Tuesday, February 9, 2016

She Prescribed and People Died

In 2011, British singer Jessie J released Price Tag (great song) in which she laments

Seems like everybody's got a price,
I wonder how they sleep at night
When the sale comes first
And the truth comes second.
Just stop for a minute and smile

She laments money and the music business, advocates that we strive for something better than monetary rewards, and the chorus 

It's not about the money, money, money
We don't need your money, money, money

may say it all. The song was popular in its original release, but was made famous by the hit movie Pitch Perfect.

There have been interesting recent stories of prosecution in workers' compensation. A prominent hospital owner has been accused of paying doctor's bonus money to use his facility. A southern California group has faced charges they billed for services that were not delivered.  

But a doctor in California made the news last October, and then again last week. According to the Los Angeles Times, Dr. Shiu-Ying "Lisa" Tseng was convicted last October of murder. That is, convicted of taking human lives, three of them. More died, but she was prosecuted for three.

When I say "doctor," I mean medical doctor. A person trained to save life. Someone expected to value human life. Doctors are cautioned to "first, do no harm." This language is not part of the ubiquitous Hippocratic oath, though many mis-perceive it to be, but it still accepted as a pretty good rule-of-thumb. Doctors are not supposed to kill people. 

Dr. Tseng's case is somewhat groundbreaking. Doctors face medical malpractice lawsuits when they kill patients, but they are very rarely prosecuted criminally. The only other occasion that comes to mind is Dr. Murray Conrad who was convicted of manslaughter for the death of Michael Jackson (the King of Pop) back in 2011. He "administered a number of dangerous drugs" to Mr. Jackson and death resulted. 

But Dr. Tseng was convicted of "Murder." That is a bit more serious a charge. She prescribed a variety of medications to patients. This physician, according to the Times "is among a small but growing number of doctors charged with murder for prescribing painkillers that killed patients." Dr. Tseng's prosecution is not unique, but her conviction for murder seems fairly so. The Times reported that the District Attorney  asserts that this is "the first time a doctor had been convicted of murder in the United States for over prescribing drugs." As an aside, last fall a Florida jury acquitted another doctor of charges related to pain medication according to the Sun Sentinel. Perhaps that opposite result helps illustrates the significance of Dr. Tseng's conviction. 

Prescription drug overdose is not a new problem. It is recently getting some national attention. People are starting to take notice of this situation, including the Food and Drug Administration. The FDA overrode its own experts three years ago to approve a drug called Zohydro, one of the strongest opioids ever. At the time, there were others clamoring about the dangers of drugs. But it was approved by the FDA, over the objections of the FDA's own experts, and marketed to doctors. Last week the FDA announced it will re-think its approach. It promises more reliance on its committees. Leadership or window dressing? Time will tell if the FDA is serious about drugs or serious about appearing functional and relevant in the pharmaceutical massacre. 

People are dying from drug overdose in America. It is a pandemic. 

Dr. Tseng may be able to help us understand why. The Times reports that in three years, between her beginning at a Rowland Heights clinic in 2007 and 2010, the "office made  $5 million."

Seems like everybody's got a price,
I wonder how they sleep at night
When the sale comes first . . .

That is some serious money. I suspect that patients were charged for office visits and consultations. But that seems like maybe a lot of patients? Charges can be significant in American medicine. 

It's not about the money, money, money

Dr. Tseng was a general practitioner, not a specialist. Some people travelled hundreds of miles to visit her clinic. Last fall at trial she defended her prescribing actions blaming "patients, pharmacists and other physicians." The jury did not buy that, and convicted her of second degree murder. At her sentencing, the Times reports she seemed to finally take responsibility for her actions, but one victim's family termed it  her "first public show of remorse."

It is easy to blame others. Taking responsibility is hard. There are great tools available to physicians today. Most states have drug databases that help identify when patients are obtaining substances from multiple physicians or pharmacists. There are drug tests available to determine if patients are taking these prescriptions or if the pills are being misdirected elsewhere. There is no complete answer to the risks of prescribing, but there are steps to employ toward the end of effective and safe prescribing. Yes, insurers and pharmacists play a role and have a responsibility, but ultimately a physician is responsible for the scripts she writes. 

