On the final day of the four-day hearing that the state Board of Medical Examiners initiated to decide whether a Helena physician should face sanctions, including the possible loss of his medical license, the board’s attorney engaged in aggressive questioning of the doctor and some of his patients.
If board attorney Mike Fanning’s goal was to rattle Dr. Mark Ibsen, to elicit an out-of-control response, it didn’t work. Ibsen, although obviously angry with Fanning, did manage to retain his composure on the final day of the hearing.
Fanning’s aggressive questioning of one of Ibsen’s patients on the third day of the hearing, a woman identified only as Patient #5, had come closest to getting a violent reaction out of Ibsen.
Patient #5 had testified that she had undergone six gynecological surgeries in 10 months in 2012 and had also suffered a painful sinus infection following oral surgery in 2012. Patient #5 testified that because other area physicians had failed to correctly diagnose some of her problems and because some of the surgeries were botched, she was mistrustful of doctors, except Ibsen. “He’s the only one I trust,” she said.
Fanning’s questioning of Patient #5 started out with a contentious statement. “For someone who doesn’t trust doctors, you see a lot of doctors,” he said, before he posed any questions. Fanning walked Patient #5 through her painkiller prescriptions in February and March 2013, which showed that throughout the period she had requested and received repeated early refills, resulting in what he said was an 81 day supply in February and a 77 day supply in March, based on the dosages listed on the prescriptions.
Ibsen was moved to tears and became very angry at what he viewed as Fanning’s mistreatment of Patient #5.
The complaints against Ibsen are allegations that he over-prescribed opiate pain medications, failed to completely and properly keep patient records, that he failed to properly treat patients with complex medical issues and vague allegations that he is mentally unstable.
Tied in with the record keeping complaint are allegations that Ibsen was not properly examining or counseling his patients or suggesting to them alternative pain treatments, such as chiropractic, physical therapy or naturopathic care. The testimony of some expert witnesses suggested that Ibsen was just writing prescriptions for narcotics without properly examining the patients.
Whether Ibsen was using proper procedures in evaluating patients and prescribing appropriately was disputed by witnesses. The crux of the problem identified by several witnesses was in Ibsen’s charting. Several of Ibsen’s patients testified that he had done physical exams and discussed their treatment thoroughly on every visit. However, St. Peter’s Hospital Director of Pharmacy, Starla Blank, offered her opinion, saying Ibsen’s charting was not appropriate. “In my opinion they were not getting the right treatment,” she said.
Dr. Camden Kneeland, the medical director of a pain clinic in Kalispell, said that without what he considered proper charting he couldn’t offer an opinion on the adequacy of care Ibsen provides. “If it’s not in the records how can I know,” he asked.
Both Kneeland and Blank referred over and over to the need for a pain management plan, a written document signed by the patient and the doctor. Blank described such a plan as critical for “responsible” use of opiates.
Despite the increasing use of written and signed controlled substances agreements involving use of narcotics for pain treatment, such contracts are not legally required. The contracts typically stipulate that the patient agrees to allow urinalysis to test for drugs, pill counts, no early prescription refills and that the patient agrees to obtain prescriptions only from one doctor. (The last stipulation is aimed at keeping patients from getting narcotic pain medications from more than one doctor, a practice commonly known as doctor shopping.)
But not everyone in the medical community thinks written controlled substances agreements are useful and some even say they’re harmful to the doctor/patient relationship, akin to treating patients as suspects.
Dr. Charles Anderson, a Helena neurologist who retired in 2012, testified on Ibsen’s behalf. In preparation for his testimony, he had reviewed the bulk of the patient records entered into evidence in the case. He also testified that he visited Ibsen’s clinic, spending a total of 50 hours or so reviewing the case.
When asked about Ibsen’s charting (patient records), Anderson said, “Most physicians tend to be independent minded.” Anderson desribed Ibsen’s charts as on the “lower half of the legibility scale.”
Anderson said that requiring signed controlled substances agreements was problematic. “Patients may lose their trust,” he said, “and there are bioethicists that agree. Patients must understand that you’re on their side.”
Anderson said he did not use contracts in his four decades of practicing medicine, although he “saw some doctors that did.”
Anderson testified, in direct contradiction to other witnesses, that he saw clear evidence in Ibsens’ records that he had successfully weaned patients from narcotics.
“My impression,” he said, “was that most patients were either tapered or in process of tapering. Each patient has his own timeline. It may take a year or two for some. Some are never able to wean. We want them to have a life and some require indefinite use of narcotics.”
Kneeland testified that in his review of Ibsen’s patient records he noted that three of nine patients reduced their narcotics use and six of the nine increased.
When asked about Anderson’s conclusions, Kneeland said, “My initial reaction was he couldn’t be reviewing the same things I was viewing.” The records were of the same patients.
When Anderson was confronted with prescription records of some of Ibsen’s patients who had apparently shown no progress in weaning, he stuck to his assertion that Ibsen was successful in his attempts to get patients off narcotics. “Do you still stand by your opinion that Dr. Ibsen was skilled (in weaning his patients off opiate pain medications)?” Fanning said. “Particularly,” Anderson replied.
