David Bryman,D.Odrbryman@gmail.com

602-524-9900

nothing

American Board of Bariatric Medicine-7 years Chair for the patient chart review committee Reviewed records in all 50 states Expertise in anorectics, office dispensing

# 1 risk-Office dispensing-controlled substances

Selling things patients don't really need Telemedicine Not informing patients that your medication

prescribed is “off label”-suggest informed consent

Documentation-templates, not examining patients, did you really do everything your template said you did?

The level that an average prudent provider in a given community would practice

How SIMILAR QUALIFIED PRACTITIONERS would manage a patients care under the same or similar circumstances

Medical Boards-there to protect patients not you-they must investigate all complaints, they may find something else they don’t like while looking at your records

Jury of your peers-not for physicians Police-no (do not make any statements if

arrested) Your attorney-yes Your malpractice carrier-maybe, if purely

medical in the scope of normal practice, but not if charged with a crime

Not all states have rules Almost all states have different rules Physicians on Medical Boards may not be in

your specialty, they will have their own expert review records

Follow your state rules carefully

Commit crimes Abuse alcohol/drugs Commit malpractice Lying to patients to cover up mistakes Make unwanted advances to patients Or staff,

(applies to both male and female) Sell things to patients that are not necessary-

certain rules in some states that only allow for a small mark up (Florida, NJ)

Fraudulent billing

Numerous cases- common themes Failure to diagnose- PE, CAD, Cancer,

Appendicitis, Dissection-aortic, carotid, Poor Documentation-use of templates, no

vital signs, illegible, incomplete, no rational for treatment, poor work-up of symptoms-urgent care at risk at end of day, primary care at risk for not referring timely, if you call a specialist document it,

Ohio-4 NY x 2 Florida x2 Ohio x3 Indiana x1 Texas 1 Kansas x2 Oklahoma x2 Arizona x3 Colorado x3 Georgia x2 Alaska x2 Oregon x1 Malpractice cases-x 18 Sting cases-10

Pharmacist turning physician over to the board-most common

Doses of meds-too high, too many pills per pharmacist

Fellow Physician turns patient in as he/she is not comfortable with treatment

DEA audits practice based on number of pills ordered per month to dispense

Undercover sting-police/DEA-very common-felony complaints

Many investigations did NOT involve any patient complaint or any injury or adverse consequence to a patient

Agent is female Flirtatious if physician is a male States recent divorce or states single Always has a BMI <23 Pays cash Will tell you they share the meds with a friend Will get at least 1 early refill Will treat for up to 6 months and NEVER lose weight Will say lost pain meds Will video and record all your interactions Will follow you outside the office Will try to make a case that your not treating a

medical condition

Physician stung by DEA/Police undercover Practicing out of a house-on the border of 2

states- multiple state license plates going in and out of house, patients using back door

State board notified by police Treated “obesity”-same term printed on all

notes

Poor Documentation- All BP 128/74 every patient, every note for over 7 years

All patients received phentermine regardless of weight, height, condition,

No medical history on chart No physical exam-psychiatrist No lab work, no EKG Diet-sheet of paper-include an apple a day, 8

glasses of water Case resolved, education program, bariatric

consultant

Physician Stung by undercover officer Officer had BMI < 27 Dispensing physician Poor record keeping/poor documentation Everyone received phentermine Used white envelope to put meds in- “take

yellow pill daily”

No Written RX Poor work up Limited exam No exam at follow up visits Duration of treatment exceeded 12 weeks Considered as “drug trafficking” in Ohio Multiple felony counts Multiple board complaints Board wanted to revoke license Case Resolved

Board Certified Bariatrician Excellent records Excellent care Excellent Results Pharmacist thought he wrote too much

phentermine and complained to the board Medical Board took all his charts and grilled

him for a year Resolved-cost him 300 thousand dollars

Pt’s wife complained that husband received phentermine with HX of Drug abuse-cocaine

Pt Never disclosed to physician Pt stated no cravings as result No abuse by patient Board unaware of newer articles that show

phentermine decreases cravings for ETOH and Cocaine

Resolved

Physician treated obesity in child 7 years old Phentermine 37.5mg 2 am 1 pm Pharm turned physician in Child lost weight, felt well No patient or parent complaintresolved

Pharm turned physician in for cytomel RX # 270 1 to 3 per day (?)