Last week, the judge sentenced Dr. Tseng to "30 years to life in prison for the murders of three of her patients." She is 46, and so could well be in prison until she is 76 years old, or longer. Her attorneys argued for leniency, noting that, since she could no longer prescribe after her medical license was surrendered, she "no longer represents a danger to society." One accepted purpose of incarceration is to prevent someone from hurting others. Another accepted purpose is to punish for what has already happened.  Yet another is to deter similar actions by others. Though their argument is perhaps persuasive regarding her hurting others, her punishment still addresses her past, ambivalent, behavior and hopefully will deter others from acting as callously.

The Times reported that "some experts fear that Tseng’s conviction will usher in a precarious new reality -- a scenario in which doctors fearful of prosecution are hesitant to prescribe potent painkillers to patients who need them." So, the experts fear the prosecution may have accomplished the accepted purposes of incarceration, deterring others from acting similarly. Perhaps there is value in having physicians pause and re-think their own prescribing habits? Should the fear bring inaction? Perhaps instead the fear should merely bring caution, retrospection, intellectual consideration of alternatives, reference of drug databases, testing of patients, and simply more caution regarding these dangerous drugs?

The Times interviewed physicians who take issue with the "use (of) the word 'murder.'” This terminology and prosecution, they say, is naturally "going to have a chilling effect.” Physicians contend that the appropriate deterrent for such prescribing practices is not criminal prosecution such as this. Dr. Peter Staats, president of the American Society of Interventional Pain Physicians was quoted by the Times saying "he believes an aggressive medical board -- not prosecutors -- should go after reckless doctors." 

That would be admirable. Self-policing and responsibility are admirable. Is there evidence that medical boards have been dealing with the pandemic of overdose deaths? Are these boards being aggressive and proactive dealing with the problem America faces? Are these boards dealing effectively with the ruined lives and death related to American prescription drug abuse? If they are, why are overdose deaths increasing annually at such dramatic rates? If the answer is for doctors to police themselves, is there evidence that they are doing so and that it is working? If so, why are the prescription overdose rates risingIf these boards are not effectively dealing with it, then why don't they start? If they choose ineffectiveness and ambivalence, can they really complain that the legal system steps in and fills the void they leave?

Were there warnings or "red flags" in the case of Dr. Tseng? Prosecutors told the court that "more than a dozen times a coroner’s or law enforcement official called" Dr. Tseng and reported that one of her patients had died. Mark that, over a dozen patients died before she was prosecuted. Despite this, they alleged Dr. Tseng made no changes in her prescribing habits. There is a critical point in the narrative. The convicted doctor was given warnings. People died and she knew. When she knew, she changed nothing. When she knew, more people died. Perhaps the most critical part of the story is that warning signs should be respected, wake-up calls should be answered. 

Dr. Tseng's actions were just inappropriate. She  did things such as facilitating a patient getting "twice as many pills" and "openly referred to her patients as 'druggies' and sometimes made up medical records." Her actions seem callous at best. She ignored the warning signs. As each patient died, she continued on without retrospection, adjustment in practice, or apparently any concern for the human beings who were putting millions in her pocket.

At In seeking a lenient sentence, Dr. Tseng said “I was not the doctor I should have been for the patients who came to me." At sentencing, there was contrition. As Pat Benatar sang, "it's a little too little, a little to late." Dr. Tseng blames depression, a stressful life, and more. Don't most doctors have stressful lives? Remorse, at a sentencing, will not bring those patients back though. The bottom line is she prescribed and people died. People died and still she prescribed. She did not learn, or care, and people died. 

Perhaps this story helps the nation to wake up to the danger posed by prescription drugs. Perhaps there can be more news coverage of the prescription deaths occurring weekly? Perhaps publicity can help. Perhaps doctors can take a more active role in dealing with pain and other symptoms; something beyond or before bottles and bottles of pills. Perhaps there can be more of a drive to mandatory use of prescription databases, and more effort to prevent drug interactions and overdose? Dr. Tseng ignored the deaths, the warning signs, and more people died. If society does no more to heed today's signals and warnings, are we less to blame for the future?

Perhaps medical boards will now become aggressive and deal with the practitioners whose prescribing practices are not appropriate and whose actions are facilitating overdose,addiction, misdirection of dangerous drugs, and death? If not, perhaps prosecutors across the country will take the lead offered by California and begin prosecuting physicians in earnest for the deaths of patients? How many physicians will go to jail before practices change? George Santayana said "those who refuse to learn from history are doomed to repeat it." So we can learn from Dr. Tseng's ambivalence, incompetence, or maleficence. Or, we can ignore it and go on with our day-to-day while others die. 

As Jessie J reminds us

It's like this, man
You can't put a price on a life


Indeed.

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