Most of you reading this do not want to sell anyone short or accept as gospel things that are blatantly untrue or seemingly "iron clad" but are based on findings or conclusions that are in error. Sadly, injustices come to light all the time including people incarcerated for decades who were railroaded into prison by prosecutors who excluded or buried evidence that cried out "this guy (or lady) is innocent" (And once someone has any sort of "record" they can and often are fingered and railroaded again and again). Something similar happens with respect to medical boards and doctors too.
Case-in-point: Physician David A. Steenblock.
In 1991, after 14 years of practice as an osteopathic physician with a focus on the prevention and treatment of chronic diseases, Dr. Steenblock found himself facing accusations he had misdiagnosed and mistreated a 13 year old girl (he saw over a 5 month period of time) and a male patient with fatigue he was alleged to have treated with adrenal cortical extract.
Investigators from the (California) Department of Consumer Affairs investigated Dr. Steenblock's charts and declared him in the clear. Then, a little over a year later, copies of Dr. Steenblock’s case records were examined by an member of the Osteopathic Medical Board of California (OMBC) who apparently was a non-practicing physician. These copies included charting and diagnostic information that was so poorly reproduced as to be illegible. The doctor did not request readable copies, but instead decided that Dr. Steenblock had committed grievous blunders that warranted legal action. He recommended that the state Attorney General revoke Steenblock’s license.
What followed was a legal struggle that basically forced Dr. Steenblock to accept a “plea bargain” on the charges brought against him.
Cutting to the chase: The only violation Dr. Steenblock signed off on in the Regulatory Action agreement with the OMBC concerned charting and issuing a warning concerning injectable iron. All the other allegations were contested from day 1 (And the charting allegation was contested as well, though Dr. Steenblock ultimately chose not to fight this in order to avoid a lengthy and costly court battle).
He was placed on probation which meant he could continue practicing medicine but had to take certain courses such as doing charting and pay a $10,000.00 fine.
Needless to say, Dr. Steenblock was now on officialdom's radar. Some of those officials including prosecutors were actually overheard saying they "would find a way to get Steenblock" (Oral communication to "Something Amiss").
These "public servants" got there chance in 1997 when Dr. Steenblock was charged with violating his probation by not paying his fine and by using three (3) unlicensed physical therapy assistants.
Dr. Steenblock paid the $10K and in 2000 paid a licensed physical therapist to supervise others doing this sort of work in his clinic. The medical board fined him an additional $3500.00 and basically extended his probation by three (3) months.
The Regulatory Action or judgment issued by the powers-that-be included this highly revealing statement: "....respondent was acting in good faith and at no time were his patients at risk of receiving substandard treatment."
Then, in August 2009, the medical board came after Dr. Steenblock again. This time their investigation and subsequent actions were triggered by a snafu on the part of Medicare involving a stroke patient he had treated with hyperbaric oxygen.
Here's what happened in-a-nutshell: A stroke patient, C.A., completed a course of 60 hyperbaric oxygen therapy (HBOT) and physical therapy (PT) sessions and then requested additional ones (He had a total of 87 HBOT & as many PT treatments by May 2005.) Dr. Steenblock’s office manager observed: “When Mr. C.A. first came to Dr. Steenblock’s office for treatment he was in a wheelchair and when he, Mr. C.A., had finished his treatment Mr. C.A. was walking and seemed very pleased with his improvement.”
Now when C.A. enrolled as a patient of Dr. Steenblock’s he and his wife signed various documents including the Physician Patient Arbitration Agreement and the Advanced Beneficiary Notice (ABN.) At the same time they were advised that they would have to pre-pay for any treatments Dr. Steenblock prescribed and that his office is not a Medicare “participating office” and customarily does not accept assignments (Patients are advised file any claims for reimbursement from Medicare and/or their private insurance provider themselves.) But, as a courtesy to Mr. and Mrs. C.A. the front office crew agreed to submit C.A.’s billing to Medicare for direct reimbursement payment to he and his wife. Note that the Advanced Beneficiary Notice (ABN) Mr. C.A. signed states that “Medicare probably will not pay for services 99203, 99215, 44 PT sessions, 60 1.5 hrs HBO because it may not be deemed medically necessary by payer.”
