Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your
Gluttony n. Excess in eating or drinking
Ahh, gluttony. I think most of us can relate to the lethargy induced by a well-celebrated
Thanksgiving Day feast. For some of us, it's more than a once-a-year affair. For
some of us yet, the propensity to over-consume is an ongoing struggle. Personally,
gluttony is my best-practiced sin. Just give me a quart of Baskin Robbins' Pralines
'N Cream, a spoon and a towel with which to wrap it so my hands don't get
frostbitten, and I can eat the whole thing. The pitiful thing is, I don't even need
an Alka Seltzer!
Of course, eating like a pig isn't against any law of which I am aware, as long
as I don't consume, say, a person. I am inclined to expand the definition of gluttony
so there can be a worthwhile examination of an area of law where physicians can
find themselves in trouble. The natural gluttony nexus would seem to be excess drinking
or drug abuse, but even though that may be technically correct, I know
the addictive disease process certainly does not arise from gluttony. Consequently,
I must thank you in advance for your indulgence in allowing me to fulfill my seven-deadly-sins
theme with this particular analogy!
During fiscal year 05/06, 65 (out of 309) cases resulting in discipline arose from
an allegation of drug or alcohol use. These cases involved self-use of alcohol,
self-use of drugs, or excessive prescribing of drugs to patients. These are always
sad cases, no matter whether the physician or the patient is the one suffering from
addiction. I clearly can remember one of my first cases alleging a substance abuse
issue, though this was not a controlled substance. A young anesthesiologist, suffering
from a terminal illness, was found by a colleague hidden inside a broom closet having
huffed fluid tape cleaner until he was barely conscious.
There are several laws relating to consumption of alcohol or drugs in the Medical
Practice Act. Business and Professions Code section 2280 prohibits a licensee from
practicing medicine while under the influence of any narcotic drug or alcohol to
such an extent as to impair his or her ability to conduct the practice of medicine
with safety to the public and his or her patients. Section 2239 prohibits excessive
use of drugs or alcohol:
The prohibition against self-prescribing a controlled substance bears repeating.
Many physicians do not realize that they may not self-prescribe any
controlled substance. This includes pharmaceutical samples.
The most common event that triggers a Medical Board investigation for a Business
and Professions Code section 2239 violation is a conviction for drunk driving. Whenever
a physician is convicted of a crime, the Medical Board is notified of it. If it's
a first conviction for drunk driving, and absent any information the physician is
suffering from a problem that could potentially impact patient care, we generally
will resolve the case with advice to the offender about our Diversion Program. Upon
notification of a second conviction, however, the investigation will be
more extensive. Investigators will obtain copies of the police reports and court
documents. Investigators will interview the physician and possibly other witnesses.
The case may be then transmitted to the Office of the Attorney General for consideration
for disciplinary action. There is also a second option. If the conduct arises solely
out of a substance abuse problem, and there are no quality of care issues, a physician
may be a candidate for the board's Diversion Program (an intensive rehabilitation
program). Here the physician signs an agreement admitting to conduct for which discipline
can be imposed, but in lieu of that discipline being imposed, the physician instead
agrees to enter the Diversion Program. If the physician fails to successfully complete
diversion (which is a five year commitment), then the underlying case is referred
to the Office of the Attorney General and treatment is imposed via the board's order
(versus the agreement originally signed). Ideally, physicians will avail themselves
of the diversion program prior to coming to the attention of the enforcement program,
but we realize it often takes a sentinel event, like an arrest (or two) before treatment
Excessive prescribing is another facet of gluttony, although the impetus for the
physician is usually a different sin: greed. In the early 90s, we revoked the licenses
of physicians who sold prescriptions for Dilaudid for distribution on the street.
Today, Oxycontin is the analgesic du jour, and was the nemesis of a physician whose
license was recently revoked for selling enormous quantities to a motorcycle gang.
