Opinion ID: 1830613
Heading Depth: 1
Heading Rank: 16

Heading: Jackie Tate

Text: ¶ 32. Between January 4, 1995, and January 16, 1996, Dr. McFadden issued thirty one (31) prescriptions for a total of 3,036 dosage units of controlled substances to Mr. Tate. Dr. McFadden described this patient as one of the top 4 or 5 possible suicide candidates in my practice, yet he failed to refer this patient to a specialist for a psychiatric evaluation. Instead, Dr. McFadden continued to prescribe Mr. Tate an average of eight (8) dosage units of narcotics per day and, at times, up to thirteen (13) dosage units per day. ¶ 33. The Board claims Dr. McFadden also issued these prescriptions at a time when he knew or should have known of the patient's possible drug abuse. Nineteen (19) of the thirty one (31) prescriptions issued during the profile period were issued early, i.e., at a time when the patient would still have had the medication if he were consuming it at the proper daily rate. ¶ 34. Eight (8) of the thirty one (31) prescriptions Dr. McFadden issued to Mr. Tate were issued with no corresponding entry in the patient's medical record. Dr. McFadden also issued this patient an additional ten (10) prescriptions in which he recorded only the drug and quantity prescribed, i.e., Dr. McFadden failed to record the patient's vital signs, any observation of the patient's condition, or any notation concerning the status of the patient's treatment plan. The Board concludes these practices are violations of Section IV.E and IV.F of the Board's rules and regulations Pertaining to Prescribing, Administration and Dispensing of Medication. ¶ 35. The Board argues the above facts demonstrate that it reasonably concluded Dr. McFadden was in violation of the rules and regulations of the Board Pertaining to Prescribing, Administration and Dispensing of Medication. The Board argues these facts also support the Board's conclusion that Dr. McFadden prescribed drugs having addiction-forming or addiction-sustaining liability otherwise than in the course of legitimate professional practice. The Board further concludes that this pattern of behavior, which Dr. McFadden continued to engage in after being warned by the Board, constituted unprofessional conduct, including dishonorable or unethical conduct likely to harm the public. ¶ 36. More specifically, the Board concludes the evidence presented at the hearing revealed that on at least forty three (43) separate occasions Dr. McFadden prescribed controlled substances without maintaining a complete record of his examination, evaluation, and treatment of the patient, including a documentation of his diagnosis and reason for prescribing, dispensing, or administering the controlled substance in violation Section IV. E. The Board also concludes that on an additional twenty (20) occasions, Dr. McFadden made no entry whatsoever in the patient's medical record to reflect that he had issued the patient a prescription for controlled substances. The Board also points out that these omissions on the part of Dr. McFadden took place after the Board's 1992 warning letter reminding him of his duty to comply with the Board's rules and regulations. The Board asserts that on this basis alone, its decision to suspend Dr. McFadden's license to practice medicine in this State was supported by substantial credible evidence. ¶ 37. The Board also claims Dr. McFadden's forty (40) violations of Section IV.F justify its action in restricting his license to practice medicine. This Section of the Board's rules and regulations Pertaining to Prescribing, Administration and Dispensing of Medication provides that [n]o physician shall prescribe, administer or dispense any controlled substance or other drug having addiction-forming or addiction-sustaining liability without a good faith prior examination and medical indication therefore. The Official Comment to this Section states that: proper medical practice require[s] that, upon any encounter with a patient, in order to establish proper diagnosis and regimen of treatment, a physician must take three steps: (a) take and record an appropriate medical history, (b) carry out an appropriate physical examination, and (c) record the results. The observance of these principles as a function of the `course of legitimate professional practice' is particularly of importance in cases in which controlled substances are to play a part in the course of treatment. Section IV.F, Official Comment. (emphasis added). The Official Comment further states that in determining whether a physician acted in good faith in issuing prescriptions for controlled substances, the Board will look to whether the physician dispens[ed] drugs to patients having no medical need, when the physician knew or should have known that the patients were addicts and repeated refills over relatively short periods of time or the issuance of prescriptions at a time when the patient should not have been finished taking the same medication from a prior prescription had the prescription directions been properly followed or the correct dosage taken. Section IV.F., Official Comment. The Board asserts that in the cases of patients Mr. Kee and Mr. Tate, Dr. McFadden