Board did not understand rational for treatment

? Normal TSH level Case resolved-outcome bad for physician

DEA sting Internet prescribing 700 RX per day phentermine Some cases 1 RX per minute 3 physicians arrested 1 prison 2 parole

Physician dispensing from more than one office

Complaint from disgruntle employee Physician prescribed to his wife Physician prescribed to children under 18(14 year old) MA refilled phentermine while physician at

other office Outcome bad for physician

Physician with multiple board complaints( 19) Records reviewed by board for an unrelated

issue Reviewer noticed that physician prescribed

weight loss meds for longer that a “few weeks” as recommended by the FDA

All records taken resolved

Medical board complaint from husband HX anxiety and depression/this state had

rules regarding prescribing “diet pills with HX of Psyciatric conditions”

Treated with phentermine Case resolved

Physician prescribed phentermine to an obese patient appropriately

Patient died of unrelated issue (cardiomyopathy)

Husband complained to the boardexpert for plaintive sited PDR for phentermine published 1959 as medical source-no malpractice alleged, just board complaint Also prescribed Thyroid for “symptoms of

hypothyroidism” Resolved after 3 years of license revoked

Physician dispensed phentermine 37.5 AM, Phendimetrizine 35mg at 4 PM to multiple patients.

DEA undercover sting- 96 felony counts for drug trafficking

All records and computers taken from “crime scene” Physician arrested, thrown on floor in front of

patients hand cuffed Poor record keeping, same treatment for all patients,

every patient treated with meds Convicted of 4 felonies for drug trafficking on pts

with BMI <30 Permanent license revocation-48 year old physician

Physician treating patients with thyroid T3 for hypothyroid symptoms-no lab

Dispensing phendimetrizine for longer than 12 weeks

1 patient developed a cardiomyopathy unrelated to his treatment. Board tried to relate this to anorectics and thyroid RX

PDR states that cytomel should not be used with sympathomimetic amines.( black box warning)

Board revoked his license

Family Doc wanted to try telemedicine to make extra money

Good doc Prescribed Zpack to ONE patient in a state

that did not yet recognize telemedicine Licensed in 14 states Cost 400 thousand dollars to resolve case as

had to defend same complaint in all 14 states

Undercover Sting Physician charged with dispensing

phentermine for more than 12 weeks and to undercover officer with BMI 20

Said it will give her energy Police measured how far his office was to an

elementary school- charged with 4 felonies Undercover officer also wanted to “buy a

prescription for a narcotic” Said she was selling them to a friend

Usually good doc No patient complaints Appropriate RX most of the time Pharmacist- can refuse to fill if pt looks like

BMI <27 or 30 Ohio Pharmacists are not clinicians Police are starting to cite “standard of care” in

their arrest reports

Dispense meds from your office-controlled substances or any meds

Prescribe narcotics for chronic pain-even if you follow all the rules

Have multiple offices Have your MA dispense your meds Prescribe higher than FDA doses Prescribe the exact same treatment for every

patient regardless of medical conditions Prescribe treatments that are not FDA approved

or treatments that make you a good profit Document poorly- must have rational for

treatment

Practice in Ohio Use non FDA approved drugs in Mississippi Prescribe or dispense HcG, 5HTP, Lipo B

shots, B12 shots, sell vitamins for profit Make claims that products cause weight loss

that are not FDA approved Make claims that you and you alone can

“cure” cancer, Fatigue, chronic medical conditions

Educate state boards Educate Pharmacy Boards Talk to your local pharmacists in person-

explain to them why you are writing a lot of one kind of medication

Educate DEA Educate law enforcement agencies Educate Physicians Educate public perception

Practice medicine like a Resident-don’t get lazy

Do not ever attempt to automate your practice-one size doesn’t fit all

There is NO easy way to make money in primary care-you will be judged in your specialty that you are certified in…

Get a specialist attitude-be thorough BACK TO BASICS-History, Physical, Diagnosis,

Treatment

Visiting state medical Boards that have out dated rules

Rule changes have resulted in Alabama, Mississippi, and Kentucky

Ok to turn away some patients-those that strong arm you into prescribing

Keep on the lookout for undercover agents OK not to use meds on some patients- YOU

MUST be able to show a medical board that you did not prescribe meds to some patients

Reviewers look to see if EVERYONE gets meds and same treatment

Practice good medicine and usually nothing to worry about

SAY NOTHING-you have a right to an attorney Your staff will turn on you in a second if

charged with a crime-100% of the time If your staff is dispensing for you in your

absence they can be charged with a crime

Tell the patient as soon as you know You are the captain of the ship-do not blame

anyone but yourself Apologize to the patient-keep it short and to

the point and be sincere If the error caused harm, notify your

malpractice carrier

Common themes- poor documentation #1 Failure to diagnose- PE, Dissection, Sepsis,

appendicitis, necrotizing fasciitis, Cancer, letting patients go home with very abnormal vital signs,

DO not EVER go back and “fix” your charts if the records are requested-common problem