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Charging the Chargers: Vermont Medical Board
SPECIFICATION OF CHARGES
NOW COMES moviedoc and alleges as follows:
1. State of Vermont Board of Medical Practice presumes to judge Vermont physician Michael E. Schorsch, MD.
2. Jurisdiction in these matters rests (vests?) with moviedoc and you the reader.
According to this public document the State of Vermont filed charges in September, 2012.
A complaint by a buprenorphine maintenance patient claiming termination without prior warning led to investigation of Dr. Schorsch's practice by Investigators Dori Tothill and Paula Nenninger. Dr. Schorsch told the Board he terminated treatment because of "consistent dishonesty" and failure to progress in "employment" and recovery activities, and that he provided ample warning that such would constitute grounds for discharge. He admitted that he did not use written agreements or contracts.
Dr. Schorsch also told the Board that he varied frequency of urine drug screens according to patient progress and utilized "pill counts" no more than occasionally.
The Board criticized Dr. Schorsch in his management of the complainant and nine other cases on eleven counts of unprofessional conduct.
II. Respondent's criticism of Dr. Schorsch's practice
The Board criticized Dr. Schorsch for failure to "document the cause" of termination of Patient A, indicating that "merely providing a list" of other physicians and a supply of buprenorphine with instructions for a taper constitute substandard treatment.
Moviedoc argues that medical ethics stipulates that patients and physicians choose each other freely, with or without cause. It appears self-evident that Dr. Schorsch was not helping the patient with her addiction and that termination was appropriate and in the best interest of the patient. Dr. Schorsch in fact need not have provided the patient with a list of physicians, information the patient could easily have obtained on her own. (I would not have wanted to be on that list.) Furthermore, he need not have provided a supply for taper. The patient could have sought detoxification in another facility.
Perhaps the most glaring deficiency in this Count, however, was the failure of the Board to document evidence that the physician ever refused to provide treatment to the patient after telling her of her discharge. Did she request an appointment or a refill? Did the doctor refuse her? If not, abandonment never took place at all.
The Board criticized Dr. Schorsch for failure to use written informed consent for treatment with buprenorphine.
Medical care is not about forms and written agreements. Such would have been self serving for Dr. Schorsch, but would not have benefitted the patient. I would recommend that he use such forms in the future to protect himself.
Again, the Board has provided no evidence that Dr. Schorsch failed to inform the patient of the risks of treatment.
The Board criticized Dr. Schorsch for failure to use a written treatment contract with patients he treats with buprenophine.
A written treatment contract would have helped Dr. Schorsch defend himself, but as in Count 2 the Board has failed to provide evidence that a patient might have behaved differently had he known of some aspect of the unwritten contract. The Board has failed to make a case for use of such a contract in this particular kind of treatment. Does the Board require a written contract for every treatment of every patient by every physician? If not, please explain this discrimination. Furthermore, such contracts, if ever read by the patient at all, probably have long since disappeared into the dust bins of memory.
The Board criticized Dr. Schorsch for failure to use regular urine drug screens in the cases reviewed.
Drug addicts can easily fool drug screens, regular or random. The Board has provided no evidence that such screens would have altered the outcome of any of the cases reviewed and has failed to provide any guideline as to frequency, type of screen, or indication.
The Board criticized Dr. Schorsch for failure to use random pill counts.
Physicians are not trained to count pills. The Board could have reprimanded Dr. Schorsch for performing a procedure for which he has no training had he admitted to counting pills. Pharmacists are trained to count pills. Pill counts accomplish nothing and should not be promoted. More here.
The Board criticized Dr. Schorsch for repeated refills when patients claim buprenorphine was lost, stolen or damaged.
No good deed shall go unpunished. The Board has failed to state a policy here. Should such claims ever lead to a refill? Does the Board not realize that, unless the physican can observe the drug melting in the patient's mouth he has no way of knowing what happens to any prescribed drug?
The Board criticized Dr. Schorsch for failure to test female patients for pregnancy prior to initiating treatment with buprenorphine. In my opinion such routine testing, which can lead to delay in treatment, is not justified. Buprenorphine may be safer in pregnancy than continued use of other opiates or than opiate withdrawal. It suffices for the physician to ask about contraception and time since last menses.
But again, most reflective of the Board's naive approach to this case: Pregnancy can occur at any time during treatment with any drug. Perhaps this august body would have every woman of child bearing age undergo pregnancy testing before picking up every prescription for any drug.
The Board criticized Dr. Schorsch for failure to document history and physical examination of each patient.
The Board criticized Dr. Schorsch for failure to use an "objective screening and assessment instrument to determine the appropriateness of buprenorphine treatment."
On the contrary, Dr. Schorsch should exercise his professional judgement rather than use an "instrument" to make this decision. Perhaps the Board has such an instrument in mind. If not, why not share it with us?
The Board criticized Dr. Schorsch for failure to use a "tool" to determine whether he should prescribe buprenorphine alone instead of buprenorphine/naloxone.
See Count 9. The Board insults and demeans physicians by implying that a "tool" can replace medical judgement. For shame.
The Board criticized Dr. Schorsch for failure to use an "tool" to determine dose adjustments.
See Count 6 and Count 9.
The Board criticized Dr. Schorsch for failure to "refer" a patient "to a counselor and document it in her patient chart."
Get yourself a rubberstamp, Dr. Schorsch. Does the Board really want us to believe that a) a patient cannot find a "counselor" on their own? b) a patient will benefit from forced treatment? c) a patient will make an appointment with such a referred counselor?
The Board criticized Dr. Schorsch for failure to keep adequate records of stocked drugs.
Dr. Schorsch should conform his record-keeping to regualatory requirements, or better yet, let the patient get the drug from the pharmacy.
III. Moviedoc's Allegations of Conduct Unbecoming a Medical Board
Sloppy writing and grammar.
Failure of transparency. The Board should name any experts, reviewers or examiners whose opinions helped them arrive at their determinations.
Criticism demonstrating failure to appreciate the patients or the condition treated.
Engaging in fantasies of control.
View of medical practice as a collection of "objective" tools more reliable than physician judgement or decision making by physician and patient together.
Use of brand names (Subutex, Suboxone) suggesting inappropriate commercial ties or promotion.
Ignorance of basic precepts of medical ethics.
Hubris. Arrogance. Cynicism. Politics. Count 9 Failure to excercise critical thinking.
This Board overvalues records. A physician should take care of people, not paper. Records can aid in that endeavour or in defending medical decisions, but care of the patient ultimately demonstrates medical competence.
I hope the Vermont Medical Board will use this critique to improve work on future cases. Their handling of this case will unfortunately hurt those who seek help for addiction by erecting higher barriers to treatment and discouraging physicians from prescribing buprenorphine. Their misguided efforts to keep buprenorphine off the street will lead to higher prices and increased availability of more dangerous full agonists like heroin and -codones. Feel good politics supporting a failed war on drugs will kill your children and other loved ones.
Tell me if I missed something in the Specification of Charges linked above, but other than Patient A who retaliated for a discharge handled appropriately, none of the case descriptions alluded to any potential harm resulting from the claimed professional misconduct. This cynical Board has used Dr. Schorsch as a scapegoat and example and should be condemned.
Read about the outcome here.