In Medical Board of Australia v Origanti [2024] VCAT 467, the Medical Board of Australia (the Board) took the unusual step of initiating concurrent proceedings against three medical practitioners under the Health Practitioner Regulation National Law relating to alleged issues with the supervision of Dr Rachel Ganthala (Dr Ganthala).
Background
Dr Ganthala qualified as a medical practitioner in Andhra (India) in 1988. She practised in India until around 1996, when she emigrated to Australia.
Dr Ganthala worked in a number of non-medical roles in Australia, before applying for and being granted provisional registration as a medical practitioner by the Board in October 2018.
As an IMG, Dr Ganthala was placed on a supervised practice plan by the Board. She was subject to the highest level of supervision, Level 1 supervision.
The Board’s ‘Guidelines: Supervised practice for international medical graduates’ (the Guidelines) define Level 1 supervision as:
The supervisor takes direct and principal responsibility for each individual patient.
- The supervisor must be physically present at the workplace at all times when the IMG is providing clinical care.
- The IMG must consult their supervisor about the management of all patients at the time of the consultation and before the patient leaves the practice.
- Supervision via telephone contact or other telecommunications is not permitted.
The Guidelines require every IMG under supervision to have a principal supervisor and allows them to have additional co-supervisors.
Dr Vasantha Origanti (Dr Origanti) was approved by the Board as Dr Ganthala’s principal supervisor and Dr Ashubabu Thadi (Dr Thadi) was approved as a co-supervisor.
Dr Ganthala commenced practising at Q1 Clinic at Hoppers Crossing under the approved supervision arrangement on 12 October 2018.
On 23 October 2019, Dr Ganthala applied for general registration as a medical practitioner, which was granted based on positive reports from Dr Origanti and Dr Thadi.
On 1 April 2019 and 10 October 2019, the Australian Health Practitioner Regulation Agency (Ahpra) received notifications regarding Dr Ganthala’s practise.
In the course of investigating these notifications, it became apparent that Dr Origanti and Dr Thadi had failed to provide the required level of supervision to Dr Ganthala. Specifically:
- For the period 12 October 2018 to 23 October 2019, Dr Origanti did not practise at Q1 Clinic at Hoppers Crossing at all and instead practised at a related practice in Highpoint. This meant that Dr Origanti, who was supposed to be the ‘principal’ supervisor, did not actually provide any day-to-day supervision of Dr Ganthala and instead met with her once every two to three weeks.
- Dr Thadi did practise at Q1 Clinic at Hoppers Crossing during the supervision period, but Medicare records confirmed that Dr Ganthala had practised on 93 days that Dr Thadi was not present at the Hoppers Crossing practise. The Tribunal also found that the supervision provided by Dr Thadi did not meet Level 1 supervision requirements and instead was “generally done on the basis of Dr Ganthala approaching [Dr Thadi] when she thought it necessary”.
All three medical practitioners provided inaccurate, false or misleading information to Ahpra and the Board either in the course of the supervision or subsequent investigation. This included by representing the supervision requirements had been complied with in work performance reports, supervised practice plans, Dr Ganthala’s application for renewal of registration and Dr Ganthala’s application for general registration.
The Tribunal found all three medical practitioners had engaged in professional misconduct, given the failure to supervise Dr Ganthala was almost a complete failure and the importance of IMG supervision to the Australian health regulation system. It was accepted that the failures identified related to issues of understanding, rather than a wilful dereliction of the required supervision, however the Tribunal considered the conduct was “at the upper end of the scale of reckless conduct”.
It was also considered an aggravating factor that Dr Ganthala saw a large number of patients during the period she was supposed to be supervised, with two cases identified where patients received inadequate care. It was also noted that Dr Ganthala continued to practise with inadequate supervision even after concerns were raised with Ahpra in April 2019. The public was therefore placed at risk by the actions of all three practitioners and some patients did suffer harm, which could be attributed to the lack of supervision.
In deciding on the appropriate penalty to be imposed, the Tribunal emphasised the most important consideration was general deterrence, noting the Australian health system heavily relies on doctors who were trained overseas to supplement the local workforce. The Tribunal stated it was necessary to demonstrate that such reckless non-observance of the standards of supervision required for IMGs will result in the imposition of at least a suspension from practice.
The Tribunal resolved that each practitioner would be reprimanded, with the following periods of suspension imposed:
- Dr Ganthala – 12-month suspension.
- Dr Origanti – 6-month suspension.
- Dr Thadi – 3-month suspension.
Dr Ganthala’s registration was also made subject to conditions relating to the completion of further education, a requirement to be supervised when practising and limitations on her practice.
Significance of supervision requirements and conditions of registration
This decision emphasises the significance with which any failure to comply with supervision arrangements or conditions of registration are treated under the Health Practitioner Regulation National Law.
