Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant facts are found: Petitioner was an applicant for licensure by examination to practice dentistry in the State of Florida. Petitioner took the dental examination in December of 1984 and June of 1985, and obtained a total overall grade of 2.60 and 2.04; respectively. A grade of 3.00 is required to pass the examination. Petitioner is here contesting only procedure 07 in which he received a grade of 0, 0, and 0 from three (3) examiners for an average grade of zero (0) and procedure 08 in which he received grades of 0, 2, and 0 from three (3) different examiners for an average grade of 0.66 on the December of 1984 dental examination and the rejection of his periodontal patient which resulted in his receiving grades of 0, 0 and 0 from three (3) examiners for an average grade of zero (0) on procedure 04 on the June of 1985 dental examination. Examiners for the dental examination are all currently licensed dentists who have been licensed in the State of Florida for the immediate five (5) years prior to the examination who have been extensively trained and standardized by the Department of Professional Regulation. A standardization exercise takes place immediately prior to each examination during which the examiners grade identical procedures and discuss any grade variance to eliminate; as far as possible; any discrepancies in interpretation of the grading criteria. Examiners are evaluated against each other in their performance during the training and evaluated against the performance of past examiners in order to rank the examiners. The lower ranking examiners are used as supervisory personnel (monitors) to monitor the clinics. Candidates are informed of the grading criteria prior to the examination through the notice to appear and the applicable laws and rules which are sent by the Office of Examiner Services to all candidates prior to the administration of the examination. The Petitioner received and was aware of the contents of the notice to appear for the dental examination on December of 1984, specifically that portion indicating that preparation of the wrong tooth would result in failure of the procedure. Petitioner was verbally given tooth assignments, including tooth assignment for procedures 07 and 08 and Petitioner was aware that tooth assignments were posted on the wall for reference. Tooth number 4 was assigned for procedure 07 and 08 on the December of 1984 dental examination but Petitioner started preparation for procedures 07 and 08 on tooth number 13 which was the wrong tooth. The evidence was insufficient to prove that Petitioner questioned a monitor concerning the procedure to follow when the wrong tooth had been prepared for procedure 07 and 08. However, had he questioned the monitor the monitor would have instructed him to fill-out what is commonly referred to as a "yellow sheet" documenting for the file and the examiner what it was the Petitioner wanted the examiner to know about preparation of the wrong tooth. There was no "yellow sheet" concerning procedure 07 and 08 in Petitioner's file. One of the monitors for the December of 1984 dental examination, Dr. Smith; who was a monitor for the section where Petitioner was performing procedures 07 and 08, remembered being questioned by an applicant in regard to the procedure to follow when the wrong tooth had been prepared but he was not sure that it was the Petitioner. In any event, his instruction to the applicant was to fill-out the yellow slip. Relief monitors filled in for the regular monitors so it was possible that Dr. Smith was not there for the full time. Petitioner, upon realizing that he had started on the wrong tooth, completed procedures 07 and 08 on the wrong tooth, tooth number 13, and then completed procedure 07 and 08 on the assigned tooth, tooth number 4. If the preparation of the wrong tooth had of been on a live patient rather than a model, the healthy tooth structure would have been destroyed or mutilated and needlessly damaged. Procedure 04, Periodontal Evaluation, is performed on a live patient and it is the responsibility of the applicant to bring an acceptable periodontal patient for this procedure. Petitioner's patient to be used for the periodontal portion of the June of 1985 dental examination was his mother, Lavonee Perrott. For the periodontal portion of the June of 1985 dental examination, a minimum of two examiners would have examined the patient and, if there was a disagreement between these two examiners, then a third examiner was called in to examine the patient. After reviewing the X-rays of the patient's teeth provided by Petitioner and giving the patient a periodontal examination, the first two examiners rejected Petitioner's patient as not meeting the criteria of a patient for the periodontal portion of the June of 1985 dental examination. Petitioner's patient was examined by Doctor Louis Pesce, a periodontal specialist, on June 12; 1985 several days after her examination for the June of 1985 dental examination. Doctor Pesce took X-rays of the patient's teeth and gave her a complete regular periodontal examination. Although X-rays are only an adjunct to diagnosis for periodontal disease, X-rays do reflect obvious subgingival calculus. However; probing is necessary by the examiner to determine if the subgingival calculus is present at the time of the examination. X-rays will not reveal the extent of the pocket depth of teeth. Doctor Pesce reached his conclusion that the patient met all the criteria for the periodontal portion of the June of 1985 dental examination on the assumption that pocket depths of four to seven millimeters was conclusive evidence of the presence of subgingival calculus and was non-specific as to what level it was present or on which teeth. Doctor Pesce found that on 12 to 14 teeth the patient had: pocket depths of between four to seven millimeters: subpragingival calculus; root roughness, and required tissue management. He also found sufficient osseous destruction. Doctor Pesce was the only witness to testify who had given the patient a regular periodontal examination but his recollection of the patient's condition was not always clear and his notes were apparently insufficient to refresh his memory such that he could reach a conclusion that the patient met all the criteria for a periodontal patient. Examiners are standardized to look for obvious subgingival calculus, obvious subgingival calculus being that which can obviously be seen and felt or is obvious on X-ray. Although a patient may not meet the criteria for the periodontal portion of the dental examination, this does not necessarily indicate that the patient does not need periodontal treatment. The focus of the dental examination is for minimum competency and not the competency of a specialist. Even though the patient testified that the examiners only probe two teeth, the more credible evidence was Dr. Simpkin's testimony that a patient cannot always tell where that patient is being probed. Petitioner did not examine the patient prior to the June of 1985 dental examination for the criteria but apparently relied on X-rays taken of patient's teeth by her regular dentist. See Petitioner's Exhibit 1, page 12 lines 23-25 and page 13 lines 1-6. Had Petitioner's patient been accepted by the examiners, the Petitioner would have had to receive a perfect score of 5 from each of the three examiners in order to receive a passing grade of 3 or better on the June of 1985 dental examination. Petitioner received the notice to appear for the June of 1985 dental examination and was aware of the criteria for the periodontal patient to be accepted.
The Issue The issue in this case is whether the license of Allen B. Erde, M.D., should be disciplined by the Florida Board of Medicine based upon actions he is alleged to have taken, or failed to have taken, between August and November, 1986, in the care and treatment of his patient, C.W.
