Civil and Administrative Tribunal New South Wales Medium Neutral Citation: Chen v Medical Council of NSW [2019] NSWCATOD 81 Hearing dates: 13 & 14 February 2019 Date of orders: 14 February 2019 Decision date: 23 May 2019 Jurisdiction: Occupational Division Before: Hon G Mullane – ADCJ – Principal Member Dr J Aitken – Senior Member Dr K Smartt – Senior Member Dr C Berglund – General Member Decision: 1 The application by the applicant for a reinstatement order under s163B(1)(c) of the National Law is granted. 2 In accordance with s149A(1)(b) of the National Law, by consent, if the National Board grants an application by the applicant for registration, the applicant's registration shall be subject to the following conditions:- (1) To obtain Medical Council approval prior to changing the nature of place of her practice. (2) To authorise and consent to any exchange of information between the Council and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these conditions. (3) To practise only in a group practice approved by the Council where there are at least 2 practitioners (excluding Dr Mengyi Chen): (a) where the patients and patient records are shared between the medical practitioners, (b) where there is always one other registered medical practitioner on site, (c) which is an accredited practice. (4) To forward evidence to the Council prior to commencing practice that she has provided a copy of her full conditions to: (a) the principal(s) of the practice, (b) the proposed and Council-approved Supervisor, (5) Not to possess, supply, administer or prescribed any "drug of addiction" (Schedule 8 drugs) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW). (6) Not to possess, supply, administer or prescribe any substance listed in Schedule 4 appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW). (7) To submit to an audit of her medical practice, by a random selection of her medical records by a person or persons nominated by the Medical Council of NSW and: (a) the audit is to be held within 6 months from the date of recommencement of medical practice and subsequently as required by the Council. (b) the auditor(s) is to assess her compliance with good medical record keeping standards and legislative requirements and compliance with conditions. (c) to authorise the auditor(s) to provide the Council with a report on their findings. (d) to meet all costs associated with the audit(s) and any subsequent reports. (8) To practise under category B supervision in accordance with the Council's Compliance Policy-Supervision (as varied from time to time) and as subsequently determined by the appropriate review body: (a) at each supervision meeting the applicant is to review and discuss her practice with particular focus on: (i) appropriate prescribing practice, (ii) medical records with a review of 10 records, (iii) for a period of 12 months to be observed by the supervisor in at least 3 of the consultations each month, and to observe the supervisor during at least 3 of her consultations each month. (b) to authorise the Council to provide proposed and approved supervisors with a copy of the Tribunal's decision and the current conditions. (c) not to practise until a supervisor has been approved by the Council. (9) To nominate an experienced specialist general practitioner to act as her professional mentor for approval by the Council in accordance with the Council's Compliance Policy-Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body: (a) at each mentoring meeting the applicant is to include discussion of the following: (i) Continuing professional education, (ii) Continuing personal development and well-being, (iii) Progress in making independent professional decisions in the consulting room, (iv) Ability to cope with the stress of general practice with specific regard to proper medical records, but also with regard to interpersonal conflicts with any members of the practice, (v) Feedback from her supervisor with regard to her competence within the scope of her practice. (b) to authorise the mentor to report, in an approved format, to the Council if there is any concern about her professional conduct or personal well-being. (10) Treat no more than 30 patients in any one day. 3 These conditions may be altered, varied or removed at the discretion of the Medical Council and the Medical Council is the appropriate body for the purposes of Part 8 of the National Law. 4 Broadcast or publication without the leave of the Tribunal of the name or other identifying information of any patient of the applicant referred to in these proceedings is prohibited. 5 The issue of the respondent's costs application is reserved. 6 Costs order made 23 May 2019: The Applicant must pay an amount of $7,161 to the Respondent towards its costs of or incidental to these proceedings. Catchwords: PROFESSION AND TRADES – medical practitioner – registration – application for reinstatement after registration cancelled – application granted subject to conditions on registration – costs Legislation Cited: Health Practitioner Regulation National Law (NSW) (the "National Law") Poisons and Therapeutic Goods Act 1966; Poisons and Therapeutic Goods Regulation; Health Practitioner Regulation (NSW) Regulation; Cases Cited: Health Care Complaints Commission v Philipiah [2013] NSWCA 342 Texts Cited: "Good Medical Practice: A Code of Conduct for Doctors in Australia" Medical Board of Australia, March 2014; "Standards for General Practices", Royal Australian College of General Practitioners, 2017; Category: Principal judgment Parties: Mengyi "Amie" Chen (Applicant) Medical Council of NSW (Respondent) Representation: Counsel: E Elbourne (Applicant) I Chatterjee (Respondent) Solicitors: HWL Ebsworth Lawyers (Applicant) I Martin (Respondent) File Number(s): 2018/00242191 Publication restriction: Broadcast or publication without the leave of the Tribunal of the name or other identifying information of any patient of the applicant referred to in these proceedings is prohibited. REASONS FOR DECISION Introduction 1. In 1984 the applicant graduated in medicine from the Guangzhou Medical College in China. She then worked as an Obstetrics/Gynaecology Registrar in China. She came to Australia in 1988. She completed a Bachelor of Nursing Degree at the University of Technology in Sydney in 1995. She was first registered as a medical practitioner in New South Wales on 25 August 2003. In 2009 she became a Fellow of the Royal Australian College of General Practitioners. 2. In Australia she first worked as a general practitioner in a practice in New South Wales on the Central Coast for about a year and then in suburban Sydney at a medical centre three days per week for about a year. In March 2010 she was working three days a week at one suburban general practice and two days a week at another. 3. In December 2011 she ceased work at the latter practice and from December 2011 instead worked two days a week at a different suburban practice. 4. On 5–9 September and on 26 October 2016 the Health Care Complaints Commission pursued complaints against her in the Tribunal. The complaint alleged that she was guilty of unsatisfactory professional conduct and professional misconduct because of inappropriately prescribing drugs of addiction and failing to maintain adequate medical records in accordance with the requirements of the Health Practitioner Regulation (NSW) Regulation 2010. 5. The applicant admitted in those proceedings the allegation of unsatisfactory professional conduct and of professional misconduct. In its decision on 28 November 2016 the Tribunal found the complaints proved and cancelled the applicant's registration as a medical practitioner. An order was made that she not be able to make any application for review of the cancellation for a period of 18 months from the date of the decision. 6. The decision of the Tribunal cancelling her registration was delivered on 28 November 2016. The applicant appealed against that decision of the Tribunal. The New South Wales Court of Appeal heard the appeal on 15 June 2017 and dismissed the appeal on 31 July 2017. 7. This was a hearing of the applicant's Application filed 7 August 2018 seeking a reinstatement order. 