Disclaimer 

The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided.  

Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 for specific advice. 

When should you inform your medical indemnity insurer about a potential medical negligence claim?

The MIPS Indemnity Insurance Policy states:

When You have to notify Us 

1. You must notify Us at the time You first become aware of: 
2. any Claim made against You; 
3. any Investigation or proceeding against You; 
4. any Incident that may give rise to a Claim against You; 
5. any condition or restrictions imposed on You or Your practice by registration bodies, Your employer, educational bodies, a healthcare facility or supervisor; 
6. any change in Your practice or provision of Healthcare (that includes amongst others the nature of Healthcare You provide or the location in which You provide Healthcare); 
7. any Claim made against a practice entity in which You have a direct financial interest; 
8. when You cease to be a Practitioner or cease to be a healthcare student; or 
9. if You become deregistered or lose Your right to practice or to provide particular healthcare services. 

This enables a contemporaneous investigation, statement of circumstances, obtaining a copy of the records and enabling a financial estimate of any risk. Failure to notify on time may prejudice your rights to indemnity and assistance.  

I've heard that medical practitioners shouldn't be afraid of saying 'sorry' when things go wrong at the practitioner's fault and that it can even minimise the harm done when the patient or the family receives bad news. Ignoring the moral virtue of taking ownership and apologising for one's wrongdoing or mistakes, is there any circumstance where apologising be taken admission of liability, and how must one tread this ground?

MIPS supports open Disclosure as stated in AHPRAs code of conduct. It is a government initiative and practised widely in public hospitals. An open and timely discussion with the patient when things go wrong, including an agreed management plan, can go a long way to mitigating outcomes. An apology such as an expression of regret /sympathy is preferred rather than an admission of liability. Always report these incidents and discuss with MIPS your plan for open disclosure and saying sorry.  

What comeback do surgeons have when our medico legal "expert" colleagues write reports that are so blatantly inaccurate and give opinions that would fail a fellowship examination

This can be a problem, but it is ultimately up to the court to accept an individual as an expert and assess the strength or weakness of their evidence. Generally, only peer experts are accepted. For example, a city ED consultant should not comment on the actions of a remote non procedural GP. There have been limited cases of such concerns being drawn to the attention of relevant Colleges and Law Institutes. Those so called “experts” usually become well known in the medical indemnity defence industry.  

Please discuss, legal/litigation influence of AHPRA Code of Conduct 'Good Medical Practice and other AHPRA accredited Medical College guidances on an expected standard of conduct and clinical practice eg RACGP (eg in respect of opioid and benzodiazepine prescribing) or others eg Faculty of Pain Medicine ANZCA (eg on cannabinoid prescribing).

You should take all reasonable steps to adhere to AHPRA codes and Colleges guidelines, but note that any guidelines are just that. Depending on the circumstances of the case and how the plaintiff’s team run their case they may or may not be significant. Equally important are local hospital/employer protocols that doctors should follow as they will be investigated. Ultimately it is the relevant legal principles such as liability, causation, foreseeability etc, which are the main factors assessed and judged in litigation. Certainly concerning AHPRA investigations, the Medical Board Code of Conduct is likely to be applied in assessing the adequacy of your conduct or behaviour. 

As a junior doctor who is many years away from private practice, how much should I be worried about litigation, and what can I do now to prepare myself and develop good habits?

Not that worried as it is rare considering the number of practitioners. As a junior doctor, you are employer indemnified. That is, your employing hospital is vicariously liable for any confirmed negligence on your part, not you personally. Each State /Territory has insurance arrangements in place for its public health institutions. You should continue to maintain your MIPS membership/insurance as we will ensure that your hospital does indemnify you, provide cover for coronial inquests, assist with AHPRA/Drugs & Poisons etc., notifications and investigations as well as provide 24/7 clinico legal advice and risk education. 

Is there a specific source we can refer to gain knowledge of the legal side of clinical practice in Australia?

The University of Melbourne provides resources as well as some law firms such as Barry Nilson. 

Your local Law Institutes and Medical /Dental Colleges occasionally run such courses.  

Why are our time and energy not compensated as a fee that MIPS can recoup from the opposition legal team and claimant when costs are awarded against them?

This can be frustrating. There is currently no legal ready to recover this. Even though the court can award costs against plaintiffs, it is often difficult to actually recoup them. They also are not reflective of the entire expense incurred. Any funds that are recovered are paid back into the membership asset pool.  

If a patient has signed Advance Care Directive (ACD) and wants no invasive treatment, but the person listed as the substitute decision-maker wants the patient to receive invasive treatment, what is the right approach? To treat to not to treat?

If the ACD is current and valid and the substitute decision-maker does not need to be engaged, the ACD would apply. Suggest you do obtain your hospital, employer or MIPS advice.  

How does NDIS impact catastrophic claims payouts? 

Ndis – What you need to know about compensation  

• What is compensation? 
• What compensation is relevant to the NDIA? 
• Why is compensation relevant to the NDIA? 
• What do you need to tell us, give us, and why? 

Could you please share some information on cases where damages awarded are greater than MDO cover? How common is this, and how does it usually end?

Policies in Australia typically provide $20 million covers, as indeed does MIPS. However, different policies apply different sub-limits to non-civil claims – meaning that specific cover will vary between policies. There has not been a MIPS case where the damages awarded plus legal costs have come anywhere near $20M. One of the most expensive medical indemnity cases in Australia was the Simson V Dr Diamond case in NSW, originally $14.2M reduced by $3.2m on appeal in the early 2000s, which partly resulted in the medical indemnity insurance crisis, a range of tort reform and changes to medical indemnity insurance.  

Could surgical assistants be involved in liability?

They are likely to be named in proceedings as they were involved in the surgery. The exact circumstances of involvement, level of supervision, etc., would need to investigated to determine if and what contribution might apply to the surgical assistant. Please ensure your current member classification will indemnify you for such practice.  

If a doctor is a full-time permanent employee of the public hospital in QLD and treats a private patient in a public hospital, in case of any issue, is the doctor also liable, or just the hospital is liable?

This will depend on the employment agreement in place between the hospital and the practitioner, which should clearly spell out indemnity and other rights and obligations in the event of a private patient being treated.    

What is the current maximum threshold for all "damages" in eg Victoria? 

