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Dose of Their Own Medicine

Integrative doctors battle the ethically conflicted NC Medical Board

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Sometimes, it's like living in a police state. They've had their offices searched and their financial records subpoenaed. Investigators regularly show up at their offices and walk off with random stacks of patient files. They've been charged with nothing, but they're all guilty of the same thing -- practicing what has come to be called integrative or alternative medicine.

When conventional medicine doesn't work, these doctors are the ones more likely to use everything from vitamins to acupuncture to cure common maladies. But as their craft has become more popular with the public in recent years, they say they've increasingly become a target of the North Carolina Medical Board, the independent body charged with policing the state's doctors. No matter how common their practices may be in other states, those who stray the furthest from what's considered to be mainstream medicine here have felt the worst of the NC Medical Board's wrath. In a state that has gained a national reputation for its lax discipline of doctors who endanger the public, it is no exaggeration to say that in some cases, the medical board has expended more energy on doctors who give vitamin B-12 shots in their offices than those whose negligence put an otherwise healthy patient six feet under.

Now some of the same integrative doctors are fighting back against a board that they say is controlled by special interests and routinely allows doctors who've had multiple malpractice judgments against them, and who've harmed their patients, to continue practicing medicine. The battle is one that threatens to widen the schism in the medical community over the way doctors are regulated in the state. Much is at stake. If the integrative doctors get their way, patients will have access for the first time to information about doctors who have repeatedly caused harm to patients. And medical special interests that have controlled the medical board for over 100 years will no longer hold sway over the board's decisions, forcing it to put regulation and discipline before politics.

For Dr. Rashid Buttar of Cornelius, the battle started over two years ago. At the time, things were looking up for him. For years he'd been trying to convince his fellow doctors that his research had found a link between cancer and the presence of Insulin-Like Growth Factor (IGF-1) in the body, but no one took him seriously. When Buttar spoke at conventions here and across the nation, he drew little interest from his colleagues, some of whom even told him they thought his theory was nutty. By the time a 2000 article in the Journal of the National Cancer Institute proved him right, he'd already invented a transdermal prescription-only product called Trans-D-Tropin, which decreased IGF levels and stimulated the body's production of human growth hormone. Its effects on athletes were so marked that players from nine NFL teams are currently using it. Within six months of the publication of the groundbreaking Cancer Institute article, Buttar -- now a recognized world authority on IGF-1 and its correlation to cancer, metal toxicity and autism -- was lecturing before audiences packed with some of the same sorts of doctors who had once shunned his ideas.

It wasn't long after that someone found a brochure for Trans-D-Tropin with Buttar's name stamped on the back at a gym and passed it on to the NC Medical Board. Suddenly, a medical board investigator began turning up at his office unannounced. Although no complaints had been filed against him, she made copies of stacks of patient files and hauled them off. Board attorneys and investigators wanted to know every detail about his research and his business interests, particularly those related to Trans-D, but no one would tell him what he wanted to know -- why he was being investigated.

Meanwhile, the board was running Asheville doctor James Biddle through a similar wringer. Biddle's problems started when a patient filed a complaint with the board that he had over-billed her. The complaint was quickly dismissed when Biddle produced documents she had signed stating that she understood his billing procedures. As it turned out, the board was more interested in what the bill was for, namely a hair analysis, zinc taste test, and vitamin shot for a patient complaining of fatigue. After an endless litany of questions and a visit from an investigator, Biddle received a letter inviting him to what was described as a formal inquiry at which he would be read his rights. He was advised to bring an attorney. Before it was all over, they'd subpoenaed his financial records and grilled him on his involvement with Great Smokies Diagnostic Laboratory, which does medical test processing for alternative doctors.

"They just keep digging until they find something to get you or they break you," said Biddle. "I spent $10,000 in legal fees to give someone a trial of B-12 shots to see if it helps them. It's vitamin B-12. It's a harmless, simple thing that old country docs used to do for people with fatigue all the time. It works often."

