Second Guessing the Medical Board

When state medical licensing boards started posting on the Web the documents associated with discipline of physician misconduct physicians worried about the negative impact on their reputations and practices. But these documents also make public the work of the boards, leaving that work open to scrutiny, analysis, and criticism.

It only occurred to me to embark on such a critique after the name of a physician in my community appeared in the regular Washington Medical Quality Assurance Commission (MQAC -- pronounced M Quack) publication. I wondered whether readers might appreciate my analysis. Whether that includes Dr. Roys or MQAC is yet to be determined.

Links to documents related to Case M2009-897 appear in order from last to first on the linked Web page.

Disclosures

I met David Roys, MD 15-20 years ago, but never knew him well or worked closely with him. I have worked as a consultant for MQAC in the remote past, reviewing patient records for the most part, although I may have examined a physician or two for them. I practice in the same community as Dr. Roys, so you might rightly consider us competitors. Robert Small, MD may have been pro tem psychiatric member of  MQAC at the time of this case. If I recall correctly Dr. Small trained in child psychiatry. I knew him when we both belonged to the medical staff of a local psychiatric hospital (presumably Overlake), and I believe we both worked as consultants for a managed care operation. I believe Dr. Small continued his career on the payer side by working for a health insurance company, perhaps as medical director. He seems to have managed to keep a very low profile on the Web. I have been a member of the Overlake Hospital medical staff for approximately 25 years.

Disclaimers

Understand that my sole source of information about this case is the five documents alluded to above. I have not reviewed medical records or discussed the case with Dr. Roys, his attorney, or anyone from the Board. Board attorney James Mclaughlin provided limited information as to who may have written the documents and Dr. Small's possible involvement. I can draw conclusions only about MQAC documents, not about Dr. Roys' handling of the case or MQAC's decisions. It is not my intention to help or hurt Dr. Roys or anyone associated with the case. It is my intention to shed light on the disciplinary process to the extent that the reports accurately reflect that process. It does occur to me that MQAC might find my analysis useful in future cases and that either side might find my analysis useful if litigation follows the complaint, as it often does. So be it. If such litigation should involve a jury trial, any prospective juror who has read this might use the fact to disqualify herself from duty.

Case Summary

According to MQAC documents, a psychotherapist refers a patient to the Respondent psychiatrist (Dr. David Roys) after failed treatment for an apparent depressive disorder with another physician. Dr. Roys makes some changes in the regime, including stopping the clonazepam, wondering whether the patient might suffer from Bipolar Disorder. After nearly 6 months the patient reports continued depressed mood with thoughts of suicide. Dr. Roys prescribes diazepam, but patient and doctor do not schedule a follow up appointment, possibly for financial reasons. Soon thereafter the patient attempts suicide (presumably) with overdose of "her medications, primarily the diazepam," is admitted to hospital, discharged back to Dr. Roys, then finds a new psychiatrist and files a complaint with MQAC (not necessarily in that order).

Sanctions

MQAC charged Dr. Roys under RCW 18.130.180 Unprofessional Conduct: "Incompetence, negligence or malpractice which results in injury to a patient or creates an unreasonable risk that a patient may be harmed." MQAC criticizes Dr. Roys' management of the case as follows:

• Prescribing too much diazepam given the purported level of suicide risk.
• Prescribing that was ineffective for treating the "noted depression."
• Stopping antidepressant medication even absent sufficient evidence for Bipolar Disorder.
• Treating the patient's anxiety without "fully addressing" (whatever that means) her depression.
• Failure to provide a "well structured care and monitoring plan."
• Asking the patient to return "only when she felt the need."
• Prescribing a drug (diazepam) that had "propensity for abuse."
• Failure to document coordination with the psychologist "to better tailor the medication plan with the mental health issues of Patient A that the psychologist was dealing with."

Points for Analysis

I will address the following issues from the official documents in this and future installments:

• Writing style and grammar
• Benzodiazepines
• Diagnosis and medication regime
• Documentation
• Scheduling of appointments
• Coordination of treatment
• Suicide attempt
• Reimbursement
• Possible unintended consequences of MQAC's expressed and implied positions

Style

In a word I find the documents, particularly the Statement of Charges and Amended Statement of Charges, sloppy, particularly given their importance. It may seem petty to criticize the authors, for example, for capitalizing generic drug names like diazepam which are not proper nouns, but the ambiguity in many statements leaves me wondering whether the statement reflects MQAC's views or whether MQAC actually knows what it wants to say or indeed understands the issues.

