Q:Would You Please Describe Your History with and Personal Knowledge of Patient C As Such

May 17, 2008

PATIENT C

Q:Would you please describe your history with and personal knowledge of Patient C as such relate to your treatment of her?

A:Patient C is the 51-year-old matriarch of the family composed of Patients A, B, D and E, and a patient of my clinic for a number of years. Patient C is the mother of Patient E and Patient A, plus one other son who was not a patient of my clinic. She is a protective mother and grandmother, and a good role model in her family – the glue that has kept many of them together over the years. C was a working mother and was employed by the Bank of America until she fell from a ladder while helping Patient B do repairs to their house in November of 2001. During that fall, she suffered a spiral, complicated fracture of the right tibia and knee, requiring immediate surgery. She had subsequent surgeries on her leg as well. Her injuries were significant and she was in a great deal of pain during post-surgical periods. She required, and received, pain management services under contract with me using opioid medications (Oxycontin CR in addition to Roxicodone (short-acting)). As with other pain patients in my practice, she was monitored frequently (every two weeks) and was required to sign a pain management contract. She was not a willing pain medication consumer and therefore presented little resistance to minimal dosing. Patient C also had a history of anxiety and night terrors of unknown cause for a number of years. Prior to her fall, she had been treated with and responded best to the use of benzodiazepines for her anxiety disorder and night terrors. Over time, she was switched to an antidepressant – Lexapro – which replaced the use of Xanax and avoided tolerance. During her recovery from her injuries, she was slowly tapered off her opioid medications and maintained on non-steroidal anti-inflammatories. She was provided with a physical therapy program in addition to an at-home exercise program prescribed by myself. Her chronic anxiety syndrome did not really change over time and required ongoing treatment. She was generally found compliant with manual therapies and did not exhibit signs of overuse or diversion of her medications for pain.

On September 14, 2005, the day of her son’s unexpected death, I provided her with a prescription to help with acute grief related anxiety, delivered to her home by Patient E. I had a brief telephone conversation with her, offering her my condolences and advising here that Px E would be bringing the prescription to her, for use, if needed for acute and grief-related anxiety. Her son, Patient E, came to my clinic on September 14 and was comforted and provided with grief counseling for at least an hour. I referred her and other family members to a grief specialty counselor on more than one occasion, but I do not believe that any of them went (Exhibit EMR Action Item March 29, 2006). All family members continued to see me as their family doctor prior to and after the funeral and continued to receive grief-related counseling and monitoring over a period of several months. Although I encouraged them to add the services of a specialty grief counselor I knew, they seemed reluctant to see any other providers.

During the period of her care at my clinic, her lab results (05/23/2002 Spectra cell lab report verifying deficiencies) supported a diagnosis of pernicious anemia. She responded positively to intramuscular injections of Vitamin B12 and folic acid supplements. She was observed to be compliant with her medications and there was never any evidence of her interchanging or mixing medications with other family members, including her spouse.

She was always observed to be a very supportive and dependable grandmother and has been a significant stabilizing force to her grandchildren, who live close by, during difficult times in their lives. Patient C remained a loyal and supportive patient of my clinic for more than six months until she abruptly stopped seeing me in March of 2006.

Q.The Statement of Charges alleges with respect to Patient C in paragraph 1.4 that you “Failed to document discussion or counseling of patient regarding her son’s death”. How do you answer that Charge?