8. The Application was heard on 13 and 14 February 2019 and orders made on 14 February. The question of the Respondent's costs in connection with the Application was reserved. These are the reasons for the orders made on 14 February 2019 and also the decision and reasons in relation to the costs application. Reinstatement Application – The Relevant Legislative Provisions 1. The Act gives the applicant a right to apply to the Tribunal to review a prior decision of the Tribunal (or its predecessor the Medical Tribunal) cancelling the registration of a medical practitioner (s 163A). 2. The powers of the Tribunal in conducting the review include the making of a reinstatement order (s 163B(1)(c)), which is defined as:- "an order that the person may be registered in accordance with Part 7 if -- (a) the person makes an application for registration to the National Board; and (b) the relevant National Board decides to register the person." 1. S 163C of the Act provides:- "(1) A review under this Division is a review to determine the appropriateness, at the time of the review, of the order concerned. (2) The review is not to review the decision to make the order, or any findings made in connection with the making of that decision. (3) In addition to any other matter the review may take into account, the review must take into account any complaint made or notified to a Council or a National Board, or a former Board under a repealed Act, about the person, whether the complaint was made or notified before or after the making of the order that is the subject of the review and whether or not the complaint was referred under Subdivision 2 of Division 3 or any other action was taken on the complaint. (4) A Council and the Commission are entitled to appear at any inquiry conducted by the Tribunal under this Division." The Evidence 1. The evidence in these proceedings comprised the following:- 1. Application for re-registration filed 7 August 2018; 2. Reply of Medical Council of New South Wales; 3. Statement of Mengyi Chen with annexures A to K dated 14 September 2018; 4. Report by Dr Michael Diamond, psychiatrist dated 24 July 2018; 5. Letter from Dr David King, general practitioner dated 1 August 2018; 6. Letter from Dr Steven Zhang, general practitioner dated 30 June 2018; 7. Letter to Dr Merissa Cappetta from HWL Ebsworth Lawyers (without enclosures) dated 11 May 2018; 8. Letter from Dr Merissa Cappetta, Staff Specialist Addiction Medicine dated 7 August 2018; 9. Letter from Dr Allan Fang, general practitioner dated 17 July 2018; 10. Letter from Dr Yanjie Liu, Cardiologist dated 5 June 2018; 11. Letter from Dr Zhen Zhang, psychiatrist dated 24 July 2018; 12. Letter from Shaoliang He, general practitioner dated 31 July 2018; 13. Letter from Dr John Martin Wild, general practitioner dated 9 August 2018; 14. Supplementary Statement of Mengyi Chen with annexures A to C dated 7 November 2018; 15. Exhibit R2 - Statement of the Respondent's costs; 16. Exhibit 1 Respondent's Reply dated 29 October 2018; 17. Oral evidence by the Applicant on 13 February 2019; 18. Oral evidence of Dr Diamond on 14 February 2019; 19. Royal Australian College of General Practitioners Point Summary for the Applicant for Continuing Medical Education Events for the period 8 February 2017 – 19 October 2018; 20. Royal Australian College of General Practitioners Point Summary for the Applicant for Continuing Medical Education Events for the period 17 October 2018 to 8 February 2019; 21. Report of Dr Hani Bittar of July 2015; 22. Report of Dr Murray Wright of 18 July 2016; 23. Report of Dr C Howle of 27 October 2018; 24. Evidentiary Certificate of the Medical Council regarding Applicant; 25. Good Medical Practice: A Code of Conduct for Doctors in Australia, March 2014; 26. Standards for General Practices Royal Australian College of General Practitioners, July 2017; 27. Certificate of Confirmation of Registration Status from AHPRA, dated 6 February 2019; 28. Letter of 12 December 2013 from Medicare to the Applicant; 29. Letter of 6 March 2014 from Pharmaceutical Benefits Branch of the Department of Human Services to the Applicant; 30. Letter of 6 March 2014 from Medicare to the Applicant; 31. Transcript of Disciplinary Proceedings before the NSW Civil and Administrative Tribunal on 5, 6, 7, 8 September 2016, and 26 October 2016; 32. Decision of the Tribunal of 28 November 2016 in Health Care Complaints Commission v Mengyi Chen; 33. Decision of Court of Appeal in Chen v Health Care Complaints Commission of 31 July 2017 and 34. Bundle of certificates and other documentary evidence regarding attendance at continuing medical education courses etc. The Reasons for The Cancellation 1. The Medical Tribunal in its decision of 28 November 2016 gave extensive reasons for the cancellation of the Applicant's registration. 2. In respect of the first complaint before it, it dealt with inadequacies, and breaches of the legislation and other requirements, in the Applicant's treatment of 15 patients. Amongst the extensive findings of unsatisfactory professional conduct, the Tribunal found that in respect of 14 of those patients the Applicant prescribed an addictive medication without making an appropriate assessment of the patient. In respect of 12 of such patients she prescribed an addictive medication in breach of the requirement for her to obtain an authority under the Poisons and Therapeutic Goods Act 1966 and the Poisons and Therapeutic Goods Regulation. 3. In the case of 8 of those patients she prescribed an addictive drug when such prescribing was contraindicated because she knew or ought to have known that the patient was exhibiting drug seeking behaviour. 4. For 9 of those patients she prescribed an addictive drug inappropriately as to the purpose or the quantity, and sometimes as to both, and not in accordance with recognised therapeutic standards. 5. There were at least four occasions when she failed to make an appropriate and timely referral of the patient to a pain clinic or an addiction specialist. 6. There were multiple occasions when she prescribed an addictive drug for a duration in excess of recognised therapeutic standards. 7. With seven patients she failed to provide a timely referral to a specialist or addiction clinic for treatment or review and/or advice when her prior medical notes indicated such was appropriate. 8. With five of the patients she prescribed an inappropriate combination of different drugs and on several occasions prescribed an addictive drug when she knew or ought to have known that another doctor in the practice had given a referral to the patient to attend an addiction centre. 9. The second complaint that was proved was that in respect of each of the 15 patients referred to in the complaint, the practitioner on numerous occasions breached the Health Practitioner Regulation (NSW) Regulation 2010 by failing to maintain adequate medical records in accordance with Schedule 2 to the Regulation. 10. The Tribunal held that the complaints proved in Complaint One and Complaint Two each amounted to unsatisfactory professional conduct and together constituted professional misconduct which, for the protection of the public, justified cancellation of the Applicant's registration. The Tribunal also made an order that the Applicant could not apply for review of the cancellation for a period of 18 months after 28 November 2016. Review of the Cancellation 1. There is evidence in the Applicant's case of the extensive changes she has made in the period since the disciplinary proceedings were commenced against her. 2. According to her statement in these proceedings, she continued to engage in the period since July 2016, in extensive continuing medical education, focused particularly on the problems identified by the Tribunal in 2016 and development of her general practice skills. By 12 August 2018 she had achieved 550 points of continuing professional development through courses she had undertaken conducted by the Royal Australian College of General Practitioners. 3. In addition, she attended the General Practitioner's Liaison and Alcohol and Other Drugs Project Forum and Survey on 18 October 2017 and the Obstetric and Gynaecological Education Evening conducted by the Australian Chinese Practitioners Society on 21 April 2018. 