Complaint to the medical board, again

Yes, it keeps getting closer and closer to completion, but that old, dreaded tendency to rewrite rather than complete keeps getting in the way.

I can't expect you to read another version, so I won't post another until the final draft. What I *will* do, however, is post the exchange of emails between Dr. Amen, director of the clinic, and myself. Pretty-much *everything* I sent to Dr. Amen I'm sending the medical board -- so what you see here will be repetitious. Sorry.

I find the emails hilarious.

Dr. Amen is my psychiatrist's (pdoc's) friend, colleague and boss. He also has a financial (and reputation) stake in my not filing (and, more importantly, *winning*) a medical malpractice lawsuit against the pdoc and the clinic.

Even knowing all that about his motivation, one has to sniff delicately around the smell of the bullshit.

I had contacted his personal assistant, who suggested she would pass along to him email I sent to her. [BTW, If you look at his bio on his web site (http://www.amenclinics.com/meet-dr-amen/), you will see he is an avid table tennis (ping pong) player.]
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[Here's my first email to him:]

Subject: Preliminary Story
Date: Friday, 3/26/2010

Hello Dr. Amen -

I'd like to express my admiration for you and my respect for Dr. [pdoc] of your Fairfield office. I could (and should) thank you for allowing Dr. [pdoc] to treat me _pro bono_ last year when my finances became nonexistent. If I may, allow me to defer those conversations for another time.

I've been looking for ways to make this story shorter yet at the same time clear and accurate.

This first telling will be a sort of an outline. Few dates. Some details omitted. I'll supply those the next time I tell the story. I'm going to start where the most recent events began and leave what preceded and followed them for later. I can supply those details and history, provide supporting documentation, and add other meaningful elements later. Please understand that this is by no means intended to convey the complete picture, but just a general overview of a relatively brief period of time (less than 6 months). Also, I'm a patient, not a doctor, so please forgive me if I get some of the terminology wrong.

The topic is the care Dr. [pdoc] provided me.

I like Dr. [pdoc] and (transference notwithstanding) I think he likes me. I wish I didn't have to say the following. And I say it not for dramatic effect, nor as an exercise in hyperbole. Dr. [pdoc]'s negligence nearly resulted in my death. It *did* result in the loss of several days of my life (and my wife's life), out-of-pocket expenses, pain and suffering, emotional distress, and whatever else a lawyer would add, but I *don't* want to get lawyers involved. I don't like lawyers very much. I am neither litigious nor avaricious (as, certainly, lawyers are). I don't want revenge or retribution. All I want is appropriate recompense. I want us to arrive at what is *appropriate* in an amicable way, not a contentious or adversarial one. I hope we can do that.

I should say before I begin that Dr. [pdoc]'s Progress Notes and the emails he and I exchanged support everything I say. To save me some work, you might ask for copies of those things from the Fairfield office (also note they haven't been able to find his Progress Notes sheet from 15 Oct 09, but he should be back in the office on Monday).

The abbreviated story:

1. I was suicidal. Dr. [pdoc] knew it. He put calls into my local sheriff's department and local hospital Emergency Psych services to explore using a 5150.

2. To the Lamictal he had put me on 3 years before, he added Abilify.

3. It drove my blood sugar sky high (I'm a diabetic), so he switched me to Lithium, to be (as his Progress Notes say) "a prophylactic against impulsive suicide." (20 Nov 09)

4. He intended to get me to 900mg QD, but (quite prudently) started me at 300mg BID.

5. After a while he ordered a Lithium blood level. The result was .9

6. He sent an email (and a copy of the lab results) saying there was no reason to increase the dosage; the level was fine on 300mg BID. .

7. I developed a suicidal ideation so strong that following a telephone interview one morning a month later he called in the 5150.

8. I was taken to a local county emergency psychiatric facility, where I stayed through the day and overnight.

Should I feel grateful that he was "looking out" for me and that he called in the 5150? Should I feel angry that I had put my life in his hands and he mismanaged my medication to the extent that I was having the strong suicidal feelings that led him to call in the 5150?