A:I deny such and cannot fathom how anyone could possibly come to such a conclusion. I was in direct contact by telephone with Patient B at home shortly after the death had been confirmed by the father’s call to the clinic when he informed me that A had passed away in the night from what he thought was another seizure. At that time, I passed my condolences to Px C and other members of the family (Exhibit No. A0007). Later that day, September 14, 2005, the chart note of the deceased’s brother, Patient E, verifies that Patient E was seen at the clinic, was afforded a considerable amount of time and received extensive grief counseling. In that patient encounter, there is reference to grief handouts being provided to Patient E for distribution to other family members at home (Exhibit No. E0104). A prescription of Xanax for the purpose of controlling grief-related stress was authorized and given to her son, Patient E, to deliver to the grieving mother at home (Exhibit No. C0048). On 09/15/2005, although it is not specifically recorded in the chart, all of these family members will verify that I and Mrs. Alsager attended at the Jennings’ home between 10.30 a.m. and 2 p.m. for the purpose of being with the family. All of the family members were there and were attended to by myself providing grief counseling and comfort to as many as possible, including Patient C, Patient B, Patient E, and others. Copies of the professional handout I use for this purpose were left in the home for any relatives who wished or needed the information (see copy). I was in telephone contact with Patient C on 09/14/2005 at approximately 4 p.m. Although it is not specifically recorded in the charts, I, Mrs. Alsager, as well as the entire office staff, attended the funeral of Patient A, which was held on September 24, 2005. On September 21, 2005, prior to the funeral, I saw Patient C at the office. The chart note specifically records “grief counseling today – 15 minutes” (Exhibit No. C0046). The chart note dated 10/15/2005 (Exhibit No. C0042) again reflects grief counseling being the primary focus of that visit. Antidepressants were added with special information provided to the patient. Her anxiolitic medications were increased to get better control of grief-related depression. A contingency plan was in place to switch to an alternative antidepressant in 30 days. Counseling was also provided and referred to in the chart note regarding her taking a short holiday to “get their minds off their son’s death” (chart note 10/15/2005, Exhibit No. C0043). Patient was seen again on 11/08/2005 where the chart note records a complaint of “feeling very sad and depressed”. The chart note reflects a significant amount of counseling for grief-related depression on that date of service in addition to medication changes (Exhibit No. C0040, C0041). Patient C was seen again on 11/16/2005 (Exhibit No. C0039) for follow up for grief and depression. Medications were revised and the chart note expresses “depression seems to be improving”. The patient was authorized to increase Halcion if needed to maintain a good night’s sleep in the face of her nighttime anxiety and grief-related depression. Extensive blood work was done in order to monitor systemic effects of medications in addition to sustained and severe grief (Exhibit No. C0039). See letter from Thompson to all pharmacies. On 11/22/2005 (see EMR for prescription refill only) the patient had called the clinic for a refill request. She indicated that two Halcion at bedtime were helping her sleep through the night and allowing her to feel much better (Exhibit No. C0035). On 11/25/2005, the prescription for sleep medication was reissued because a Safeway pharmacist in Auburn had refused to fill it. On encounter 11/29/2005 (Exhibit No. C0032, C0033, and C0034), this patient was followed up again during a visit where I had questioned the wisdom of a proposed trip by Patients C and B to Las Vegas to deal with marital problems of another son. There was a question in my mind of the wisdom of taking on additional stress by Patient C during this period of grieving. There is a notation in the chart that her level of depression was improving with treatment. It was also noted that there appeared to be a pattern of early refill since her son’s funeral, reflecting astute monitoring of her condition and medication use. On visit 12/13/2005 (Exhibit No. C0028-C0029), the chart note clearly reflects that the patient is still seeking and obtaining grief/depression counseling regularly at my office. Anti-depressant medications as well as anxiolitics (benzodiazepines) were again reviewed and a treatment plan was implemented to slowly reduce the Xanax and maintain Effexor. Extensive grief counseling was recorded on that visit, in addition to an order directing the patient to obtain more regular, specialized grief counseling. The patient was ordered to start increasing exercise as well as taper down on her medications (see chart note 12/13/2005, Exhibit No. C0029). Patient ordered to Grief Counselor. On 01/04/2006 (Exhibit No. C0027), the chart note again refers to “counseling received – 10 minutes”. On a visit dated 01/12/2006 (Exhibit No. C0025), the chart note reflects that the patient received more counseling regarding grief-related depression. The patient had brought a medical examiner’s report to the office for which assistance in interpretation was provided (Exhibit No. A0090.9 Death Investigation Toxicity Report. It was then that I promised her to research all aspects to find the reason for Px A’s death. In addition, there was counseling for at least 15 minutes. Antidepressant medications were again adjusted on that visit. On patient encounter 02/02/2006, the patient had indicated “the medication regime is helping a lot” (Exhibit No. C0021). On patient encounter 02/15/2006, the chart note reflects that the patient was again counseled for grief-related depression (Exhibit No. C0019). Patient C was continued on anxiolitics and antidepressants until 03/10/2006 when she abruptly stopped seeing me.