4. She completed the Monash University Course "Issues in General Practice Prescribing". Her course commenced on 25 July 2016. On average she spent 40 hours per week undertaking learning activities and completing assignments. Topics covered during the course included "Selecting the Right Medication", "Prescribing for the Individual in Society", and "Sorting the Evidence". 5. The course she completed was conducted (before her cancellation) over the period 18 July 2016 to 16 October 2016. She was awarded a distinction for her performance in the course. 6. For a month in July/August 2017 she attended the Sydney Pain Management Centre as a clinical observation placement under the guidance of Dr Alister Ramachandran, a pain specialist who specialises in the treatment of patients who suffer from chronic non-cancer pain. For five weeks she attended the Sydney Pain Management Centre at Parramatta every Wednesday from 8:00 am – 4:00 pm and usually observed Dr Ramachandran's consultations with between 5 and 10 patients suffering from chronic non-cancer pain. A consultation with a new patient usually lasted about 45 – 60 minutes and involved taking a detailed history including all previous therapies (including analgesics), physical examination, discussion of Dr Ramachandran's impressions, and the establishment of a multidisciplinary management plan including adjustment and/or wean-off opioid analgesics, physiotherapy and psychotherapy. 7. Subsequently, Dr Ramachandran would consult with existing patients for follow-up review and those appointments lasted about 20 – 30 minutes. They involved a progress review with the patient to assess their pain management plan. Periodically there was a team session with a physiotherapist and psychologist who were also enlisted as part of the review process. 8. The Applicant's evidence is that the purpose of the clinical placement was for her to observe first-hand a multidisciplinary team approach to managing chronic pain. She did not actively participate in the consultations. If she had any questions or queries, she would raise them when she was given an opportunity to review patient's records and discuss questions with Dr Ramachandran at the end of the consultation. 9. She also discussed with Dr Ramachandran general issues in relation to pain management, along with the book entitled "Fast Facts: Chronic and Cancer Pain" by Michael Cousins and Rollin Gallagher, which emphasises the principles that opioid analgesics alone are ineffective and unsafe as chronic pain therapy and appropriate management for chronic non-cancer pain management is a multidisciplinary care team. 10. She also discussed with Dr Ramachandran and other professionals interventional methods for chronic pain management and she observed Dr Ramachandran perform a scapular nerve block injection. 11. In addition to observations of those consultations, she also observed the quarterly WorkCover conferences. These were attended by the practice manager, the pain specialist, the physiotherapist and the psychologist, together with the patient and the case manager representative. During those meetings, there were discussions about the particular patient with a view to setting treatment goals and tracking the patient's progress to ensure that the goals were being achieved or alternatively which goals required adjustment. 12. The Applicant kept an extensive diary of all of her attendances at the Sydney Pain Management Centre. 13. In addition to that, during the period between her cancellation and the hearing of this application, the Applicant undertook a clinical placement with the Department of Drug Health Services at the Concord Repatriation Hospital. The placement occurred on 15, 18, 19, 23 and 25 January 2018. It was under the supervision of the staff specialist in addiction medicine. On these occasions, she observed patient consultations for those seeking admission for detoxification and she also observed the medical and general ward rounds. The usual procedure involved observing consultations with about five new out-patients seeking admission and suffering from addiction from a range of substances that included methamphetamines, heroin, prescription opioids benzodiazepines, alcohol and cannabis. Those consultations consisted firstly of history taking including drug/alcohol/smoking history, mental health history, general medical/surgical history, family history, social history, legal history and medication history. The staff specialist would then perform an examination and develop a management plan including pathology tests and a treatment regimen such as short-term Diazepam or Olanzapine for withdrawal symptoms before weaning-off within days and/or introduction of Methadone or Suboxone therapy. 14. Once the out-patients had been seen she would attend the medical ward rounds and the general ward rounds observing the patients and procedures. An addiction consultant, a psychiatry registrar, a resident medical officer and an intern participated in the medical ward round. In these rounds, the progress of patients was assessed and their treatment regimens adjusted as necessary. 15. The general ward rounds were attended by the addiction consultant, registrar, resident, intern, nurse, social worker and a physiotherapist. Those rounds involved discussions of holistic patient care, patient progress and whether there were any issues of concern. Discharge planning and discharge arrangements were also discussed where appropriate. 16. When the Applicant had any questions or queries, she could review the patient notes and ask questions of the addiction consultant and/or the psychiatric registrar. The Applicant kept an extensive diary of her involvement and learning during that clinical placement. 17. The Applicant also had a subsequent clinical placement with Dr Steven Zhang and Dr David King which was still current when the hearing commenced on 7 February 2018 and was still continuing when the hearing before the Tribunal occurred in September and October 2018. At first she commenced a placement with Dr Zhang at a medical centre in Burwood in February 2018 and attended there once a fortnight on Wednesdays for five hours. She observed the doctor's consultations for about 12 – 22 patients and at the end of some of the consultations they took time to discuss their treatment and she reviewed his records, including history, examination, investigation(s) and treatment regime. 18. In those observations, chronic and acute pain was one of the common presentations. The chronic pain presentations included rheumatoid arthritic hand pain, osteoarthritic knee pain, shoulder capsulitis and rotator cuff syndrome, lower back pain, disc prolapse with sciatica, and gouty arthritic foot pain. 19. She observed that the treatment regimens consisted of pharmacotherapy such as paracetamol, NSAIDs, topical NSAIDs, local steroidal injection, physiotherapy and exercise including regular walks and Tai Chi. None of these chronic pain patients were on opioid analgesics. She instanced an example of a 60 year old woman who wanted to take Panadeine Forte for osteoarthritic pain for which she had been taking that medication (prescribed by other doctors) for two years. Dr Zhang explained and advised that that medication was not appropriate treatment for osteoarthritis and the alternatives were discussed. No prescription for Panadeine Forte was given. 