On the ABN Mr. C.A. check marked and initialed an option designated #1 (YES) which states “I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. Please submit my claim to Medicare. I understand that you may bill me for items or services and that I may have to pay the bill while Medicare is making its decision.” Just above the signature of Mr. C.A. it states in all capital (bolded) letters that “I AGREE TO PAY FULL FEE FOR SERVICES WITHOUT LIMITS”
As you can see things were set up so that any monies paid by Medicare to Mr. C.A. would be sent directly to him. Unfortunately, Medicare officials made a scanning error on the dates of service while processing C.A.’s paperwork which came to the attention of Dr. Steenblock’s office manager. She wrote a letter to them on 5-6-2005 in which she requested the claims be resubmitted and any check issued sent directly to Mr. and Mrs. C.A. (A copy was sent to Mr. and Mrs. C.A.)
On 5-31-05 Dr. Steenblock’s office received a letter from Valerie Walker, Medicare Overpayment Recoupment Unit, of CMS (Center for Medicare and Medicaid Services) in which she expressed thanks for being informed of the processing error and stating that the claims were being reprocessed to reflect the correct information.
The office manager then made numerous phone calls to make sure that Mr. and Mrs. C.A .received the full reimbursement from Medicare that they were entitled to.
What should have then happened is issuance of a check to C.A. by Medicare. Instead, the government agency sent the check to Dr. Steenblock’s Clinic in his (Dr. Steenblock’s) name. Naturally Dr. Steenblock’s office manager and billing clerk immediately set about to get this screw-up straightened out including returning the check to Medicare along with a request that they send the check directly to C.A. This resulted in a delay in Mr. C.A. getting due reimbursement but eventually he got this.
Unfortunately, during the period of time in which the Medicare screw-up was being worked out C.A. and his wife got frustrated with the situation and filed a complaint with the California state medical board. Mind you, their unilateral move actually violated the very Physician Patient Arbitration Agreement they had signed.
There was, in short, no misrepresentation, fraud or other act of wrongdoing on the part of Dr. Steenblock or his office crew. Unfortunately, Mr. and Mrs. C.A.’s act of filing a complaint obligated the state medical board to investigate.
In California the Medical Board of California (MBOC) is the first to investigate a complaint. When the complaint is made against an osteopathic physician (D.O.) they do an investigation and then forward their findings on to the Osteopathic Medical Board of California (OMBC).
In Dr. Steenblock’s case the MBOC carried out their investigation and concluded the complaint had NO merit and should not go forward. The OMBC on-the-other-hand followed a course-of-action that should raise concern on the part of anyone interested in justice and fairness. How so? Take a look at the litany of charges they came up with:
(1) The accusation alleged gross negligence, repeated negligent acts, acts of clearly excessive prescribing and treatment, and a failure to maintain adequate records, all in connection with respondent's provision of hyperbaric oxygen and physical therapy treatment to stroke patient C.A.
(2) The accusation also alleged that respondent engaged in an act involving dishonesty, that he improperly held himself out as board certified, and that he disseminated a public communication containing a false, misleading, or deceptive statement, all in connection with a representation on his two websites that he was "board certified" by two particular entities.
(3) Finally, the accusation alleged, as a "discipline consideration," that respondent's license had been previously disciplined in 1994 for failing adequately to document his examination and treatment of two patients.
Rather than go through each of the allegations it is easier to list the OMBC’s findings:
a. Respondent failed, during his initial assessments of C.A., adequately to document C.A.' s condition, diagnosis, and rationale for treatment. This failure constituted a simple departure from the standard of care.
b. Respondent failed, during the course of his ongoing treatment of C.A., adequately to document C.A.'s continuing need for HBO and physical therapy after January 2005. This failure constituted an extreme departure from the standard of care.
c. Respondent committed acts of clearly excessive prescribing of treatment and clearly excessive use of treatment facilities by virtue of the continuation of C.A.'s physical therapy after January 2005. These acts constituted a simple departure from the standard of care. Respondent did not, however, prescribe clearly excessive HBO for the period after January 2005.
d. Respondent failed to maintain adequate records of his treatment of C.A., and this failure constituted an extreme departure from the standard of care. This finding follows necessarily from Findings 50(a) and (b).
e. Respondent committed a dishonest act by falsely representing on his two websites that he was board certified by the American Board of Family Practice and the American Board of Chelation Therapy.
f. Respondent held himself out to be board certified by the American Board of Chelation Therapy and the American Board of Family Practice without such certification having been granted by these two boards. This finding necessarily follows from Finding 50(e).
g. Respondent disseminated and caused to be disseminated a public communication through an internet website containing a deceptive or misleading statement for the purpose or with the likely effect of inducing the rendering of professional services in connection with the professional practice for which he is licensed. This finding follows from Finding 50(e).