Findings Of Fact At all times material hereto, Respondent has been licensed as a physician in the State Of Florida, having been issued license number ME-0008625. Respondent was C.W.'s obstetrician during her pregnancy in 1986, and initially examined her on August 26, 1986, when she was six weeks pregnant. During this initial visit, C.W. was informed by Respondent that her pregnancy was progressing normally. At her second visit, on September 23, 1986, Respondent detected no fetal heartbeat. However, he informed C.W. that this was not a problem. He requested that she bring her husband with her for her third visit so that they both could hear the heartbeat. Prior to her third visit, C.W. saw Respondent in his office on October 6, 1986, complaining of urinary problems, and a stiff neck and back. Respondent treated her for a urinary tract infection. Later that same day she began to bleed vaginally, passed clots and experienced cramping pains. She then saw Respondent at the Winter Haven Hospital emergency room, but was told that nothing seemed wrong. Respondent advised her simply to go home, put her feet up, and rest. There were several other occasions during October, 1986, when C.W. experienced cramping and vaginal bleeding. She called Respondent each time to express her concerns, but was told simply to lie down, and keep her feet up. On October 22, 1986, C.W. and her husband visited Respondent for her third scheduled visit. No heartbeat was heard. Respondent again told C.W. that there was no cause for concern, the baby was just small and probably behind her pelvic bone. C.W. was presumably 14 weeks pregnant at this time, but Respondent's office records indicate that the fetus was decreasing in size, there was no weight gain, and no heartone. C.W. continued to experience pain and bleeding, sometimes accompanied by clots. She was not gaining weight, and had none of the other indications of pregnancy which she had experienced in her prior pregnancies. C.W. continued to express concern to Respondent, but his advice remained simply to lie down, and keep her feet up. In response to a five day episode of bleeding, C.W. saw Respondent in his office on November 12, 1986. Although she was 17 weeks pregnant at that time, Respondent's office records indicate a fetus 14 weeks in size. Respondent did not order any fetal viability tests, and there is no evidence in his office record that he considered any testing of the fetus. C.W. saw Respondent for her fourth scheduled visit on November 19, 1986, and, again, no fetal heartbeat was detected. She was still experiencing vaginal bleeding. Her uterus was only 10-12 weeks in size, although she was presumably 19 weeks pregnant at this time. C.W. was distraught, and expressed great concern to Respondent that she was presumably almost five months pregnant and no fetal heartbeat had ever been detected. C.W. demanded that Respondent do something. He then ordered a quantitative Beta-subunit Human Chorionic Gonadotropin blood test to determine her hormone level. On November 2l, 1986, Respondent called C.W. at her place of employment, and informed her that her hormone levels were extremely low, and that she might not have a viable pregnancy. He told her she should keep her next regularly scheduled appointment with him, but if she experienced any severe bleeding or cramping to call him. C.W. left work and became increasingly upset. She contacted him later on that same day for a more complete explanation of what she should expect. Respondent told her that the fetus was "reversing itself and was losing weight instead of gaining." C.W. was not informed by Respondent that the fetus was not viable, and she took his advice to mean that if she was extremely careful there was still a chance of carrying the pregnancy to term. Respondent admitted to the Petitioner's investigator, Jim Bates, that he knew the fetus was dead at this time, but he was trying to let nature take its course, and if she did not abort in two or three months, he would take the fetus. Because she was extremely upset and her friends were concerned about the advice she was receiving from the Respondent, an appointment with another obstetrician, Dr. Vincent Gatto, was made for C.W. by one of her friends. Dr. Gatto saw C.W. on or about November 21, 1986, and after examining her he immediately diagnosed her as having had a missed abortion. A sonogram confirmed this diagnosis. A dilation and curettage was performed on C.W., and subsequent pathological reports revealed remnants of an 8-week fetus. The medical records which Respondent maintained of his care and treatment of C.W. are incomplete and contain discrepancies concerning his evaluation of the patient. They do not reflect C.W.'s numerous telephone calls, or that she was increasingly upset over the course of her pregnancy. There is no delineation of a plan of treatment in these records, or any explanation of the type of treatment he was pursuing for her. There is no explanation or justification in these records of Respondent's failure to order a sonogram or test, other than the one Beta-subunit Human Chorionic Gonadotropin, for C.W., although she repeatedly reported vaginal bleeding and cramping, and there was a continuing inability to detect a fetal heartbeat. Respondent failed to carry out the correct tests on C.W., and therefore, he failed to make a correct diagnosis of missed abortion, or to treat her correctly. He allowed her to carry a dead fetus for almost two months. Retention of the products of a non-viable pregnancy can lead to several complications, including infection, blood clotting and psychological trauma. In fact, this experience caused C.W. severe emotional anguish. In his care and treatment of C.W., Respondent failed to meet the standard of care that is required of a physician practicing under similar conditions and circumstances.
