the Tribunal decision dated 18 June 2010 and a copy of this Decision to all of his future employers, supervisors and mentors; (12)The practitioner is to attend an appointed Review Interview at a place and with a person to be nominated by the Council at a time approximately three months after commencing practice, or as otherwise directed by the Council; (13)The practitioner is to authorise the Council to forward copies of this Decision and any subsequent Council Review Interview or other reports and information relevant to his health and treatment, to the Council appointed medical practitioners, and to his treating medical practitioners. Health Conditions 110The Health Conditions referred to in paragraph [107] above are as follows: (1)Except for medications that may be purchased from a pharmacy without prescription, the practitioner is not to prescribe for self-medication; (2)The practitioner is not to self-administer: (a)Any substance detailed in Schedule 4, 4D or 8 of the NSW Poisons List or Schedule 1 of the Drug Misuse and Trafficking Act; (b)any narcotic derivative, non-prescription compound analgesic or cold medication; (3)The practitioner must not take any medications of the type referred to in Health Condition (2) above unless such medications are prescribed at the direction of the practitioner's treating medical practitioner/s; (4)The practitioner is to attend for review by a Council Appointed Psychiatrist on a three monthly basis or as otherwise directed by the Council, such reviews to be at the Council's expense; (5)Should the practitioner be prescribed or directed to take: (a)any Schedule 4D or Schedule 8 drug; (b)any narcotic derivative; (c)any non-prescription compound analgesic or cold medication; the practitioner must notify the Council Appointed Psychiatrist and the Council of any instance of illness requiring the administration of any such medications as described above. In addition, within 7 days of a prescription of the above drugs, the practitioner must provide the Council with written confirmation for the recommendation of such treatment from the treating practitioner/s; (6)The practitioner is to take any medication that may be from time to time prescribed by his treating medical practitioner/s; (7)Unless otherwise directed by the Council, the practitioner is to attend for thrice weekly Urine Drug Testing (including testing for Zolpidem, Pethidine and Tramadol) in strict accordance with the Council's protocol. Results of Urine Drug Testing are to be forwarded to the Council Appointed and treating medical practitioners, and to the Council. Such Urine Drug Testing will be at the expense of the practitioner; (8)The practitioner is to attend for treatment by a general practitioner of his choice, at a frequency to be determined by the practitioner and his treating medical practitioner. The practitioner is to authorise his treating medical practitioner to inform the Council of any failure to attend for treatment, termination of treatment or if there is a significant change in the practitioner's health status (including a significant temporary change). The treating general practitioner should not be one who practises at the practitioner's work place or at a practice owned by the practitioner; (9)The practitioner is to attend treatment sessions with a psychiatrist of his choice, at a frequency to be determined by the practitioner's treating psychiatrist. The practitioner is to authorise his treating psychiatrist to inform the Council of failure to attend for treatment, termination of treatment, or if there is a significant change in the practitioner's health status (including a significant temporary change); (10)The practitioner is to attend for treatment by a drug and alcohol physician of his choice, at a frequency to be determined by that treating physician. The practitioner is to authorise the treating physician to inform the Council of failure to attend for treatment, termination of treatment, or if there is a significant change in the practitioner's health status (including a significant temporary change); (11)The extent of the practitioner's professional medical duties in practice is to be guided by his health status and by the advice of his treating medical practitioners and any Council appointed medical practitioners; (12)The practitioner is to have samples of his blood taken for measurement of Carbohydrate Deficient Transferrin (CDT) levels at monthly intervals in strict accordance with the Council's protocol for such tests. The results of all such tests are to be forwarded to the treating and Council appointed medical practitioners, and to the Council. Such testing will be at the expense of the practitioner; (13)The practitioner is to attend Doctors in Recovery Group meetings at Northside Clinic, at a minimum of weekly intervals, save for any weeks where no such meetings of that Group are scheduled to take place. Review body for NSW and interstate review of conditions 111The Review Conditions referred to in paragraph [107] above are as follows: (1)These conditions may be altered, varied or removed by the Council at any time, and the Council is the appropriate review body for the purposes of Division 8 of Part 8 of the National Law (NSW); (2)Should the practitioner seek to change or remove any of the conditions imposed by virtue of orders made in these proceedings when his principal place of practice is anywhere in Australia other than in New South Wales, sections 125 to 127 inclusive of the Health Practitioner Regulation National Law are to apply, so that a review of these conditions can be conducted as required by the Medical Board of Australia. ********** Appendix 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. Decision last updated: 30 April 2013