Damages for non economic loss (general damages/pain & suffering /compensation) are only recoverable where a plaintiff has sustained a significant injury” (not applicable to sexual offences). In injury other than psychiatric injury, the impairment must be more than 5%, and for psychiatric injury, 10%. Experts must assess impairment as permanent. The cap is indexed annually and is currently in the order of $620,000. The big ticket items are economic loss, loss of earning capacity, attendant care (plus interest and super). In catastrophic cases, these can be very substantial, and in theory, there is no cap for them. Still, the assessments must be substantiated by detailed medical and other expert evidence and agreed by the parties or determined by the court.   

Is it fair to state that most claims are successful when both court rulings and out of court settlements are taken into account?

That is a fair comment. However, for the most part, plaintiff solicitor firms are diligent in what cases they will take on. Those firms that provide a no win no fee model carefully triage out those cases that “have no legs”. Many claims are settled at conferences, at mediation and the door of the court. Many are settled with effectively no settlement on the basis that both side “bear costs and walk away”. It is rare for cases to go to trial and judgment.  

We thank you for sending in your questions in the comments section during the 'Dealing with errors and the plight of perfectionism' webinar. In order to address all your unedited questions, the following is a summary we have split into a selection of general categories:

1. Any suggestions for good coaching book/ mainly dealing with how to prevent or treat doctor burnouts?

• The resilience factor by Karen Reivich, PhD & Andrew Shatté , PhD.
• Developing Resilience by Michael Neenan

2. I am not clear with confirmatory bias. Please explain in simple. Thank you.

This is our tendency to see what we want to see of expect to see. We tend to search for information that is confirmatory, we weight this evidence more heavily than disconfirming information, and we interpret ambiguous information as consistent with what we already believe or want.

3. Are the growth and set mindset a bit or nature vs nurture? To some extent some people just "got it" or don’t, right?

When it comes to fixed mindset it is common to think that is genetic; we either have it or we don’t. But we know from research is that the adult brain is malleable and there are also epigenetic factors at play. Thus, you may have inherited a gene, but it may not get triggered until you experience certain experiences in the environment and we also kno

w that genetics it is not synonymous with biology. When you practice and work on something the part of your brain that controls that function gets more neurons in it, more neural connections. You’re changing your biology. So, this is much more complex than we ever realised.

4. What are your tips for junior doctors who are trying to navigate a unbiased decisions but within the hierarchies that exist in medicine?

Do you mean if you see someone senior making a biased or incorrect decision? It’s important to speak up. You can do this respectfully by posing a question – “I was wondering if it might be possible that this patient is suffering from X”

5. The operational governance often clashes with clinical governance structure when it comes to risk management. How do you think we navigate through it? especially since a clinical mindset has different priorities than operational managers.

This is a difficult issue. It is the job of the organisation’s top leadership to make sure that operational and clinical governance align but unfortunately this often does not happen.  For the clinician caught in this, talking with senior clinical colleagues, those in top leadership positions, can be helpful. Point out the gaps that you see, and how these gaps are interfering with good clinical practice, and then offer to help, perhaps by leading a project to close one of the gaps. 

Resources

Dealing with errors and the plight of perfectionism handout

Dealing with errors and the plight of perfectionism on demand          

Disclaimer 

The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided. 

Thank you for attending our most successful webinar to date. We appreciate your engagement throughout the presentation and present to you below the answers to your questions received before and during the webinar.  

If you require further clarification contact MIPS on 1800 061 113 or via info@mips.com.au 

How can general practice manage unvaccinated patients and staff? 

MIPS recommends that all practice staff should be encouraged to get vaccinated. We are aware of at least one private employer who has made getting the vaccine a requirement for staff. Practitioners must be aware of legal implications regarding enforcement, but you are able to make it a requirement to staff where it reasonable and practicable to do so. See Safe Work Australia for employer guidance. 

For patients, practitioners should encourage the uptake in line with the Australian Government’s public health program and directives.

Current COVID-19 vaccine issues are very difficult to discuss with angry and anxious patients. What tips can you suggest dealing with such patients? 

 Although COVID-19 has created a heightened level of anxiety in the community, practitioners are encouraged to always remain calm and exercise foresight even more so when dealing with challenging patients. Implement treating methods best suited to dissipate the levels of anxiety in accordance with your Code of Conduct We have provided a summary of key tips at the end of this Q&A that you may find useful.

How do we talk rationally to misinformed militant anti-mask, anti-vaccine, COVID-19 conspirators/deniers who quote case studies and bad research as their evidence? 

MIPS recommends keeping your advice professional, concise and clinical. Do not entertain broader discussions. In MIPS’ experience it is unlikely you will convince or sway those with strong beliefs to the benefits or value of the vaccine. Engaging in further discussion may not lead to any significant outcome immediately and the individual may only change their mind in the days or weeks ahead.  Be sure to take care in documenting discussions. 

If a patient refuses to be COVID-19 tested or refuses to be vaccinated how much should we document?

You should document carefully not only that the patient refused but cite a short summary of their reasoning and the advice you provided. Some of the questions you can ask yourself are:  

• “Did I outline the risks and benefits?” 
• “Did I direct the patient to valid online resources?” 
• “Did I provide printed materials to inform them?”

Can we self-organise basic blood test and throat swab collection for COVID-19 test? 

Yes, there is no barrier to tests being conducted from a doctor’s clinic. For example, Queensland health advises “General Practice doctors, or GPs, can do COVID-19 testing or arrange these through private pathology providers, or they will refer you to another facility (like a pathology collection centre) for a test”. Pathology labs have instructions for clinicians. See Melbourne Pathology for example.

Does MIPS indemnity include missed diagnoses etc due to using telehealth? 

Yes, telehealth is a standard part of healthcare and MIPS’ insurance cover, subject to the terms and conditions of the policy. You need to be mindful that telehealth can only be used where it is appropriate and there are MBS and AHPRA guidelines. Where a consultation ought to be done in-person but isn’t, any issues arising will not be as easily defensible and your care may be criticised. See MIPS’ full list of COVID-19 resources.

Who is responsible for COVID-19 vaccination complications? 

Where the matter relates to a product (vaccine) issue, then the manufacturer of the product (vaccine) will be at fault. If a member becomes involved in this type of allegation, MIPS will indemnify and assist to ensure the appropriate entity (vaccine manufacturer) is held accountable. Where the matter relates to a negligent act or omission concerning the administration of vaccine, then the practitioner is likely to be responsible. We are yet to receive more information regarding the Federal Government’s COVID-19 indemnity scheme. See MIPS’ full list of COVID-19 resources. 