20. The second practitioner placement was with Dr David King at Erina and commenced on 15 February 2018. She attended his practice on Thursdays from 8:30 am – 12:30 pm to observe patient consultations. She usually stayed afterwards to engage in discussion with Dr King. He usually consulted 10 – 12 patients during her observations in the mornings and the patients' population included small children, elderly retirees and other adults. It reflected a broad spectrum of pain conditions in general practice including lower back pain, neck pain, shoulder pain, knee and ankle pain and finger joint pain, being typical examples of chronic pain presentations. Dr King after consultations discussed with her the holistic multidisciplinary approach to treating chronic non-cancer pain without the use of opioid analgesics. She also discussed with him drug seeking behaviours, doctor shopping patients, patients diverting or selling drugs including prescription medications, and utilising resources such as the Pharmaceutical Regulatory Unit. The Applicant also kept an extensive diary of her attendances during her placement with Dr King. 21. The practitioner also had the benefit of mentorship by Dr Fang, a general practitioner. They would meet occasionally but usually each month to discuss general practice issues. During these meetings they would review some of his patient cases and discuss issues and cases surrounding chronic non-cancer pain management, drug seeking behaviours and prescription shopping. Her evidence is that "We also discuss common comorbidity of chronic pain, mental disorders and drug addiction. We have specifically discussed record-keeping in accordance with the RACGP Standards". The issues discussed have included the principle that opioid analgesia is not indicated for chronic pain as opioids are ineffective in treating chronic pain, instead leading to significant side effects of addiction and induced hyperalgesia (induced sensitivity to pain) in some patients. She was further encouraged to accept the proper approach to chronic pain is multidisciplinary team care which includes a pain specialist, physiotherapist, psychologist and a patient's self-motivated participation. She said in her statement:- "We discuss drug-seeking behaviours, including common tactics employed such as manipulation, in order to enhance my ability to identify these behaviours and my skills to handle drug-seeking patients. Dr Fang uses his own patient cases to demonstrate the usual behaviours and the usual techniques he uses to manage difficult patients. Dr Fang has also emphasised to me the need to establish safe professional boundaries and to persist with assertiveness when facing demanding drug-seeking patients. I believe my assertiveness has improved since the original Decision, I now feel confident to resist these behaviours and deal firmly and appropriately with such patients". 1. The Applicant recognises Dr Fang's mentorship as an important part of her support network during the last 18 months. They have frequently talked about ways to address the deficiencies highlighted in the disciplinary hearing in 2016. The Applicant has kept a very detailed diary of her meetings with Dr Fang and his mentorship generally. 2. In her statement the Applicant has a section "Lessons Learned" in which she states:- I have thought long and hard about my previous inappropriate professional conduct, and how to prevent it from recurring. I have learnt a great deal about my own previous limitations and worked hard to improve my professional knowledge and ability, in order to rectify those defects that caused the conduct which was before the original Tribunal. In summary, in addition to my theoretical studies with Monash University (prescribing course) and the other CPD activities, the pain management clinical observation placements offered me the opportunity of first-hand experience in a multidisciplinary team that manages chronic non-cancer pain more effectively, and the Drug Health clinic placement allowed me to see and emphasize with the struggles and distress of those patients with drug addiction thus re-enforcing the crucial importance of appropriate and safe prescribing. Having regard to what I have learned, if I had the opportunity to go back and treat the patients who were the subject of the initial complaint again, I would now treat them pursuant to the management plan I have prepared which is set out in the document annexed hereto and marked "J". I have discussed these management plans with Dr King". 1. The evidence of the Applicant is that the cancellation of her registration and the consequences of that have had a very serious effect on her emotionally, including high levels of stress. She has been concerned about the importance of maintaining her mental well-being and has had assistance from a psychologist to assist her to cope with the disciplinary proceedings, and also the outcome. She has had counselling sessions in March, April, July and August 2018 with the psychologist and she proposes to see her further if required. 2. The psychologist has provided her with coping strategies, relaxation techniques and skills for managing stress and maintaining a healthy, balanced life. She has also had advice from the psychologist about addressing the criticisms raised in the disciplinary proceedings and ways of improving her assertiveness with demanding patients and also establishing professional boundaries. The Applicant further says that she now feels better equipped to deal with those difficult issues with patients. 3. The Applicant also has continued to regularly see her own general practitioner for her personal health needs including for occasional asthma and other checks. 4. The Applicant has acknowledged that she has received significant support from professional colleagues including those who have provided her with testimonials in support of her application. She considers their support as ongoing. 5. The Applicant concludes in her statement as follows:- "62. I am deeply ashamed and remorseful for my professional misconduct. I accept that it was inappropriate and I have since realised that at the time I did not have adequate skills to deal with such complex and difficult patients. 63. Looking back, I now realise that I lacked the relevant skills and knowledge to ensure that I practised medicine at the standard required of me in relation to prescribing drugs of addiction. I am very ashamed for that. In addition, I was too heavily influenced by my senior colleagues and was not assertive enough as an independent practitioner to make my own professional judgments. 64. I have undertaken serious reflection upon my conduct which resulted in the Decision of deregistration, and I am determined to address the issues and criticisms raised by the PRU, HCCC and the initial Tribunal, as set out above. 65. I have proactively taken actions through CPD studies, conferences and clinical placements to guide and implement changes to improve myself as a person and a medical practitioner. 66. Maintaining accurate and adequate medical records is my professional and legal responsibility. This complaint process has highlighted the importance of keeping good medical records. I am aware now, more than ever, of the importance and significance of detailed and accurate record-keeping for patient care. 67. I have tried to make every effort to ensure that if I return to the practice of medicine, I do not repeat my earlier mistakes and will practise medicine safely and appropriately. 68. I am passionate about medicine. Being a doctor is very important to me, as demonstrated by my commitment to becoming registered in Australia over some years, after moving here from China. I feel I still have a lot to contribute to the community and will be a better doctor because of what I have experienced. My husband was and remains supportive. 69. I understand that if I am permitted to return to practice that it will be subject to such conditions as may be imposed by the Tribunal. I am fully prepared to strictly comply with any conditions that may be imposed. I was completely compliant when I had conditional registration previously, prior to being deregistered. A copy of proposed conditions for the consideration of the tribunal is annexed and marked "K"." 1. The Applicant's evidence is supplemented and reinforced by very positive statements by Dr Zhang, Dr King, Dr Cappetta (the Staff Specialist in Drug Health Services at Concord Repatriation Hospital) and Dr Allen Fang. Those references are professional references and some of them given in the role of an expert witness. 