9. The psychiatrist with whom I met in the hospital the next day scoffed at the suggestion a 265-pound man could have a Lithium blood level of .9 on 300mg BID. [In fact, no other psychiatric professional with whom I've met (psychiatrists, psych nurses, or even psych techs), before or since talking with that psychiatrist in the county emergency facility, has had any other reaction than incredulity at the notion my ".9" blood level was possible at that dose. I said "scoff" earlier. It isn't a word I've found reason to use in as long as I can remember, but it describes their responses accurately.] It was at that point he explained the meaning of a "trough level" blood test.

10. +++Surprise interruption+++ The reason I hadn't heard about "trough level" tests, by that or any other name or description, is that Dr. [pdoc] never told me to get one. Never told me what it was. Never provided instructions about how to get one. So far as I know, until I told him what it was after my stay in the emergency psych hospital, he had never heard of it. One might infer that from his emails of 22 Jan 10. That seems unlikely, surely, but whether he knew or not, by his not telling me, the results were the same.

11. A different doctor, a few weeks later, told me to just increase to 900mg -- "You probably could take 1200, but start with 900 and get another test. A *trough* level this time."

12. So I increased to 300mg 2QD pm + 300 1QD am, a total of 900mg QD. (I only recently changed to it one dose/day, 300mg 3QD pm)

13. I took a trough level test (having the draw done BEFORE the morning dose). It was .5. The third psychiatrist with whom I met said that while .5 is lower than the usual .6(or sometimes .8) to 1.2 efficacious range quoted in the literature, based on my improvement, it may be that combining it with the Lamicatal made it effective. It was not recommended that I increase the dose, but rather that I seek CBT or (preferably) DBT.

14. Now I am neither a doctor nor a chemist nor a mathematician, but wouldn't you guess .5 on 900mg/day would be roughly 3.3 at 600mg/day?

15. I've been learning about Lithium. It's what I call a "Goldilocks and the 3 Bears" medication -- not a technical term, I know. Dose just a little too high, big problems -- maybe death of patient. Dose too low, it does nothing at all. Dose just right, prophylaxis against impulsive suicide.

16. I'm not certain of my medical terminology here, but I believe Dr. [pdoc] was prescribing to a patient with known suicidal ideation the equivalent of a placebo.

17. I'm lucky to be alive.

I haven't given extraneous details (at least, I hope, not many) and I have many more things to say. But here's the truth: If Dr. [pdoc] didn't know how to monitor and manage Lithium (i.e. ordering a trough level blood test), he shouldn't have been prescribing it. Whether he had no experience doing so or hadn't sufficient *recent* experience and had forgotten, prescribing it without knowing how was negligent. If he *did* know how to monitor and manage it, he needed to tell me (or write it down) to ensure the results were meaningful. In that case, not doing so was negligent. I'm sorry to have to say this, but in *any* event the negligence is real. The results are bad. The potential results were tragic.

I understand you have requested copies of the Progress Notes. I will send the emails, as well as a more detailed narrative, once you express an interest in reading them. Please, let's work this out.

I can tell you 3 of the 4 things I want now, I haven't yet figured out the details of the fourth, but can sketch them out in general.

A. I want you to pay my out-of pocket expenses associated with the 5150. Invoices from the County for their emergency psychiatric services, the ambulance company and the psychiatrist who saw me there total just slightly more than $3,000. (Available on request)

B. I want you to promise to discuss this matter with Dr. [pdoc] and take steps to prevent it happening again. I'm not asking you to fire him or demand he give up his license to practice medicine. I'm asking that you not allow him to prescribe medications with which he either isn't familiar or might choose not to educate his patients. What I'm saying is: I want you to look out for your patients' well-being.

C. I want you to have Dr. [pdoc] write me a letter of apology. Nothing elaborate of [note: this was a typo in the original email. It should say "OR humiliating"] humiliating; perhaps merely a note saying he's sorry he never (for whatever reason) told me to get a trough level Lithium blood test and he's sorry for the resulting consequences. He needn't elaborate on the specifics of those consequences. I will, of course, sign a release and a nondisclosure (or whatever is appropriate) when we conclude this matter.