In summary, there are multiple documented events in Patient C’s chart verifying that grief-related counseling was in place immediately following the death of her son and continued for a considerable period of time afterwards.

Q:The Statement of Charges alleges with respect to Patient C in paragraph 1.5 you prescribed “opioids and benzodiazepines without a compatible diagnosis, and without attempting non-narcotic or less potent narcotics and without documented efficacy”. How do you answer this Charge?

A:Not true at all. Patient C was being treated for bone fractures – first a fracture of her hand (Exhibit No. C0170) and then later, a significant, complex fracture of the right knee and adjacent bones from a fall (Exhibit No. C0128, C0120, 04/28/2004; Exhibit No. C0071, C0072, 04/07/2005; Exhibit No. C0067, C0068, encounter 04/27/2005; Exhibit No. C0060, C0061, 06/24/2005). Patient C was prescribed a low dose of Oxycodone for pain, in addition to non-steroidal anti-inflammatory therapy. Her underlying, preexisting complaint, however, was a long-time anxiety disorder. She had a history of anxiety and panic attacks throughout her adult life and did not function well without the use of anxiolitics on a daily basis (05/07/2004, Exhibit No. C0116). Her complaint is documented on 04/17/2004 (Exhibit No. C0126, C0127). She was placed on long-acting Xanax on which she seemed to do quite well and achieve stability. The pain from her fractures worsened her anxiety syndrome. She did well when she was treated for pain during the night with long-acting Oxycontin, supplemented by Roxicodone for breakthrough pain during the day PRN (max 5/day). Simultaneously, the long-acting Xanax XR was very effective to treat her longstanding, underlying anxiety syndrome (see chart note 04/20/2004, Exhibit No. C0124, C0125). The patient, on the following visit, 04/22/2004, indicated “the anxiety is definitely improved” (C0122, C0123), verifying the efficacy of the treatment plan involving the use of a combination of narcotics for daytime pain and long-acting Xanax to treat the underlying anxiety syndrome which manifests at its worst during nighttime.

Q:The Statement of Charges alleges with respect to Patient C in paragraph 1.12 that you “lacked sufficient treatment plan for non-opioid treatment or concomitant treatment”. How do you answer this Charge?

