In Va., it's up to patients to keep an eye on doctors

A decade after a legislative panel found that Virginia allowed dangerous doctors to keep practicing for years before losing their licenses, a national study says the state remains among those least likely to take serious disciplinary action against physicians.

"Something is wrong," said Dr. Sidney Wolfe, director of Public Citizen's Health Research Group, which conducted the study. "Why are they asleep at the wheel? There are doctors practicing in Virginia now doing things that, if they did them in some other state, they would be much more likely to get disciplined."

The issue has been thrust back into the spotlight by the case of a Virginia Beach doctor accused of contributing to the deaths of a series of patients during the past five years.

The Virginian-Pilot has documented that 10 patients of Dr. Stephen Plotnick have died since 2004, according to medical board records, civil lawsuits and medical examiners' reports. At least seven of those were overdose deaths directly traceable to drugs Plotnick prescribed.

Plotnick, a rheumatologist, agreed in January to surrender his license for two years and, if it is reinstated, not to treat chronic-pain patients.

Why did it take five years to put him out of business? There is no easy answer.

Like most states, Virginia uses a complaint-based system to discipline doctors. The state Board of Medicine receives thousands of complaints every year, and it can be difficult to ferret out the relatively few cases in which patients are being gravely harmed.

Most complaints come from patients. People inside and outside the regulatory system say there is widespread reluctance among doctors and other health-care professionals to report their colleagues for suspected malpractice.

And Plotnick's area of practice - chronic pain management - increasingly is becoming a medical minefield. The medical board is taking steps to better educate doctors about the dangers of prescribing the many powerful, addictive painkillers on the market today.

But so far, those measures are voluntary. Doctors are free to ignore them - until a pattern of tragic cases comes to light.

Several family members of patients of Plotnick had questions about the doctor's practices while their relatives were receiving treatment.

But because the medical board took no public action until 2008, concerned patients and relatives had no way of knowing that others were raising the same issues. Or, until it was too late, that some patients even had died.

Patricia Laird first questioned Plotnick's methods more than five years ago. Her brother, William Jeffcoat, was troubled by lingering pain after two back surgeries and had begun seeing Plotnick in 2001.

Plotnick diagnosed Jeffcoat with fibromyalgia, a little-understood ailment, and put him on a regimen of heavy narcotics such as OxyContin and Dilaudid.

Jeffcoat's family gradually grew alarmed as he became increasingly lethargic and spent more and more days in bed, semi-comatose.

In October 2003, Laird had had enough. She filed a complaint with the Board of Medicine about Plotnick.

"I told them this doctor had him on an absolutely unbelievable cocktail of narcotics," she said.

By February 2004, according to medical board records, at least one of Plotnick's patients was dead of an overdose of narcotics he had prescribed.

Yet it was not until August 2008 - almost five years after Laird's complaint - that the board suspended Plotnick's medical license.

The board's action came too late to help Jeffcoat. On Sept. 18, 2008, his ex-wife, Kathi, found the Norfolk man dead in bed of an overdose, a lethal level of the narcotic methadone in his blood. He was 51. On the bedside table was a methadone prescription from Plotnick.

In a scathing report in 1999, a state watchdog agency, the Joint Legislative Audit and Review Commission, or JLARC, found that Virginia's medical regulatory system allowed dangerous doctors to keep practicing for years before losing their licenses.

In response, the General Assembly enacted a package of reforms in 2003 designed to streamline the system and make it more responsive to citizen complaints.

By one measure, the system is more efficient now. The 1999 report found that the medical board took an average of 983 days to resolve discipline cases; last year, the average was 421 days.

But an annual survey by Public Citizen, a national consumer group, found that relative to other states, Virginia is meting out less discipline to doctors now than it was five years ago, when the reforms were enacted. Virginia's rate of serious disciplinary actions per 1,000 doctors ranked 39th among the 50 states in 2007, down from 30th in 2003.

No systematic update of the 1999 JLARC study has been done, and state Sen. Linda Puller, D-Fairfax, thinks it's time for one. But for two years running, her bill calling for a follow-up JLARC study has been killed by a House committee.

Puller said several citizens have come to her with stories of doctors going unpunished for harming patients. She suspects that despite the reforms of 2003, a culture of doctors protecting doctors persists in Virginia.

"I've heard that doctors look out for their own," she said. "We need them to look out for the citizens of the commonwealth."

That viewpoint gets a sympathetic ear from Stephen Heretick, president of the Board of Medicine.

Heretick, a lawyer and Portsmouth city councilman, called the Plotnick case an "anomaly" and said one reason it takes so long to resolve such cases is the sheer volume of complaints. The board receives upwards of 2,000 a year.

"Out of 2,000 cases, we may have 20 which rise to the level of a situation like Dr. Plotnick's," he said. "And it's very, very difficult, at least at first blush, to figure out which of those is which."

It would help, Heretick said, if other doctors would more readily report suspected cases of malpractice - as they are required to do by state law.

"I can tell you after almost seven years of doing this, it is very rare that a doctor will report another doctor," he said. "For example, I have to wonder aloud why, in these particular cases, there was no complaint ever made by a single medical examiner."

It's only now, after the board has taken action against Plotnick, that Heretick is hearing from other doctors.

"One, an emergency room physician, told me that 'Plotnick' is a verb in their practice," Heretick said. "They'll say, 'Oh, yeah, this patient was Plotnicked.' Apparently, his issues have been recognized in the medical profession for quite some time."

Since The Pilot first reported on the Plotnick case in January, dozens of his patients and their family members have called or e-mailed the newspaper. Running through their stories are common themes of addiction, family dysfunction, anger, helplessness and isolation.

One of them is Kathi Jeffcoat. She said that as she read about the string of deaths among Plotnick's patients - there were five known cases at the time - she couldn't hold back the tears.