NOW LET'S BREAK THESE DOWN AND LOOK AT THEM CLOSELY:
I. Articles a., b. and d. concern inadequate documentation (charting.) Even if one allows that this was the case as concluded by the OMBC – something disputed by Dr. Steenblock and his expert witness, Ken Stoller, MD (This is contained in the body of the Board’s decision) – it is a “sin” shared by many practicing doctors. Consider what Cynthia M. Lipsitz, MD, MPH, wrote about this in a post titled “Top 5 Physician Documentation Errors":
As the senior medical reviewer for Washington and West, a denials management company, I’ve seen documentation errors and omissions that clearly put hospitals and physicians at risk
for denials. What’s more, as I review medical records from across the country, I’m starting to see patterns of errors at individual hospitals and by individual physicians. And, if I’m seeing
patterns as one lone reviewer, you can just imagine what government auditors are finding.
Understandably, health care providers put patient care first, and we wouldn’t want things any other way. When I’m called to see a patient with chest pain, writing a detailed note is just
not the first thing on my priority list. Too often, though, providing excellent patient care is used as an excuse for very poor documentation.
Some physicians feel that writing good notes isn’t their concern – that they have PA’s, NP’s or residents to do the work. Some don’t see the link between quality care and documentation,
and think that as long as their patients do well, that’s all that really matters. Of course everyone is stressed for time, and so notes are dashed off all too quickly. And some physicians
honestly don’t have the information they need to do a better job of documenting.
The fact is, we physicians haven’t been taught very much about documentation in medical school or training. We usually get a general introduction to writing histories and physicals, and
to the problem-oriented medical record. We get some legal tips on documentation practices aimed at reducing professional liability risks. But when it comes to writing detailed notes
that justify our medical care decisions, well, that medical school class never happened.
Dr. Lipsitz’s comments have been included not to justify or excuse any real or perceived deficiencies in Dr. Steenblock’s charting and documentation but, rather, to illustrate the fact that this sort of thing likely can be said of many if not most practicing physicians. In all likelihood if MBOC investigators to randomly pull a handful of charts from the files of 20 practicing MD’s and the OMBC investigators did likewise with respect to 20 practicing DO’s they would likely find charting and documentation errors that could be construed or interpreted as a “departure from the standard of care.”
If documentation and charting errors or lapses are indeed a commonplace sin of omission then Dr. Steenblock is likely in good company. But again, while this does not justify or excuse any bona fide or perceived failings on his part most fair-minded folks would have to wonder how much weight to give this in the scheme-of-things. Perhaps less than the OMBC did when it adjudicated Dr. Steenblock’s case.
II. Article c. concerns “excessive prescribing of treatment and clearly excessive use of treatment facilities by virtue of the continuation of C.A.'s physical therapy after January 2005.” Excessive apparently is in the eye-of-the-beholder. According to Dr. Steenblock’s office manager (Noyemy) in a sworn affidavit:
“When Mr. C. A. first came to Dr. Steenblock’s office for treatment he was in a wheelchair and when
he, Mr. C.A., had finished his treatment Mr. C.A. was walking and seemed very pleased with his improvement.
Upon information and belief and based on my recollection of the facts of the case the A’s were so pleased with Mr. C.A.’s progress after the first 60 HBOT sessions that they
requested more HBOT and Physical Therapy sessions.”
When something works is it then excessive? So wasn’t the OMBC aware of the fact Mr. C.A. improved? They heard this from Dr. Steenblock but basically hung their hat on a single criterion reflected in the testimony of the OMBC’s own expert witness, Jerome Stenehjem, M.D. who stated that “Excessive treatment is determined by a review of the patient's chart.”
Among Dr. Stenehjem’s other comments:
“According to Dr. Stenehjem, respondent's records for November 30, 2004, were inadequate because they did not document a level of impairment or disability from which a treatment could be assessed, i.e., they did not quantify the level of C.A.' s paralysis adequately, so that it could serve as a benchmark for measuring the effects of treatment.”