prematurely issued at least forty (40) prescriptions for controlled substances. ¶ 38. Furthermore, according to the Board, Dr. McFadden's one hundred and three (103) violations of Section IV.E and Section IV.F constitute dishonorable or unethical conduct likely to deceive, defraud or harm the public. Section 73-25-29(8)(d) of the Mississippi Code states that unprofessional conduct such as dishonorable or unethical conduct likely to deceive, defraud or harm the public constitutes grounds for the Board to suspend, revoke or restrict a physician's license to practice medicine in Mississippi. Miss. Code Ann. § 73-25-29(8)(d); See also Miss.Code Ann. § 73-25-83(a) (authorizing the Board to discipline a physician for dishonorable or unethical conduct likely to deceive, defraud or harm the public). In its November 22, 1996, Order, the Board concluded that Dr. McFadden's repeated violations of the rules pertaining to controlled substance record keeping/patient monitoring constituted unprofessional conduct within the meaning of Section 73-25-29(1). ¶ 39. The Board also notes that under Section 73-25-29(13) [v]iolations of any provision(s) of the Medical Practice Act or the rules and regulations of the [B]oard or of any order, stipulation or agreement with the [B]oard are action giving the Board authority to suspend, revoke or restrict a physician's license to practice medicine in Mississippi. Miss.Code Ann. § 73-25-29(13). The Board argues that its disciplinary sanctions against Dr. McFadden were clearly authorized by these statutes governing such actions. ¶ 40. The Board further asserts that the expert testimony offered at the hearing clearly established that Dr. McFadden's prescribing practices were outside the course of legitimate professional practice and amounted to unprofessional conduct. The Board's expert Dr. Patrick concluded that Dr. McFadden had issued prescriptions outside the course of legitimate professional practice to each of the four patients at issue. Dr. Patrick also concluded that Dr. McFadden issued prescriptions for controlled substances without proper medical indication when he stated that in virtually every case here, certainly three of the four cases, there was just insufficient [medical] evidence to put these patients even on short-term opioid [controlled substances], because the diagnosisthe diagnosis is either controversial or nonexistent. Dr. Patrick further concluded that Dr. McFadden's prescribing practices amounted to unprofessional conduct likely to harm the public. Concerning Ms. Lovelace, Dr. Patrick concluded that [i]t is inconceivable to me that a knowledgeable physician would place such a patient on six to seven Tylenol Number 3's per day for long-term ongoing management of a pain problem diagnosed as fibromyalgia. Regarding Mr. Gilmore, Dr. Patrick concluded that the volume of controlled substances Dr. McFadden prescribed was totally inappropriate. Concerning the volume of controlled substances prescribed to Mr. Tate, Dr. Patrick stated he could not find adequate basis [or] anything appropriate about that. ¶ 41. Finally, the Board alleges that Dr. McFadden's own admissions support the Board's decision to suspend his medical license. The Board notes that Dr. McFadden is a self trained pain medicine specialist. The record reveals Dr. McFadden had no residency or internship training in any speciality which involves the practice of pain management, i.e., anesthesiology, neurosurgery, neurology, orthopaedics, etc. Dr. McFadden is a pediatrician by formal medical training. ¶ 42. The Board also argues that during his testimony Dr. McFadden acknowledged having issued prescriptions for controlled substances with directions to the patient that were contrary to the maximum daily dosages set forth in the Physicians' Desk Reference (i.e., he told Mr. Kee to take one to two Vicodin ES every four to six hours). The Board claims that Mr. Kee could have taken up to six Vicodin ES per day per Dr. McFadden's directions. The Board states that the maximum daily dosage recommended by the Physicians' Desk Reference for Vicodin ES is five per day, i.e., the specific warning being that [t]he total 24 hour dose should not exceed five tablets. ¶ 43. The Board also directs this Court's attention to Dr. McFadden's admission that the advice contained in the Board's 1992 warning letter concerning his controlled substance prescribing/patient monitoring practices was good advice and Dr. McFadden's comment that he knew all that ... and was carrying out most of that. In addition, the Board calls attention to Dr. McFadden's acknowledgment that the Board's rules and regulations concerning patient records require physicians to make a record of the examination, evaluation, and treatment of the patient, including a diagnosis and reason for prescribing any controlled substances. When asked if he understood that just entering a prescription only in a patient's file was insufficient, Dr. McFadden responded that he never understood it that way. Concerning the Board's record keeping/patient monitoring rules, Dr. McFadden further stated that I had no knowledge that you people wanted something in the record. I'll have to change my