A:Again, not true. Patient C was initially treated with non-steroidal anti-inflammatories (C0170, C0066). The patient was also prescribed exercise on that visit. Other examples of non-opioid treatment modalities used were dietary changes (visit 01/23/2002, Exhibit No. C0169), special treatments for fatigue (Bontril SR) (see encounter 02/27/2002, Exhibit No. C0163), specialized Spectracell tests to look for micronutrient deficiencies that may have been contributing to her symptoms (encounter 04/10/2002, Exhibit No. C0161). The patient was treated with stress management counseling (05/29/2002, Exhibit No. C0150). The patient received trigger point injections for pain from muscles as a non-pharmaceutical alternative (encounter 07/23/2002, Exhibit No. C0145). The patient was treated with osteopathic manipulation treatments multiple times, stretch exercises were prescribed, hot soaks, and stress management counseling (see chart note 10/24/2002, Exhibit No. C0136 and C0137). Aggressive diagnostic imaging was used to identify underlying causes of pain including MRI studies (chart note 11/27/2002, Exhibit No. C0134), CT scans and x-rays (Exhibit No. C0134). Physical therapy was also prescribed; however, the patient indicated on visit 01/17/2004 that “PT did not help”, so it was discontinued in favor of osteopathic manipulation to which she responded more favorably (Exhibit No. C0130). When the patient presented with a fractured right leg (complex, displaced, comminuted) on 04/08/2004 (Exhibit No. C0128, C0129) she was followed appropriately with conservative therapy and appropriate pain management (using long-acting Oxycontin 10 mg for baseline pain control, plus Oxycodone 15 mg PRN breakthrough pain). Considering the nature of her injuries, this was appropriate conservative therapy and was not excessive, nor was the amount used excessively increased over time (see chart note 04/20/2004, Exhibit No. C0124 and C0125). Her baseline anxiety syndrome became worse following her leg fracture and required an increase in the anxiolitic doses. The visit of 04/22/2004 verified that the “anxiety is definitely improved” indicating good efficacy of her medical management of pain and simultaneous anxiety. Her visit dated 05/06/2004 indicated how the efficacy of her program deteriorated when she attempted to taper off the Xanax. A tapering program resulted in the reoccurrence of “frightening dreams at night”. Xanax 1 mg was reinstated including a long-acting XR and the panic attacks at night resolved. There is reference during that visit for long-range plans involving adding Lexapro to take over when Xanax was to be discontinued (see visit 05/07/2004, Exhibit No. C0116). On 05/18/2004 the chart notes verify the patient was to again try physical therapy. There is also an indication in that chart note that one of the fixation screws viewed on x-ray appeared to be coming loose and probably responsible for a significant amount of pain. In spite of that occurrence, her opioid pain medication was maintained at the same level (Exhibit No. C0114 and C0115). The chart note of 07/13/2004 indicates various assistive devices (crutches and canes) were evaluated to assist with the patient’s pain control and accident-related gait abnormalities. Physical therapy was in place and working. The amount of pain medications being used by Patient C did not need to be increased. The patient had another surgery to remove the screw in her leg bone on 08/24/2004 (Exhibit No. C0115, C0103). Bextra (Exhibit No. C0101) (an NSAID) was prescribed rather than increasing opioid pain medications. The patient continued to be monitored closely with labs (see encounter 09/08/2004, Exhibit No. C0101). The patient was monitored closely for side effects of medications as reflected by blood draws (06/29/2004, Exhibit No. R-3 (C0171.1-C0171.17)– Lab results). The patient was evaluated further with diagnostic imaging on 09/16/2004. Pain medications were not increased. Consideration was given to alternate Cox2 NSAIDs – “Celebrex versus Mobic versus Bextra” referenced in the chart note 09/17/2004. The patient was reevaluated on 09/18/2004 for possible bone loss and placed on a special medication regime to avoid bone loss during a period of time when she was in recovery from right leg and knee fractures. A therapeutic exercise program was outlined and put in place (10/05/2004, Exhibit No. C0093). Just prior to the visit on 01/25/2005, the patient had yet another surgery on the right knee and lower leg and had more metal removed. The prescriptions for her chronic anxiety syndrome were maintained and prescriptions of narcotics were not increased. On 04/07/2005, the patient was prescribed and instructed on the use of Lidoderm patches (non-opioid) as a method of pain control (see Exhibit No. C0071). Injection therapy was also used on 04/19/2005 in response to elbow pain that developed as a result of overuse of her assistive devices (canes and crutches). During this time, Patient C was functioning on 15 mg Roxicodone taken PRN max five a day – a very conservative dose for someone with this degree of severe bone injuries and surgeries that she had endured. On 05/26/2005, her function was improving, by her indications that she was now “mowing the lawn” and was “planning on going on a cruise” (see Exhibit No. C0065). At that point, Voltaren (NSAID) was added and she was maintaining Roxicodone 15 mg as before without change. Her anxiolitic medications were also maintained without increase. In keeping with the osteopathic traditional approach to patient care (treating the whole person) there are numerous references in Patient C’s chart notes regarding efforts to monitor side effects of medications on liver and kidney function as well as maintaining monitoring and treating hyperlipidemia and other general health concerns. Manipulation was used frequently as a modality to reduce pain as is evidenced in the chart notes of 07/05/2005 (Exhibit No. C0059) and 07/13/2005 (Exhibit No. C0050). Prior to her son’s funeral on 09/21/2005, there was no increase in the use of pain medications. In fact the use of Roxicodone for her bone pain had decreased from a maximum of five a day to a maximum of three a day (Roxicodone 15 mg tablets). She was still doing well on the NSAID Voltaren at 75 mg per day.