“Dr. Stenehjem testified that respondent's ongoing charting for C.A. represented an extreme departure from the standard of care because it was inadequate to justify continued HBO and physical therapy treatments for C.A. after January 2005.”
“Dr. Stenehjem testified that the HBO and physical therapy treatments provided to C.A. after January 2005 were excessive, because of the absence of documentation showing any continuing benefit to be derived from these modalities. This excessive treatment constituted an extreme departure from the standard of care.” (Note: The OMBC disagreed with Dr. Stenehjem: “Respondent did not, however, prescribe clearly excessive HBO for the period after January 2005.”)
As Dr. Steenblock’s charting was dealt with in the prior section there is really no need to belabor this. However, is it fair for any medical board to decide whether a treatment is excessive where charting notes are inadequate, incomplete or missing? Yes, point out charting issues and impose remedies on the physician who failed to “clear the bar” – but why not allow for input from those with intimate knowledge of the patient’s responses to therapy to help fill in the gaps? Dr. Steenblock and his office manager offered this. Little weight was apparently given this by the OMBC. OK, so why did their investigators not include asking Mr. C.A. about his responses to therapy? If they did, nothing made its way into the OMBC Decision.
If the rules are intended to catch physician failings in the documentation realm, this is all fine and good. But when it comes to determining whether a course of therapy had merit or conversely had little or none (and was even excessive) it seems – especially in a situation in which a physician’s license is on the line – that some latitude would be given in terms of searching out supplemental information from the patient and those who were involved in his or her care.
III. Articles e., f. and g. round out the OMBC’s findings with respect to Dr. Steenblock and concern some his having “committed a dishonest act by falsely representing on his two websites that he was board certified by the American Board of Family Practice and the American Board of Chelation Therapy.”
As the OMBC notes in its Decision, “Respondent was certified with the American Board of Family Medicine from 1977 to 1984. He is not currently certified with that board.” And “The American Board of Chelation Therapy was established in 1982. The name was later changed to the American Board of Clinical Metal Toxicology (ABCMT). Respondent is not currently a member of the ABCMT, and had not been a member for at least the past five years.”
The references to board certification appeared on two of the many websites Dr. Steenblock maintains: Namely, www.strokedoctor.com and www.stemcelltherapies.org.
Dr. Steenblock does not dispute that these statements existed on the aforementioned websites. But he does take exception with the OMBC‘s conclusion that this constituted “a deceptive or misleading statement for the purpose or with the likely effect of inducing the rendering of professional services in connection with the professional practice for which he is licensed.“ The simple fact is Dr. Steenblock directed one of his assistants at his nonprofit research institute (SRI = Steenblock Research Institute) – a biostatistician/administrative assistant who handled the websites in question – to have the board certification notations struck from them back well before Mr. C.A. became his patient. Unfortunately this directive got lost in the shuffle at SRI and was not brought to anyone’s attention until the OMBC filed its charges.
Bottom line: The Board imputed a sinister motive (“…for the purpose or with the likely effect of inducing the rendering of professional services…”) where none actually existed. Dr. Steenblock and the overworked biostatistician/administrative assistant discussed this with anyone and everyone who asked. The Board came down on the side of this episode constituting something self-serving on Dr. Steenblock’s part as opposed to a slip-up on the part of an underling.
In-a-word, the Board put Dr. Steenblock on probation which included paying a hefty fine, taking a medical record keeping course, and filing quarterly statements of compliance with the terms of his probation.
As you can well imagine Dr. Steenblock had every reason to feel he had been railroaded by the OMBC and was thus not especially eager to do everything asked of him. After failing to file some of the aforementioned quarterly compliance reports, the Board took action to revoke his license but were stopped by the fact Dr. Steenblock's attorney took matters to the San Francisco Superior Court and tried to get the Board's decision stayed or set aside and Steenblock's probation terminated. Ultimately, the Board had its way and the old probation terms plus some new ones were imposed. Dr. Steenblock's probation will be completed during January 2017.
Something to mull over
Journalists, medical consumer advocates, researchers, and members of the justice system (among others) have a professional obligation to zero in on the truth; and to do this with a focus on being accurate and fair. This is clearly missing in many respects from the OMBC’s dealings with Dr. David Steenblock and in the way many medical consumers, skeptics and reporters have summarized these decisions.