D. The complex one. I want recompense for the days I lost in an emergency county psychiatric facility, as well as all the time I spent in follow-up meetings and sessions. I want something for my wife's time, as well. I want something for the pain and suffering and the long-term impact on my self-image and esteem. I want something for having to check the "Yes" box when asked about Psychiatric hospital treatment on future New Patient forms.

Part of that suffering is the weeks I spent where the last thought before I fell asleep, the first thought when I woke in the morning, and my thought every minute my mind wasn't occupied with something else during the day was of killing myself. Not so oddly enough, I haven't had those thoughts since my medication level became efficacious. Not once since February 10th. Even in the midst of my depression, when I was undermedicated, both before and after the 5150, I was able to write down a few of my ideas in support of suicide -- although I wasn't able to focus long enough to complete a treatise of any length. If you want to read them, I can send them to you. I have no interest in the subject; no interest in my writings any more. I literally cannot now imagine having those thoughts.

Nobody should have those feelings. Once Dr. [pdoc] began prescribing Lithium *specifically* to prevent them, I shouldn't have had them either.

Please get back to me.

Be well,

Rich Orwell

p.s. In the years before diabetes caused adhesive capsulitis, I used to be one heck of a table tennis player. Did you know when Tom Hanks was shown playing in the movie "Forest Gump" it was all "cgi" (computer generated)? A pity.
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[his first reply]
Subject: RE: response
Date: Saturday, 3/27/2010

Dear Rich:

I am pleased you are doing better.

I feel sad that you are turning your anger against someone who sincerely tried to help you, without cost, because he cared about your well-being.

I have looked at Dr. [pdoc]'s notes, communicated with him on numerous occasions about your care, and feel that he did what he felt was appropriate for you. Dr. [pdoc] is an esteem [sic] psychiatrist and does not feel that any apologies are necessary or that you should receive any money from us. I concur with him, and will forward any more correspondence you send to my staff to our attorneys if you persist in asking for us to pay for your expenses of the 5150.

I hope you are receiving further care from professionals you trust.

I use a shake hands paddle grip, the pen holder grip never quite did it for me.

Warmest regards,

Daniel G. Amen, MD
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Hmmmmmmmmm. "Pdoc did a good job. We will sic the attorneys on you."

Right.

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[my 2nd email to him]

Subject: RE: response
Date: Saturday, 3/27/2010

Dear Dr. Amen -

First, it's an honor to "talk" with you (although I *hate* communicating via email).

Please look at this and send one more reply with a response to the question below.

How much spin may the server apply to the ping pong ball when dropping it?

OK, OK, that wasn't the question :)

I agree with everything you said about Dr. [pdoc] as s man and as a professional. I, too, hold him in high regard. He's an very intelligent man with eclectic tastes, as are you and (to a lesser extent) am I.

I am not "angry" at him.

I agree he did everything he reasonably could have done for me, and more, with one exception.

I can sum it up in one sentence: By relying on the meaningless results of the random Lithium level blood test he ordered instead of getting a TROUGH LEVEL test, he left in place a worsening suicidal ideation that he treated with the equivalent of a placebo.

So, here's my question. It concerns prescribing Lithium: To paraphrase what every other psychiatrist with whom I've spoken says, "Trough level blood tests are meaningful. Basing the dose you prescribe on any OTHER kind of blood test (random or peak level) is simply wrong." Please tell me, do you agree or disagree with those other doctors? I respect you and trust you will tell me the truth.

If you disagree, please say so and point me to somewhere I can read and learn to think along the lines you do.

If, despite what you believe is true about Lithium, your attorneys tell you not to make an admission that might hurt you, let me suggest an alternative. Instead of answering the question directly, why not ask me another question that sustains a dialog? If you've talked about me with Dr. [pdoc], he's probably told you I'm not a weasel. I'd like to put all this behind me.

Thank you for your good wishes. I, too, wish you well.

