Jan 3, 2014
1
0
Status
Non-Student
Hi everyone,

Please accept my apologies if, for whatever reason, you feel this is out of place. I am an investigator for a state agency handling the licensure of physicians. I recently started working on a few psychiatry-related cases, so I thought I'd join this board - hopefully I'm not viewed as the enemy! I’m not investigating any cases in particular using this board. I had a couple of brief and general questions but I thought it wouldn't be fair to post unless I was willing to answer your questions as well and let you know what I do since some of you may be interested. My waiver: I'm not advising you on anything related to any case you have, with my agency or others. At all. In particular, I have no clue how agencies in other states operate.

For some brief background, our agency is complaint-driven, so we never "seek out" violations. We don’t broadly monitor prescribing habits or anything of that nature - I believe the DEA does and on occassion they may come to us with a complaint. In addition to complaints, we also open investigations for every malpractice suit filed or settled (we receive notifications), disciplinary actions in other states, and criminal convictions. As you can imagine, the scope of the complaints we receive is very broad. Approximately 50-75% of complaints are screened out before they even reach me because the complaint completely lacks merit or, even if taken as true, wouldn't warrant any discipline. Nearly every allegation of inappropriate sexual conduct passes screening, however. Our agency has a unique relationship with our state's medical board. While I am a state employee, the board pays my salary through physician licensing fees. When a case is opened for investigation, it is assigned an investigator, an attorney, and a member of the medical board as an advisor. I investigate the case pretty unilaterally, with occasional attorney and board member guidance. Once my investigation is concluded, I provide a summary of the evidence to the attorney and member of the medical board. Together, they decide whether or not to pursue the complaint (or whether additional information is needed) - I am notably not part of the decision-making here. Most cases are concluded without any action or discipline. The cases that warrant discipline are almost always "stipulated", meaning the respondent and the agency agree to recommended discipline (often taking extra CME's, or an administrative warning). The agency, however, doesn't make the final decision on discipline - every case goes to the medical board (made up primarily of physicians) for a ruling. Admittedly, it is unusual that the medical board would reject the agency's proposed stipulation but it can happen. If the agency wants to pursue a case and can't reach an agreement with the licensee, they can take legal action which is essentially presenting the case in front of an administrative judge. After that process is complete, the administrative law judge's findings and recommendations are sent to the medical board for their decision. Note: all states are different.

Our agency has a policy of acknowledging that not all "mistakes" warrant discipline (whether it's formal or informal, I'm not sure). A competent doctor who makes one reasonable medical mistake, not indicative of any habitual problem or competency issue, generally won't be disciplined or will face very minor discipline. For example, a respected radiologist who misses a fracture in a spine, below the minimum standard of care, may not be disciplined if it is a one time occurence, there is no indication that he failed to make a thorough evaluation, and there's no other evidence of incompetence. We also, “technically”, don’t look at outcomes, only behavior. So a physician whose care of a patient results in a terrible outcome, such as death, may receive a lighter punishment than a physician whose negligent care results in no negative outcomes at all. For example, a competent and respected physician who leaves a small sponge in a patient, resulting in death, despite having and following specific and documented counting procedures, almost certainly won’t lose his license - a rarity altogether. It was a bad mistake. And a negligent mistake – that will probably result in a large lawsuit. But it isn’t the sort of professional incompetency that puts the public in permanent danger. However, say a pain clinic physician takes the blood pressure of a 70 year old patient who recently started medication for high blood pressure. Her BP is 50/40. He writes her a script and tells her to follow up with her primary care physician the next day. She leaves the office and drives right to the ER where they find she is in renal failure. Here, there’s no negative outcome caused by the physician because the woman went right to the ER anyways – which is what should have ordered. However, it may be considered an extremely high level of incompetence which may warrant severe discipline (perhaps monitoring by another physician for a period of time). All that being said, it's human nature to consider negative outcomes more seriously.

The areas that seem to warrant the most investigation work deal with overprescribing narcotics and sexual conduct. It is not uncommon to find bad “charting” as part of an overprescribing investigation and certain attorneys in our agency will often seek discipline for that. Overprescribing cases are obviously difficult cases to prove, often because the physicians who prescribe the most have the patients in the most need (pain clinics or ADHD treatment centers, for example). With psychiatrists in particular, one red flag is the prescription of opiates. There are plenty of justifiable reasons why a psychiatrist may prescribe opiates – even unrelated to psychiatric issues – but it is nonetheless something we’ll look at. In bad overprescribing cases, we may order a complete listing of all narcotics prescribed by the physician. Personally, I recognize the problems of isolating the patients with the highest dosages among a complete listing of patients – a doctor who sees hundreds of patients is bound to have a few patients with higher than normal dosages. That said, extremely high dosages for one patient or consistently high dosages for many (without pill counts, drug testing, or other preventative measures) can be a problem. We’ll also look at how often the patient is getting new scripts. If the patient is continually getting scripts early, by the end of a year the patient can end up with 2-3 months extra of medication. Additionally, some attorneys I work with really dislike seeing consistent and long-term prescriptions of short-acting narcotics (which are more desirable for resale and abuse) without attempts at long-acting narcotics. There are certainly catch-22’s with that line of thinking and that behavior alone probably won’t warrant discipline – but it can be one thing among many that shows a pattern of bad practices.