"I thought I was the only one," she said. "I had no idea so many other people were going through the same thing - watching a family member disintegrate."

Her husband, a heating and air conditioning technician for the Navy for more than 20 years, "was a hard-working father and husband," she said.

He ha d an addictive personality, she added, and was a recovering alcoholic - which she said she pointed out to Plotnick when she argued with him about her husband's medications.

She said Plotnick dismissed her concerns, telling her she didn't understand chronic pain: "He was 'a pioneer in his field.' I can't tell you how many times I heard that." Plotnick lectured frequently on fibromyalgia and pain management.

In a brief interview, Plotnick said he has been instructed by his attorneys not to discuss his case publicly.

"What we've done in our clinic has always been for the benefit of our patients," he said. "That's all I can tell you."

Ultimately, William Jeffcoat's increasingly comatose state cost him his job and his marriage. He retired on disability, and his wife divorced him.

A year before his death, Jeffcoat had an auto accident, striking another car three times with the Jeffcoats' daughter, Caitlin, in the back seat.

"He never knew he had hit the car," Kathi Jeffcoat said. "Our daughter had to give the police his name and address. He couldn't do it."

When she confronted Plotnick after that incident, she said, his response was to increase Jeffcoat's dosage of methadone.

Jeffcoat is preparing to sue Plotnick for malpractice - an avenue that is not open to Kevin Nelson.

Nelson's wife, Mary, had been a patient of Plotnick's since 2000, when he was based at Portsmouth Naval Hospital. Kevin Nelson, a Virginia Beach Navy retiree, watched with increasing concern as Plotnick kept adding drugs to Mary's treatment regimen.

There was one drug to help her sleep at night and another to help her wake up in the morning. There was Actiq, a powerful narcotic approved only to treat severe pain in terminal cancer patients, which is dispensed via a "lollypop" held between the patient's cheek and gums.

"Mary would have one of those in her mouth all the time, it seemed like," Nelson said. "Toward the end, after he put her on methadone, she was really loopy."

Before he left for work each morning, Nelson had to wake Mary up and make sure she was aware and coherent enough to care for the youngest of their three sons, Ian, now 8.

On June 1, 2006, Nelson found his wife dead in bed of an overdose - a toxic cocktail of methadone, oxycodone and four other drugs. She was 37.

"I was in disbelief," Nelson said. To the best of his knowledge, Mary had always taken her medications as prescribed. Was this an isolated case, or was this a problematic doctor? He had no way of knowing.

For months afterward, he searched the Internet, looking for any hint that Plotnick had harmed other patients. He found nothing - not even on the Board of Medicine's Web site, where a doctor look-up feature lists disciplinary actions and paid malpractice claims.

"He was listed in good standing," Nelson said. "I didn't feel I had any recourse."

After reading about the other overdose deaths, Nelson considered filing a lawsuit but learned he was too late. Virginia has a statute of limitations that bars medical malpractice suits after two years.

Some of Plotnick's patients continue to defend him and believe that his discipline was too severe. Terri Gabriele of Portsmouth was both a patient and an employee of Plotnick.

"It's terrible about the patient deaths," Gabriele said.

She expected some kind of sanctions but was shocked that Plotnick won't be able to practice medicine for two years.

"He cares so much about people," she said. "He wanted to take away their pain or at least make their pain manageable."

Dr. William Harp, executive director of the Board of Medicine, said dangerous doctors account for a tiny fraction of the medical profession.

"The vast, vast majority of physicians are practicing safe, ethical medicine," he said.

He acknowledged, however, that there is room for improvement. The state could, for instance, move from the current complaint-driven system to a more proactive one. One example would be a peer review system in which doctors are reviewed by a colleague in the same specialty every five years.

Another example of a more robust system, said Wolfe of Public Citizen, would be to send investigators into pharmacies to inquire about doctors who might be misprescribing or overprescribing drugs.

Public Citizen also advocates lowering the legal standard for disciplining doctors. Virginia law now requires "clear and convincing" evidence. Public Citizen favors replacing that with a "preponderance" of the evidence - the same standard used in civil litigation. It has been adopted by medical boards in 38 states.

Heretick, the medical board president, would like to see the state take a mor e aggressive stance on chronic pain management, which he called "one of the most problematic areas of practice these days."

Already, the state has created a prescription database that doctors can consult to track the prescriptions they write. The medical board also has held pain-management seminars around the state and mailed out 20,000 copies of a guidebook on responsible prescribing of narcotics.

All those measures, however, are voluntary.

A few states have made continuing education in proper prescribing of narcotics a requirement. Virginia has not.

Since 2006, the medical board has been formulating a set of regulations for pain management, which, unlike voluntary guidelines, would include teeth for enforcement. The proposed regulations are still under review by Gov. Timothy M. Kaine's administration.

Another possible weak link in the current system occurs at the point of filling prescriptions.

Many health care entities - doctors, hospitals, malpractice insurers - are required by law to report suspected malpractice. But pharmacists who are asked to fill questionable prescriptions are not.

For six years, Jennifer Scott worked as a pharmacy technician at Bayview Plaza Pharmacy in Norfolk, where many of Plotnick's patients went to get prescriptions filled.

Scott said the doses often seemed excessive and the combinations of drugs dangerous, but the prescriptions usually were filled if the patient's insurance company approved the claim.

Over the years, Scott said, she watched many of Plotnick's patients descend into a steady downward spiral marked by slurred speech, disheveled appearance and lethargy alternating with flashes of anger. Sometimes they would fall asleep sitting or even standing at the counter as they waited for their medications.

"These patients went from being normal people to zombies in a matter of months," she said. "It was sad to watch."

Bill Sizemore, (757) 446-2276, bill.sizemore@pilotonline.com