How do we deal with patients who ask for mask exemption? 

It is lawful not to wear a mask if you have a medical condition. Exceptions may be provided where warranted. The requirements for this vary in each state. In NSW people need to have proof of an exemption such as a certificate from a doctor or the NDIS. In Victoria, the Department of Health and Human Services has not defined what medical conditions are, but has advised that an exemption is suitable for people “who have a physical or mental health illness or condition, or disability which makes wearing a face covering unsuitable, including persons with obstructed breathing, a serious skin condition of the face, an intellectual disability, a mental health condition or persons who have experienced trauma”. Please check your local jurisdiction Department of Health advice.

Non-compliance, non-attendance, aggressive and rude patients: How and when can you disengage and end their practitioner-patient relationships?

You can disengage with a patient provided you meet your code of conduct requirements. You have an ongoing duty to treat the patient in an emergency, but Australian law does not compel you to continue to see a private patient. If you do choose to end a practitioner-patient relationship you should document this in your notes and the reason (see Good health records support a good defence). If your notes illustrate this, the matter will be more easily defended should there be a complaint or claim.

You should consider if the patient’s best interests are being served by ending the relationship. If the relationship has deteriorated and there is no longer trust or good communication, it may be in the patient’s best interest to see another practitioner. Where possible, ending a relationship this should be done in person. If you are concerned the patient will return and be rude or violent, you can further protect yourself by putting this in writing following your conversation. If the patient does not respond, you need to exhaust your follow up procedure, see How far to go in follow up.

How should practitioners approach separated parents when there is a difference in the thoughts about a child's care, or there is a bitter relationship between the parents, for example they can't agree or even be in the same room? 

Your first priority should be to cater to the best interests of the child, while always adhering to any court orders. See MIPS’s practice note Separated parents - Don't become the meat in the sandwich.   

What about rural and cross cultural, literacy and language issues? And after hours VMO and rural?

As per section 4.3.7 in the MBA Code of Conduct, you must take all practical steps to ensure that arrangements are made to meet your patients’ specific language, cultural and communication needs and you are aware of how these needs affect a patient’s understanding.

Further information and support:  

• The Australian Government Translating and Interpreting Service (TIS) or 131 450
• Aboriginal and Torres Strait Islander fee-for-service language interpreters are available through state-based services.
• Aboriginal Interpreting WA
• 2M Language Queensland
• The National Auslan Interpreter Booking and Payment Service

What's MIPS’ advice on allowing patients to record consultations and can we audio record the consent in terminal cases? 

Laws for recording conversations are state-based. With few exceptions, you must obtain the consent of the patient. This applies in reverse and patients must obtain your consent. If you think you are being surreptitiously recorded, it is reasonable to advise the patient that it is unlawful for them to record the consultation without the consent of everyone present and ask them to cease the recording. See MIPS’ practice note Are you being recorded?

How do you show empathy to a rude patient is being disrespectful?

Always ensure your approach is consistent as with all consultations; maintain good eye contact, be conscious of your language and tone and show interest. It may help to tell your patient that you are offended but, in some cases, you will have to accept that no matter how conscious and polite you are, you will not be able to win over a challenging patient. Always try to remain calm and professional. 

How do you disengage with a patient on long-term opioid therapy from a previous practitioner when they are refusing to engage in a pain management programme and not likely to be taken up by another GP?  

You should aim to pro-actively manage your patients’ expectations from the outset of a therapeutic relationship. Issues to cover during the consult: 

• Risks and benefits expected 
• How to manage potential side effects 
• The consequences of not following the health advice you are providing 
• Financial costs involved 

If the situation does not improve, you can always terminate the therapeutic relationship if you are unable to reach an agreement or common ground with the patient. Ensure you comply with your obligations under the MBA Code of conduct 

Good medical practice involves ensuring that the patient is adequately informed of your decision and facilitating arrangements for the continuing care of the patient, including passing on relevant clinical information. 

How do we deny unreasonable demand by patients? Eg Young patient demanding Oophorectomy?

Here are some tips to guide you through dealing with patients who make unreasonable demands:

Do not feel obliged to accept the request and give in to unreasonable requests. All treatment must be clinically justified and properly investigated. If appropriate, find a way to say “no” in a respectful and neutral way so there is no room for ambiguity. 

Seek to understand why the patient is asking for the drug or treatment. This approach will allow you to determine where you need to focus your attention and establish what is at the heart of the matter.    

Explain why you are unable to meet the request and the clinico-legal reasons that guide your judgement. Clarify to the patient that it is not a personal decision.  

Convey that your decision is in their best interests and try to arrange extra time to discuss the issue in further detail.  

Explain the clinical and scientific reasons why additional tests or referrals are necessary before a definitive diagnosis can be reached.  

If you think the therapeutic relationship may be severely compromised, you may consider terminating the relationship. Be mindful to keep a professional attitude and refrain from making this situation personal. You have the legal and ethical obligation to ensure and facilitate the continuity of care as you transition the patient’s care. You must also comply with the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia when ending a doctor-patient relationship. 

What about patients taking notes in the consultation about the consultation? 

This is reasonable and you cannot ask a patient not to take notes. Where you suspect a patient is doing this to ensnare you or document something to create evidence for their own civil proceedings, your best defence is to take good notes. You can also call MIPS for assistance and speak with an experience clinico-legal adviser to help you document the consultation. See MIPS’ online unit, Health Records.

What is the difference between doctor shopping and drug information from the Qld state?

Doctor shopping refers to patients who deliberately seek to obtain more medicines than they clinically need. This is often achieved by booking consultations with different doctors without disclosing their previous visits. Some characteristic behavioural patterns are:

• Lives or works far from the practice or may claim to be from out of town. 
• May present to the practice without a booking or late in the day. 
• Makes appointments with different doctors. 
• Insists that prescriptions have been lost or they ran out early. 
• Gets distressed if told ‘no’ to their requests. May make threats and/or offer bribes. 
• Asks for specific drugs by name. 
• Asks for brand names. 
• Requests to have the dose increased. 
• Claims multiple allergies to alternative drugs. 
• Displays anger or irritability when questioned closely about symptoms such as pain.

