STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
STATE OF FLORIDA, DEPARTMENT ) OF PROFESSIONAL REGULATION, ) BOARD OF MEDICAL EXAMINERS, )
)
Petitioner, )
)
vs. ) Case No. 85-2798
)
WILLIAM E. LAMB, M.D., )
)
Respondent. )
)
RECOMMENDED ORDER
Notice was given, and on February 28, 1986, a formal hearing was held in this cause. The location of that hearing was Jacksonville, Florida. Charles C. Adams presided as the hearing officer. The parties in the person of counsel have submitted proposed recommended orders which have been considered. To some extent the fact proposals in those recommendations have been utilized in preparing the recommended order. Counsel were afforded an opportunity to have the hearing officer explain the basis for rejecting the remaining facts and waived that opportunity.
APPEARANCES
For Petitioner: Harry L. Shorstein, Esquire
Department of Professional Regulation
615 Blackstone Building
Jacksonville, Florida 32202
For Respondent: F. Gordon Blalock, Esquire
2301 Independent Life Building Jacksonville, Florida 32202
ISSUES
This case concerns an administrative complaint brought by the Petitioner against the Respondent alleging various
violations of Chapter 458, Florida Statutes. Generally speaking, the Respondent is accused of prescribing controlled substances in bad faith, deception, untrue and fraudulent representations in the practice of medicine failing to keep written medical records justifying treatment gross or repeated malpractice or the failure to practice medicine with the requisite level of care, skill and treatment expected of him and with the violation of a related provision of law, premised upon the aforementioned substantive violations.
FINDING OF FACT
The parties, through counsel, have stipulated to certain factual matters related to this dispute. That stipulation is accepted, and the facts are found as follows:
The medical records of the patients listed in the Administrative Complaint were produced by the Respondent pursuant to Subpoena Duces Tecum and are admissible without testimony.
The dates and amounts of the prescriptions which appear in the various paragraphs of the Administrative Complaint are correct.
The prescriptions were written by the Respondent for the patients.
George R. Wilson, M.D., is an expert witness in the field of medicine, generally, is an expert and Board certified in family practice. He is qualified to testify as an expert and to render expert opinion testimony.
The Respondent has no medical records for the patients listed in the Administrative Complaint other than those produced pursuant to the Subpoena Duces Tecum.
William E. Lamb, M.D., is a physician licensed to practice medicine in Florida as recognized by the State of Florida, Department of Professional Regulation, Board of Medical Examiners. He has held that license at all relevant times in
this inquiry and has practiced general medicine in his office in Jacksonville, Florida. That practice is as a sole practitioner, through a small office with the staff assistance of a receptionist and a secretary. Dr. Lamb is not engaged in hospital practice. His practice is constituted of walk-in business.
Dr. Lamb is a graduate of the University of Maryland School of Medicine, having attained his medical degree in 1951. He completed his internship and residency while serving with the United States Public Health Service.
The Respondent sees forty to fifty patients a day, during office hours 9:00 a.m. to 12:00 p.m. and 2:00 p.m. to 5:00 p.m. The only office equipment which the Respondent has to provide services is a diathermy machine. He does not have such specialized equipment as x-ray, laboratory, a microscope or other specialized diagnostic equipment. His base charge per patient visit is $20.
The administrative charges which form the basis of this dispute were filed on July 15, 1985. Having been appropriately served with the Administrative Complaint, Respondent made a timely request for formal hearing in accordance with Subsection 120.57(1), Florida Statutes.
Over a period of time commencing on December 6, 1983, and continuing through April 25, 1984, the Respondent prescribed to his patient T.Y. Didrex 50 mg., 100 hundred tablets. This occurred on seven different occasions, for a total of 700 tablets. This product name pertains to the substance Benzphetamine Hydrochloride. This substance is a Sympathomimetic Amine. It has a pharmacologic activity which is similar to that of amphetamines. Didrex is used in the treatment of obesity. This class of drugs has been referred to as an anorectic, related to appetite suppression. According to the Physician's Desk Reference, which is accepted as an authority in the description of the characteristics of Didrex and other drugs which are discussed in the course of this recommended order, Didrex is indicated as being an appropriate substance to be employed in the management of exogenous obesity in the short term, i.e., a few weeks, in association with a regimen of weight reduction through control of caloric intake. Didrex has limited application in weight control and must be considered in the face of possible risks associated with the use of the substance. The risks include the fact of central nervous system stimulation and elevation of blood pressure. Didrex
carries with it the possible occurrence of drug dependence, especially given the fact that Didrex is chemically and pharmacologically related to amphetamines. Amphetamines and related stimulant drugs are the subject of extensive drug abuse. The Physician's Desk Reference, in describing dosage and administration of Didrex, indicates that this must be considered on the basis of the response of an individual patient. The suggested dosage would range from 25 to 50 mg. one to three times daily. The Physician's Desk Reference goes on to say that the dosage of 25 to 50 mg. should be prescribed once a day with subsequent increases to meet the needs of the patient according to the patient's response to the use of this substance.
As can be seen in the treatment of T.Y. and as will be described in a subsequent discussion of the Respondent's treatment of other patients with the substance Didrex, Respondent far exceeded the suggested use of Didrex limited to a period of several weeks. In so doing, he placed T.Y. and other patients at considerable risk of problems with drug dependence to Didrex. Didrex is a controlled substance regulated by Section 893.03, Florida Statutes.