Then there are the run-of-the-mill-pill cases: physicians who provide prescriptions
for Vicodin, or whatever else the patient requests, without an appropriate prior
examination and a medical indication. Los Angeles is particularly rife with drug
cases and the occasional high-profile case involving excessive/inappropriate prescribing
to celebrities. The tragic aspect of these, and many of the complaints we receive,
is that often the physicians do not come to the board's attention until someone
Frequently, a complaint is initiated because Dr. X is prescribing huge amounts of
Norco and Soma to the complainant's spouse. The complainant is worried - angry -
frustrated because their loved one just got out of rehab. The complainant called
Dr. X to implore him to stop writing prescriptions, especially the ones from which
the loved one was just detoxified, and Dr. X will not stop. Other times, the complainant
is the parent of a child who has overdosed. The parent finds their dead child among
hundreds of bottles of pills. Sometimes the complainant is another law enforcement
officer who pulls someone over and finds scores of pill bottles in their vehicle.
Over prescribing cases can be very complex to investigate. This is because investigators
must determine whether the patient is suffering from a legitimate pain condition
and is legitimately receiving large quantities of narcotics, or whether the patient
is merely drug seeking or diverting drugs for sale on the street. Sometimes, to
further complicate matters, a patient may be both.
The discernment process ordinarily begins with a review of a Controlled Substances
Utilization Review (CURES) report for both the physician and the patient. The report
is called a Patient Activity Report (PAR) and is used to analyze patterns of over
prescribing. The PAR form
can be downloaded from the board's Web site. What kinds of things pique our curiosity?
The quantity of a particular drug is just one piece of information. There are circumstances
where a huge amount of narcotics may be perfectly appropriate. So, we look to see
how many doctors the patient is visiting. Is the patient "doctor shopping" and going
to different pharmacies to avoid detection? Does the patient live a ridiculously
long way from the physician's practice? None of these factors, in and of themselves,
may be problematic. Our index of suspicion rises, when we see a multitude of these
patterns. Please see page 12 for a list of potential indicators that may
suggest a patient is using prescriptions inappropriately. This is an excerpt from
a Department of Justice brochure entitled, Guidelines for Combating Prescription
Drug Abuse and Fraud.
An investigator may initiate surveillance, or undertake an undercover operation.
If the undercover operation proves fruitful, then a search warrant may be considered.
Prescribing without a legitimate medical purpose is a both an administrative and
But, before you are incapacitated with concern that board investigators may be lurking
in your waiting rooms, please understand that the office waiting areas, where search
warrants are executed, often look like a Grateful Dead reunion. By the time a warrant
is sought, usually one or two operatives have visited the clinic on several occasions
and received controlled substances for absolutely no legitimate medical reason.
MBC investigators know that most patients receiving narcotic medications are receiving
them in a perfectly legitimate way. MBC investigators also have no interest in discouraging
physicians from prescribing narcotic analgesics to patients suffering from a medical
condition causing pain; that is why so much time is spent distinguishing the legitimate
pain management practice from the pharmaceutical drug peddler. Investigators are
mandated to receive specialized training in pain management cases to make certain
physicians who follow the intractable pain guidelines (Business and Professions
Code section 2241.5) are not disciplined for over prescribing. Also unique to these
cases is that once investigators obtain medical records, interview all of the relevant
parties, and interview the physician, if it appears there may be a violation of
law, the case must be reviewed by two experts: one whose specialty is pain
management, and one whose specialty is that of the prescribing physician. That is
important for you to know: we investigators do not decide whether the standard of
care has been met. Your peers make that determination. Our job is to provide the
board's peer reviewers with the best information possible from which to render an
unbiased and thorough opinion.
The Medical Board's Web site (www.mbc.ca.gov)
is an information glutton's dream. You can find guidelines and laws regarding pain
management, prescribing, ordering CURES reports and the Diversion Program (among
many other subject matters). This is an excellent resource to familiarize yourself
with these and other issues, and there are numerous resources available to you online,
if you have concerns about a patient, a colleague, or your own situation.
In the spirit of gluttony, I have grossly exceeded my allocated space. Now I must
scamper off to rescue my ice cream before it melts or heaven forbid, someone wants
to share it!
Coming up next: Greed.