Some States and Territories have implemented real-time prescription monitoring services to inform healthcare practitioners about their patient's registered medicines usage, outside of their consultations.

Health practitioners across Australia can access the Australian Government’s Prescription Shopping Programme where they can verify a patient’s PBS subsidised medicine prescription history to help them make more informed prescribing decisions. The information service is available 24/7 on 1800 631 181. Only frequent drug seeking patients will be flagged by the system when they have received 25 prescriptions from six or more medical visits. The service does not monitor private scripts or those from the Department of Veterans’ Affairs.

A patient seeking drug information, on the other hand, may seek information about drugs and their effects. Refer to QLD government drug information 

Is it okay to have a practice nurse sitting as witness, when anticipating a difficult consultation?

Absolutely yes. They can serve as a deterrent for poor behaviour and can independently verify your’s or the patients conduct. Most forms of chaperones can be highly helpful and in MIPS’ experience can improve the quality of healthcare.  

Can you refuse to do home visits?

Yes, but you must consider the context, for example, have you seen the patient before and set a precedence to do home visits? It may be a reasonable alternative to conduct a consultation over the phone or via video and ask patients to present to you at a later date.

6 key tips when dealing with challenging patient interactions

1. Always remain calm and professional.  
2. Consider your own safety by undertaking a rapid risk assessment. However, if that is not possible (and the patient is showing signs of being abusive or physically violent) offer to speak with them in a quiet place (with a witness) and close to an exit or doorway. 
3. Hear the person out. Active listening. This is often lacking in high stress and busy environments which can then create a spiral of negativity and a breakdown in communication. 
4. Acknowledge the person’s frustration/anxiety/other issues of discontent. 
5. Always use active listening techniques like nodding and maintaining good eye contact, exercise empathy and remain in ‘control’ (but not ‘controlling’). 
6. Use positive body language techniques to help convey your message. Such as:

•  Maintaining good eye contact – scanning and making regular eye contact to all present in the conversation of more than one person on the conversation. Sitting or standing to mirror the person to whom you are speaking.  
• Exercise appropriate body orientation – don’t put a desk or object between those in the conversation, circular seating plans are best for groups or difficult conversations and ensure your body is facing or oriented to the person/s with whom you are communicating.
• Be expressive but refrain from over-expansive hand gesturing. Overuse of expansive gesturing is perceived as power and not effective for collaborative conversations/presentations.
• Try to maintain a relaxed face during difficult conversations– smiles convey confidence and immediacy but may not be appropriate in all difficult conversations.

Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 for specific advice. 

Disclaimer 

The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided. 

Thank you for all your questions both pre webinar and all the interaction during the event. We have not answered all questions as some relate to clinical issues (this was education about communication and professional behaviours) and some issues were beyond the remit of MIPS.

We have also provided the poll results and some fellow member chat box comments (deidentified) which you may find interesting.

If you require further clarification contact MIPS on 1800 061 113 or via info@mips.com.au 

A patient questioned my qualification and competency based on my accent. I felt quite upset and bullied by his comments. So my question would be.. how do you stop this communication from a patient without not being emotional? I feel like there is more to the story for his behaviour but I was so disgusted by his attitude and manner that I have asked for him not to be booked back in with me.

Clearly an unpleasant experience for you and it would be difficult to not be effected emotionally. We would suggest you calmly outline your qualifications and the fact that you are AHPRA approved to provide healthcare in Australia.   You can also advise him that patients are free to seek healthcare elsewhere if they wish.  If the patient does not back down with his attitude, you should advise him that your practice does not tolerate rude or bullying behaviour from patients. It is then your right to terminate the consultation.

Why is there no process to manage hospital culture?

Each health service or healthcare practice is responsible for their own workplace.  They have a legal requirement to provide an appropriate and safe workplace culture according to the jurisdictional work, health and safety laws.  If an unprofessional workplace culture is brought to their attention, they are duty bound to deal with it.  It is up to us, as practitioners, to hold management accountable for their duty of care.

What about the implementation in a patient/significant other escalation system for patient care?

Ideally there should be such systems in place, and they have proved to be effective tool in de- escalating family concerns and improving patient safety. They will vary in power and impact depending on the size and culture of the health service involved.

Do we have some kind of warning system Re the Henty’s of the world?

As mentioned in Question 2, the workplace environment is the responsibility of management and we practitioners need to ensure we do our job of notifying them.  There are however other avenues that can be explored.  AHPRA, for example, has a duty to investigate behaviour if it is in breach of Section 5. of their Good Medical Practice publication entitled: Respectful Culture.  This is especially so when a patient is harmed.  These are always difficult issues, and we would encourage you to contact MIPS for advice and support to determine the best way forward.

Perhaps all of the characters in this play are in need of help?

That is a very fair comment. There were many areas for improvement.  The key message we tried to highlight is the need for effective and professional communication between all staff members, and between staff and patients / families.   We tried to highlight the need for respect, the role of listening and the need to provide a professional non-toxic work environment to allow effective teamwork.  This enables practitioners to function at their best and helps to ensure optimal patient care.  This is an enormous topic which we hope members will continue to reflect upon in their own practice.  Communication courses are widely available.

Shouldn't Dr. Henty be reported to the Medical Board? He seems to have unscarred in this scenario? No absolute reprimand, since he has the option of relocating to another Hospital.

As mentioned in Question 4., a notification to AHPRA is the prerogative of everyone involved, whether it be Mrs Bryant, the CEO, the medical or nursing staff.  Following the Coronial Inquest, if the Coroner was sufficiently concerned about Dr Henty’s behaviour, the Coroner is also obliged to report that to AHPRA.  We must remember that as healthcare practitioners we have a mandatory requirement to notify AHPRA of colleagues if we believe that their behaviour or practice may place the public at risk.  As mentioned, this is a difficult decision to process, and as such, MIPS is always available to discuss your situation and help you determine whether you have reached a threshold for reporting.

Any comments on the underperforming junior staff? Also not uncommon.

As supervising practitioners, we have a clear duty to manage underperforming staff.  Junior practitioners and/or those within training programs must meet minimum standards in terms of competency and development to ensure patient safety.  Fair and reasonable critiques, where there is underperformance, is not bullying or harassment, but should always be carefully considered and documented.  Skilful communication is, as always, at the heart of effective feedback.

Chat box comments

POLL RESULTS

Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 for specific advice. 