Petitioner's Exhibit 1, a copy of the medical records of the Respondent related to the patient T.Y. in the relevant period inquired of through the Administrative Complaint, gives very sparse information about the patient. It reflects that the patient was first treated on January 5, 1982. At that time the patient weighed 207 1/4 pounds. T.Y. is a man around six feet tall and is a weight lifter. Respondent indicates that the prescription of Didrex was for the purpose of removing what the Respondent felt to be excess weight around the abdomen of the patient. In the course of the treatment of the patient, the patient weighed as much as 219 3/4 pounds and as little as 194 1/4 pounds. When last seen on July 2, 1984, the patient weighed
209 pounds. In the patient records there is an indication of blood pressure readings related to the patient which were infrequently noted. Otherwise there is no depiction of other observations of the patient in the examination process. Those records do not show any significant weight control, either. This is true even though Respondent prescribed the aforementioned 700 Didrex tablets in dosages of 50 mg. in the
above referenced period. A total of 1500 Didrex were prescribed during the period of the treatment of the patient which began January 5, 1982, through November 8, 1983. There is no indication in the patient records that the Didrex was prescribed for obesity, nor is there any indication that other medications were prescribed for chronic back pain. As with other patients
and their maladies, Dr. Lamb indicates that he recalls prescribing medications for obesity and back pain for T.Y., recollections which would not be of any benefit to other treatment professionals who have to rely upon the quality of the patient records of T.Y. and the other patients who are the subject of this Administrative Complaint which records are deficient in describing diagnoses for which drugs were prescribed.
The pain medications which the Respondent gave to T.Y. for his back problems were Tylenol No. 3 and Empirin No. 3. One Hundred and fifty Empirin were prescribed and 30 Tylenol. Tylenol and Empirin are controlled substances under the terms of Chapter 893, Florida Statutes. Respondent testified that he did not feel that the two medications were prescribed in excessive quantities. Dr. Lamb also prescribed Fastin for T.Y. in the amount of 60 capsules. Fastin is an anorectic drug and is a controlled substance found in Section 893.03, Florida Statutes.
Given the range in weight of the patient T.Y., and his height and the description by the Respondent as to the location of the excess weight, T.Y. is not found to have been obese during the time that the Didrex was prescribed for him by Dr. Lamb. Although proven by Respondent's testimony at hearing, Respondent's medical record of T.Y. did not indicate the height of patient T.Y., and the absence of such information makes it difficult for any other person who reads the record to know whether the patient is obese, when the only information imparted relates to weight.
With patient T.Y., from December 6, 1983, through April 24, 1984, Respondent prescribed more Didrex than was necessary to comply with the suggested frequency of administration of the controlled substance set forth in the prescription. This takes into account three pills a day as the indicated daily amount. There were more than enough pills to cover three times a day for each day within the intervening period between December 6, 1983, and April 24, 1984.
Although it is not reported in their medical records, Respondent, in dealing with his new patients such as T.Y., made inquiry about previous illnesses, types of diseases, to include cancer, diabetes and tuberculosis and questioned them about allergies to medicines.
From the Respondent's testimony in the course of the hearing, Didrex would be utilized in addressing the situation of
patients who were overweight and who might be expected to lose weight by the use of this substance, as contrasted with the use of Didrex to deal with obesity.
Respondent treated the patient C.S. over a number of years. That patient was first seen in April 1975 and for purposes of this inquiry was last seen on June 15, 1984. This patient was treated for weight control and chronic lower back pain. Treatment of the weight problem was by the use of Didrex in 50 mg. dosage. In the period November 8, 1983, through March 16, 1984, 600 Didrex pills were prescribed in amounts of 100 on six occasions. During the period beginning with November 8, 1983, and prior to the prescription of 100 pills on March 16, 1984, taking into account the number of tablets that the patient was allowed to take on each day, three, more Didrex tablets were prescribed than would be necessary to meet the daily limitations for appropriate usage. In other words, more than three pills were provided per day in the relevant period.
Petitioner's Exhibit 2 is a copy of the patient records of C.S. for the time period contemplated by the Administrative Complaint. When the patient was first seen, she weighed 157 pounds, and while in the care of the Respondent, the patient weighed as little as 143 1/2 pounds. She weighed as much as 175 pounds on September 25, 1979, and when last seen on June 15, 1984, weighed 169 1/2 pounds. For patient C.S. the information in the medical record does not justify the prescription of Didrex or of other Chapter 893, Florida Statutes, controlled substances, namely Soma Compound, Fiorinal No. 3, Obetrol 20 mg., and Biphetamine 20 mg., and Fastin. Fiorinal and Soma Compound were used to treat the patient's strained back. Didrex, Obetrol, Biphetamine and Fastin were used in weight control. Obetrol is an amphetamine.
The range of weights for the patient C.S. does not indicate any particular success with the use of the described controlled substances in addressing the weight problem of the patient. Respondent in his testimony at hearing observed that the patient had not lost as much weight as she should have. Nonetheless, he continued to prescribe excessive amounts of controlled substances for weight control, in particular Didrex, far in excess of what is contemplated by the Physician's Desk Reference on the use of Didrex and what is medically acceptable.