Recommendation Based upon the foregoing, it is recommended that Florida Board of Medicine enter a Final Order suspending Respondent's license to practice medicine for a period of five years, and imposing an administrative fine of $3,000. DONE AND ENTERED this 21st day of August, 1989 in Tallahassee, Florida. DONALD D. CONN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 Filed with the Clerk of the Division of Administrative Hearings this 21st day of August, 1989. APPENDIX (DOAH CASE NO. 88-4785) Rulings on the Petitioner's Proposed Findings of Fact: Adopted in Finding l. Adopted in Finding 2. Adopted in Finding 3. Adopted in Finding 4. Adopted in Finding 5. 6-7. Adopted in Finding 6. Adopted in Finding 7. Adopted in Finding 8. Adopted in Finding 9. Adopted in Finding 10. Adopted in Finding 11. Rejected as irrelevant. 14-17. Adopted in Finding 13. 18-21. Adopted in Finding 12. 22. Adopted in Finding 14. The Respondent did not file Proposed Findings of Fact. COPIES FURNISHED: Mary B. Radkins, Esquire Northwood Centre, Suite 60 1940 North Monroe Street Tallahassee, FL 32399-0792 Allen B. Erde, M.D. P. O. Box 1817 Winter Haven, FL 33883-1817 Allen B. Erde, M.D. 198 First Street, South Winter Haven, FL 33880 Dorothy Faircloth Executive Director Northwood Centre 1940 North Monroe Street Tallahassee, FL 32399-0792 Kenneth Easley, General Counsel Northwood Centre 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0729
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Since 1990, Respondent has operated a recreational club in Broward County, Florida. Horse riding is among the activities offered at the club. Horses owned by Respondent and stabled on the club's premises are used by club members. Respondent has sold approximately six horses during the time he has operated the club. Two of these sales were made to Orlando "Pete" Trilla and his wife. The first of these two sales to the Trillas was made on or about December 31, 1994, when Respondent sold a quarter horse named Chance to the Trillas for $1,800.00. Pursuant to the Trillas' instructions, Respondent delivered Chance to Troy Doniny's stables. Respondent provided the Trillas with all of the paperwork that he (Respondent) had regarding Chance, including a report of a negative Equine Infectious Anemia (EIA) Laboratory Test administered August 20, 1993, and a report of a subsequent negative EIA Laboratory Test administered within 12 months of the date Respondent relinquished possession of Chance to the Trillas. (Respondent, who does not sell horses on a regular basis, did not retain copies of the paperwork he provided the Trillas.) The Trillas had difficulty handling Chance. In or about October of 1995, they asked Respondent if they could exchange Chance for another horse. The Trillas subsequently entered into an agreement with Respondent, which provided that the Trillas were to receive a Tennessee Walker named Walker from Respondent in return for Chance plus $1,000.00. On or about October 30, 1995, Respondent, through his agent, Daryl Woods, delivered Walker to the Trillas at the Trillas' residence in Palm Beach County, Florida. 3/ At the time of delivery, the Trillas were provided with all of the paperwork that Respondent had regarding Walker, including a report of a negative EIA Laboratory Test administered within the previous 12 months. 4/ (Respondent did not retain copies of the paperwork he provided the Trillas.) After receiving Walker, the Trillas relinquished possession of Chance to Woods. Chance returned to Respondent's club on Wood's trailer. The Trillas were dissatisfied with Walker. They complained to Respondent that Walker had "bad feet" and asked that Respondent return Chance, as well as the money that they had paid to obtain Walker. Respondent refused. The Trillas subsequently filed a civil action against Respondent. A trial was scheduled. The Trillas' lawsuit was dismissed when they failed to appear at trial.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Department enter a final order dismissing all charges against Respondent. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 27th day of December, 1996. STUART M. LERNER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 27th day of December, 1996.
The Issue The issues are whether Respondent is guilty, in his care of each of several patients, of failing to perform a statutory or legal obligation by performing unnecessary diagnostic tests, failing to keep legible medical records justifying the course of treatment, exercising influence on the patient to exploit the patient for the financial gain of Respondent or a third party, prescribing legend drugs other than in the course of his professional practice, and failing to practice medicine in accordance with the applicable level of care. If Respondent is guilty of any of these violations, an additional issue is what penalty should be imposed.
Findings Of Fact At all material times, Respondent has been a licensed physician in Florida, holding license number ME 51631. At all material times, Respondent has been Board-certified in ophthalmology. Respondent has not previously been disciplined. From 1996 to 1998, to supplement his income from the practice of ophthalmology in Deerfield Beach, Florida, Respondent worked at the Metabolic Treatment Center in Ft. Myers, typically receiving patients twice weekly at the center. At the Metabolic Treatment Center, Respondent typically saw patients whose many complaints had not been resolved by other physicians. The treatment philosophy of the Metabolic Treatment Center and its staff, including Respondent, was to check for and treat the metabolic component of patients' disorders. While Respondent worked at the Metabolic Treatment Center, between one and three physicians worked at the center, although Respondent, rather than another physician, typically saw his patients. Respondent's employment at the center ended shortly after the persons who owned it when he started working there sold it to a publicly traded corporation. After the change in ownership, Respondent did not like the new chief operating officer of the Metabolic Treatment Center. Respondent claims that he declined an offer from the chief operating officer to become the medical director of the center. Problems multiplied at the center until, one day, management abruptly locked out the staff and closed the center. In September 1999, the corporation owning and operating the Metabolic Treatment Center was administratively dissolved by the Florida Department of State. In subsequent litigation between Respondent and the Metabolic Treatment Center, Respondent obtained a circuit court order requiring the center to turn over medical records to him, but this order appears to have resulted in little, if any, actual relief, and the court case was closed in February 1999 without Respondent's obtaining copies of extensive medical records. Neither party disputes the fact that, while employed at the Metabolic Treatment Center, Respondent kept handwritten medical notes on each patient whom he saw. Respondent testified that these brief handwritten notes constituted less than five percent of the chart entries that he made on each patient. Respondent testified that he supplemented his handwritten notes, which he made while seeing a patient, by dictating or otherwise inputting more elaborate notes into a computer at the center. Petitioner contends that the handwritten notes were the only medical records that Respondent prepared for each patient. The Administrative Law Judge credits Petitioner's contention. Respondent attributed the loss of the more detailed medical records to the sudden termination of his relationship with the Metabolic Treatment Center and the subsequent refusal of the center's owners to allow Respondent access to these computer-stored records. It is impossible to credit Respondent's claim, at least to the extent of inferring the existence of extensive, detailed records for each of the