January 23, 2008

You Can Have Your License Revoked For That?

It's hard to see the truth when the truth is uninteresting, long, or contained in PDF.  What's left is the interesting untruth, which then becomes truth.

And then we all have a big problem.

Close to home (and to the area almost completely responsible for the housing collapse) comes the case of Dr. Edward Sanders who, according to the Marin Independent Journal, had his license revoked because, among other reasons:

In its filing, the medical board said Sanders' failure to order periodic eye exams for the patients to whom he was giving Seroquel was an "extreme departure from the standard of care."

It is my clinical opinion that eye exams are unnecessary.  It is a fact that most psychiatrists don't even know what slit lamp actually is, let alone order it for the majority of Seroquel patients.  And, therefore, I am absolutely certain that those two facts alone make it impossible that his actions were a departure from the standard of care, let alone an extreme departure.

Let's be forensically rigorous.  The law doesn't ask if the treatment is bad, it asks if there's malpractice, as defined:

  1. breach of standard of care-- what a "reasonable minority" of docs would do
  2. a harm occurred

Not majority-- minority.  If 20% of docs think slit lamp is unnecessary, and they have at least a quasi-united voice on that matter, it is not negligence.  And regardless of whether 100% of docs do it 100% of the time: unless someone actually got a cataract, it's not a lawsuit.

Further: it isn't what docs think, it's what they do.  Example: it is now almost universally accepted that blood sugars should be monitored for antipsychotics.  However, this is not in any way close to a universal practice. So it's not negligent.  I'd argue that if blood sugars were monitored even once a year, it's not even a discussion of negligence.  It sucks, there should be some punching, but not a finding of negligence.

And again: if they didn't actually develop diabetes, there is no malpractice.

So for the Board to discipline Sanders for, among other things, the lack of eye exams, seems preposterous.

Which brings us to the question for today: was this news story wrong, or was the licensing board out to get him?


I looked up the Board's Edward Sanders Decision (PDF: reserve 30 min for downloading.)  If the information there is to be believed, Dr. Sanders was clearly up to some nonsense.  Billing for visits he never conducted, acting as payee for patients on SSI, altering records he sent to the Board (NB: don't ever do that, it's a trap; when the subpoena for the records comes, they already have a copy.)

But, unfortunately, contained within that document are a number of "Acts and/or ommissions" which, while nominally wrong, are things I see doctors do routinely, without malice: coaching patients not to work more than X hours because it would sabotage their disability payments; billing for a diagnosis that the patient (theoretically) had, but was not what was being treated (from memory, don't quote me: billing for urinary tract infection but being treated for asthma, but had both). For example, the payment is the same regardless of diagnosis.  I can't tell you how many psychiatrists bill "296.3" (depression) as a default.

Having it all mixed together-- indeed, in not restricting the case to the things which are clearly wrong-- the Board does itself a disservice by appearing to be engaged in a vendetta/witch hunt, etc.

Indeed, a cursory reading of the Decision could very well leave one with the distinct impression that the thing he did wrong the most-- the thing that the Board talked about the most-- was prescribing Seroquel and Abilify:

[Sanders] was not surprised to learn [from the Department of Human Services invesitgator] that was the largest prescribing physician of Seroquel in California.
Well, someone has to be, right?  And unless you're accusing him of kickbacks (which they are not) then it shouldn't be in there.

So, for what it is worth-- and it is worth nothing-- my opinion is that (if the information in the Decision is accurate) the Board seems to have had legitimate problems with Sanders, but they were not well articulated or focused in their Decision.


That's reality, anyway, and as long as it took me to look all this up and write this post is twenty times longer than anyone in America will ever spend on researching the actual facts of his case now, post Decision.

Which means that we all just swallowed the Blue Pill: the only remaining accessible document about the Sanders case is the news article, which equalizes Medi-Cal fraud with prescribing Seroquel without an eye exam.

And so it goes, another bit of preposterousness becomes true.

Welcome, as the magus said, to the real world.