Respondent first saw patient C.A. on July 25, 1981. Copies of the Respondent's records for this patient may be found at Petitioner's Exhibit 3. When first seen the patient weighed
155 pounds. On July 6, 1983, the patient weighed 126 pounds, and when last seen on September 18, 1984, weighed 143 pounds. Respondent treated this patient for weight problems, low back discomfort and hormonal imbalance. In trying to control her weight, he prescribe Didrex between November 14, 1983, and May 10, 1984, on nine different occasions in dosage of 50 mg. and in quantities of 100 tablets on each occasion. On May 11, 1984, an additional 100 Didrex tablets were prescribed for the patient. There is no written justification in the patient record that would demonstrate the reason for prescribing Didrex. The weight is given and there are indications of blood pressure readings; however, there are no other indications of a diagnosis and statement of condition of the patient resulting from other forms of examination of the patient. Tylenol No. 3 and Darvocet N-100 were prescribed for the patient's back discomfort. These are controlled substances under Chapter 893, Florida Statutes, for the treatment of pain. Respondent testified that the patient was given Meprobamate 400 mg., a tranquilizer which was used to try to curb the eating habits of the patient. This is a controlled substance under Chapter 893, Florida Statutes. The patient had also received Fastin, Laxis and Soma Compound. Again, the amount of Didrex that was prescribed for the patient was more than enough to comply with Respondent's contemplated usage of the controlled substance by the patient, when taking into account the frequency on a given day, compared to the number of days to be used.
Patient D.C. was treated by the Respondent. A copy of the patient's medical record in the relevant time period is found as Petitioner's Exhibit 4. The patient was first seen on March 28, 1980, and weighed 132 1/2 pounds at that time. On a number of occasions during the treatment of the patient, she weighed 115 pounds when seen by the doctor. On September 25, 1984,, she weighed 129 pounds. Beginning November 16, 1983, through May 3, 1984, the patient had been provided Didrex on eight separate occasions in the amount of a prescription of 100 tablets in dosage of 50 mg. As with other patients previously discussed, this was too much Didrex when measured against the number of days to be covered by the prescriptions and the fact that the prescription contemplated a use of no more than three tablets per day On May 4, 1984, the patient had been given an additional 100 tablets of Didrex. The Didrex was prescribed for weight control. There is no justification in the record for prescriptions in these amounts of the drug. The records contain the various weights of the patient when seen and an occasional blood pressure reading. There are no indications of other forms of examination or tests and there is no statement of diagnosis
of the patient's condition. In looking at the weights given, there is no showing of effective control of the weight, even assuming the propriety of what is an excessive amount of Didrex prescribed for the patient. All other patients discussed in this recommended order who received Didrex received excessive amounts of this controlled substance. All told, Respondent prescribed a total of 3000 Didrex 50 mg. dosage to the patient
D.C. between March 28, 1980, and November 15, 1983.
Respondent saw patient M.C. beginning on October 24, 1975, through July 2, 1984. On that first date, the patient weighed 120 1/2 pounds. While under treatment, the patient weighed as little as 115 pounds on April 3, 1976, and as much as
145 pounds on October 12, 1981. On the last date, the patient was seen, she weighed 126 pounds. A copy of the patient's medical record may be found as Petitioner's Exhibit 5. Again, this patient received numerous prescriptions of Didrex for weight control. Between November 14, 1983, and January 29, 1984, the patient received 300 Didrex tablets in 50 mg. dosage, by receiving 100 tablets on three separate occasions. On January 30, 1984, an additional 100 tablets in the 50 mg. dosage were prescribed for the patient. In prescribing the Didrex, contemplating a frequency of use of three times per day in the stated time frame, too much Didrex was prescribed to accommodate that frequency of usage.
When the Respondent first saw the patient M.C., he observed that the patient had weighed considerably more than the weight at that time, given the lap of skin which he observed on the patient extending from the navel to the pubis. Contrary to the Respondent's comment at hearing, the patient's weight during his treatment of her did not stay within four or five pounds of
125 pounds.
M.C. also was prescribed Meprobamate by the Respondent in a dosage of 50 mg. Other drugs prescribed for the patient included Obetrol, Preludin, Biphetamine 20, Ionamin, Phentermine, Tranxene and Tylenol No. 3.
The patient records do not demonstrate justification for the prescriptions given to the patient M.C. There is no indication of the examination of the patient's physical condition other than weight and blood pressure. Finally, there is no indication of any written diagnosis of the patient's condition.
Respondent first saw patient I.M. on November 10,
1971, at which point the patient weighed 150 1/2 pounds. The patient was treated for weight control with Didrex, Obetrol, and Biphetamine 20, over time. In addition to her other medication, Respondent prescribed Laxis for the patient. When the patient was last seen on September 12, 1984, the patient weighed 186 pounds and had shown a fairly steady progression of weight increase over the years. This can be seen in the patient's records, a copy of which may be found as Petitioner's Exhibit 6. In addition to being treated for weight control, the patient was treated for a hormone imbalance and for her diabetic condition.
The records related to patient I.M. do not reflect any justification for the prescription of Didrex. They do not point out the physical condition of the patient other than her weight or offer a diagnosis of her condition.