Thank you for attending our webinar Understand, respond and reflect – the art of active listening . We appreciate your engagement throughout the presentation and present to you below the answers to your questions received before and during the webinar.  

1. I think I find it difficult when a patient has many doctors that talk to one another or don't care about what each other wants/needs.

Insufficient cooperation and coordination, together with poor communication practices, can pose significant barriers not only to achieving effective patient transitions and engagement while receiving primary care, but can also cause medical errors and unintentional harm to patients.

Efficient communication depends upon the healthcare practitioner taking practical steps to ensure they have really heard and recorded the patient’s needs so as to provide personalised and timely care.

You can actively decrease the risk of patient harm and communication errors, by adopting active listening skills and ensuring you maintain adequate health records.

To reduce your clinico-legal risk, MIPS advises you to:

• Implement active listening behaviours into your practice, to ensure your communication approach is clear and intentional. This includes:
  • Avoiding unnecessary distractions.
  • Looking directly at the person with whom you are engaged in conversation and asking questions to confirm your understanding:
    • “Can you give me an example of . . .”
    • “How frequently does this happen?”
• Rephrase what you understood and ask the patient to confirm what you have just said. 
  • “What I hear you saying is . . .”
• Let the patient finish speaking and then clarify their meaning before you formulate your response.
• Ask open ended questions and avoid making conclusions too quickly.
• Ensure the content of patient health records is accurate and up to date, including any lifestyle risk factors. Health records should include:
  • How long a patient has been attending the practice.
  • The management planning, preventive health interventions and referrals made for a patient.
  • Evidence of care provided by other healthcare professionals for long-term patients.
• Timely review and action on tests and results:
  • How long a patient has been attending the practice.
  • The management planning, preventive health interventions and referrals made for a patient.
  • Evidence of care provided by other healthcare professionals for long-term patients.
  • Notify patients when a practitioner leaves your practice.
  • Look back and review previous patient entries and test results.
  • A patient sitting in front of you, even in a one-off consultation to get a prescription – is your patient and you have a duty of care.
  • Failure to adequately do a handover to another practitioner or institution potentially gives rise to an adverse outcome.

2. It is critical that senior clinicians lead by example. if we practice with empathy, our junior colleagues learn from us and do the same.

Empathy has been recognised as a significant skill in healthcare. It is crucial for health practitioners to accurately assess their patients’ feelings, opinions and experiences in order to evaluate their real needs and act accordingly, offering patient-centred care. Reaching this goal makes the development of empathetic skills necessary.  Empathetic modelling from senior clinicians, professors and healthcare leaders enhances junior practitioners’ empathy including mental flexibility, regulation of emotional self, and perspective taking practices.

3.Can you comment on the use of directing follow-up time to patients?

Follow-up is the act of contacting a patient or caregiver at a later, specified date to check on the patient's progress since his or her last appointment. Timely follow-ups can help you to identify misunderstandings and answer questions, make further assessments or adjust treatments. In addition, follow-up promotes good therapeutic relationships between you and your patients.

• Decide on the reasons for follow-up.
  • Monitor health status and treatment progress.
  • Re-state treatment instructions and action plans.
  • Confirm medicine regimens.
  • Book appointments.
  • Verify follow-through on allied health referrals.
  • Communicate laboratory results.
• Identify who will follow up with patients.
  • Who follows up depends on the purpose of the communication (primary care clinician, nurse, other practice staff)
• Choose the ways your practice will follow up.
  • Phone
  • Secure email
  • Postal mail
  • Automated calling system
• Track your follow-up
  • Record all follow-ups in the patient’s health records

Disclaimer 

The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided.

If you require further clarification contact MIPS on 1800 061 113 or via info@mips.com.au  

We thank you for sending in your questions in the comments section during the 'Self-esteem and Body Image - A growing social and community issue' webinar. In order to address all your unedited questions, the following is a summary we have split into a selection of general categories: 

Questions:

• Cosmetic surgery is higher in higher socio economic population. So is it a problem of riches?

No.   People of all income and social levels are seeking surgery or less invasive procedures.  This is now the third most common reason to get a bank loan (after a mortgage and a car……)

• As a practitioner, how do we access the PAT to be able to incorporate in our practice?Access agreements are under discussion.  
  

This will either be via an organisation (such as MIPS), or as an individual.  We hope to have this in place by the beginning of April 2023.The difficulty is that there is no ACM accredited college for aesthetic medicine currently, yet many of us would benefit from being part of the pilot.  I would very much like to be kept updated in the progress of rolloutThank you.   We will let you have details of how to use the PAT as soon as they are finalised.

• Do you think religion can play a role? Preaching created from God image therefore not to change

For those with strong religious beliefs this might be helpful – but an understanding that appearances have a less strong role in happiness, social & occupational success etc is also necessary to reduce levels of dissatisfaction & distress.

• What about people who are ugly and feel fine?

This is to be encouraged!  These people are usually more psychologically resilient and have higher levels of wellbeing/happiness.

• What are the characteristics of the 20-33% of people who are not bothered?

This group have higher self-esteem, a sense of self-worth that is built on a variety of attributes other than appearance (for example, sense of humour; skill in a sport or hobby; social skills; success at work, etc), a lower reliance on the opinions of others for their sense of self-worth, and a pre-disposition to be ‘half-full’ (optimistic), rather than ‘half-empty’ (pessimistic) in their view of the world.

• Doesn't the gender surgery fall into this topic as well? ("I'd like to be someone else")

There are some similarities……the two areas can certainly share unrealistic expectations about the likely psychological & social gains after treatment…but more research is needed in both fields.

• To what extent does this pertain to Gender Dysphoria and those seeking Gender reassignment surgery?

See answer to previous question….

• Does body art (tatoos) fall into the same category as aesthetic medical or dental procedures as an indicator of self esteem and body image ?

Body art is often a statement of identity/individualism.  Aesthetic medical/dental procedures are more often about achieving a perceived ‘norm’ of appearance (ie to look like other ‘desirable’ people.

• Working in forensic medicine - I am concerned about children and young people, even adults who are watching pornography and developing ideas about perfect genitals and seeking surgical changes.  Many vulnerabilities and exposure to non-medical, backyard solutions etc any thoughts on this area?