But the board's inquest didn't stop there. When it learned that Great Smokies provides lab results related to alternative therapies for integrative doctors across the state, it sent the laboratory a subpoena demanding a list of all the North Carolina physicians who do business with the lab. The lab did not return Creative Loafing's calls for comment.

Others like Dr. Walter Ward of Winston-Salem are more resigned to the endless inquisition. The use of vitamins is a central part of Ward's practice, one that has caused him to spend endless hours explaining their benefits in treating everything from acne to post nasal drip to medical board investigators with a bottomless supply of pointed questions.

"Every time I turn around they're investigating me about one thing or another," said Ward.

So far, Ward has foregone the attorney fees and taken his chances, betting that he can talk his way out of the board's latest inquest with graphs, charts and stacks of scientific research supporting his methods. In the process he's saved himself tens of thousands of dollars in legal fees, but risked his license and clean record in the process.

Worse yet, when integrative doctors were called before the board to explain themselves in the past, doctors unfamiliar with alternative therapies sat in judgment over them. The board had also barred doctors who were the sole practitioners of an alternative therapy in North Carolina from calling witnesses from other states to help defend them, essentially leaving them defenseless.

It was the equivalent, Buttar and others say, of the board calling in a neurosurgeon to review the work of a gynecologist.

Concern or Harassment?
Last year, according to the National Practitioner Data Bank and an analysis by the group Public Citizen, disciplinary actions (license suspension, revocation, or restriction of clinical privileges) were taken against only 8.1 percent of North Carolina physicians with two or more malpractice payouts. Meanwhile, 17.6 percent of integrative physicians in North Carolina have had to hire attorneys to answer for them in investigations or appear before the Board (compared to 1.1 percent of all physicians).

The trend is not unique to North Carolina, says Neal Pattison, research director for Public Citizen, a group founded by Ralph Nader that, among other things, studies the track record of medical boards nationwide. In states like ours where there's a direct relationship between the physician trade group and the board that disciplines doctors, problems often arise.

In North Carolina, 7 of the 12 members of the medical board are appointed by the North Carolina Medical Society, a powerful private physicians' special interest group with more than 11,000 members statewide. In recent years, various attempts by legislators to rein in the medical society's power over the board, through bills that end its ability to appoint its members, have gone down in flames thanks to the society's proficient lobbyists.

"It's a real conflict," said Pattison. "Being a doctor is a noble calling, but it's also a business and as a bunch of businessmen, these docs are often influencing the conduct of their state medical boards. They are very concerned about something that might be a business threat to the doctors, like a new type of medicine coming to town."

When it comes to integrative medicine, there's much for the mainstream to be financially concerned about. Since 1998, the number of Americans who solicit alternative medical treatment has steadily increased. Last year, a Harvard University study showed that 42 percent of Americans had sought some sort of alternative medicine in the previous six months. Another study by the Duke Center for Integrative Medicine found that there are now more visits annually to alternative care providers than to primary care providers, and that Americans are spending an average of $30 billion a year out of their own pockets for this care. At the same time, insurance providers are increasingly offering employers coverage packages that include alternative therapies like homeopathy, massage, chiropractic medicine, acupuncture and acupressure, which were considered controversial only a decade ago.

According to a state law passed in 1993 after a legislative battle by integrative medical practitioners, the medical board cannot revoke or deny a license to a physician for practicing a therapy that is "experimental, nontraditional, or that departs from acceptable and prevailing medical practices unless, by competent evidence, the Board can establish that the treatment has a safety risk greater than the prevailing treatment or that the treatment is generally not effective."

Dale Breaden, director of public affairs at the NC Medical Board, says it's patently untrue that the board is targeting integrative doctors.

"As long as someone isn't being harmed by them, the board doesn't interfere with the practice of nontraditional methods," he said.

But in Buttar's case and the others, the board never suggested that anyone was harmed or could potentially be harmed in its correspondence with the physicians. It merely asked a long series of questions about their methods before hauling them into court-like hearings, something the board could do because, like law enforcement agencies, it has subpoena power.