2. There are also character references from medical colleagues including Dr Yanjie Liu, a Consultant Cardiologist who has known the Applicant since 2011, Dr Zhen Zhang, a psychiatrist who has known her since 2010 when they worked in the same medical centre for about three years, Dr Martin Wild, who worked with her on the Central Coast practice, Dr S He, who has known her since 2014 when they met at a medical conference, following which the Applicant assisted Dr He in preparing for his GP Fellowship examination. They are both members of the "Sydney Doctors Group". The worked together in a Sydney suburban medical practice, which Dr He joined a short time before the hearing of the disciplinary proceedings. Expert Evidence – Doctor for the Applicant - Dr M Diamond 1. Dr Michael Diamond, consultant psychiatrist, gave expert evidence in the Applicant's case. Dr Diamond was briefed with extensive factual material and documents. 2. Dr Diamond had read the Expert Witness Code of Conduct and agreed to be bound by it. There is no issue about his expertise, but there is a lengthy section in his report setting out his relevant qualifications and experience. He interviewed the Applicant on 13 July 2018 for 2 hours 10 minutes. 3. He sets out in his report extensive details that he obtained from the Applicant about her circumstances, family and background. She talked to him extensively about the matters she had learned from her experience of the disciplinary proceedings. 4. She also gave him extensive details of the activities she had engaged in since the deregistration with a view to eliminating inadequacies in her practice that were identified by the disciplinary proceedings. She told Dr Diamond that after the deregistration she had first been distressed and unhappy and then there was a period where she was anxious and upset about what she had done. He reported:- "She said it did not constitute an illness, but was rather seen as an appropriate reaction to her circumstances". 1. She said it was reassuring and helpful that her colleagues gave her so much support. She talked about the extensive efforts she had made to improve her knowledge and functioning as a doctor and the studies she had undergone. Her accounts to Dr Diamond were consistent with the briefing he had been provided by her solicitors. The Applicant told him that she is under the care of her general practitioner and takes no regular medications. She is treated "symptomatically for occasional bouts of asthma". Dr Diamond reported that the Applicant:- "Showed a clear and deep understanding of the issues she faces in relation to remediating the professional misconduct that she was engaged in. She related appropriately and was a good historian". 1. He said there was no suggestion of obfuscation or manipulation and he found the Applicant to be "candid". He said her affect was in the normal range and appropriate and there was no overt distress. Her mood state was normal. He said that her speech and thought processes demonstrated intrinsic intelligence and an absence of any disorganisation or disturbed thought processes. "There was no evidence of disturbed perception or persecutory ideation. Her cognitive functioning was normal and consistent with her intellect". 1. He also said that she had well-developed insight and had deeply thought about professional misconduct and its context. She accepted responsibility for what she had done, she was aware of psychological vulnerabilities that she carried and "has made impressive attempts to remediate these vulnerabilities. This is reflected in her forthrightness, her preparedness to admit fault and to seek better alternative ways to deal with the problems that she failed to properly acknowledge and deal with in the past in her professional roles." 2. He said that her account of what occurred in the past and answers she gave to questions was consistent with the documentation. 3. He said that his opinion was that she was suffering from no overt psychiatric illness although she was experiencing some distress, having had her registration cancelled and having to come to grips with her misconduct. He said she had appropriately sought assistance through the General Practice Support Program of the RACGP. She had also been in touch with the Employee Assistance Program and was provided with three psychological consultations. She attended those and then decided she would benefit from further visits and had attended the fourth counselling session the week before Dr Diamond saw her. 4. Dr Diamond reached the following conclusions from his assessment of the Applicant:- • "She has accepted the reasons for the findings of the Tribunal amounting to professional misconduct in support of the determinations made; • She has responded to the cancellation of her registration in an appropriate and ultimately productive manner; • She has revisited the decision of the Tribunal and reflected upon her conduct; • She has made sensible and substantial efforts to address the substance of her professional misconduct; • She accepts responsibilities for her actions; • She does not blame others; • She has pursued additional training and instruction to remediate lack of knowledge and skill that was intrinsic to her professional misconduct; • She has viewed the misconduct from the perceptive of the deficient patient care and the effects upon patients subjected to her medical practice in the past; • She has formed an appropriate and clear understanding of the necessity to document medical notes and to refer to existing medical notes in the course of conducting medical practice; • The efforts at remediation of her shortcomings detailed in the body of his report were confirmed against the assumptions he was asked to make in his instructions; • He could find no evidence of a pre-existing or current psychiatric illness or disturbance and her psychological responses were consistent with her predicament; • The relevant psychological issues were described in terms of her personality features and appeared to have been identified and canvassed by the psychiatrist who saw her before the 2016 Tribunal Hearing; ; • The Applicant acknowledged features of her personality functioning in relation to a preference for harmony and compliance as opposed to being fearful of disharmony or conflict in the past; • The Applicant had explained relevant cultural features that had influenced her in the past. She appreciated that she followed the effects of her personality functioning and cultural heritage without careful thought or appreciating the need to depart from her habitual manner in the past; • She recognises the damaging and inappropriate effects of failing to address her responsibilities directly and to recognise the necessity to make independent and responsive decisions when carrying out the duties of a medical practitioner; • In his view she now has sufficient insight into the circumstances that led to her cancellation; • She now has additional insight into her personality vulnerabilities and how these conflicted with the responsibilities borne by a registered medical practitioner; • She does not in his opinion have any significantly different capacity to function appropriately and to express additional education and training so as to assist her in negating the expression of conduct that has cause to her having her registration cancelled; • He would support her request to return to the practice of medicine subject to conditions being imposed on her registration; • She accepts the need for these conditions and welcomes them as being additionally supportive of the changes she has made overall since her registration was cancelled; • She has also demonstrated the ability to practise without incident in the context of the patient. She has been compliant and respectful of the conditions that were imposed; • Reflecting the overriding requirement to consider the necessity to protect the public he supported her request to return to the practice of medicine subject to conditions as seen appropriate to meet the protection requirement; • His assessment of her is that she is a mature and balanced person overall; she has embraced enquiry, education and remediation of her shortcomings; • She does not suffer from a significant or dysfunctional or disabling personality disorder or any psychiatric illness; • She has shown notable resilience, determination and effectiveness over the years in overcoming potential hardship and also in emerging as a respected, supported and acknowledged individual within the medical fraternity that she remains a part of, within a community more generally and with her family; • She has retained the respect and support of senior