Yes – absolutely – I share this concern.  Access to pornography (via smart phones) etc, gives people very unrealistic ideas about norms of appearance of genitalia and other body parts (e.g. labia; breasts).   Instead of understanding the enormous variety (& lack of symmetry) that exists in the broader population, viewers come to think they need a particular type to be acceptable. 

• How do you differentiate between those patients seeking cosmetic surgery who have issues with self-esteem and psychological vulnerabilities and their suitability towards said procedure?

The Patient Assessment Tool (PAT) is designed as a first step in identifying different types of psychological vulnerability (including low self-esteem), highlighting potential risks for sub-optimal outcomes following aesthetic treatment and suggesting appropriate ways of managing these risks.  In some areas of vulnerability, it is suggested that a fuller psychological assessment would be beneficial.  

• A lot of female sales reps and those in the media who are getting older often have minor cosmetic procedures as find it helps their employability. What can be done about this as they are still judged by their appearance

Yes, there is more pressure for people in some professions.  An education programme for employers and employees is needed to bust the myths about appearance on both sides of the equation and also to persuade employers that the skill/talent of the employees is going to be more closely related to their productivity than their appearance 

 MIPS' advice

The law differs between States and Territories but most prohibit recording of consultations without the specific consent of the patient.  

Ensure you contact MIPS for 27-hour Support and Advice on 1800 061 113 in the event of an adverse event or where there is a threat of a claim or notification made against you. 

Resources

Good medical practice: a code of conduct for doctors in Australia

Dental Board of Australia: Code of Conduct          

Author: Dr Owen Bradfield

In a recent webinar, MIPS Chief Medical Officer, Dr Owen Bradfield addressed the most asked questions by our members regarding voluntary assisted dying (VAD). 

While our panel of experts including Prof Ben White from the Australian Centre for Health Law Research, Melanie van Diemen, a care navigator at Peter MacCallum Cancer Centre, and Dr Andrew Bendrups from Royal Melbourne Hospital provided valuable insights during the webinar, there were additional member questions that could not be covered due to time limitations. 

As a result, we have compiled answers to address the outstanding questions in three main categories: legal, clinical and employment. 

Legal

Is Voluntary Assisted Dying (VAD) available for people with mental illness? 

People with mental illness have the same rights as others in the community to access to VAD. However, having a mental illness alone is does not make a person eligible to access VAD. Therefore, people with a mental illness must also have an advanced disease or terminal condition likely to cause death within six months (or 12 months for neuro-degenerative diseases in Victoria). It is also a requirement that an individual must be capable of consenting to VAD. It is therefore important to ensure that an individual living with mental illness who wants to access VAD is capable of consenting to VAD. The capacity of everyone wishing to access VAD must be carefully assessed.

Can I raise VAD as part of a general advance care planning discussion?

This depends on the state in which your patient resides. Health practitioners may not raise VAD in Victoria and SA, even if it is part of advance care planning. However, in other states, medical practitioners can raise VAD as part of a discussion about other palliative care or end-of-life options. If it is not raised as part of a wider discussion about other care options, then it may amount to a breach of the legislation across all the states. It is permitted an Advance Care Directive cannot contain instructions for illegal activities, such as euthanasia, assisted suicide or assisted dying.

Can I conscientiously object to participating in VAD?

A conscientious objection is when a person declines to participate in a lawful process or procedure due to their personal beliefs, values, or moral concerns. In Victoria, SA and NSW, you are not under an obligation to be involved in any aspect of VAD if you conscientiously object. However, in Qld, WA and Tasmania, you must provide basic information or refer a patient to another practitioner, even if you conscientiously object. 

As a general rule, an employee must follow any reasonable or lawful instruction given to them by their employer. However, the law allows for people to be conscientious objectors and while it is a lawful direction if you are a conscientious objector, then you can argue it wasn't a reasonable direction and you don't have to comply with it. 

Can a guardian, family member or medical treatment decision-maker consent to VAD on behalf of an individual? 

While guardians, family members and carers can support patients, only the patient can consent to VAD and there is no scope for a substitute decision-maker to decide. This is an important part of making sure the person’s decision is voluntary and not made on behalf of a carer, family, friend or other support person. 

Can I assess or advise a patient about VAD using telehealth?

MIPS strongly recommends that members do NOT use telehealth to assess a patient’s eligibility for VAD or to discuss VAD with patients. This is because Commonwealth laws still make it an offence to insight suicide through the use of a carriage device. An excellent summary of these issues can be found here. 

Clinical

Do all patients have to receive a psychological or psychiatric evaluation prior to being able to access VAD? 

No, but patients must be assessed by at least two medical practitioners to determine eligibility. The patient seeking VAD must be given information such as prognosis, treatment options, palliative care. If both practitioners assess the patient as being eligible, then the patient is able to make a written request called a Written Declaration. The third and final request is the administration - whether they want to self-administer or practitioner-administer. One of these medical practitioners may request a patient be assessed by a psychologist or psychiatrist to determine the patient’s capacity or to ensure that the patient’s judgment is not being clouded by a mental health condition, such as depression.

What counselling or support is available to doctors who choose to be involved? 

The Voluntary Assisted Dying Care Navigator Service is available in each jurisdiction where VAD is currently lawful. Part of their important role is also a contact point for health practitioners seeking information about or assistance with VAD. Navigators can work closely with medical practitioners and healthcare teams to support the needs of the person. 

The service may provide:

• general information about VAD 
• individualised support and information, either in a face-to-face consultation or by post
• assistance in connecting people with appropriate medical practitioners and health services
• information about or access to VAD support packages 
• holistic advice and follow-up on appropriate end-of-life care services
• education to health services and health practitioners. 

How do we complete a death certificate if a patient dies after taking a VAD substance?

If a patient dies as a result of taking a VAD substance, the cause of death to be recorded on their death certificate should be the disease, illness or medical condition that was the basis for the person accessing VAD. In most jurisdictions, there is the option of ticking a box to confirm that the patient died following use of a VAD substance. That information will not be publicly available.

How do I become a VAD practitioner?

VAD practitioners need to have minimum qualifications and experience. Each state law also requires practitioners to do mandatory training before they can accept a request from a patient to assess their eligibility for VAD.

Visit your state’s health department website to find out more: 

What should I do if I believe that a patient’s family is coercing them into accessing VAD? 

It is an offense across all states to coerce or induce a person to access VAD. A patient's family cannot make decisions on behalf of the patient. 