It is easy and even convenient to accept official pronouncements and findings as well as media stories and consumer advocate pieces as “gospel.” Unfortunately, this sort of thing tends to let unjust and unfair practices, conclusions and acts on the part of public officials and members of the fourth estate slip through the cracks.
This article utilized material from "Goliath v. David" © 2013 by Dr. A. G. Payne. Used with permission.
STILL THINK MEDICAL BOARDS DO NOT ENGAGE IN MISCONDUCT?
TAKE A LOOK AT TWO OTHER CASES
Here are two examples of how recent misconduct on the part of medical boards in two separate states, Texas and Alabama, became the focus of activism on the part of the Association of American Physicians and Surgeons, Inc:
DOCTORS SUE TEXAS MEDICAL BOARD FOR MISCONDUCT
Cites institutional culture of retaliation & intimidation
The entire Texas Medical Board (TMB) and its officials have been named in a lawsuit filed by the Association of American Physicians and Surgeons (AAPS). The complaint, filed this week in District Court in Texarkana, accuses the board of misconduct while performing its official duties, specifically:
1. Manipulation of anonymous complaints;
2. Conflicts of interest;
3. Violation of due process;
4. Breach of privacy; and
5. Retaliation against those who speak out.
HALL OF SHAME – ALABAMA BOARD OF MEDICAL EXAMINERS
• Politically motivated license revocation on the pretext of sloppy handwriting
HYPERBARIC OXYGEN THERAPY FOR CHRONIC STROKE: If this is a "departure from standard of care", it's a needed one!
Summary of patient responses at Dr. Steenblock's clinic presented as a Poster Session titled "Improved therapy for Rehabilitation of Stroke" given by Dr. Steenblock at the National Stroke Association Ninth Annual Stroke Rehabilitation Conference
Dr. Steenblock, who has been doing HBOT for various neurologic conditions since 1989, has seen HBOT effect clinically significant improvements in a large enough population of patients to compel his continued reliance on it right on up to the present (2016).
What Dr. Steenblock has seen and documented is buttressed by studies (including many recent ones) which clearly show that HBOT produces clinical benefits in chronic stroke sufferers including those who are many years out from their original stroke. Let's look at one:
In January 2013 a very rigorous Israeli clinical study on HBOT and chronic stroke was published in the open access journal PLOS Clinical Trials. The results of the study were written up as a paper titled “Hyperbaric Oxygen Induces Late Neuroplasticity in Post Stroke Patients – Randomized, Prospective Trial” which can be access at http://bit.ly/10cVdNA. The conclusion tells the tale:
“The results indicate that HBOT can lead to significant neurological improvements in post stroke patients even at chronic late stages. The observed clinical improvements imply that neuroplasticity can still be activated long after damage onset in regions where there is a brain SPECT/CT (anatomy/physiology) mismatch.”
If this somewhat technical jargon is leaving you glassy-eyed, here is something from a lay-level write-up on this study that appeared on the ScienceDaily website on 1-23-2013:
“For their study, the researchers sought post stroke patients whose condition was no longer improving. To assess the potential impact of HBOT treatment, the anatomical features and functionality of the brain were evaluated using a combination of CT scans to identify necrotic tissue, and SPECT scans to determine the metabolic activity level of the neurons surrounding damaged areas.
“Seventy-four participants spanning 6 to 36 months post-stroke were divided into two groups. The first treatment group received HBOT from the beginning of the study, and the second received no treatment for two months, then received a two-month period of HBOT treatment. Treatment consisted of 40 two-hour sessions five times weekly in high pressure chambers containing oxygen-rich air. The results indicate that HBOT treatment can lead to significant improvement in brain function in post stroke patients even at chronically late stages, helping neurons strengthen and build new connections in damaged regions.”
“Although the study focuses on patients only through three years post-stroke, Dr. Efrati has seen similar improvement in patients whose brain injuries occurred up to 20 years before, belying the concept that the brain has a limited window for growth and change.”
Here is a link to the ScienceDaily article in question: http://bit.ly/UW1RmE. Citation: American Friends of Tel Aviv University. “Oxygen chamber can boost brain repair years after stroke or trauma.” ScienceDaily, 23 Jan. 2013. Web. 23 Jan. 2013.