patients in question. Respondent knew that any data that he inputted into a computer at the Metabolic Treatment Center were in jeopardy, unless he made copies of the computer files. As a self- described "per diem" physician at the center, Respondent knew that, at anytime, he could lose access to the facility and the computer-stored data at the facility. Before his abrupt termination, Respondent had encountered growing problems with the new Metabolic Treatment Center owners. Familiar with computer hardware and software, Respondent easily could have made copies of the computer files containing the medical records of his patients, but he failed to do so, and he cannot adequately explain this failure. The "failure" is because no such more detailed records ever existed. Respondent does not appear to have been especially attentive to detail, at least when practicing metabolic therapy at the Metabolic Treatment Center. In certain respects, the underlying conflict in these cases is between Respondent, practicing--holistically--metabolic therapy, and Petitioner's expert, Dr. Elton Shapiro, practicing--analytically-- endocrinology. Whatever else may be said of Respondent's holistic methodology, it cannot be said that a single tree ever blocked his view of the vast forest. At one point during the hearing, Respondent misread simple data on a chart. At no point during the hearing did Respondent claim the smallest recollection of any detail about any of the several patients involved in these cases. Although Petitioner's delay in prosecuting these cases would have presumably contributed to Respondent's failure to recall the details of his care for these patients, it is unusual that Respondent would lack any recollection whatsoever of any of the four patients who were clearly under his care at the center. Respondent claims to have spent an hour and a half with each new patient--a claim that is not credited--but nothing else in his testimony or the record contradicts the impression created by other aspects of the record of a high-volume practice at the Metabolic Treatment Center. A high-volume practice was not conducive to the kind of detailed record-keeping that Respondent claims to have undertaken. As Respondent himself testified, the center's management supplied him with forms that identified packages of lab tests, so that a single package combined useful tests with tests of little value, given the complaints, history, and findings concerning a particular patient. Respondent's ready acceptance and use of these test packages also militate against a finding that he attended closely to detail in his metabolic therapy practice. Discrediting Respondent's claim of a vast trove of detailed medical records does not mean that the present records are complete or even unaltered. Respondent's relations with the new owners of the Metabolic Treatment Center deteriorated to the point of hostility. A significant possibility exists that, following the cessation of operations at the center, existing medical records were not safeguarded and some records were lost. Likewise, records may have been altered. One record in these cases bears a handwritten printing of Respondent's name, misspelled. Another bears an awkward depiction of Respondent's letterhead from his east-coast opthamological practice--of which Respondent plausibly disclaims any knowledge. Although the Administrative Law Judge excluded records that appeared altered, some handwritten notes, lab results, and other materials may be missing from the present records. In making the findings below, the Administrative Law Judge has considered--patient-by-patient, entry-by-entry--all reasonable bases for inferences of the existence of other medical records, such as other handwritten notes or lab reports, that would support the quality of care that Respondent may have provided to any patient. The primary effect of this inferential process has been not to find, after examination of the admitted medical records, that the omission of a record of a patient history means that Respondent did not take one. With one minor exception, the sole basis for the admission of the medical records that have been admitted is Respondent's testimony identifying specific pages of records. The medical records adequately identified by Respondent are contained exclusively in Petitioner Exhibit 9, which is the transcript of Respondent's deposition taken, while he was still represented by counsel, on November 17, 2005. Attached to the transcript are about 300 pages of copies of purported medical records. (These pages are numbered 1-222 and 24-105.) The transcript discloses which records, by page number, that the Administrative Law Judge found that Respondent had adequately identified. After reviewing all of the evidence, the Administrative Law Judge has determined that he improperly admitted at the hearing other medical records. These records, which Respondent has never identified adequately, came from two main sources, although the original source in all cases was (or should have been) the Metabolic Treatment Center. The sources of these excluded records are of insufficient reliability to justify their admission. None of the patients themselves identified their medical records. Petitioner obtained the excluded records, which Respondent has never adequately identified, from two sources. First, Petitioner obtained some of the records from J. H., who is a cost-control employee of the insurer whose concerns led to the investigations that culminated in these cases. J. H. contacted Respondent during the course of her investigation into the reasonableness of the testing and treatment ordered by Respondent. In an odd twist, Respondent invited J. H. to assume the role of a patient at the center, and J. H. accepted his invitation. Presumably, Respondent took a history, made physical findings, and may have recommended a plan of treatment for the insurance investigator, who then, presumably foregoing the treatment plan, caused herself to be included among the 11 patients who eventually formed the subject of DOAH Case No. 04-4111PL. (As noted above, Petitioner has dropped its allegations concerning investigator/patient J. H.) The Administrative Law Judge finds that medical records produced exclusively from the insurer or J. H. lack sufficient reliability, under the facts of these cases, including the unusual involvement of the insurer's investigator in producing facts on which to prosecute Respondent, to justify their admission. Second, Petitioner obtained some records from Respondent's former attorney, who testified briefly at the final hearing. However, the source or sources of these records are unclear in the record. Given the age of these cases, the lack of proof concerning the preparation and custody of the putative medical records, and the fact that Respondent's former attorney obviously obtained the records from one or more other sources, it is impossible to find that the records identified by counsel are sufficiently reliable as to admit them into evidence. Only one category of medical records, besides those adequately identified by Respondent, is sufficiently reliable to be admitted into evidence. This category comprises those few records that Dr. Shapiro testified at the hearing were linked in time and content to other records already adequately identified by Respondent. This post-hearing exclusion of additional evidence affects only C. M. among the nine patients remaining in these two cases. For C. H., P. G., Sarah B., and S. A., Petitioner relied exclusively on the medical records attached to Petitioner Exhibit 9, substantial portions of which Respondent adequately identified. For B. H.-M., G. H., L. L., and R. B., Petitioner acknowledged at the hearing that it was relying exclusively on testimony because no records pertaining to these patients had been admitted. The absence of any acknowledgement by Respondent that he treated B. H.