In relation to the Didrex medication given I.M. beginning on November 15, 1983, through April 29, 1984, Didrex in a 50 mg. dosage was prescribed on seven different occasions,
100 tablets for each prescription. On April 30, 1984, an additional 100 tablets of Didrex 50 mg. were prescribed for the patient I.M. Again, the Respondent had prescribed too much Didrex, taking into account the frequency of usage contemplated by the prescription in comparison to the number of days covered in the period November 15, 1983, to April 29, 1984.
Respondent saw the patient D. T. and treated her for her weight condition. Records related to this patient may be found as Petitioner's Exhibit 7. The patient was first seen by the Respondent on February 20, 1973, when she weighed 163 pounds. During the time the patient was seen, she weighed as little as 135 1/4 on October 12, 1974, and as much as 193 pounds on April 5, 1983, following a period of time in which she had not been seen between December 5, 1979, when she had weighed 178 pounds, until April 5, 1983. When last seen on September 24, 1984, the patient weighed 154 1/4 pounds. As can be seen, there was great fluctuation in her weight, notwithstanding attempts to treat her weight by the prescription of controlled substances. The Respondent's Exhibits 2 and 3 depict the weight variance. Photo Exhibit 2 showed the patient weighing 208 pounds in August of 1982 and weighing 150 pounds in December of 1984 as reflected in Exhibit 3. Didrex 50 mg. was prescribed for this patient by the Respondent. In the period November 21, 1983, through May 8, 1984, 600 tablets were prescribed in 50 mg. dosage by the prescription of 100 tablets on six different occasions. On May 9, 1984, an additional 100 tablets of Didrex 50 mg. was prescribed for the patient. Again, too much Didrex had been
prescribed between November 21, 1983, and May 8, 1984, when taking into account the contemplated use under the terms of the prescription of one tablet three times per day.
When the records of D.T. are considered, there is no written justification for the prescription of the Didrex, there is no indication of the patient's physical condition other than weight and with the exception of a reference to a "pap smear" there is no indication of any examination of the patient. Further, there is no indication of a diagnosis of the patient's condition which would warrant the prescription of Didrex.
In addition to prescription of Didrex, Respondent had prescribed Obetrol, Melfiate, Biphetamine 20 and Ionamin for the benefit of the patient D.T.
The patient C.R. was seen by the Respondent beginning on February 26, 1982, and continuing through September 26, 1984. During the period November 7, 1983, through June 25, 1984, Tylox was prescribed for the patient in amounts of 50 capsules per prescription on twelve different occasions. A copy of the patient's records related to this patient may be found as Petitioner's Exhibit 8. Between August 4, 1982, and September 26, 1982, 420 Tylox capsules had been prescribed to this patient. Respondent also prescribed Librium for the benefit of the patient. Tylox is a controlled substance within the meaning of Chapter 893, Florida Statutes. Tylox contains oxycodone, a semi-synthetic narcotic for pain. It is prescribed for pain, according to the Physician's Desk Reference which source of information is accepted.
This man, C. R., was born without a fully developed male sex organ and has undergone a number of operations. He had one testicle removed and has had a bladder operation and prostate surgery, and has problems with kidney stones. He also has experienced prostate stones. In addition, the patient has had back surgery.
In examining the records by the Respondent for the patient C.R., specific reasons for prescribing Tylox for the treatment of the patient cannot be determined. In describing the explanation for providing Tylox to the patient, Respondent at hearing said that it had been given because he knew that the patient was hurting from various and sundry operations and had had prostate stones, back operations and a testicle removed for cancer. Respondent further stated that the pain pills were probably given to the patient for his back more so than for
kidney problems. There is absolutely nothing in the record to note a diagnosis of back problems.
Respondent first saw the patient S. G. in August 1979, and continued to see her through September 25, 1984. During the period March 9, 1984, through July 2, 1984, Respondent prescribed Percodan, a controlled substance under Chapter 893, Florida Statutes. This is a pain medication. A total of 168 pills were prescribed to the patient during the related time period. Between June 19, 1981, and September 25, 1984, Respondent prescribed a total of 1700 Percodan tablets to S.G. He also prescribed Tranxene which has a tranquilizing effect and which is a controlled substance within the meaning of Chapter 893, Florida Statutes. The patient suffered from disk problems in her back, from chronic cystitis, urethritis, and from bladder stones. The pain medications and tranquilizers were designed to address her difficulty with her back. Respondent concedes that the use of these amounts of Percodan and Tranxene could potentiate each other. Copies of the records related to this patient's treatment by the Respondent may be found in Petitioner's Exhibit 9.
In examining medical records for S.G., they do not contain a patient history or an adequate diagnosis of her condition. The records do not indicate a justification for the ongoing prescription of Percodan and Tranxene.
In remarking about the amount of Percodan prescribed for the patient S.G., Respondent did not feel that the prescription was too much. He felt that this amount helped the patient to go about her business and kept her comfortable and that this justified his choice of prescription. This explanation is not a reasonable justification for the amount of Percodan prescribed. Too much Percodan was prescribed for this patient when taking into account the addictive qualities of that substance as described in the Physician's Desk Reference, which information is accepted as factually correct. The amount of tranxene prescribed for the patient is also not justified medically, given the amounts of that substance being prescribed and the amount of Percodan with the attendant risk of potentiation through the simultaneous use of the two substances.