practitioners who have engaged with her rehabilitation and who have provided mentorship; • Since the cancellation the inappropriate conduct that was the subject of the disciplinary proceedings, the Applicant has acted with effort and sincerity to overcome such conduct; and • She shows a lack of other features that would suggest that she is a recidivist or that she is likely to be susceptible to repeating the errors of her past." 1. Dr Diamond gave oral evidence on 14 February 2019 and was cross-examined on 13 and 14 February 2019. He confirmed the gist of his opinions that were in his report. He talked in answer to questions about pressure from patients. He said that some patients can be very demanding and they give rise to problems when trying to cope with them. Dr Diamond said that the Applicant identified four matters which were the cause of her cancellation. One was a lack of professional skills another a lack of knowledge. He said she had addressed those. Another was the deficiencies in her records and she had addressed that. 2. She identified the other problem was that she thought that she was a "fill in" doctor in a practice, the minute she saw herself as not initiating prescription of medications but merely repeating prescriptions that had already been prescribed by another "permanent" doctor in the practice. She did not have that problem when she was working in other practice and there made such decisions herself independently. 3. Another issue that she said arose was that she had not been allocating sufficient time for proper assessment of a patient before prescribing a medication which had previously been prescribed by a more senior doctor in the practice and she had not recognised that it was her responsibility to carry out a proper assessment if she was considering prescribing for a patient. She said she put that down to a lack of experience and it also involved her perceiving her role as a subservient to the role of the senior practitioners and part of her respect for them was to think that she should not contradict them in relation to what prescriptions she gave. She said it was a lack of experience that caused her to fail in relation to prescriptions of addictive drugs, naivety of doctor shoppers, ignorance of drug seeking behaviour and other addictive behaviours. 4. She denied that her failures were attributable to laziness or lack of care. Dr Diamond was asked whether the applicant identified laziness or non-caring as one explanation for her discretions, and he said that he did not get such an impression. He also said that such an explanation was not consistent with the efforts she has made to rectify since the complaint was made about her conduct. He said that obviously she could have done better in the particular practice and circumstances, but the reasons she did not are other than laziness and not caring. He said her insight now is "not total, but it is substantial and very different to what it was". He contrasted her behaviour since the cancellation and identified that as being more typical of her behaviour. He also said that such an explanation still did not fit the change in her insight which is quite substantial. In answer to a member of the panel, Dr Diamond said that he could not say for certain that the Applicant has developed skills to make her own independent assessments, but he said she does what she can and that it is at a level now where she should be able to return to practice with supervision. 5. In answer to questions from panel members, Dr Diamond confirmed that the Applicant had admitted the deficits in her skills and knowledge and identified them and undertaken education and experience in areas where there were deficits. 6. Dr Diamond said that he did not accept that her conduct, the subject of the disciplinary proceedings, could be attributed to laziness and lack of care. 7. In his oral evidence. Dr Diamond testified that the Applicant has expressed regret about the conduct which led to her cancellation. He also said that she had referred to the opinions of the more senior practitioners working with her whereas she now recognises the responsibility she has includes making her own assessment and her own decisions as to medication and other treatment. 8. He also said she had acknowledged the deficits in her practice and had addressed them through education and experience in those areas. He said that her response to the identification of these matters was "substantial and prolonged" and she had substantial insight and had undertaken extensive steps to remedy those deficits. 9. Dr Diamond also testified the Applicant had demonstrated considerable merit in addressing the issue of record-keeping and time pressures. He said that he "would suggest there be some limit on the number of patients she could see." He said that "her capacity to withstand pressure and resist inappropriate demands by assertive patients has increased, but needs to be tested". Expert Evidence for the Respondent – Dr S Howle 1. Dr Howle is a general practitioner with more than 40 years of experience and considerable expertise in that field. He was instructed by the Respondent to provide answers to particular questions in relation to the Application. He was provided with extensive material which is listed in Attachment "B" to his report. His curriculum vitae is Attachment "A" to the report. Dr Howle records in his report that he has read the Expert Witness Code of Conduct in the procedural direction of the Tribunal and agrees to be bound by the code. 2. The questions and summaries of the answers in his report are as follows:- Question 1: Is the training, education and observership/s the Applicant has undertaken since then sufficient to maintain her skill? Answer 1: I believe that these documents show clearly that she has applied herself diligently to ongoing training and education. As well she has spent some time observing both speciality areas and more recently in general practice. As a result I think that despite the lapse of active clinical practice for more than two years, the above should be sufficient to maintain her skill. Question 2: Are the steps in 1 above sufficient to address the deficiencies in her practice of medicine identified by the Tribunal decision with respect to:- (a) Her prescribing; and (b) Her medical record-keeping? Answer 2(a): While it appears that Ms Chen has addressed the deficiencies in her prescribing as described in the Tribunal decision of 28 November 2016, in my opinion should the Tribunal make a reinstatement order, such an order should be subject to protective conditions that restrict her ability to prescribe drugs of addiction. Answer 2(b): Similarly to 2(a) … I believe she has addressed this deficiency in her practice of medicine but feel close monitoring of her records would be advisable if she were to regain registration. She should be advised to make sure that her records comply with Health Practitioner Regulation (NSW) Regulation 2016 and the RACGP 5th Standards for General Practice, Standard 7 (pp 897). Question 3: If not, what further training and education would be required to address the deficiencies in her practice highlighted in the Tribunal decision? Answer 3: I think Ms Chen has answered these deficiencies adequately but as stated above conditions limiting her practice including careful monitoring of her consultations with feedback by a supervisor and further training and education is required. Question 4: Assuming that the Applicant is granted a reinstatement order provide your opinion as to what conditions, if any, would be appropriate in your view to ensure the protection of the public?. Answer 4: If the Applicant is granted a reinstatement order, the conditions as listed by Ms Chen herself are reasonable and comprehensive in nature and would ensure the protection of the public. Question 5: Subject to being provided with further documentation please comment on whether the Applicant is currently fit to return to the practice of medicine. Answer 5: Based on the information and the documents supplied, including letters from various medical practitioners especially from Dr Michael Diamond who assessed Ms Chen once on 13 July 2018, I believe the Applicant is currently fit to return to the practice of medicine. 