By February 2003, Buttar and eight other integrative doctors from across the state decided they'd had enough. They formed the North Carolina Integrative Medical Society and hired their own lobbyist to work on changing state law. At an April press conference attended by a mere three members of the media, plus lawyers for the medical board and members of the medical society, Buttar's hand shook as he blistered the medical board for the way it treated integrative doctors. After media coverage of the event and subsequent testimony by Buttar before the North Carolina legislature, lawmakers asked the board to compromise with the doctors on a bill that, for the first time, mandated that one appointed member of the board be a doctor who practices integrative medicine, and that integrative doctors defending themselves before the board be allowed to call witnesses who also practice integrative medicine, including those who live outside the state. The bill, which eventually became law, also stipulates that an integrative doctor must review the care in question before the license of another integrative doctor can be revoked.

Two weeks after Buttar's blistering testimony at the legislature, a letter arrived in the mail from the medical board inviting him and his attorney to appear before the board to answer questions about his practice of medicine and advising him that his rights would be read to him when he appeared. When Buttar declined the invitation, the board subpoenaed him to appear before them.

With his license potentially at stake, Buttar feared he wouldn't get a fair hearing. Worse yet, because the board summarizes hearings and then destroys the tapes, he feared there'd be no record of it. The board refused his attorney's request for a taped copy of the hearing or to allow Buttar to hire a court reporter to document it. To protect his license, Buttar sued the board and emerged with a consent order stating that the board would provide him with a transcript if they took disciplinary action against him.

After two years of harassment and $20,000 in legal fees, Buttar emerged from the hearing poorer but with his clean record intact.

"It's like they realize that the mere expense involved in hiring lawyers will itself be punishment enough or fair warning that they are in control and we are under their thumb," said Keith Johnson, an integrative doctor from Southern Pines. "They are searching for anything to use as an excuse to bring charges against someone like myself; not that the charges are ever substantial."

Inconsistent Judgments
Two years ago, Sandra Joyner, a 45-year-old mother of two, died at the Center for Cosmetic and Plastic Surgery on Billingsley Road in Charlotte after plastic surgeon Peter Tucker performed a mini-facelift. According to board documents, she died after a nurse anesthetist injected her with a substance that was known to occasionally cause respiratory failure.

Although the board had considered suspending Tucker's license for a year, it decided to allowed him to continue practicing in exchange for agreeing to do a better job managing his nurses and allowing the board to inspect his office at any time. In a consent order that read more like a glowing defense of Tucker's actions, the board stated it was, "fully confident and satisfied" that it was safe for Tucker to practice medicine.

But the order never addressed the majority of the board's own charges against Tucker in the investigation. Initial charges by the board say Tucker's staff didn't realize that Joyner was still suffering from profound respiratory depression after they revived her and that given her oxygen saturation count, she should have been intubated and ventilated, but wasn't, which led to her death. But later board documents say it was Tucker, not his staff, who revived Joyner after the surgery. In the board's findings, Tucker's involvement with Joyner's medical treatment after he revived her is never discussed. Other charges left unaddressed were preoperative tests which initial board documents say Tucker was supposed to perform but didn't, why there were incomplete records of crucial details of the operation, and why Tucker administered certain medications to Joyner before the operation without an order by the treating physician. Joyner's family is currently suing Tucker for malpractice in civil court.

When Dr. John Pittman of Raleigh learned about Tucker's case, he was outraged. After Pittman, an integrative doctor, administered ozone and a diluted form of hydrogen peroxide intravenously to a patient who complained of chronic fatigue -- a procedure he performed regularly -- the patient experienced hemolysis, a known but rare side-effect of this treatment. The patient was hospitalized for five days while she recovered, but suffered no permanent physical injury. According to board documents, like Tucker, Pittman failed to properly monitor the patient. As punishment, the board permanently suspended Pittman's license, but stayed all but 60 days of the suspension, meaning that Pittman couldn't practice for two months. More devastating to Pittman's practice, though, was the condition the board put on his ability to practice. He can no longer act as a supervising physician to physician assistants, nurses or clinical pharmacist practitioners, even though failure to supervise employees was never raised as an issue in the charges against him.