Through testimony of the patient S.G. in course of hearing, it is identified that she was operated on for disk problems in 1978. In treatment for her bladder condition, she
had Darvocet which she feels was not adequate to address her pain. The doctor treating her for that bladder condition did not wish to prescribe anything stronger than Darvocet. The doctor who had treated her for her back problem stopped prescribing Percodan after approximately one year. These doctors most recently described are not the Respondent.
S.G. has taken all of the Percodan prescribed by the Respondent. The prescription was given to her following her indication to Dr. Lamb that she did not find Darvocet to be adequate to afford relief of her pain. When she first went to see Dr. Lamb, he examined her chest, took a urine sample, examined her bladder, took her blood pressure and temperature. Eventually Dr. Lamb told her that Percodan was too strong and that he would not write her those prescriptions anymore. Dr. Lamb has never described for her the possibility of Percodan and Tranxene having qualities which would cause potentiation. Lamb did tell her that she could become addicted to Percodan. Dr. Lamb has also stopped prescribing Tranxene for the patient.
Respondent first treated the patient B.M. on February 4, 1976, and according to his patient records relevant to this inquiry has seen her as recently as September 17, 1984. Petitioner's Exhibit 10 is a copy of the patient records. Between November 2, 1983, and June 22, 1984, Respondent prescribed 1000 Tylox tablets for the patient B. M. In the period July 16, 1982, through September 17, 1984, he had prescribed 1200 Tylox tablets for the patient. The Tylox was prescribed for the treatment of pain in association with a colostomy operation. Respondent has also treated the patient for weight control. Respondent's patient records for B.M. do not contain adequate diagnosis of the patient's condition, examination and test results to justify prescription of the amount of Tylox prescribed.
Respondent indicates that the pain medication related to the colostomy has to do with severe spasms experienced by the patient.
The records of the patient B. M. simply note the existence of the colostomy, not the existence of pain associated with that situation. At hearing, Respondent identified that pain related to the colon operation was experienced by the patient in the intestinal tract due to spasms. Respondent also indicated the patient had diarrhea. He further stated that the Tylox assisted in the use of an antispasmatic which he had prescribed to help slow down the workings of the intestinal
tract of the patient. Too much Tylox was prescribed to the patient, when taking into account the addictive qualities of this controlled substance.
Petitioner presented the deposition of Dr. George Rice Wilson in support of its prosecution. The original of this deposition may be found as Petitioner's Exhibit 12. Dr. Wilson is an expert as described in the statement of the stipulation between counsel which is set forth in the facts of this recommended order. Dr. Wilson practices medicine in Green Cove Springs, Florida, and has practiced there since 1979. Dr. Wilson is familiar with the practice of medicine in the greater Jacksonville area which would include the location where the Respondent has his office. In preparing to give his testimony on the conduct of the Respondent related to the treatment of the patients described in this recommended order, the patient records which have been discussed were examined by Dr. Wilson. In examining these records, Dr. Wilson correctly noted that there was no diagnosis given as to treatment of the patients for weight control. The assumption that it was treatment for weight control was based upon the types of medication used.
Dr. Wilson commented on the fact that the records of the patient D.T. did not indicate any formal physical examination being made of the patient other than one occasion on which a "pap smear" was taken.
Dr. Wilson tended to concur with the opinions set forth in the Physician's Desk Reference to the effect that Didrex has only short term value in treating obese patients. He felt that the effectiveness of Didrex would end around four to six weeks. This opinion is found to corroborate the statement in the Physician's Desk Reference on the topic of the period of time in which it would be appropriate to prescribe Didrex. In summary, it would not be appropriate for a physician to prescribe Didrex for longer than three to six weeks.
Dr. Wilson correctly points out that in using an appetite suppressant drug, it is necessary to document its efficacy as a treatment form. Accordingly, it must be shown in a program monitoring weight loss that the weight loss is being achieved. He questions the justification for the use of Didrex based upon the idea of apparent weight loss over a period of years. This is in contrast to a more immediate short term benefit in the use of the appetite suppressant drug. In some instances shown with the patients described before, the use of the appetite suppressant drug did not promote weight loss. In
other situations related to the aforementioned patients, there was a demonstrated weight loss, but it occurred over exceedingly long periods of time in which Didrex was being used far beyond the three to six weeks appropriate in utilizing that drug.
Dr. Wilson questions the propriety of the use of appetite suppressant drugs; however, if they are used, he correctly observes that they should not be used more than three times a day with the administration of the drug prior to each meal. Again, Respondent has inappropriately prescribed Didrex in an amount which is greater than would be necessary to provide one tablet or pill three times a day. Finally, Dr. Wilson correctly indicates that most of the time this type of medication is used once a day.
Dr. Wilson feels that the quality of the care, skill and treatment which Respondent provided to patient D.T. was inappropriate in that it was not at the level recognized by reasonably prudent and similar physicians as being acceptable under similar conditions and circumstances. Dr. Wilson did not feel that Respondent appropriately prescribed a controlled substance for the patient D.T. in a way that was in the best interests of the patient. Dr. Wilson did not feel that the medical records justified the course of treatment of the patient D.T., in that the records were inadequate. These opinions held by Dr. Wilson are accepted as factually correct.