-M., G. H., L. L., R. B., or C. M., coupled with the absence of any admitted medical records for these five patients, preclude any factfinding about Respondent's care of these patients, or even that Respondent cared for them at all. Petitioner has therefore failed to prove any of the alleged violations concerning these five patients. C. H., a 46-year-old female, presented at the Metabolic Treatment Center for an initial visit on June 6, 1996. For C. H., pages 3 and 5-26 under tab "C. H." in Petitioner Exhibit 9 are admitted. On June 6, Respondent performed a physical examination of C. H. that revealed nothing of clinical significance. Under "impression," Respondent noted "pending labs & NCV." "NCV" is a study of nerve conduction velocity. An NCV study measures the speed of conduction of a nerve, which is an indication of the nerve's condition. C. H. completed an 11-item checklist for her health history and symptoms. Her history reported mitral valve regurgitation and prolapse, fibromylagia, and hypoglycemia. However, C. H. circled the "no" response to the question, "Do you have diabetes?" On another form, C. H. denied having had any of the listed conditions. C. H. also completed a checklist circling "yes" or "no" next to each of 14 symptoms and 11 conditions. C. H.'s symptoms included dizziness, chest pain, numbness in hands or feet, back pain, neck pain, shortness of breath, "a feeling that your heart skips a beat," "a fluttering sensation in your heart," fatigue, weight gain, inability to lose weight, depression and menstrual problems. C. H. indicated that her history did not include any of the listed conditions. Prior to sending C. H. to obtain NCV studies from another physician working for the Metabolic Treatment Center, Respondent completed a Metabolic Treatment Center form entitled, "Letter of Medical Necessity." The purpose of the form, according to the preprinted contents, is for Respondent to certify that services are "medically necessary" and "reasonable and necessary." The form shows that Respondent ordered NCV studies of the upper and lower extremities by the Metabolic Treatment Center to rule out peripheral neuropathy, possibly of a diabetic nature. Dr. Martin S. Goldstein of the Metabolic Treatment Center performed the NCV studies on the date of the initial visit. Bearing the date of June 6, 1996, and the heading, "Metabolic Treatment Center," the report states that a "slowed conduction is demonstrated" for the left upper extremity. The report includes the impression of "peripheral neuropathy." Respondent never addressed the question of diabetes according to the medical records. Blood work performed on June 7, 1996, June 28, 1996, and July 24, 1996, revealed that glucose was in the normal range and serum insulin was normal on June 7 and July 24, but high on June 28. The records do not indicate whether Respondent ruled out diabetes, as was his documented intent on the original office visit, nor do the records contain any discussion of Respondent's conclusions from this repeated blood work, if he did not feel that he could rule out diabetes. The portion of the rule-out diagnosis mentioning diabetes merely faded out of the records, except, of course, for repeated blood work that typically assists a practitioner in diagnosing diabetes. At least as to Respondent's handling of the question of diabetes, Petitioner proved that the medical records fail to justify the course of treatment following a rule-out diagnosis of peripheral neuropathy, possibly of a diabetic nature. Petitioner also proved that Respondent's ordering of the NCV studies was unnecessary and excessive, despite the abnormality disclosed in the upper left extremity. The salient facts are: 1) Respondent ostensibly ordered the NCV studies to rule out peripheral neuropathy, possibly of a diabetic nature; 2) the NCV studies revealed likely peripheral neuropathy of the upper left extremity; and, most importantly, 3) Respondent's medical records contain no discussion of the meaning of the abnormal finding from the NCV study of the upper left extremity. Notwithstanding the abnormal NCV finding, Respondent failed to refer C. H. to a neurologist, undertake treatment himself, or document why he was taking neither action. Respondent's failure to act on the abnormal finding proves that he never intended to do anything if the NCV studies uncovered anything wrong, as one did. Additionally, Respondent ordered the NCV studies without first testing C. H.'s sensory or motor functions and despite the patient's denial of any tingling in the arms or legs. The evidence establishes that C. H.'s tests were unnecessary and excessive. By failing to act on the abnormal NCV finding, Respondent failed to conform to the applicable standard of care. However, Petitioner's standard of care allegations cite only inappropriate and excessive testing, failing to perform an appropriate history and physical examination, and inappropriately and inaccurately diagnosing C. H. The excessive testing with respect to the NCV studies, discussed above, is better described as a failure to conform to a statutory duty than a failure to satisfy the applicable standard of care. Other excessive testing, discussed immediately below, is better described as the exploitation of a patient for financial gain. For the reasons noted in the Conclusions of Law, below, it is impossible to conclude that Respondent's failure to act on the abnormal NCV result violates the applicable standard of care because of the absence of a specific allegation to this effect. The blood work of June 28 and July 24, 1996, was excessive for several reasons. In most cases, items tested were normal when first tested on June 7, but this first round of blood work was generally appropriate. However, no medical reason existed to retest such items three weeks later or one month after the second round of blood work. For example, Respondent ordered an iron reading on June 7, despite any basis to suspect anemia. The reading was normal, but Respondent retested it on June 28 and July 24--on which occasions, iron remained within the normal range. Respondent tested amylase on all three occasions--despite any complaint, such as acute abdominal pain, that would suggest pancreatitis and justify a test for amylase--and on all three occasions amylase levels were normal. As noted above, Respondent tested serum insulin on all three occasions, again for no apparent reason, after the initial test was normal and the second test revealed only a slight elevation. Respondent ordered additional tests that were unnecessary in connection with the above-described blood work. Items tested unnecessarily include prolactin (absent any problem with excessive milk production), cortisol (especially as it was not a suppression test, but was a random test, which is useless), ACTH (especially because it was ordered before any cortisol abnormality was found), DHEA (absent any finding of masculinization), and human growth hormone (in the absence of any indication of an abnormality in growth hormone). Petitioner proved that Respondent ordered unnecessary and excessive tests to exploit C. H. for financial gain. On June 13, 1996, Respondent saw C. H. for the first time after her initial visit a week earlier and started her on Cytomel, 5 mcg each, four times daily. Cytomel is T3, a synthetic thyroid hormone. T3 combines in the blood with another thyroid hormone, T4, to regulate the metabolism of the cells within the body. Normally, when these hormones fall too low in the blood, the pituitary gland produces thyroid stimulating hormone (TSH), which stimulates the thyroid gland to produce more T3 and T4. The June 7 blood work revealed that total T3 and TSH were well within the normal range, although T4 was either at the low range of normal or just below the normal range. The June 28 and July 24 blood work showed values only for total T3, which were again well within the normal range. Without any support in the medical records except a notation of "low energy," Respondent elected to commence thyroid hormone supplementation. Within a week after starting on this prescription, C. H. had reduced the frequency of taking the Cytomel to three times daily due to heart palpitations, which is a known side effect of the drug. However, during an office visit on June 27, Respondent advised C. H. to resume taking Cytomel--5 mcg, five times daily--obviously after learning of the heart palpitations, but before obtaining the results of the June 28 lab work showing a normal total T3 level. C. H. discontinued taking Cytomel on July 11, 1996, due to feelings of fatigue. On August 9, 1996, C. H. reported, for the first time, that she "feels great," although, judging from the medical records, her recovery seems to have been spontaneous. Petitioner proved that Respondent's initial prescription of Cytomel was inappropriate and outside the course of practice because the blood work indicated normal values for the relevant hormones. The medical records contain no trace of a discussion of why Respondent would prescribe T3 for a patient with these values, complaints, and history. Not only was the Cytomel useless, but, for C. H., it produced cardiac side effects. If Petitioner had alleged the inappropriate prescription of thyroid medications as a basis for an alleged violation of the applicable standard of care, as it did with respect to C. M. and S. A., Petitioner would also have proved that the increased prescription of Cytomel, on June 27, violated the applicable standard of care. The resumption of the Cytomel prescription on June 27 departed from the applicable standard of care because Respondent knew that the Cytomel had produced a potentially dangerous side effect, and he ordered C. H. to increase the dosage of Cytomel before he had even seen the results of the blood work done the following day--which results again showed a normal total T3 level. Respondent's treatment plan, if it fact it can be called a plan, seems completely unrelated to C. H. and the findings of any physical examination and lab work or the complaints and history that she related to Respondent. Not surprisingly, her recovery seems similarly unrelated to any treatment plan. However, Petitioner failed to allege the prescription of thyroid medication as a basis for an alleged violation of the applicable standard of care as to C. H. Petitioner failed to prove the three alleged grounds for an alleged violation of the applicable standard of care. Petitioner failed to prove that the history or physical examination was inadequate or that the only diagnosis in the records--a rule-out diagnosis--was inaccurate or inappropriate. Although Petitioner proved some inappropriate and excessive testing, this improper testing is best described as a failure to perform a statutory obligation, with respect to the NCV studies, and as the financial exploitation of a patient, as to the repeated and unjustified blood work. Thus, as to C. H., Petitioner proved a failure to perform a statutory obligation, a failure to maintain adequate medical records, the exploitation of a patient for financial gain, and the inappropriate prescription of a thyroid replacement medication, but not a violation of the applicable standard of care. P. G., a 43-year-old female, presented at the Metabolic Treatment Center for an initial visit on July 3, 1997. For P. G., pages 43-44 (top), 47-48, and 55-69 under tab "P. G." in Petitioner Exhibit 9 are admitted. Following a physical examination, Respondent noted diminished deep tendon reflexes at the right and left dorsal pedal sites, right and left biceps sites, right and left post- tibial sites, and right and left poplyteal sites. Respondent obtained a history that included high blood pressure and heart disease, as well as a family history of heart disease. P. G. complained particularly about depression, pain, swelling in the joints for five years, faulty memory, joint pain, and poor concentration. She also complained of fatigue, numbness, tingling, and muscle aches. Petitioner failed to prove a violation of the applicable standard of care for a failure to perform an adequate physical examination or history. Respondent made a working diagnosis of hypothyroidism, hypertension, endocrine gland disorder, and chronic fatigue. He also made a rule-out diagnosis of pituitary access disorder. Respondent ordered blood work and directed P. G. to record her basal temperature daily. Petitioner failed to prove a violation of the applicable standard of care for a misdiagnosis, at this point in Respondent's care of P. G. Petitioner's expert witness described NCV studies that Respondent ordered of P. G.'s upper and lower extremities on July 3, but Petitioner failed to prove that these studies took place. The portion of the medical records (p. 45 under tab "P. G." in Petitioner Exhibit 9) discussing the results of the NCV studies was not admitted into evidence, and the NCV reports themselves were not offered into evidence. Petitioner failed to prove a failure to perform a statutory obligation for ordering unnecessary NCV studies. The blood work resulting from a collection occurring on July 8, 1997, revealed elevated glucose and cholesterol components. Earlier blood work done in January 1997 revealed elevated cholesterol components, but not glucose. The July 1997 lab work reported normal levels of total T3, T4, and TSH, which are consistent with the results of the January 1997 lab work for T4 and TSH (T3 was not tested in January 1997). In ordering the blood work for July 7, Respondent ordered analysis of insulin, iron, cortisol, growth hormone, and prolactin. For the reasons discussed in connection with C. H., Petitioner proved that these tests were medically unnecessary. Petitioner thus proved that Respondent exploited P. G. for financial gain in ordering all of these unnecessary tests. P. G. returned to Respondent's office on July 11 to discuss the results of the blood work. Respondent diagnosed her with, among other conditions, hypothyroid "both by temperature and symptoms." Although Respondent noted the thyroid readings from the July 7 blood work, he failed to discuss the relationship between these normal readings and his diagnosis of hypothyroid. Petitioner thus proved that the medical records do not justify the course of treatment. Additionally, distinct from this shortcoming in the medical records, Petitioner proved that Respondent inaccurately diagnosed P. G. with hypothyroidism and thus failed to satisfy the applicable standard of care. The lab work relating to P. G.'s thyroid function resembles the NCV studies of C. H. in terms of a lack of medical necessity. In the case of C. H., Respondent ordered the NCV studies for a reason other than to assist in diagnosis because, when they disclosed an abnormality, he ignored the positive finding and took no action. In the case of P. G., Respondent ordered the thyroid tests for a reason other than to assist in diagnosis because, when they revealed no problems with thyroid function, he ignored the negative finding and proceeded as he presumably would have if the tests had produced a positive finding of thyroid abnormality. Petitioner has proved that the blood work on thyroid function lacked medical justification and was unnecessary, and Respondent thus failed to perform a statutory obligation. On July 11, Respondent started P. G. on Cytomel, "0.5" mcg, four times daily. (An error in the sequencing of Respondent's medical records under tab "P. G." in Petitioner Exhibit 9 places immediately after the page describing the July 3 visit a page noting an increase in the dosage of Cytomel. Given the presence of an August 22 entry on this latter page, it is obvious that the page containing the entry increasing the Cytomel should have followed the page that ends with the July 31 visit.) Also on the July 11 office visit, Respondent started P. G. on human growth hormone. The July 7 blood work did not support this treatment because