The Shadow Practice: A Physician’s Problems Can Often Start at Home

It wasn't the U.S. Drug Enforcement Agency banning the doctor from prescribing addictive drugs.

It wasn't a patient almost dying on the operating room table.

It wasn't a previous patient who did die.

None of these things prompted the Medical Board of California to take serious action against Dr. Scott Bickman, a Los Angeles anesthesiologist. Instead, it was a classic dilemma that doctors find themselves in every day. Should a doctor prescribe drugs to family members? Some doctors avoid treating their family and friends as a rule, lest they lose their objectivity and make a bad decision. That’s why both the American Medical Association and the American College of Physicians recommend against physicians treating family members.

Dr. Anthony Youn, a Detroit plastic surgeon, wrote a great piece about the dilemma for CNN’s The Chart last year.

William Beaumont Hospital, where I operate and act as associate professor of surgery, forbids surgeons from operating on family members. As physicians, we are taught to hold the doctor–patient relationship sacred and to keep a proper professional boundary between us and our patients. In this way, we can prevent emotions from clouding medical judgment.

Bickman did choose to treat his wife, according to Medical Board of California records. The board says he did so to a negligent degree with addictive drugs. The board refers to Bickman’s wife as “A.R.”, writing:

[Bickman] was interviewed by the Board regarding his treatment of patient A.R., during which he was asked about the prescriptions he wrote for her. Although he was able to find some of his medical records for A.R., thereafter, he further explained that he maintained medical records for A.R. on a laptop computer, but that the memory on the computer crashed and that he subsequently gave the computer away. Although he was able to locate some of his medical records for A.R. that may correspond to some of the CURES [the state drug tracking program] entries, he could not find all of them. Regarding his prescriptions for A.R., [Bickman] stated that he only prescribed medications to her when her regular doctor moved out of town or was not available. He acknowledged that he typically, in his prior practice, did not prescribe the medications that he prescribed to patient A.R. In fact, he did not even possess a prescription pad because his medical practice did not include prescribing medications. Instead, his practice was limited to administering medications in the setting of anesthesia and perioperative care. 

What’s truly surprising about the case is the fact that the board, while saying it is concerned with the amount of drugs Bickman prescribed and the underlying reasons for those prescriptions, seems to be giving Bickman a partial pass.

On Dec. 4, 2012, the Board asked for documentation for prescriptions Bickman made for A.R. in 2010 and 2011.

Three days later, Bickman prepared documents dated Dec. 7, 2012, that went back in time and justified the previous prescriptions. When the Medical Board returned to interview Bickman on Feb. 21, 2013, it accepted these new documents as “late entry additional records for A.R.”

What?

This seems to defeat the entire purpose of documenting prescribing practices. If physicians are called to account for out-of-line prescribing, can’t they just make up whatever they want and call it a “late entry”?

There’s a second problem with this tactic by the board. A big part of the case against Bickman is what the board describes as haphazard record keeping in relation to his prescribing patterns, but these "late entry" references indicate that the Board is giving credence to these notes.

I recently asked the Medical Board, “Why would the Board allow a physician to document a prescription years after the prescription was written? And is there a time limit on a late entry?”

Jennifer Simoes, the board’s chief of legislation, told me that the board has quite a bit of leeway in how it characterizes these after-the-fact notes:

A physician may make a "late entry" into a patient's medical chart, but it is ultimately up to the medical expert who reviews the case to characterize the entry as appropriate or not. There are instances where a late entry is not a deviation from the standard of care; it would largely depend upon the context of the entry, the timeliness of the entry, and if the late entry impacted continuity of care rendered to the patient.  If the board is alleging a violation of B&P Code Section 2266 (failure to maintain adequate and accurate records), and if the late entries were not deemed excusable, they could be considered a violation.

It would be interesting to see where the board has deemed these late entries a violation of state code. I could see notes being jotted down the next day after a long day at the office, but two weeks, two months or two years later seems like a stretch.

To my mind, it’s as if the IRS audited a taxpayer this year and asked for proof of a tax exemption that was claimed in 2010. The taxpayer was unable to provide any proof, so the IRS said, “That’s OK. Just write something up and submit it.”

That would never happen.

I’ll keep you posted on the Bickman case as it proceeds. I’ve also asked Bickman for comment and will let you know if he shares his thoughts. For now, someone calling themselves “SB MD” has written about the case on mdansthesia.blogspot.com under the banner “Where is the justice for DEA Drug Diversion.” The blogger writes:

Some facts that are simply DEA lies. I never ordered, paid for any DRUGS or sold my Registration to anyone. The DEA simply wants to write a story and misrepresent the facts and at the same time cover up their role in allowing this diversion.

To simply say I should have known and revoke my Registration based on this is totally absurd. It is time for citizens to hold the DEA accountable for their findings and actions. They are NOT doing their job and we need to expose them for their corrupt behavior before more people overdose[,]  physicians lose their career all so they can fill their Public Storage spaces with cash while getting fat on Munchos and Dr. Pepper.

Now that’s an image fit for a Quentin Tarantino movie.

Image by Melanie Tata via Flickr