Rich

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[his 2nd reply]

Subject: RE: response
Date: Saturday, 3/27/2010

No spin when you throw the ball. I don't drop it.

The lithium level is meaningful, trough or not, if you know what you are doing and depends on many different clinical factors. Your situation was complicated, as you likely remember and you were not being seen as you needed to be. He was trying to save your life.

Daniel

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[my 3rd email to him]

Subject: RE: response
Date: Saturday, 3/27/2010

Hello, Dr. Amen -

Thank you for your time.

I used to hit the ball out of my hand, but got busted for it. Apparently, one should toss or drop the ball a certain distance to demonstrate there's no initial spin on it. I also learned to play using sandpaper paddles. Kids today play with mattresses on their hands. Luckily, I stopped playing :)

Please understand that I *absolutely* believe Dr. [pdoc] was trying to save my life. A good man, a kind man, a caring man, a better man in many respects than I. I'm sorry to say, however, none of that is germane.

My understanding of the standard of care for Lithium is that one does not order a peak or random blood level to decide the appropriate dose. (I say this gently) I would rather he had found another psychotropic solution than use one improperly. I don't know how often I should have been seen. I know I was lucky to have been seen *at all* -- that was generous on your part and his. But when he initiated a protocol that requires monitoring, he took on an obligation to do it right. Isn't that so?

The problem is that in not monitoring the Lithium level correctly, while he may not have exacerbated my suicidal depression, he didn't help at all. That is demonstrated by the simple fact that a 300mg QD increase in Lithium after the 5150 completely eliminated the suicidal ideation.

Had he ordered a trough level test, it would have shown a reading of .3 -- the .9 he got 1 or 2 hours after my morning dose led him to the erroneous conclusion I had an efficacious level in my body. Seeing the .3, he surely would have increased the dosage and ordered another follow-up test.

The test was on 12/16/09. On 12/18/09 he sent this via email: "Your lithium levels are fine with the 600 mg. per day so there is no need to raise it at this time."

That simply wasn't true. The test he ordered by mistake was meaningless.

Whether he didn't *know* to order a trough level test or he just forgot to tell me doesn't matter. When you say, "The lithium level is meaningful, trough or not, ..." are you saying you would routinely order *other* than a trough level? If so, may I ask how often? Based on my (limited) conversations with psychiatrists and (rather extensive) research of the literature online, I can't believe you would (except in extraordinary situations, about which I haven't heard) do other than get trough level readings.

I hope you don't for a moment think I *like* to be saying these things. I do, however, think what I suffered shouldn't have happened. I think it was very preventable. Don't go running to the lawyers, but I think my seeking reasonable compensation for it is entirely appropriate.

Thank you,

Rich Orwell

p.s. If you want, you can put my name into YouTube to see a dozen or so short videos of me doing stand-up comedy on stage. I already have much longer videos of you on PBS.

Original psychology/psychiatry-oriented humor. I think I've only told the first one on stage:

Being bipolar is like buying a Peter Paul candy bar. Sometimes you feel like a nut; sometimes you just wanna f---ing kill yourself.

I prefer to pronounce it BIP-uhlar (sort of like Tripoli), because buy-PO-lar sounds too cold and clinical. BIP-uhlar sounds more, I don't know, *perky*, doncha think?

You can gauge a bipolar's mood by having him spit in a glass of water. If it sinks, he's depressed. If it floats, he's phlegm-buoyant."

Good advice: "Don't focus on the minutiae. Take it with a grain of gestalt."

Be well,

R.
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It was at that point that he stopped sending replies.

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[my 4th email (after the 3rd got no response)]

Subject: RE: response
Date: Monday, 3/29/2010

Good morning, Dr. Amen -

[It is difficult to build a friendship on the foundation of one man seeking money from the other. That's not a proverb; merely an observation. I wish we had met under different circumstances (although we probably did so briefly at some A.D.D. function 10 or 15 years ago).]

I've been thinking about what you wrote about Lithium levels.

May I ask you one more hypothetical question? "If you were presented a Lithium level reading, told the patient's current dose, and asked what dosage you'd recommend, would you ask how long before the test it had been since the patient's last dose?"