whole practice. ¶ 44. The Board also notes that when confronted with the fact that he had issued twenty one (21) premature prescriptions for controlled substances to Mr. Kee, Dr. McFadden claimed the problem was the pharmacist here because there is no way that the pharmacist should have filled some of these prescriptions as early as he did. And I have no knowledge that Dwight [Kee] was taking so many of these pills as he was sometimes. So that was a mistake on my part. The Board notes Dr. McFadden's expert Dr. McKellar admitted that two or three premature refills to a patient would indicate there is a problem, and that 21 premature refills would be pretty high. Dr. McKellar also stated that premature refills would be a red flag to you that there's a problem and could indicate that the patient is hoarding the medication or disbursing it to others. ¶ 45. The Board argues these responses exemplify Dr. McFadden's failure to properly manage patients to whom he was prescribing large quantities of controlled substances having addiction forming qualitites. The Board also states that it is not surprising that Dr. McFadden had no knowledge that Dwight [Kee] was taking so many of these pills, in light of the fact that he failed to properly record twenty three (23) of the fifty six (56) prescriptions he issued to Mr. Kee during the profile period. The Board also points out that when asked to account for these premature prescriptions, Dr. McFadden tried to place responsibility on the pharmacist who had simply filled the prescriptions according to Dr. McFadden's orders. The Board further notes that regarding Dr. McFadden's nineteen (19) premature prescriptions issued to Mr. Tate, Dr. McFadden acknowledged that the quantity of drugs prescribed was excessiveif he took it all. In addition, the Board reminds this Court that Dr. McFadden admitted to having issued prescriptions without the proper record keeping notations in the patient's medical files. Dr. McFadden explained that he failed to maintain his patient files properly because of a misunderstanding of the Board's rules and regulations. ¶ 46. The standard of review applicable in the instant case requires this Court to give great deference to the trier of fact concerning issues of fact as well as the credibility of witnesses. As previously stated, the reviewing court is only concerned with the reasonableness of the administrative order, not its correctness. Weems, 653 So.2d at 281. Based on the substantial evidence discussed above, we conclude that the record supports the reasonableness of the Board's decision to suspend Dr. McFadden's medical license. ¶ 47. Dr. McFadden misconstrues several cases claiming they support his claim that the Board should not have taken this disciplinary action against him. Dr. McFadden cites Miller v. State Bd. of Pharmacy, 262 So.2d 188, 191 (Miss.1972), for the proposition that poor record keeping in the dispensing of controlled substances is, of itself, insufficient to support the revocation of a pharmacist's license. However, in Miller, the administrative board was reversed because no statute, or rule or regulation of the Board ... has been cited to us as having established any standards for the keeping of records by pharmacists. Miller, 262 So.2d at 190. The Miller case is distinguishable from the instant case. Dr. McFadden violated Sections IV.E and IV.F of the Board's rules and regulations Pertaining to Prescribing, Administration, and Dispensing Medication which clearly establish the standard for physicians in keeping medical records. ¶ 48. Dr. McFadden also relies upon Hogan v. Mississippi Bd. of Nursing, 457 So.2d 931, 935-36 (Miss.1984), in which this Court reversed an administrative board's finding that a nurse had misappropriated controlled substances. However, Hogan involved different statutes and different substantive allegations than those at issue here. Id. at 932-33. In Hogan, the question was whether a nurse misappropriated supplies of controlled substances held by her employer. Id. Here, the question is whether a physician failed to follow the rules requiring him to maintain specific records concerning treatment of his patients. We conclude that Hogan is not controlling here on this issue. ¶ 49. In addition, Dr. McFadden relies upon the foreign jurisdiction cases of McNiel v. Tennessee Bd. of Med. Exam'rs, No. 01-A-01-9608-CH-00383, 1997 WL 92071 (Tenn.Ct.App. March 5, 1997), Johnston v. Department of Prof. Reg., Bd. of Med. Exam'rs, 456 So.2d 939 (Fla.Dist.Ct. App.1984), and In re DiLeo, 661 So.2d 162 (La.Ct.App.1995). The McNiel case involved the question of whether the opinion of a single expert witness constituted substantial, credible evidence that the defendant physicians had overprescribed controlled substances. McNiel, 1997 WL 92071 at -3. The Johnston case and the DiLeo case both involved allegations that the defendant physician overprescribed controlled substances to certain patients. Johnston, 456 So.2d at 939-40. However, there was no allegation in any of these cases that the defendant physician failed to maintain proper records of the prescriptions at issue. Hence, we find that Dr. McFadden's reliance on these cases is misplaced.