Kneeland testified that his success rate at weaning patients off opiates is 73 percent at reduced dosages and 10 percent off completely.
No one testified in exact terms whether Ibsen was prescribing too many narcotic pain medications.
Anderson, Ibsen’s witness, said “I cannot tell for sure whether there were times when they were receiving too much.”
Pharmacist Blank, when asked if Ibsen was exceeding the drug manufacturer’s limits, said “no.”
The allegations of misconduct were lodged by Sarah Damm, a licensed chiropractor who worked in Ibsen’s clinic, Urgent Care Plus, for three years. She filed her complaint against Ibsen 28 days after Ibsen fired her. Ibsen said he dismissed Damm for using profanity in front of patients, failing to follow instructions and gossiping about Ibsen with other employees. When she testified in October, she was employed as a truck driver at a beet farm in North Dakota.
At all four days of the hearing, Ibsen’s patients packed the rooms. At the final day there were about 30 or so of his supporters. Many spent the entire eight hours listening to the testimony, some standing for extended periods outside the room.
Pain relief debate
Nationally, the debate is ongoing about the use of opiates for pain relief, especially as it is used for chronic pain. The medical community divides pain into two categories: chronic and acute. Acute pain is the short term type, such as after a surgery or from a broken limb. Chronic pain is, as the name suggests, long term or as one medical professional put it “any pain than goes on longer than would normally be expected.”
For many years, pain was undertreated. Opiates were typically only used to treat the worst types of pain, such as from advanced stages of cancer or other terminal diseases. In the late 1980s things started to change and the medical community eventually recognized pain as the “5th vital sign.” The use of opiates to treat pain increased dramatically throughout the 1990s.
Chronic pain commonly leads to major depression and suicide. At the Ibsen hearings, St. Peter’s pharmacist Blank cited statistics on opiate use and abuse. The U.S. has only 18 percent of the world’s population (the U.S. Census Population Clock puts the percentage at 4.43 percent) but uses 95 percent of the world’s hydrocodone and 75 percent of the world’s opiates, she said.
Kneeland also had statistics: one death for every 500 opiate doses prescribed. He also noted that there are more deaths from opiate pain medications in Montana that car wrecks.
What neither side quoted, however, is the number of people who commit suicide as the result of ineffectively controlled chronic pain, according to Dr. William Hurwitz, a Virginia physician specializing in treating pain. He describes the Drug Enforcement Agency's investigation and prosecution of doctors as “regulatory ignorance.” According to Hurwitz, the “intimidation of doctors” has cut the availability of help for pain patients.
During his testimony, Ibsen said he spent extensive time with all his patients and his opinion on treating pain with opiate pain medications, beginning with his experience in emergency rooms, was “give it until it’s enough.”
In recent years as the War on Drugs has extended its battlefields to the doctors’ offices, the DEA now investigates physicians and as a result many doctors will not treat pain patients.
Dr. Jean-Pierre Pujol, who was with Urgent Care Plus until July, was asked a series of questions about Ibsen.
“Is he a good doctor?” “Yes,” said Pujol.
“Is he hard working?” “Yes,” said Pujol.
“Is he honest?” “Yes,” said Pujol.
“Is he caring?” “Yes,” said Pujol.
Pujol testified that he left Urgent Care Plus out of concerns over the investigation into Ibsen. “It made me nervous,” he said. “I wasn’t sure what would spill over into my personal life.”
Pujol said that Ibsen is providing service to a community of patients few physicians are willing to help. “Many doctors, including myself, don’t want to deal with it (pain patients),” he said.
Anderson concurred with Pujol’s assessment of pain treatment availability. “Most doctors don’t want to mess with that,” he said. “It’s hard to find a sympathetic doctor in Helena who will work with you -- the legal implications and the regulations.”
During Ibsen’s testimony, he touched on the ethical considerations of his treatment of pain patients. One patient came to his office that had been treated for chronic pain by a Florence physician (Dr. Chris Christensen) who lost his license in April in connection with his prescribing practices. “He had a failed neck surgery and back pain and he was on a mix of opiates. He was in opiate withdrawal,” Ibsen said. “I was moved. Somebody had put him in withdrawal. It wasn’t me.” Ibsen said his motivation to help is his ethics. “It’s about suffering,” he said.
Ibsen denied that he merely feeds addictions. “I never say to them don’t think you’re always going to have pain. My job is to get people off pain medication. If I don’t treat them then who will?”
Ibsen explained why he didn’t use written pain contracts. “Patients shouldn’t have to grovel and beg for medication, have pill counts and pee in a cup,” he said
Now that the hearings have been completed, the process of arriving at a recommendation on Ibsen’s case could likely go on for a few months before the hearing officer arrives at a recommendation on whether or not Ibsen should be sanctioned and what those sanctions should be. Once those recommendations are complete, the final decision will be made by a panel comprised of members of the Board of Medical Examiners.