We all know the serum level varies dramatically over time. The standard of care in prescribing Lithium is the use of trough level tests.

You said, "The lithium level is meaningful, trough or not, if you know what you are doing and depends on many different clinical factors." If you don't know if you're looking at a trough, random or peak reading, just how meaningful is it? No matter what your levels of education, experience and expertise, I would contend you can't "know what you are doing" in that case.

Further, by not telling the patient specifically to get a trough test and not inquiring as to the timing of the patient's last dose relative to the test time, do you not run the risk of keeping the patient on a dose so low as to be essentially a placebo? That's exactly what happened to me. My test result was THREE TIMES what a trough level would have shown.

I have some good news. I've worked out a way you can pay me without admitting liability. You can buy my jokes to use in your books, speaking engagements, PBS appearances, etc. Here are some sample attributions you can use:

o Rich Orwell, A.D.D. Patient
o Rich Orwell, Comedian
o Rich Orwell, Friend

Or, you may use them without attribution. Simply pay what I will ask. This is not about extortion; this is about making me whole for out-of-pocket expenses, the cost of my time and my liberty, and the pain and suffering I experienced as a result of negligence.

You may be tempted to get lawyers involved (although not about the quality of the joke below). I hope you don't. While I am not a "tough guy" negotiator, I know my story would resonate with a jury.

Dr. [pdoc] is a very good man who wanted to save my life. He made a mistake that nearly ended it instead. I have no wish to see that aired in open court. I know in an adversarial court action you would risk far greater financial exposure than what I'll be asking. Let's skip it.

You may say, "What the heck, that's why we have malpractice insurance." Instead, why not ask what I want?

I look forward to hearing from you.

Be well,

Rich Orwell

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[my 5th email (after the 3rd & 4th got no response)]

Subject: Goodbye for now, I suppose
Date: Monday, 3/29/2010

Hi, Dr. Amen -

I don't want to bother you any more than I have already, so this will be my last email unless you send a reply.

While I hoped to continue a dialog concerning the standard of care for prescribing Lithium, I understand if you consider it against your best interests to do so.

I rather had expected, though, some response to (the longer versions of) "Eskalith for bipolar bears", "A manic's spit floats because he's phlegm-buoyant" and "Take it with a grain of gestalt." Either rants or raves would have been welcome; it's rare for me to find an somebody who understands certain parts of my material. I do better in the Mensa humor groups.

Be well,

Rich

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I want to comment on what he said in his 2nd reply on 3/27: "The lithium level is meaningful, trough or not, if you know what you are doing and depends on many different clinical factors."

I defy you to find another doctor who prescribes Lithium who will agree.

If I haven't talked about it already, let me make a simple statement: The Standard of Care (or "Standard of Practice") for prescribing Lithium is called Therapeutic Drug Monitoring (sometimes "Therapeutic Drug Management") -- TDM. It relies on the "trough level" blood test -- standardized as "12 hours after last dose" around the world. Every guideline specifies certain ranges of Lithium in blood to help determine therapeutic (efficacious) doses.

While it is true a doctor will take into account other aspects of a patient's health (such as age and kidney function) in determining how much Lithium to prescribe (and whether to prescribe it *at all*), I'm more than "pretty certain," after researching the subject for nearly 3 months, you won't find anybody who says anything but get "trough level tests."

I have to add one more thing, something I said in one of the 4th email I sent:

If you don't know if you're looking at a trough, random or peak reading, just how meaningful is it? No matter what your levels of education, experience and expertise, I would contend you can't "know what you are doing" in that case.

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To call Dr. Amen, a man I honor and respect in almost any situation, a lying sack of s#$% would be rude, perhaps inappropriate. But Dr. Amen's pdoc is also his friend and Dr. Amen doesn't want to get sued. So, I'm sorry to say, in this case I believe "lying sack of s#$%" is appropriate, indeed.

And, by ignoring my request for a small amount of compensation, Dr. Amen has brought on himself a complaint to the state medical board and a big, fluffy malpractice suit. And I'll win.