We have assisted a number of clients who did not appreciate that a failure to comply with supervision arrangements or conditions of registration is a very serious matter. Some practitioners are of the view that some breaches of any conditions or supervisory arrangement must be expected and a degree of flexibility is necessary to allow for human error.
The Board’s ‘Good medical practice: A code of conduct for doctors in Australia’ (Code of Conduct) contains a number of general obligations requiring medical practitioners to behave ethically and in a manner that warrants the trust of the community.
In handing down this decision, the Tribunal referenced the following comments from the decision of Medical Board of Australia v Win (Review and Regulation) [2015] VCAT 1289:
The honesty and reliability of health practitioners is essential to ensuring that patients receive proper care and that patients and other practitioners may place trust in the expertise of those providing health care. It is also essential when practitioners are dealing with the Board and other regulatory agencies – those bodies rely on practitioners honestly providing information which is important to decisions regarding registration and other matters.
It is often the case that medical practitioners are asked to provide certificates or opinions in respect of patient’s Medicare claims, their capacity to attend work, study or undertake other activities and in connection with workers’ compensation and transport accident claims.
Medical practitioners are also asked to witness statutory declarations. Medical practitioners are relied upon by various organisations and the community at large to undertake these tasks honestly, mindful of their seriousness, and responsibly given the reliance that will be placed on their professional obligations and their word.
The Win decision concerned deliberately dishonest conduct on behalf of a medical practitioner, whereas in this matter it was accepted that all parties acted recklessly, but with no intention to disregard their supervision obligations.
Despite this, the Tribunal found that the “abject absence of reliability, accuracy and responsibility” justified a finding of professional misconduct even in the absence of intention. All three medical practitioners were held responsible for the failures, although the penalties imposed reflect differing degrees of responsibility.
There is a relationship between the obligations of trust, honesty and integrity outlined in the Code of Conduct and the commitments a practitioner makes when they undertake to provide supervision to a colleague. Put simply, practitioners are expected to meet their commitments, particularly where those commitments relate to healthcare and safe practice. A failure to properly understand such commitments can be seen as similar to a wilful disregard of those commitments, particularly where such a failure was reckless (as was found here).
In our experience, both the Board and judicial authorities treat any non-compliance with supervisory arrangements or conditions of registration extremely seriously. These conditions and supervisory arrangements play a significant role in the national regulatory scheme for individual health practitioners and it is imperative they are respected. Any ongoing or wilful non-compliance with such restrictions by a registered health practitioner will generally result in a period of suspension being imposed.
The recent Western Australian decision of Medical Board of Australia v Dave [2023] VR 86 is another example of this. Dave also related to non-compliance with conditions of registration with respect to the prescription of medications and supervised practice. 76 occasions of non-compliance were identified and there were also concerns about the provision of complete and accurate information to the Board regarding the supervised practice conditions.
The practitioner in Dave was found to have engaged in professional misconduct, reprimanded, his registration was suspended for 12 months and conditions were imposed on his registration relating to the practitioner completing education, mentoring and audits of his practice.
Importance of understanding supervision obligations
We have observed that many health practitioners have good intentions in agreeing to supervise their colleagues, but fail to properly consider the burden and significance of supervision obligations. Many practitioners agree to assist their colleagues in the spirit of collegiality and find it difficult to decline requests for assistance.
It is absolutely critical that any registered health practitioner who agrees to provide any level of supervision for a colleague has a complete and accurate understanding of their obligations under the proposed supervision arrangement.
In our experience, Ahpra is proactive in explaining the obligations of each party participating in a supervision arrangement. However, supervision arrangements can be confusing and relate to different regulatory processes. For example, ‘Level 2 supervision’ for IMGs under the Guidelines mandates a different level of supervision than ‘Indirect Level 2 supervision’ for the purposes of Ahpra’s National Restrictions Library.
It is therefore critical to seek advice if you have any concerns about your understanding of or compliance with any supervision obligations you are involved with.
If a supervision arrangement relates to an IMG registration pathway, then generally supervision obligations will be outlined in the Guidelines and in correspondence from Ahpra’s Compliance department. It is also helpful to check the public register entry of the practitioner who is under supervision, as their registration may be subject to conditions that provide further insight regarding the necessary level of supervision.
Where a supervision arrangement relates to a ‘notification’ or performance or conduct concern, the supervision obligations will generally be outlined in any conditions of registration of the supervisee practitioner’s registration. This is usually accessible via the Ahpra public register and will also be outlined in correspondence from Ahpra’s Compliance department. Generally, supervisors in this scenario must review the conditions of the supervisee medical practitioner as part of their nomination as a supervisor and confirm they understand their obligations.
If there are any concerns about your ability to continue to provide supervision to a colleague, it is important that you seek advice as soon as possible and consider withdrawing as an approved supervisor. Supervisors can withdraw from a supervisory arrangement at any time by communicating their withdrawal to Ahpra (and by extension the relevant National Board).