In discussing the treatment of the patient B.M., Dr. Wilson noted that the fact that B. M. was provided a colostomy associated with an operation for colon cancer did not indicate a prognosis of chronic pain in the future. Consequently, there was no apparent reason to believe that the patient would need medication for severe pain on a continuing basis. Moreover, Dr. Wilson noted that nothing within the patient record for the patient B.M. gave any indication of a chronic pain condition. Dr. Wilson assumed that the Tylox given to B.M. was prescribed based upon the existence of the colostomy and not related to attempts by the Respondent to control the weight of the patient
B.M. This assumption comports with the testimony of the Respondent. Dr. Wilson noted that Tylox is a potentially addictive drug. In this connection, he felt that 1000 capsules provided to the patient over a period of seven months would very probably promote addiction. Dr. Wilson's opinion was that nothing in the medical records would justify the prescription of Tylox in the quantities described in the medical records. Dr. Wilson did not feel that the treatment provided patient B.M. by the Respondent, especially as it related to the prescription of
Tylox, was in keeping with the care, skill and treatment recognized by reasonably prudent similar physicians under similar conditions and circumstances as being acceptable. He did not feel that the Respondent had prescribed Tylox in good faith. Nor did the medical records, according to Dr. Wilson, justify the prescriptions that were given to B.M. These remarks and opinions by Dr. Wilson related to patient B.M. are accepted.
On the subject of patient S.G. Dr. Wilson did not feel that the medical records kept by the Respondent for that patient indicated a need for the amount of Percodan and Tranxene prescribed for that patient. He noted that Tranxene is a Valium related tranquilizer, not normally prescribed in conjunction with a pain narcotic. The two controlled substances are for completely separate purposes, in the opinion of Dr. Wilson. He remarked upon the potential synergistic activity in using two depressants at the same time, in that the depressant effect can be magnified. Dr. Wilson was uncertain of the medical justification which Respondent had in mind when prescribing Percodan and Tranxene. Dr. Wilson also believed that even if the Respondent was aware of the condition of chronic cystitis, urethritis, and problems with bladder stones, it did not justify the use of Percodan over the periods of time that it was prescribed for this patient. Dr. Wilson did not feel that the amount of Percodan prescribed for the patient was justified, in the absence of the patient's history and a diagnosis and examinations being periodically performed on the patient. Dr. Wilson did not feel, based upon his review of the records related to the patient S.G., that the Respondent had performed as a practitioner with a level of care, skill and treatment recognized by reasonably prudent similar physicians as being acceptable under similar conditions and circumstances. He described the performance of the Respondent as being below the level of appropriate care and treatment. The controlled substances which were prescribed for the patient S.G. were not found to be the act of appropriate prescribing on the part of the Respondent. These observations and opinions by Dr. Wilson are accepted.
Dr. Wilson was also aware of the other patients who received Didrex from the Respondent, which patients have been described in previous sections of the fact finding of this recommended order. Dr. Wilson reviewed the medical records for those other patients. In those instances he did not find a medical record entry which formed a sufficient diagnosis to warrant the prescribing of Didrex. As to the additional patients and the use of Didrex in treating those patients on the
part of the Respondent, the use of that substance was not appropriate, as Dr. Wilson sees it. Dr. Wilson's observations and opinions about the use of Didrex for those patients described in this paragraph are accepted.
In describing the situation with patients D.T., .M. and S.G., Dr. Wilson felt that the prescription of Tylox and Percodan, as those drugs apply to the respective patients, was excessive and inappropriate. These observations and opinions by Dr. Wilson are accepted.
Dr. Wilson feels that in use of any form of an anorectic type of drug or any depressant type drug in the treatment of a patient's problems with weight, it is necessary to have a good understanding of the patient's circumstance including eating habits, whether the problem is long-standing, whether it is an acute problem, whether there was weight gain in the past two years, etc. In this pursuit, the idea of ruling out the explanation for weight gain as being ascribed to a disease process must be undertaken. In dealing with this problem, follow up must be established on a routine basis and Dr. Wilson feels that the further prescription of medicines in weight control is not indicated absent some demonstrated showing of weight loss in the intervening period following initial prescription of the medication. Dr. Wilson notes that in some of the patients described in this recommended order, Respondent was noting a gain of weight and still prescribing weight control medication. These observations by Dr. Wilson are found to be an accurate assessment of appropriate medical response in dealing with weight problems in patients. These approaches were not followed by the Respondent. By contrast, the Respondent over prescribed weight control drugs for the patients who are under discussion, without the benefit of meaningful medical records, without regard for the limitations placed upon the use of those substances set forth in the Physician's Desk Reference and fairly inferred, without due regard for the patients.
Dr. Wilson correctly observed, on the subject of the use of pain medication in the patients under discussion, that such medication deals with the pain itself, not with the cause of the pain. The Respondent, in these situations, gave little regard for the cause and merely prescribed excessive quantities of pain medication in lieu of meaningful treatment of the condition. This is not a good faith prescription of a controlled Percodan, as those drugs apply to the respective patients, was excessive and inappropriate. These observations and opinions by Dr. Wilson are accepted.
