Reporting other doctors

[whopper]

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Scenario:

There's another doctor in your area. 1/2 of your patients with a prescription drug problem are his patients, and they get their drugs of abuse from this specific doc.

The local area drug abusers call him "Dr. Feelgood" or the "Candyman".

Some of the patients you mutually treat with this guy have some very suspicious prescriptions: a patient obtaining over 10mg of xanax a day for years, a patient without any chronic pain receiving years of percocet etc.

Several of the patients you mutually treat, you feel there is no justifiable reason to keep them on the meds of abuse they are on. Most of these patients meet the DSM IV dx of dependence for these meds.

You've already written the guy telling him to taper down the patients you mutually have on benzos and pain meds, and he ignores you.

WHAT DO YOU DO AT THIS POINT? Do you consider reporting him to the DEA? Do you ignore it for fear of professional flamewarring? Any feedback?


OK, seperate question but same case.

Now its about 1 year later and several pharmacists have reported this guy. The gov has now put this guy under investigation. Now you find out that all your patients that have been receiving xanax from this guy for years have now had their xanax abruptly stopped, without a taper down, despite the risk of seizure & death from such a practice.

WHAT DO YOU DO AT THIS POINT? Do you report him or not? If you report him, to whom? Do you leave it alone?

 

[lloyd braun]

For the first instance, I believe it is reasonable and perhaps even an ethical duty to report the physician's practices. You made a reasonable effort to alleviate the situation without involving authorities, but to no avail. We have a responsibility as physicians to ensure, within reason, that the field of medicine maintains its good name. Any deviant behavior should be reported.

In regard to the second scenario, I think the most important issue is making sure the patients are being tapered safely. It sounds like he is already being investigated, so reporting his actions might not be necessary and they may already be known.

 

[whopper]

Most residents I know who are in this situation are told by their attendings to just ignore it. They tell me as long as we're not making the mistake, we're in the clear, but what they don't answer is should we take further action.

I think there's a lot of politics with this one. I don't know if I'm getting the legally or ethically or politically correct answer.

If anyone with good legal experience here can answer if there are any legal directives with this type of situation please reply.

 

[Adam_K]

Ethically, your duty is to your patients, not your fellow professional.

Legally, you can always report it to the medical board. As to what action they'll take, that's another matter. Some boards allow anonymous reporting if you are worried about repercussions.

 

[sdn1977]

Most residents I know who are in this situation are told by their attendings to just ignore it. They tell me as long as we're not making the mistake, we're in the clear, but what they don't answer is should we take further action.

I think there's a lot of politics with this one. I don't know if I'm getting the legally or ethically or politically correct answer.

If anyone with good legal experience here can answer if there are any legal directives with this type of situation please reply.

What specific further action are you interested in taking??? Would you want to have his license suspended?

I'm a pharmacist & have been in the middle of this scenario many times. Each state has its own reporting system for reporting the misprescribing the controlled susbstances. You can go directly to the DEA, but sometimes there are easier systems within the state which link to the DEA. Some states allow for anynomous reporting - others don't. In CA...you can check on what has been filled for a particular pt, who wrote it, when, etc....you can also check on yourself to see if someone is using your DEA # without your knowledge (office staff for example). But...I think only pharmacies can check on prescribers - I'm not sure if you can check on another prescriber yourself.

It sounds as though the Dr in your example has indeed had his DEA # either put on hold for further investigation or has had it suspended or revoked. That would prevent him from allowing tapering of any controlled susbstance because he can't write for them anymore. When this occurs, in my area, the care of these pts is transferred to another prescriber. But...this transfer may not be what you were wanting....to have the pt received "better" care. They are often transferred to another "candyman" because that's exactly what the pt wants.

 

[whopper]

Yeah.

Trust me, I'm not out to put heads on a pike. I just want to make sure I'm doing the right thing.

What I just want to know is, are there any specific legal standards that demand us to report? For example, in several ethics board questions they'll often have scenarios where the right answer is to report immediately-e.g. when a surgeon is intoxicated and about to perform a surgery.

Is this a case scenario where you have any legal obligation to report?

Ethically, of course what I think the specific attending in question is doing isn't right, but I'm being told to not report him.

Attendings tell me to just make sure we're not doing it, to write the guy doing it and tell them taper down off the meds of abuse the patient is on, and don't report. I don't know if they're giving me the right answer or the answer that makes it easier for everybody, because when you blab on a colleague, you can get screwed and cause some very severe professional problems.

That's pretty much all I'm getting from the attendings I'm asking on this one. I don't know if they're looking out for their own necks or doing what is considered standard of care.

While it doesn't exactly sound ideal, from my own limited knowledge, it seems to me this is what most docs do--and if that is the case that is probably standard of care. The only times I've seen a doctor really get critical on another doctor is when its an attending on a resident. I've never seen an attending do that to another attending.

There seems to be an unwritten rule that you never ever report fellow attendings in most professional circles.