"The board thinks I'm more dangerous than a plastic surgeon that kills patients," Pittman wrote in a recent letter to his colleagues. "This guy who kills a patient got off completely."

What some find even more disturbing is that Tucker's case is not an anomaly. In fact, Public Citizen, which studies the effectiveness of the country's state medical boards based on how they discipline doctors who repeatedly harm patients, has consistently ranked the North Carolina medical board at about 45th in the nation.

For the last year, lobbyists for the NC Medical Society have been pushing for changes in state laws that will make it even harder for patients to sue doctors. The society claims this is necessary because malpractice claims are driving up the cost of medicine. But a report by Public Citizen recently documented the lax discipline standards the board has applied to doctors who practice mainstream medicine.

According to the National Practitioner Data Bank (NPDB) and Public Citizen's analysis of NPDB data, disciplinary actions (license suspension or revocation, or a limit on clinical privileges) have been few and far between for North Carolina physicians. Only 15.2 percent (24 of 158) of North Carolina doctors who made three or more malpractice payouts were disciplined by the Board. Of the 22 doctors with five or more malpractice verdicts against them, only five were disciplined by the board.

"Some of these people have three, four, five bad outcomes that don't look like just bad outcomes but look like a pattern, and they are still not disciplined," said Biddle.

Breaden, the director of public affairs at the NC Medical Bard, says the board has limited resources and that there are only so many cases it can take on.

"Each malpractice case is reported to us and evaluated with great care by a committee of this board and an action is taken if appropriate," Breaden said. "In the vast majority of cases, as any look at the history of malpractice will demonstrate, it does not in fact reflect lack of competence, which is our concern, but a variety of other issues that are involved in malpractice decision-making in the case of malpractice liability law."

Breaden says the board isn't concerned about the Public Citizen report.

"This is basically Ralph Nader who has his own agenda," Breaden said. "We're not interested in Mr. Nader's agenda."

Breaden took issue with the statistics in the report because he said doctors often hold licenses in more than one state. So the malpractice actions against North Carolina doctors listed in the Public Citizen report could have actually occurred while the doctors were practicing in another state.

Still, the board regularly disciplines doctors who hold licenses and practice in other states but also hold North Carolina licenses. The board requires the reporting of malpractice claims against doctors licensed here, no matter which state they practice in.

"What if you're a consumer in North Carolina and you are going to be attended to by a physician and someone says, "Oh, but that physician has injured eight patients.' And you say, "That sounds bad,' and they go, "But six of them weren't in North Carolina.'" Public Citizen researcher Pattison asks. "Do you suddenly feel better about that physician?"

Breaden encouraged CL to look at the board's discipline record for 2002 rather than Public Citizen's report, so we did.

In 2002, of the 26,581 physicians the board regulates, 28 were formally charged. The board took action against only four licensees for failing to meet accepted standards of care, and revoked the license of only one despite 1,581 complaints from patients and colleagues registered with the board. Of the 15 licenses it suspended, 10 of the suspensions were stayed, or never acted upon.

That's not good enough, the physicians of the North Carolina Integrative Medical Society (NCIMS) say. Despite changes in the law, the way the board polices physicians still needs to change.

In 41 states, laws bar links between politically active medical societies and the boards that discipline doctors. In the coming year, NCIMS doctors say they'll be pushing to end the NC Medical Society's ability to appoint the majority of the medical board. They want an annual independent review of the disciplinary actions of the board and the investigatory methods employed by their staff by a group not linked to the medical society. They also want the public to have better access to malpractice verdict information.

The members of the group acknowledge that it will be an uphill battle. But it isn't one that the integrative doctors of North Carolina started.

Contact Tara Servatius at tara.servatius@cln.com

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