The Amended Statement of Charges includes several "amendments" to the original Statement. The original refers to the referring professional as a psychologist, but this individual becomes a "therapist" in the Amended Statement. Was this a physical therapist, massage therapist, or a psychotherapist? If, as I suspect, he or she was a psychotherapist I hardly think it would break the MQAC budget to add those extra six letters.

Both Statements allude to whether the patient "was bi-polar." Not only is there no hyphen in the term, but Patient A may have had bipolar disorder; it is incorrect to say that she was bipolar. The patient may have taken antidepressant medications, not "anti-depression" medications. According to the Statement paragraph 1.7 the patient "manifested serious depression and anxiety." Apparently we are not to confuse this with comical depression or anxiety.

In paragraph 1.8 the report indicates that Dr. Roys told the patient to return "as needed." We see this term recorded later as "prn," an abbreviation of the Latin pro re nada which physicians usually reserve for prescriptions. Since we learn later that the patient's budget may have affected the frequency with which she wanted to visit Dr. Roys, and that MQAC criticized Dr. Roys handling of this matter, one wonders whether this pejorative language accurately reflected the event.

Paragraph 1.11 uses the legal term "grounds" to describe the patient's motivation for transferring care to a new psychiatrist. The author should have chosen a more appropriate word; legal jargon is gratuitous. This paragraph also refers to Dr. Roys as "not resolving" the patients symptoms. Doctors do not resolve symptoms; they treat them. Symptoms and illnesses might, however, resolve with treatment, or indeed without treatment.

With paragraph 1.12 the author takes us abruptly from laying out the facts to criticizing Dr. Roys' handling of the case leaving me with the impression that MQAC has failed to discriminate between facts and charges. I believe this shift justifies a separate, appropriately labeled, section in the report. The original Statement criticizes Dr. Roys' treatment as "not effective," seeming to insinuate that ineffective treatment is negligent treatment. Since psychiatric illness frequently fails to respond to standard treatments the author acted correctly in dropping this statement from the amended version. Also correctly omitted from the amended report is the ambiguous criticism of Dr. Roys' in paragraph 1.13 for not "fully addressing her depression." Psychiatrists do not "address" depression. We treat it.

The ambiguity continues in 1.14 of both statements which refer to a "well structured care and monitoring plan." In this paragraph in the original statement the author states Dr. Roys "was asking her to return only when she felt the need." This language leaves me wondering when and how often he "was asking," and more importantly, given the pejorative tone, whether MQAC criticizes Dr. Roys for what he did (was asking) or for what he should have done. Paragraph 1.14 in the amended statement provides little more clarity in stating that Dr. Roys "on several occasions did not schedule appropriate follow-up visits." Does MQAC want us to understand that he did schedule inappropriate visits? How does MQAC differentiate between appropriate visits and inappropriate visits? Perhaps we should focus instead on the fact that he did not schedule (the visits). If so, all physicians should indeed fear board sanction. In fact I myself have spent this entire morning not scheduling visits of any kind, appropriate or inappropriate.

The original statement criticizes Dr. Roys for prescribing a "large amount of Diazepam (Valium) which had the propensity for abuse." Was it the amount that had the propensity for abuse, or was it the diazepam? If the latter, does MQAC expect us to believe that some diazepam has a propensity for abuse and other diazepam does not? Does not all diazepam have a propensity for abuse? Is that not why it is a controlled substance? The author correctly omitted this language from the amended statement.

Paragraph 1.15 in the original statement is a near total disaster. In it the author criticizes Dr. Roys' records for failing to "reflect the kind of coordination with Patient A's psychologist that would be required in monitoring the patient, to better tailor the medication plan with the mental health issues of Patient A that the psychologist was dealing with." Fortunately for us readers the author clarifies this mess, at least partly, in the amended report.

One can only hope that MQAC was less sloppy in adjudicating this case than these documents reflect.

In my next installment I will address questions surrounding medication, especially the benzodiazepines clonazepam and diazepam.