1. Dr Howle stated limitations on his opinions provided in answer to the questions and those limitations can be summarised as:- • She should be limited to a practice in which the supervisor can observe her for at least one session per week for the first three months; • Further limitation is reported by Dr Murray Wright of an apparent character flaw "of susceptibility to environmental factors – time constraints, lack of available information, dominant patients" … Again this can only be seen to be adequately addressed by her performance in practice and this aspect of her personality should be made very clear to her supervisor. • I was unable to find evidence that Ms Chen had carefully read the "Good Medical Practice; A Code of Conduct for Doctors in Australia", 8.4 Medical Records and the RACGP 5th Standards for General Practices Standard 7 Content of Patient Health Records. It would be advisable to read both if she is granted a reinstatement order. • Re her ability to "exercise any independent clinical judgement" explored by Dr Murray Wright, based on the experience she has had in observing several experienced practitioners at work, she should have developed a lot more knowledge and ability to handle new and confusing clinical scenarios as happens frequently in general practice. • Subject to my limitations outlined above any reinstatement should be granted subject to the following conditions:- (1) To obtain Medical Council approval prior to changing the nature or place of her practice; (2) To authorise and consent to any exchange of information between the Council and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with the conditions. (3) To practice only in a group practice approved by the Council where there are at least two practitioners (excluding Dr Chen ) (a) Where the patients and patient records are shared between the medical practitioners; (b) Where there is always one other registered medical practitioner on site; and (c) Which is an accredited practice. (4) Forward evidence to the Council prior to commencing practice that she has provided a copy of her full conditions to:- (a) The principal(s) of the practice; and (b) The proposed Council-Approved Supervisor. (5) Not to possess, supply, administer or prescribe any "drug of addiction" (Schedule 8 drugs) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW); (6) Not to possess, supply, administer or prescribe any substance listed in Schedule 4 Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW); (7) To submit to an audit of her medical practice by a random selection of her medical records for person or persons nominated by the Medical Council of NSW and:- (a) It is to be held within six months from the date of recommencement of medical practice and subsequently as required by the Council; (b) The auditor(s) is to assess her compliance with good medical record-keeping standards and legislative requirements and compliance with conditions; (c) To authorise the auditor(s) to provide the Council with a report on their findings; and (d) To meet all costs associated with the audit(s) and any subsequent reports. (8) To practice under Category B Supervision in accordance with the Council's Compliance Policy – Supervision (as varied from time to time) and subsequently determined by the appropriate review bodies:- (a) At each supervision meeting the practitioner is to review and discuss her practice with particular focus on:- (i) Appropriate prescribing practice; (ii) Medical records with a review of 10 records; and (iii) To be observed by the supervisor in a number of her consultations and to observe the Supervisor during a number of his consultations. (b) To authorise the Council to provide proposed and approved Supervisors with a copy of the Tribunal's decision and the current conditions; (c) Not to practice until a Supervisor has been approved by the Council. (9) To nominate an experienced specialist general practitioner to act as her professional mentor for approval by the Council in accordance with the Council's Compliance Policy - Policies Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body:- (a) At each mentoring meeting the practitioner is to include discussion of the following:- (i) Dr Chen's continuing professional education; (ii) Her continuing personal development and well-being; (iii) Her progress in making independent professional decisions in the consulting room; (iv) Her ability to copy with the stressors of general practice with specific regard to proper medical records, but also with regard to interpersonal conflict with any members of the practice; and (v) Feedback from her supervisor with regard to her competence within the scope of her practice. (b) To authorise the mentor to report in an approved format to the Council if there is any concern about her professional conduct or personal well-being. Orders Sought in the Application and Respondent's Reply 1. The Applicant proposed in her Application that the orders filed 7 August 2018 that there be an order "That the Applicant be reinstated into the Register of Medical Practitioners subject to conditions". 2. In her supplementary statement of 7 November 2018, the Applicant said that she had been attending continuing medical education seminars and courses and provided evidence in that regard. 3. She stated that she had read Dr Howle's report and read the documents he suggested she should read regarding medical records in "Good Medical Practice: A Code of Conduct for Doctors in Australia" and the RACGP 5th Edition Standards for General Practices, Standard 7. She stated that she had read them again once she received Dr Howle's report. 4. She also stated the TEMPO Course she attended in October 2017 and the clinical observations she did in the practices of Drs Zhang and King all emphasised for her the importance of adequate and informative medical record-keeping. 5. In its Reply of 29 October 2018 to the Application the Respondent noted that it accepted that the Applicant had undertaken appropriate training, education and clinical observations to address the deficiencies identified by the Tribunal in November 2016 and the Council's expert had accepted that she had "applied herself diligently to ongoing training and education and the Council accepts this view". The Reply stated though, that if there were a reinstatement order made protection of the public would require the Applicant's registration be subject to conditions identified in Annexure "A" to the Reply. Similarly, in relation to medical records, if a reinstatement order were made Council would propose there be a condition requiring the Applicant to submit to a medical records audit. 6. The Reply also referred to the report of Dr Howle and proposed further conditions for the Applicant's registration generally in accord with the conditions recommended by Dr Howle. 7. The Applicant noted in her supplementary statement that the conditions proposed by the Medical Council were very similar to the proposed conditions set out in Annexure "K" to her statement of 14 September 2018 and Dr Howle had agreed that those conditions were "reasonable and comprehensive in nature and would ensure the protection of the public". 