A decision to access (or refuse access to) VAD must be voluntary, and therefore free of coercion. If coercion is identified, it is important to discuss this with the patient and, to the extent possible, ascertain their thoughts and views of the patient without their family present if the patient allows this. 

What happens if my patient cognitively declines after being approved for VAD?

A patient must be capable at all stages of the VAD process, including at the end of the process when a patient requests a VAD prescription. If a patient loses capacity at any time before a prescription for self-administration has been completed, then the patient is no longer eligible to access VAD.

Do we need family consent?

No, the decision to access VAD must be the patient’s decision. If you are assessing a patient’s eligibility for VAD, you must also ensure that their decision to access VAD is free from coercion, including coercion from family and carers. However, patients may request that their family or carers be involved in their decision-making. 

Employment

Can my faith-based employer/health service prevent me from discussing VAD with a patient on religious grounds?

As stated above, in Victoria, SA and NSW, you are not under an obligation to be involved in any aspect of VAD if you conscientiously object. However, in Qld, WA and Tasmania, you must provide basic information or refer a patient to another practitioner, even if you conscientiously object.

The hospital cannot direct you to breach any legislative requirements. A faith-based hospital may lawfully decide not to support VAD and may make public statements that make this clear. However, their staff must abide by the legislative requirements in each jurisdiction. Therefore, in Qld, WA and Tasmania, staff must still provide basic information or refer a patient to another practitioner, even if the hospital does not support VAD. 

If the doctor goes beyond the provision of information, such as by assessing patients at the hospital, then the hospital may be able to take steps to prevent you from doing that. 

Additional Resources

• MIPS on-demand webinar: Voluntary assisted dying
• https://support.mips.com.au/home/case-study-supporting-patients-through-voluntary-assisted-dying
• https://support.mips.com.au/home/voluntary-assisted-dying-post-webinar-activity
• VAD Care Navigator Service - (03) 8559 5823 or vadcarenavigator@petermac.org
• Gippsland: vadsupport@lrh.com.au
• Grampians: voluntaryassisteddying@bhs.org.au
• Hume: VADCareNavigator@nhw.org.au
• Loddon Mallee: vad@bendigohealth.org.au
• Barwon: VADEnquiries@barwonhealth.org.au
• QUT End of Life Law in Australia - https://end-of-life.qut.edu.au/assisteddying
• Victorian VAD training - https://vicvadlearninghub.com/

More information

If a member has concerns about their involvement in VAD and require medico-legal assistance, contact us on 1800 061 113.

During a recent webinar on Risk Management for Oral Health Practitioners, we had the pleasure of hosting guest presenter Sinead Wright, an experienced Oral Health Therapist and clinical educator. Her valuable insights on scope of practice and informed consent proved to be highly informative.  

Due to time constraints, some member questions couldn't be addressed during the live session. Therefore, we have compiled the following information that covers key themes relating to those outstanding questions. 

If you require assistance or have questions about a specific circumstance, please don't hesitate to reach out to MIPS advisors at 1800 061 113.  

Scope of Practice

Medicare provider numbers 

Since 1 July 2022, dental hygienists, dental therapists, and oral health therapists can access Medicare provider numbers to directly claim for services under the Child Dental Benefits Schedule (CDBS), raising the question of OHTs working independently without dentists.  

Practicing under your provider number is possible under Medicare, but the situation may differ with health funds due to their individual business rules. It is advisable for OHTs to verify with the relevant health funds in advance if their provider number and item number are accepted for claims. Failing to do so could lead to complications for both the practitioner and the patient. 

Read more in the Australian Government Department of Health factsheet which explains how to apply for a Medicare provider number, the services that can be claimed, and where to find more information. 

Business legalities for independent practice

When working as an independent practitioner, OHTs must consider the business legalities associated with performing certain procedures, such as taking radiographs and administering local anaesthesia (L.A.). It is crucial for OHTs to assess their scope of practice and ensure they possess the necessary qualifications, skills, and knowledge for the procedures they undertake. This self-assessment is vital as it enables them to substantiate their capabilities to regulators or in legal proceedings if ever required. 

Additionally, OHTs operating their own practice or premises should consider whether they might benefit from obtaining public liability insurance. This covers liability for public liability incidents – for example, where a patient is injured from a hazard that you have negligently created in the workplace. More information can be obtained from a general insurers or brokers. This type of insurance package typically includes coverage for fire, contents, equipment, and public liability. 

Regaining Competence

If you haven't practised a skill recently, you may wonder how to regain your competence. Ensuring you have the fundamental qualifications, skills, and knowledge is essential and should be kept up to date. Observing a colleague's performance or enrolling in a relevant course are both valuable options to consider. By doing so, you can refresh your understanding and proficiency. Ultimately, confidence in your abilities is vital, as it enables you to substantiate your appropriate scope of practice if ever challenged. 

Informed Consent

When it comes to advising on informed consent, MIPS relies on the Dental Board's code of conduct as a valuable resource. As your conduct will be evaluated against this code, incorporating its guidelines in your decision-making process will help uphold ethical standards and foster the highest level of care for your patients. 

Guidelines for best practice

Informed consent is a crucial aspect of healthcare, representing a person's voluntary decision made with a comprehensive understanding of the associated benefits and risks. Practitioners seeking guidance on providing patients with the necessary information can refer to the National Health and Medical Research Council (NHMRC) publication titled "General Guidelines for Medical Practitioners in Providing Information to Patients". These guidelines cover essential areas such as detailing proposed management or approaches, especially where risks of harm are more substantial and offering advice on effective information presentation. 

Adhering to good practice involves several key principles: 

1. Communication with Clarity: Practitioners should present information in a manner that patients can easily comprehend before seeking their consent. 

2. Informed Consent: Prior to conducting examinations, investigations, treatments, or involving patients in research or teaching, obtaining informed consent or valid authority is essential. However, in emergencies, this may not always be possible. 

3. Transparent Cost Communication: When referring patients for further investigations or treatments, practitioners should inform them about the possibility of additional costs, allowing patients to seek clarification before proceeding. 

4. Consent for Impaired Patients: When dealing with patients whose capacity to give consent may be limited or impaired, obtaining consent from individuals with legal authority to act on their behalf is crucial. Practitioners should also attempt to secure the patient's consent as much as practically possible. 