Respondent failed to test for human growth hormone either after exercise stimulation or glucose suppression. The value for human growth hormone in the July 7 blood work appears to be within the normal range. At the next office visit, which took place on July 31, 1997, Respondent also increased P. G.'s Cytomel to 10 mcg four times daily and ordered her to take human growth hormone on a cycle of five days on and two days off. As on July 11, Respondent, on July 31, lacked any justification to prescribe Cytomel or human growth hormone to P. G. Petitioner proved that Respondent inappropriately prescribed controlled substances to P. G. However, this finding applies only to the prescription of Cytomel because Petitioner never alleged that Respondent inappropriately prescribed human growth hormone. Although the inappropriate prescription of Cytomel probably would also constitute a violation of the applicable standard of care, Petitioner did not make such an allegation regarding P. G. Thus, as to P. G., Petitioner proved a failure to perform a statutory obligation, a failure to maintain adequate medical records, the exploitation of a patient for financial gain, the inappropriate prescription of a thyroid replacement medication, and the violation of the applicable standard of care. Sarah B., a 52-year-old female, presented at the Metabolic Treatment Center for an initial visit on September 5, 1996. For Sarah B., pages 72-80 and 87 under tab "Sara [sic] B." in Petitioner Exhibit 9 are admitted. No patient history was admitted into evidence, but it is impossible to infer from this omission that Respondent failed to obtain an appropriate patient history. Completed forms were present for other patients, the forms seem to have been readily available for completion by patients (not Respondent), and completed forms, which supplied numerous conditions or complaints that the patient had only to recognize and mark, set the stage for metabolic treatment of these numerous conditions or complaints. The records document Respondent's physical examination of Sarah B. on September 5, 1996, and disclose no abnormalities. Under "impression," Respondent stated, "pending labs and NCV." Petitioner failed to prove a violation of the applicable standard of care for a failure to perform an adequate physical examination or history. Performed on September 5, the NCV studies, again performed by Dr. Goldstein of the Metabolic Treatment Center, find a "mild focal peripheral neuropathy." Respondent next saw Sarah B. on September 12 and 20, 1996, but his notes omit any mention of the neuropathy. Once again, Respondent failed to treat the condition revealed by the NCV studies, refer the patient to a neurologist, or at least explain why he was taking no action. For the reasons discussed in connection with C. H., Petitioner proved that the NCV studies ordered by Respondent lacked medical justification and were unnecessary, and Respondent thus failed to perform a statutory obligation. Respondent ordered analysis of cortisol, DHEA, human growth hormone, iron, prolactin, and amylase. The records reveal no justification for these tests. Petitioner proved that Respondent exploited Sarah B. for financial gain. The September 5 blood work revealed normal values for T4, total T3, and TSH. Despite the absence of any thyroid abnormalities, on September 12, Respondent started Sarah B. on Cytomel, 5 mcg, four times daily. Respondent's notes reveal no reason why he started Sarah B. on Cytomel and lack even the specificity of the notes on the same issue with respect to P. G. Petitioner proved that the medical records fail to justify the course of treatment. However, Respondent discontinued the Cytomel one week later. Although the notes fail to explain the reason for his action, Respondent's prompt discontinuation of Cytomel demands more proof than Petitioner has provided, if it were to prove that the weeklong prescription of Cytomel was inappropriate or, had Petitioner pleaded the prescription of Cytomel as a violation of the applicable standard of care, deviated from the applicable standard of care. Thus, as to Sarah B., Petitioner proved a failure to perform a statutory obligation, a failure to maintain adequate medical records, and the exploitation of a patient for financial gain, but not the inappropriate prescription of a thyroid replacement medication or the violation of the applicable standard of care. S. A., a 53-year-old female, presented at the Metabolic Treatment Center for an initial visit on June 3, 1998. For S. A., pages 88-90, 92, 97-99, and 100-06 under tab "S. A." in Petitioner Exhibit 9 are admitted. After performing a physical examination, which included pulses and reflexes of the extremities, Respondent formed the impression that S. A. probably suffered from peripheral neuropathy. As is the case with Sarah B., no patient history is contained in the medical records, but, for the reasons stated above, it is impossible to find that Respondent failed to take a history. Petitioner thus failed to prove a violation of the applicable standard of care by failing to perform an appropriate physical examination or history. S. A. is dissimilar to the above-described patients in several respects. First, according to the testimony of Dr. Shapiro, S. A. suffered from hypothyroid disorder, so the ordering of blood work to assess thyroid function and the prescribing of thyroid supplement were appropriate. Second, judging from the medical records, Respondent did not order NCV studies. Third, S. A. was an uncooperative patient. Fourth, the lab reports on the blood work are substantially illegible, likely due to poor copying, with the result that it is impossible to read the values and ranges for particular items that are tested and, in some cases, read the items themselves. In general, no clear picture of the findings, diagnoses, and treatment plan emerges from the record, with the sole exception stated in the following paragraph. The sole exception is that it is clear from the records that Respondent, again, ordered tests of numerous items, such as testosterone (absent masculinization), prolactin, cortisol, growth hormone, and blood type, that were unnecessary. Petitioner thus proved that Respondent exploited S. A. for financial gain, but failed to prove the remaining S. A.-related allegations.
Recommendation RECOMMENDED that the Board of Medicine enter a final order dismissing DOAH Case No. 04-3222PL and dismissing all counts in DOAH Case No. 04-4111PL, except the four counts alleging the financial exploitation of C. H., P. G., Sarah B., and S. A.; the three counts alleging the failure to perform a statutory obligation regarding C. H., P. G., and Sarah B.; the three counts alleging the failure to maintain adequate medical records regarding C. H., P. G., and Sarah B.; the two counts alleging inappropriate prescriptions to C. H. and P. G.; and the one count alleging a violation of the applicable standard of care as to P. G. For these violations, the Board should enter a final order imposing an administrative fine of $29,000 against Respondent and placing his license on probation for five years. DONE AND ENTERED this 5th day of May, 2006, in Tallahassee, Leon County, Florida. S ROBERT E. MEALE Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 5th day of May, 2006. COPIES FURNISHED: Timothy M. Cerio, General Counsel Department of Health 4052 Bald Cypress Way, BIN A02 Tallahassee, Florida 32399-1701 Dr. M. Rony Francois, Secretary Department of Health 4052 Bald Cypress Way, BIN A00 Tallahassee, Florida 32399-1701 Larry McPherson, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 Irving Levine Department of Health Prosecution Services Unit 4052 Bald Cypress Way, BIN C65 Tallahassee, Florida 32399-3265 Marvin Reich 1979 West Hillsboro Road Deerfield Beach, Florida 33442
The Issue The issue in the case is whether the allegations in the Administrative Complaints are correct and, if so, what penalty should be imposed.