Dr. Wilson feels that in use of any form of an anorectic type of drug or any depressant type drug in the treatment of a patient's problems with weight, it is necessary to have a good understanding of the patient's circumstance including eating habits, whether the problem is long-standing, whether it is an acute problem, whether there was weight gain in the past two years, etc. In this pursuit, the idea of ruling out the explanation for weight gain as being ascribed to a disease process must be undertaken. In dealing with this problem, follow up must be established on a routine basis and Dr. Wilson feels that the further prescription of medicines in weight control is not indicated absent some demonstrated showing of weight loss in the intervening period following initial prescription of the medication. Dr. Wilson notes that in some of the patients described in this recommended order, Respondent was noting a gain of weight and still prescribing weight control medication. These observations by Dr. Wilson are found to be an accurate assessment of appropriate medical response in dealing with weight problems in patients. These approaches were not followed by the Respondent. By contrast, the Respondent over prescribed weight control drugs for the patients who are under discussion, without the benefit of meaningful medical records, without regard for the limitations placed upon the use of those substances set forth in the Physician's Desk Reference and fairly inferred, without due regard for the patients.
Dr. Wilson correctly observed, on the subject of the use of pain medication in the patients under discussion, that such medication deals with the pain itself, not with the cause of the pain. The Respondent, in these situations, gave little regard for the cause and merely prescribed excessive quantities of pain medication in lieu of meaningful treatment of the condition. This is not a good faith prescription of a controlled substance. This is an indication of substandard medical treatment of Respondent's patients.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and the parties to this action in accordance with Section 120.57(1), Florida Statutes.
In the deposition testimony of Dr. Wilson, Petitioner's Exhibit 12, at page 7, counsel for Respondent had objected to the following language in an answer provided by the deponent and asked that it be stricken as hearsay:
Several years ago the pharmacists in and around Jacksonville got together and even decided not to fill amphetamine prescriptions. They would take a prescription and hold it for several days just to try and cut down the use potential.
The objection is well taken and that portion of the answer is stricken.
Respondent is charged by the present administrative complaint with six violations related to the treatment of ten of his patients.
Count One accuses the Respondent of violating 458.331(1)(h), Florida Statutes, in that he failed to perform a statutory or legal obligation placed upon a licensed physician. The statutory or legal obligation alluded to is set forth in Section 893.05, Florida Statutes, which allows for the prescription, administration, dispensing, mixing or other preparation of controlled substances only in those instances in which the practitioner, on this occasion a physician, has been involved with the controlled substance in good faith and in the course of professional practice. That latter section identifies the appropriate use of the controlled substance on the part of the practicing physician. It does not affirmatively describe the statutory and legal obligations as envisioned by Section 458.331(1)(h), Florida Statutes. Therefore, no violation of that provision has been shown.
Count Two to the Administrative Complaint accused the Respondent of violating Section 458.331 (1)(1), Florida Statutes, in that Respondent has made deceptive, untrue, or fraudulent representations in the practice of medicine or has employed a trick or scheme in the practice of medicine when such scheme or trick fails to conform to the generally prevailing standards of treatment in the medical community. It is difficult to tell what the Petitioner had in mind in bringing this charge, other than to glean from the tone of the prosecution that the Petitioner felt that patients of the Respondent were being duped into the payment of fees for office visits in the perpetuation of an arrangement whereby the Respondent prescribed unnecessary medication to the patients.
On balance, Petitioner has not shown a course of conduct which forged the alleged deception, untrue or fraudulent representations in the practice of medicine or the employment of a trick or scheme in the practice of medicine.
Count Three refers to an alleged violation by the Respondent that is contrary to Section 458.331(1)(n), Florida Statutes, in that he failed to keep written medical records justifying the treatment of the patients, including, but not limited to, patient histories, examination results, and test results. Respondent has violated this provision and thereby is subject to the penalty set forth in Section 458.331(2), Florida Statutes.
Count Four to the Administrative Complaint accuses the Respondent of violating Section 458.331(1)(q), Florida Statutes. That provision states that the Respondent can be disciplined for prescribing, dispensing, administering, mixing, or otherwise
preparing a legend drug, including any controlled substance other than in the course of the physician's professional practice. For the purposes of this paragraph, it shall be legally presumed that prescribing, dispensing, administering, mixing, or otherwise preparing legend drugs, including all controlled substances, inappropriately or in excessive or inappropriate qualities is not in the best interest of the patient and is not in the course of the physician's professional practice, without regard to his intent. Respondent has violated this provision and is subject to the discipline set forth in Section 458.331(2), Florida Statutes.
The fifth count to the Administrative Complaint charges a violation of Section 458.331 (l)(t), Florida Statutes, in that the Respondent is said to be guilty of gross or repeated malpractice or failure to practice medicine with that level of care, skill and treatment which is recognized by reasonably prudent similar physicians as being acceptable under similar conditions and circumstances. In all particulars, Respondent has violated that provision and is subject to the discipline set forth in Section 458.331(2), Florida Statutes.
Finally, by Count Six to the Administrative Complaint, Respondent is accused of violating Section 458.331(1)(x), Florida Statutes, by violating any provision of Chapter 458, Florida Statutes, and/or a rule of the board or department.
This is read to pertain to some provision of law within Chapter 458, Florida Statutes, and/or rules of the board or the department, other than those provisions which have been previously described in discussing Counts One through Five.
There being no other specific provisions of statutes or rules alleged to have been violated, this count has not been proven.