I don't agree with it, but then again, I'm not exactly looking to be a martyr either. Most of the times I see attendings get in trouble by peer review, they get a very light slap on the hand (again by my limited experience). Only times I see them lose big is if they're in court for malpractice.

The idealist in me agrees with Lloyd, that it would seem that we have an ethical duty to report, but I don't see docs doing that on other docs.

 

[50960]

This is not ethics, but a legal ?. Here in Colorado you are mandated to report such behavior, but in Ca you are not allowed to. Check your state law....

 

[Anasazi23]

This is a tough, slippery-slope type question. To play devil's advocate, who's to say that he feels that for these patients, he's practicing proper psychiatry? There is an attending in my hospital who's clinical decisions (including medications) I disagree with on an almost daily basis. Should I report him? The answer is that your attending is most likely correct. You open yourself up to a big can of worms by involving yourself in this. You can report him to the AMA practice committee, who may conduct a review. But you won't know how they'll take it, or if they'll act on it. Make sure you practice safely and ethically (as you see fit)...you have enough to worry about as a resident.

Good luck.

 

[Milo]

Where's the onus on the patients in this scenario? Be it 10 mg of Xanax or a fifth of 'Jeiger' daily there ain't a whole helluva lot o' biochemical difference.

Nobody's forcing the patient to go to Dr. Feelgood, and the fact that he is addressed by that name in the community means people are not under his care expecting standard of care medicine.

The patient should be approached with motivational interviewing techniques and should have dependence issues addressed regardless of the source of the dependence.

It also becomes an issue in your practice if you are treating depression or anxiety with a medication or therapy without first addressing the underlying substance dependence. Adding an SSRI to the mix when a benzo dependence is a primary diagnosis imo isn't the best first approach.

As one of my attending points out you can't do much with the software (neuronal circuitry, receptors etc) if they are continually damaging the hardware (bzd, etoh et al)

If patients chronically remain in a precontemplative phase regarding getting their fix with this dealer I think you'd have to have discussions with the patient about the benefits of continued psychiatric treatment and consider that continual substance abuse is therapy interfering behavior.

 

[Alone]

This is an interesting discussion. On the subject of whether or not he is doing wrong, we could take as a base whether it is malpractice--i.e. whether he is negligent AND there is a damage. Being on 10mg of Xanax, while bad, isn't automatically a damage. (Withdrawal might be, but then the damage is only the withdrawal, so for example you survive the withdrawal with no after effects, and there's probably not much of a suit.) I'm not saying malpractice should be the standard, but that should be the minimum, I think, before you take someone's license.

But on another, more broad issue: I think a lot of us are frustrated with the loose practice of the Xanax/Percocet prescribers in the inner city. But imagine for a moment that they all disappeared. What would happen? Think all the xanax seekers would disappear?

In large part, many city psychiatrists and primary docs have the luxury of pretending they "don't give out xanax and percocet" because there is somewhere else for the patients to go. If there wasn't, I'm pretty sure the entire enterprise would collapse. The analogy is the economy of Zimbabwe, which exists only because there is a tolerated black market for currency exchange.

We can say we still wouldn't give them out, but I think that's both disingenuous and unfair. Xanax and percocet aren't placebos, they do what is promised. Whether the risks outweigh the benefits isn't something that can be answered a priori-- each patient's situation is different. So saying "I don't give Xanax" willfully ignores the uniqueness of each patient's existence, as well as the clinical data that says the thing works.

But the black market thing was my main point.

http://thelastpsychiatrist.com

 

[Anasazi23]

I agree with you. There is an unspoken, "unwritten" culture and unwritten rules regarding how each psychiatrist practices, and how they choose to view themselves how they practice.

Some people are so uncomfortable with benzodiazepines, they feel comfortable giving only klonopin under the mistaken notion that it is "softer." While I personally prescribe much more klonopin than xanax, your point is well taken.

When you say, "the entire enterprise would collapse," I'm curious as to what you mean. Do you refer to the underground market for abusable prescribed substances?

 

[Jiminy Cricket]

If it makes you happy, it cant be that bad! Right?!....haha, jk.

 

[whopper]

Nobody's forcing the patient to go to Dr. Feelgood, and the fact that he is addressed by that name in the community means people are not under his care expecting standard of care medicine.

If it were that simple, I wouldn't have as much of a problem with it.

The problem is that several of this guy's patients had no intention of becoming addicts, trusted this guy, and eventually became addicts because he chose to treat their mild anxiety on his own with mega doses of xanax on a long term basis.

Or they clearly had intentions of abusing the meds he provided but later see the light and want to stop their addiction, but he won't taper down the supply they are on. Part of the problem with addiction is availability.

Add to that, he works in the ER I work in, and he constantly dumps patients on me who aren't medically cleared-e.g. the guy has a broken leg, he hasn't done any x rays, and simply because the guy said he was depressed (because he has a broken leg), the guy is now medically cleared for psychiatry, with no attention paid to the broken leg. Or my favorite-the guy has chest pain, but because he doesn't speak English, and because this doc doesn't understand him, the patient "must be clearly psychotic" so he then medical clears this guy- dumping the pt having a possible MI to psychiatry.
So that little style of care just has me a little pissed.