Findings Of Fact At all times material to this case, the Respondent was a licensed physician in the State of Florida, holding license number ME0039986. DOAH Case Number 01-3795PL Between May 22 and June 5, 1998, the Respondent ordered a series of diagnostic lab tests for Patient C. H., a 63-year- old female. As to the care provided to Patient C. H., the Petitioner presented the testimony of Hamilton Fish, M.D., whose testimony was persuasive and is credited. According to Dr. Fish, many of the tests performed on Patient C. H. were not medically indicated according to a review of the information set forth in the patient's medical records, and the medical treatment care provided by the Respondent to the patient was inappropriate and failed to meet the applicable standard of care. According to the hemoglobin test performed on Patient C. H., the patient was diabetic and the diabetes was uncontrolled. The Respondent did not provide proper treatment to the patient for the diabetes. According to one of the lab tests, Patient C. H. was deficient in calcium. The Respondent did not provide appropriate treatment for the calcium deficiency. Although there was no medical indication that Patient C. H. had a thyroid problem, the Respondent prescribed a thyroid hormone medication. The thyroid medication was inappropriate and could have exacerbated the diabetic condition. DOAH Case Number 01-3796PL The Petitioner introduced into evidence an advertisement that appears to have been published in the June 25, 1999, edition of the "Sun-Sentinel Community News." There is no evidence that the Respondent created, read, placed, or paid for the advertisement in the newspaper. The ad offered a complementary consultation with the Respondent, who was identified in the ad as a diplomate of the "American Board of Anti-Aging." Florida law requires that a disclaimer appear in such advertisements advising a patient of the right to essentially decline non-free services that are recommended on the basis of the free consultation. The cited advertisement did not include the disclaimer. The Petitioner's administrative rules prohibit advertisement of affiliation with groups not "recognized" by the Petitioner. The Petitioner has not approved of the "American Board of Anti-Aging." DOAH Case Number 01-3797PL Patient D. E. On or about July 21, 1998, the Respondent ordered a series of diagnostic lab tests for Patient D. E., a 53-year-old male. According to the records, Patient D. E. had complained of impotency and loss of sexual desire. As to the care provided to Patient D. E., the Petitioner presented the testimony of Timothy Shapiro, M.D., whose testimony was persuasive and is credited. According to Dr. Shapiro, many of the tests performed on Patient D. E. were not medically indicated according to a review of the information set forth in the patient's medical records. At least one of the tests performed on several of the patients referenced herein (the "Barnes Basil Temperature Test") is not recognized in the medical community as providing valid information for the conventional diagnosis or treatment of any disorder. On or about August 18, 1998, the Respondent diagnosed Patient D. E. with hypothyroidism, panhypothyroidism, food allergies, and impotence of organic origin. He prescribed Cytomel, Armour Thyroid, and testosterone gel for the patient. According to the testimony of Dr. Shapiro, the prescribed medications were inappropriate because the medical record fails to indicate any deficiencies being addressed by the medication. The course of treatment provided for the patient is not documented by the medical records and is below the standard of care. Patient J. N. On or about August 27, 1998, the Respondent ordered a series of diagnostic lab tests for Patient J. N., a 50-year-old female. According to the records, Patient J. N.'s symptoms included fatigue, numbness, tingling and burning in the extremities, muscle and head aches, insomnia, swelling, depression and easy bruising. As to the care provided to Patient J. N., the Petitioner presented the testimony of Hamilton Fish, M.D., whose testimony was persuasive and is credited. According to Dr. Fish, many of the tests performed on Patient J. N. were not medically indicated according to a review of the information set forth in the patient's medical records. On or about September 10, 1998, the Respondent diagnosed Patient J. N. with chronic fatigue, probable hypothyroidism, and unspecified liver disorder. An existing diagnosis of ischemic heart disease was confirmed; he prescribed various medications for the patient. According to the testimony of Dr. Fish, the prescribed drugs (Cytomel, Hydrocortisone, Rezulin, and a female hormonal transdermal gel) were inappropriate and below the standard of care, and the medical records do not justify the course of treatment provided by the Respondent. Patient T. B. On or about October 8, 1998, the Respondent ordered a series of diagnostic lab tests for Patient T. B. (also identified as T. P.) a 49-year-old female. According to the records, Patient T. B.'s symptoms included muscle ache, migraines, insomnia, vaginal discharge, and neck, back and stomach pain. As to the care provided to Patient T. B., the Petitioner presented the testimony of Hamilton Fish, M.D., whose testimony was persuasive and is credited. According to Dr. Fish, many of the tests performed on Patient T. B. were not medically indicated according to a review of the information set forth in the patient's medical records, and the medical treatment care provided by the Respondent to the patient was inappropriate and failed to meet the applicable standard of care. On or about October 21, 1998, the Respondent diagnosed Patient T. B. with hyperthyroidism, migraine headaches, chronic fatigue, yeast infection, and unspecified disorder of the intestines, stomach, and duodenum. He prescribed various medications for the patient. According to the testimony of Dr. Fish, the prescribed drugs (Cytomel and Armour Thyroid) were inappropriate and below the standard of care, and the medical records do not justify the course of treatment provided by the Respondent. The Respondent failed to perform a pelvic examination or to refer the patient to a gynecologist despite the diagnosis that she was suffering a yeast infection, and therefore failed to meet the applicable standard of care. The diagnosis of unspecified disorder of the stomach, duodenum, and intestines was apparently based on described pain. There is nothing in the medical record indicating that appropriate testing to determine causality was ordered or performed. Patient A. M. On or about August 26, 1998, the Respondent ordered a series of diagnostic lab tests for Patient A. M. According to the records, Patient A. M.'s symptoms included muscle and head ache, constipation, cramps and menstrual irregularity, decreased libido, sore throat and sinus problems. As to the care provided to Patient A. M., the Petitioner presented the testimony of Hamilton Fish, M.D., whose testimony was persuasive and is credited. According to Dr. Fish, many of the tests performed on Patient A. M. were not medically indicated according to a review of the information set forth in the patient's medical records, and the medical treatment care provided by the Respondent to the patient was inappropriate and failed to meet the applicable standard of care. On or about September 9, 1998, the Respondent diagnosed Patient T. B. with hypothyroidism, chronic fatigue, hyperinsulinemia, and unspecified ovarian dysfunction. The lab test results do not support the diagnosis. On December 2, 1998, the Respondent prescribed various medications for the patient. According to the testimony of Dr. Fish, the prescribed drugs (Cytomel, Rezulin, Glucophage, glycine, and fish oil) were inappropriate for the patient and below the standard of care, and the medical records do not justify the course of treatment provided by the Respondent.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Agency for Health Care Administration, Board of Medicine, enter a final order suspending the medical license of Robert M. Knight, M.D., for a period of one year followed by five-year period of probation, and imposing an administrative fine of $5,000. DONE AND ENTERED this 19th day of April, 2002, in Tallahassee, Leon County, Florida. ___________________________________ WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 19th day of April, 2002. COPIES FURNISHED: Kathryn E. Price, Esquire Agency for Health Care Administration Post Office Box 14229 Tallahassee, Florida 32317-4229 Robert M. Knight, M.D. 5650 Camino del Sol, Number 101 Boca Raton, Florida 33433 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Mr. R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Tanya Williams, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