5. Documenting Consent: Proper documentation of consent is vital, especially for procedures that carry a risk of serious injury or death. Consideration should be given to obtaining written consent in such cases. 

Fees and financial consent  

Establishing clear and transparent communication with patients is of paramount importance, and a crucial aspect of this communication is the disclosure of fees and obtaining financial consent from patients or clients. Prior to providing any health service, it is imperative to ensure that patients or clients are fully informed about all the fees and charges associated with their course of treatment, including out-of-pocket expenses where Medicare is billed.  

Engaging in a professional discussion about fees is equally essential, as it ensures that patients understand the costs of all required services and enables a mutual agreement on the level of treatment to be provided. By adhering to these principles, healthcare practitioners can foster trust and facilitate a patient-centered and financially transparent healthcare experience. 

Children and young people 

Caring for children and young people entails additional responsibilities for practitioners, and adhering to good practice involves the following key principles: 

1. Placing the interests and well-being of the child or young person as the top priority. 

2. Considering the young person's capacity for decision-making and consent. In cases where practitioners ascertain that a person possesses sufficient age and mental and emotional capacity to give consent to a service, that individual should have the right to request and provide informed consent for receiving services without the involvement of a parent, guardian, or legal representative. However, where parents disagree about treatment and the practitioner believes the child is capable of consenting, it would be wise to seek a second opinion about the child’s capacity and the proposed treatment. 

3. Ensuring respectful and effective communication with children and young individuals. Practitioners should treat them with respect, listen to their views, encourage questions, and provide information in a manner that they can easily comprehend. Additionally, acknowledging the role of parents and, when appropriate, encouraging the child or young person to involve their parents in decisions about care are vital aspects of good practice in paediatric healthcare.  

4. When a child is not capable of consenting to treatment and parents disagree about treatment, it can be difficult to know how best to respond. In these situations, practitioners are strongly encouraged to seek legal advice and support, to ensure that they comply with your legal obligations. 

By following these principles, healthcare practitioners can ensure the well-being and active involvement of children and young individuals in their healthcare decisions. 

Additional Resources

Dental Board AHPRA   - Codes and guidelines

• Code-of-conduct 

• Know-your-scope 

• Supervised-practice-framework 

• Reflective-practice-tool 

• VIDEO Overview of your obligations 

MIPS dental practitioner education - 1hr online modules

• The-pitfalls-when-dealing-with-third-parties-in-dental-practice 

• Extractions-beware-the-risks 

• Top-5-clinico-legal-issues-dental 

• Saying-no-and-managing-complaints 

• The-evolution-of-a-dental-complaint 

More information

If a member has concerns regarding risk management and requires clinico-legal assistance, contact MIPS on 1800 061 113 

What do I do if I am unsure if a patient has capacity to consent to cosmetic surgery? Who has responsibility for assessing the capacity of the patient?

Medical practitioners should specifically assess your patient’s capacity before discussing or offering cosmetic surgery, including through the use of a screening tool. If they are still unsure, then they should refer to a specialist for capacity assessment. Assessment of suitability starts with the referral.

The practitioner performing the surgery must:

• Discuss and assess the patient’s reasons and motivation for surgery.
• Assess the patient for underlying psychological conditions such as Body Dysmorphic Disorder (BDD).
• Discuss other options with the patient, including surgery, procedures or treatment offered by other health practitioners and the option of not having the surgery.

A medical practitioner must decline to perform the surgery if they believe that it is not in the best interests of the patient.

Are there any specific tools to assess if cosmetic surgery is appropriate?

There are currently no approved tools for screening for BDD, but many are available.

See guidelines for registered medical practitioners who perform cosmetic surgery and procedures. These include Patient assessment and body dysmorphic disorder (BDD) screening, MBA BDD-screening, and Australian Plastic surgery Foundation, APFS body-image-program.

What should I do if I don’t think the patient needs or should have the cosmetic procedure which they want the referral for?

If you don’t think cosmetic surgery is appropriate for your patient, based on your clinical assessment, then you are not under an obligation to refer them for surgery.

One reason for obtaining a referral is to provide information to the practitioner about the patient’s history. A discussion with the patient about their motivation does not require detailed knowledge of specific surgeries. The practitioner performing the surgery is responsible for providing information about the surgery.

The Board does not expect GPs to have detailed knowledge of every cosmetic surgery. It is not their role to provide information about the proposed procedure.

The referral should indicate the nature of the patient’s request, but the decision about which surgery is provided (if any) will be made by the patient and the practitioner performing the surgery. A referral is only required for cosmetic surgery, not for non-surgical cosmetic procedures.

Please note, the referrer cannot work in the same practice and cannot themselves perform cosmetic surgery or procedures.

Do cosmetic surgical procedures now have a “cooling off period”?  

For cosmetic surgery, the cooling off period is 7 days for adults and 3 months for children under 18 years. For cosmetic procedures, there is no cooling off period for adults, but a 7-day cooling off period for children under 18 years.

Do these regulatory reforms apply to cosmetic procedures and cosmetic surgery?

The Cosmetic Surgery Guidelines apply to cosmetic surgery and non-surgical cosmetic procedures, although some requirements differ. The general Ahpra advertising guidelines apply to all regulated health services, including cosmetic surgery and non-cosmetic surgical procedures performed by medical practitioners. However, the new Advertising Guidelines for Cosmetic Surgery only apply to cosmetic surgery.

Are there resources for patients about the regulatory changes which outline best practice for cosmetic procedures?

Ahpra provides a comprehensive cosmetic surgery hub which includes “Information for the public” and “Information for practitioners”.

I am not sure whether the procedure is reconstructive or cosmetic? How should I approach this?

Ultimately this is your clinical judgement, but you need to be able to substantiate your decision if challenged. Generally, whether or not a procedure is reconstructive (as opposed to cosmetic) primarily depends on the intention, rather than the procedure itself. You should always ensure you comply with the MBS item descriptor for any procedure you seek to claim through Medicare. Please call MIPS if you are unsure about your obligations.

Do I need to assess a patient for BDD before using cosmetic injectables?

You should always exercise clinical discretion in deciding whether a psychological assessment would be in your patient’s best interests. The Cosmetic Surgery Guidelines require screening prior to cosmetic surgery for all patients, but only for patients under 18 years prior to non-surgical cosmetic procedures. The code of conduct Good Medical Practice provide further broader guidelines on which any healthcare provided can be judged.