 

[Milo]

If it were that simple, I wouldn't have as much of a problem with it.

The problem is that several of this guy's patients had no intention of becoming addicts, trusted this guy, and eventually became addicts because he chose to treat their mild anxiety on his own with mega doses of xanax on a long term basis.

Or they clearly had intentions of abusing the meds he provided but later see the light and want to stop their addiction, but he won't taper down the supply they are on. Part of the problem with addiction is availability.

Add to that, he works in the ER I work in, and he constantly dumps patients on me who aren't medically cleared-e.g. the guy has a broken leg, he hasn't done any x rays, and simply because the guy said he was depressed (because he has a broken leg), the guy is now medically cleared for psychiatry, with no attention paid to the broken leg. Or my favorite-the guy has chest pain, but because he doesn't speak English, and because this doc doesn't understand him, the patient "must be clearly psychotic" so he then medical clears this guy- dumping the pt having a possible MI to psychiatry.
So that little style of care just has me a little pissed.

Ugh that sucks. I'm sold, report his a$$.

 

[sdn1977]

So....I'm curious....report him to whom?

State medical licensing board? I guess thats a possibility.

But, your own ER uses the guy. If I remember, you're near Santa Cruz..I'm not sure how that works since most ER's in N CA are run by ER groups - is this guy in an ER group or an independent practioner who moonlights there? I guess you could report him to the chief of that service, but that is getting involved in hospital politics - a nasty business right there. If he's moonlighting in a CA hospital ER....I'm guessing they're having a hard time staffing that ER - gotta wonder why or what connection he has to work there? He must have his own private practice since no ER will continue to prescribe controlled substances in CA.

The DEA already has heard about the guy, so no need to report him there.

Where else would you go to "report" him?

What redress are you looking for? To have his license pulled? I can't speak to how often that happens, but the DEA # will only be put on hold for a bit. It is rarely completely revoked unless he loses his medical license.

Is it the drugs & the volume of drugs he is prescribing that bug you, the way he practices medicine or the way he forces you to practice medicine??? Again...just curious...since every community has "candyman" physicians.

 

[50960]

Medical Staff.

 

[whopper]

"But, your own ER uses the guy. If I remember, you're near Santa Cruz..I'm not sure how that works since most ER's in N CA are run by ER groups - is this guy in an ER group or an independent practioner who moonlights there? I guess you could report him to the chief of that service, but that is getting involved in hospital politics - a nasty business right there."

Not to sound like I'm only tying to protect my own arse, but if the attendings know, I don't think I should go any higher than that.

That's one of the reasons why I brought this up. No one in medschool tells you what to do in this type of situation. I told the attendings what was going on and they just told me these types of things happen and that if you tried to take out every idiot doctor doing this type of poor practice, you're going to be digging your own hole.

So I really don't know the "textbook" or conventional way to handle this. Now I could of course go higher up and make a stink about it, but I'd be the only one doing it--out of several other residents who wont' do this and my attendings won't do this (at least as far as I know, maybe there's internal things going on that I don't know about)...so I think the more I pursue this, the more I'll look like some flamebrand.

Last time I got into a brouhaha with this idiot doc, I had a patient with known history of recurrent Staph aureus infection with an absecess on her arm & a fever get cleared by him for the Crisis Psychiatry unit. So I tell him that in such a patient, Staph aureus has to be ruled out first, and he told me if it'd make me feel better, he'd give her an oral antibiotic (and one that wasn't effective for Staph aureus) but he wasn't going to rescind his medical clearance. So I call my attending, and this specific attending is a pushover, and she's not in the ER with me (she's at home), so she tells me to admit the patient. I tell both of them that this ER guy giving her oral antibiotics now may screw up any results a bacterial culture may provide, but they still both agree to it.

So I admit the patient, with an ID consult. The ID consult next day demands that the patient be immediately isolated, and needed IV antibiotics immediately. They take her up to the floor and yes, now a culture can't be trusted.

The guy's an idiot. I guess maybe my standards are too high because as far as I know its not like anyone in the hospital's trying to take this guy out.

 

[sdn1977]

So....you've got your answer. You don't report him because you've got nowhere to whom (who???) to report him.

Yes...medically, he may be an idiot. But, apparently, he's an accepted idiot within your community & everyone seems to work around him.

Since the hospital knows & they have shared responsibility/liability & choose to do nothing...there is nothing more you can do except do exactly what you're doing - covering your arse and try not to look like a "know it all" tool.

Some day he may really screw things up & have a huge mistake, which may or may not result in a liability case, but more likely than not - just harm a pt.

But, my 30 years of being a hospital & outpt pharmacist have shown me there are physcians I'd never let near me or anyone important to me for exactly the reasons you've indicated. Some are just plain BAD!.

Yep - thats just the way it is......