8. She referred to the recommendation of Dr Howle that she observe her supervisor "in a number of consultations". She noted that she had already observed an extensive number of consultations by other registered practitioners as she set out in her statement of 14 September 2018, but if further observation is required, for example for a period of, say three months, she would undertake it. 9. She also referred to Dr Howle's recommendation and the Reply of the Respondent that proposed discussion at each supervision meeting of "Medical records with a review of 10 records". She noted also that she has already proposed as had the Respondent in its Reply of 29 October 2018 that her medical records be subject to a random audit within six months. She therefore proposed that her supervisor could address the medical records in supervision meetings as the supervisor requires. Supplementary Statement of the Applicant and Oral Evidence of the Applicant 1. The Applicant was cross-examined by counsel for the Respondent on 13 February 2019 for about four hours. She also answered questions from the panel members. She impressed as a forthright and honest witness. She freely made concessions and admissions where appropriate. But the evidence she gave in cross-examination did not compromise the extensive evidence of the changes she has implemented since conduct that gave rise to the cancellation of her registration to avoid any further conduct such as was the subject of the complaints in the disciplinary proceedings against her. Agreed Orders 1. On 14 February 2019 the parties had previously agreed that a reinstatement order should be made. After the evidence was completed, the Tribunal was satisfied that the positive changes the Applicant had made since the cancellation order were such that a reinstatement order should be made (subject to conditions to provide additional protection of the public). After further discussions, the parties reached an agreement that if the Applicant were granted a reinstatement order, then the orders should include the imposition of conditions on the Applicant's registration as set out in pars 2 & 3 of the orders made on 14 February. 2. The Tribunal found on the evidence, particularly the expert opinions, and both parties agreed, the conditions that should be imposed on the Applicant's registration and other orders that should be made. The Tribunal was satisfied that such conditions and orders were appropriate for the protection of the public and the reputation of the profession and also for the trust and confidence the public should have in the profession. 3. For those reasons the Tribunal made the reinstatement order and orders 2 and 3 of 14 February 2019. Privacy - Non-Publication Order 1. In order to protect the privacy of any patient of the practitioner referred to in the reasons, order 4 of 14 February 2019 was also made in relation to possible broadcast or publication of identifying information of any patient. Costs 1. In these proceedings the Respondent in closing submissions sought an order that the Applicant pay one half of the Respondent's costs, which total $14,322.00. The Tribunal reserved on the costs issue on 14 February 2019. Accordingly, the costs Issue is dealt with in these reasons. 2. The Tribunal's power to award costs is in cl 13 of schedule 5D of the National Law. It provides that generally costs follow the event (See Health Care Complaints Commission v Philipiah [2013] NSWCA 342) and a successful party's costs will be paid by an unsuccessful party. 3. The Application was filed on 7 August 2018. The Applicant filed her statement and most of her documents (including Dr Diamond's report) in September 2018. From the filing of the Reply on about 29 October 2018, the Applicant was not opposing the application for a reinstatement order. The contested issue was what conditions should be imposed on a new registration. The Applicant has succeeded in obtaining a reinstatement order as sought. 4. After cross examination of the Applicant and Dr Diamond the parties agreed to conditions for any new registration. Both parties have acted to minimise costs in these proceedings. But the proceedings would not have occurred and the costs of the Respondent would not have been incurred if the Applicant's conduct had not given rise to the disciplinary proceedings in the Tribunal. 5. In all the circumstances the Tribunal finds that the fair order is for the Applicant to pay half the Respondent's costs of these proceedings ($7,161.00). That order is now made. Orders 1. The application by the applicant for a reinstatement order under s163B(1)(c) of the National Law is granted. 2. In accordance with s149A(1)(b) of the National Law, by consent, if the National Board grants an application by the applicant for registration, the applicant's registration shall be subject to the following conditions:- 1. To obtain Medical Council approval prior to changing the nature of place of her practice. 2. To authorise and consent to any exchange of information between the Council and Medicare Australia and Pharmaceutical Services for the purpose of monitoring compliance with these conditions. 3. To practise only in a group practice approved by the Council where there are at least 2 practitioners (excluding Dr Mengyi Chen): 1. where the patients and patient records are shared between the medical practitioners, 2. where there is always one other registered medical practitioner on site, 3. which is an accredited practice. 1. To forward evidence to the Council prior to commencing practice that she has provided a copy of her full conditions to: 1. the principal(s) of the practice, 2. the proposed and Council-approved Supervisor, 1. Not to possess, supply, administer or prescribed any "drug of addiction" (Schedule 8 drugs) as defined by the Poisons and Therapeutic Goods Act 1966 (NSW). 2. Not to possess, supply, administer or prescribe any substance listed in Schedule 4 appendix D of the Poisons and Therapeutic Goods Regulation 2008 (NSW). 3. To submit to an audit of her medical practice, by a random selection of her medical records by a person or persons nominated by the Medical Council of NSW and: 1. the audit is to be held within 6 months from the date of recommencement of medical practice and subsequently as required by the Council. 2. the auditor(s) is to assess her compliance with good medical record keeping standards and legislative requirements and compliance with conditions. 3. to authorise the auditor(s) to provide the Council with a report on their findings. 4. to meet all costs associated with the audit(s) and any subsequent reports. 1. To practise under category B supervision in accordance with the Council's Compliance Policy-Supervision (as varied from time to time) and as subsequently determined by the appropriate review body: 1. at each supervision meeting the applicant is to review and discuss her practice with particular focus on: 1. appropriate prescribing practice, 2. medical records with a review of 10 records, 3. for a period of 12 months to be observed by the supervisor in at least 3 of the consultations each month, and to observe the supervisor during at least 3 of her consultations each month. 1. to authorise the Council to provide proposed and approved supervisors with a copy of the Tribunal's decision and the current conditions. 2. not to practise until a supervisor has been approved by the Council. 1. To nominate an experienced specialist general practitioner to act as her professional mentor for approval by the Council in accordance with the Council's Compliance Policy-Mentoring (as varied from time to time) and as subsequently determined by the appropriate review body: 1. at each mentoring meeting the applicant is to include discussion of the following: 1. Continuing professional education, 2. Continuing personal development and well-being, 3. Progress in making independent professional decisions in the consulting room, 4. Ability to cope with the stress of general practice with specific regard to proper medical records, but also with regard to interpersonal conflicts with any members of the practice, 5. Feedback from her supervisor with regard to her competence within the scope of her practice. 1. to authorise the mentor to report, in an approved format, to the Council if there is any concern about her professional conduct or personal well-being. 1. Treat no more than 30 patients in any one day. 1. These conditions may be altered, varied or removed at the discretion of the Medical Council and the Medical Council is the appropriate body for the purposes of Part 8 of the National Law. 2. Broadcast or publication without the leave of the Tribunal of the name or other identifying information of any patient of the applicant referred to in these proceedings is prohibited. 3. The issue of the respondent's costs application is reserved. 4. Costs order made 23 May 2019: The Applicant must pay an amount of $7,161 to the Respondent towards its costs of or incidental to these proceedings. I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales. Registrar Amendments 23 May 2019 - Order 6 date amended. 23 May 2019 - Representation field corrected. 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: 23 May 2019