Having considered the facts, and the conclusions of law reached and having in mind the gravity of the violations, it is,
That Counts One, Two and Six to the Administrative Complaint be dismissed; that Respondent be found guilty of violating Counts Three, Four and Five to the Administrative Complaint; and that his license to practice medicine be revoked. The violations proven point to an appalling lack of understanding or a callous indifference to the implications of the misprescription of controlled substances with addictive qualities. Moreover, this practice is long-standing and does
not describe a practitioner whose skills are remediable. It is for this reason that the ultimate penalty is recommended.
DONE AND ENTERED this 25th day of April, 1986, at Tallahassee, Florida.
CHARLES C. ADAMS, Hearing Officer Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 25th day of April, 1986.
COPIES FURNISHED:
Harry L. Shorstein, Esquire Department of Professional
Regulation
615 Blackstone Building
Jacksonville, Florida 32202
F. Gordon Blalock, Esquire 2301 Independent Life Building Jacksonville, Florida 32202
Dorothy Faircloth, Executive Director Board of Medical Examiners Department of Professional
Regulation
130 North Monroe Street Tallahassee, Florida 32301
Fred Roche, Secretary Department of Professional
Regulation
130 North Monroe Street Tallahassee, Florida 32301
Salvatore Carpino, General Counsel Department of Professional
Regulation
130 North Monroe Street Tallahassee, Florida 32301
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AGENCY FINAL ORDER
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BEFORE THE BOARD OF MEDICAL EXAMINERS
DEPARTMENT OF PROFESSIONAL REGULATION,
Petitioner,
DPR CASE NO. 0048164
vs. DOAH CASE NO. 85-2798
LICENSE NO. ME 0004925
WILLIAM E. LAMB, M.D.,
Respondent.
/
FINAL ORDER OF THE BOARD OF MEDICAL EXAMINERS
This cause came before the Board of Medical Examiners (Board) pursuant to Section 120.57(1)(b)(9), Florida Statutes on June 6, 1986, in Tallahassee, Florida for the purpose of considering the hearing officer's Recommended Order (a copy of which is attached hereto) in the above-styled cause.
Petitioner, Department of Professional Regulation, was represented by Harry L. Shorstein, Esquire. Respondent was present and represented by F. Gordon Blalock, Esquire.
Upon review of the recommended order, the argument of the parties, and after a review of the complete record in this case, the Board makes the following findings and conclusions.
FINDINGS OF FACT
The Board accepts and adopts and incorporates herein the Findings of Fact of the Hearing Officer.
There is competent substantial evidence to support the Findings of Fact.
CONCLUSIONS OF LAW
The Board has jurisdiction of this matter pursuant to Section 120.57(1), Florida Statutes, and Chapter 458, Florida Statutes.
Respondent shall pay an administrative fine in the amount of costs in this cause to the Executive Director of the Board within thirty (30) days of the date of this Order.
Respondent shall not administer, prescribe, or dispense any Schedule II substances.
Respondent shall complete at least fifty (50) hours of Category I CME per year in the areas of drugs and record-keeping and general medical treatment of obesity.
Respondent shall submit semi-annual reports to the Board.
Respondent shall appear before the Board at the first meeting after his probation begins and at the last meeting before his probation ends and at such other times as directed by the Board.
During this period of probation, semi-annual investigative reports will be compiled by the Department concerning Respondent's compliance with the terms and conditions of probation and the rules and statutes regulating the practice of medicine. On the record at the meeting, Respondent waived confidentiality-with regard to these reports as to the Board of Medical Examiners only, thus permitting them to review the semi annual reports during his term of probation notwithstanding any statutory or rule provisions to the contrary.
If Respondent leaves Florida to reside or practice outside Florida for a period or periods of time longer than thirty (30) consecutive days, Respondent shall notify the Board in writing of the dates of departure and return. Periods of residency or practice outside Florida will not apply to the reduction of Respondent's probationary period. The Respondent shall advise the Board of any change in his residence or office address.
Pursuant to Section 120.59, Florida Statutes, the parties are hereby notified that they may appeal this Final Order by filing one copy of a notice of appeal with the clerk of the agency and by filing the filing fee and one copy of a notice of
appeal with the District Court of Appeal within thirty (30) days of the date this order is filed, as provided in Chapter 120, Florida Statutes, and the Florida Rules of Appellate Procedure.
DONE AND ORDERED this 23rd day of July, 1986.
BOARD OF MEDICAL EXAMINERS WILLIAM F. BRUNNER, M.D.
Chairman
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing FINAL ORDER has been provided by certified mail to WILLIAM E. LAMB, M.D., 39 Ponce Boulevard, Jacksonville, Florida 32218 and F. Gordon Blalock, Esquire, 2301 Independent Life Building, Jacksonville, Florida 32202; by U. S. Mail to Charles
C. Adams,.Hearing Officer, Department of Administration, 2009 Apalachee Parkway, Tallahassee, Florida 32302, and by hand delivery to Harry L. Shorstein, Esquire, Department of Professional Regulation, 130 North Monroe Street, Tallahassee, Florida 32301 at or before 5:00 P.M., this 4th day of August, 1986.
| Issue Date | Proceedings |
|---|---|
| Apr. 25, 1986 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Aug. 04, 1986 | Agency Final Order | |
| Apr. 25, 1986 | Recommended Order | Physician misprescribed addictive drug over long period of time for numerous patients. Recommended revocation. |