Finally, I’ll say that if a complaint is filed against you, I recognize it can be frustrating, especially if it takes a long time to resolve. Completely baseless sexual allegations are particularly difficult. I wish we had the resources so that our case load was lighter, but with 60-70 active cases per investigator we tend to work on specific ones in spurts. At least in my state, physicians who are pleasant to the investigators (who, remember, don’t “pick” which cases to investigate and don’t set the number of hours in a day) are afforded the same respect. If a physician hires an attorney to represent him, I don’t hold it against the physician at all, whatsoever. I don’t know that anyone where I work would. To me, hiring an attorney is simply a way to pass over much of the inconvenience a licensing complaint brings – it doesn’t indicate guilt at all, to me. Some attorneys cause more problems than they're worth and others represent their clients extremely well. Where there is undisputed negligence or inappropriate behavior, the medical professionals who take full responsibility and don’t lie during the investigation will probably do better than those who minimize the problems. For example, a doctor who criminally pleads guilty to possessing marijuana (which results in a notification to our agency) would not be best served by arguing that it is “only” marijuana and he had medical reasons for smoking it (obviously I don’t work in Colorado). A doctor who smokes marijuana almost certainly isn’t going to lose his license or anything close it – so just accepting responsibility seems to lead to the best outcomes. Likewise, as an example, a doctor who prescribes hypothyroidism medication to a patient with hyperthyroidism probably shouldn’t place all the blame on a nurse he alleges misread the lab report. That’s not to say you shouldn’t defend yourself – not at all – just accept responsibility where appropriate even if your culpability might be low. “Yes, I believe the nurse misread the lab report but at the end of the day I should have looked at the report myself before ordering the medication.” I personally treat the respondents in our cases with a ton of respect, especially if they are “guilty” of the allegations. Obviously a medical license comes with a lot of responsibility, but I also know that it’s tough to be scrutinized more than people in other professions. I’ll end by saying that, in my state (purposely left out), the cases that lead to suspension or revocation aren’t your run of the mill “mistakes.” They aren’t cases where a doctor prescribed a little too much Adderall a few times without doing a proper examination. They are usually cases with habitual problems after numerous complaints had been filed over a period of years, cases where significant illegal activity is proven (cash for scripts, blatant billing fraud, sexual assault, for example), and cases where exceptional incompetence is present (often in aging doctors experiencing dementia or related health problems). Addiction problems, for first-time offenders, are typically dealt with through a special program that requires monitoring and testing. Unfortunately, while most relevant to many of you, I don’t deal much at all with initial credentialing.

Please let me know if you have any questions – I likely won’t be able to answer them immediately, but I’ll try to get answers to you within 24 hours.

With respect to my questions, I’ll preface this by saying I’m not looking to “hold” anyone to anything. I also realize that many of you are students. I’m simply new at this and thought I’d reach out for guidance on an issue that I’ve seen come up quite frequently in your area of practice. Also, if you have any advice for me as an investigator, don’t hesitate to dish it - seriously. But remember that I’m just a guy working his 8-5, not trying to meet my weekly “revocation quota.”

Questions (feel free to answer one, all, or none): If you are prescribing ADHD medication, what dosage of Ritalin or Adderall do you typically start with for an adult or child patient? How high is appropriate to start? What’s inappropriate? I’ve noticed many doctors don’t bother with long-acting amphetamines, is there a reason? How do you decide what is the maximum dosage you’re willing to prescribe and what/where do you consult to make that decision? Are you particularly hesitant about prescribing methamphetamine or other ADHD medications? I stumbled upon an old/closed case recently where a 110 pound female patient was prescribed 270mg of Adderall per day (30mg x 9) and 20mg of methamphetamine (5mg x 4). Would a prescription like this be patently unwarranted or can you think of circumstances where it’d be appropriate?
 

michaelrack

All In at the wrong time
10+ Year Member
Dec 22, 2007
3,950
1,092
Memphis TN
Status
Attending Physician
Questions (feel free to answer one, all, or none): If you are prescribing ADHD medication, what dosage of Ritalin or Adderall do you typically start with for an adult or child patient? How high is appropriate to start? What’s inappropriate? I’ve noticed many doctors don’t bother with long-acting amphetamines, is there a reason? How do you decide what is the maximum dosage you’re willing to prescribe and what/where do you consult to make that decision? Are you particularly hesitant about prescribing methamphetamine or other ADHD medications? I stumbled upon an old/closed case recently where a 110 pound female patient was prescribed 270mg of Adderall per day (30mg x 9) and 20mg of methamphetamine (5mg x 4). Would a prescription like this be patently unwarranted or can you think of circumstances where it’d be appropriate?
Adult starting dose of Ritalin 10-20 mg/d typically. Long-acting amphetamines are typically more expensive. On Adderall usually max out at 90 mg per day and would be hesitant to prescribe more than 120/day
 

TexasPhysician

Moderator
10+ Year Member
Sep 1, 2008
4,773
1,952
Status
Attending Physician
I've had bariatric patients require higher dosing and IR due to drastic changes in GI absorption.

Otherwise I prefer XR formulations and start low unless the patient has been doing well on a certain regimen.

Stimulants are dosed case by case and hopefully titrated carefully.
 
  • Like
Reactions: GroverPsychMD