Falling Down

MDNG Pain Management, January 2009, Volume 2, Issue 1

Considering the stresses of the job and the ease of access to powerful narcotics, it’s not surprising that some physicians become addicts.

On weekends, Louis Ortenzio, MD, makes house calls of a sort. Driving around his West Virginia hometown, the 55-year-old former family practitioner serves people in need. He doesn’t carry a little black bag or wear a white coat, though, and the job commands far less prestige than most doctors are accustomed to.

Louis Ortenzio delivers pizzas.

It isn’t an eccentric hobby. Ortenzio’s primary job, selling office supplies, doesn’t pay quite enough to make ends meet, so he needs the extra income from the pizzeria. The arrangement is still a step up from some of the other jobs he’s held since losing his medical license in 2005.

With few marketable skills outside of medicine, and a federal felony conviction on his record, Ortenzio suddenly faced a drastically narrowed set of job options. “I dug ditches for a month, I worked as a janitor for six months, I went to a golf course and push-mowed grass for 10 months last year, and then the guy that I bought a copier from when I first set up practice in ‘82 came playing through on the golf course and said ‘Lou, maybe you ought to be with people, let me hire you,’” says Ortenzio.

Hawking pens and keeping track of the pepperoni and anchovies aren’t typical career goals for new medical graduates, but Ortenzio’s trajectory is not entirely unique. The year he lost his license, he was one of about 2,000 American physicians whose privileges were revoked or suspended for disciplinary reasons, according to statistics from the Federation of State Medical Boards. The same data reveal that the total number of disciplinary actions by medical boards is on the rise.

Most news coverage of these incidents focuses on a few truly outrageous cases, but Ortenzio’s story is much more typical. He is not the surgeon who carved his initials on a patient’s abdomen, or the gynecologist accused of sexual assault, or the internist who ran an illegal online pharmacy. He is just an ordinary doctor who made a few simple, but ultimately devastating, mistakes.

His own worst patient

Ortenzio’s path into medicine is a familiar one. As an undergraduate at Gettysburg College in Gettysburg, PA, he gravitated quickly toward his future career. “I liked biology, I did well in biology and I thought medicine was a great area of service—do something good for the community, do something good for your fellow man,” he says.

Medical school at the University of Maryland followed, and he graduated from that program’s psychiatry track in 1979. “I thought I wanted to be a psychiatrist, and they had an accelerated psychiatry program there that allows you to finish medical school in three and a half years. By the end of the medical school experience, I realized I wanted to do family practice,” explains Ortenzio.

The other thing he wanted to do was move to West Virginia. Though his childhood had been spent largely in suburban College Park, MD, on the outskirts of the nation’s capital, Ortenzio’s fondest memories were of his family’s summer vacations in the mountains. With his medical degree in hand, the new doctor headed there directly and started his family practice residency at United Hospital in Clarksburg.

Nestled into the western foothills of the Appalachian mountains at the northern end of West Virginia, Clarksburg had—and still has— all of the benefits and problems of a small, rural town. Housing is cheap, crime is low, and many residents are on a first-name basis with each other.

However, like most former manufacturing and mining centers, Clarksburg has experienced a painful transition into the modern economy, with its population declining continuously for the past 50 years. Today, with just under 17,000 residents, the city’s biggest employers are a large strip mall, the hospital, and a major Federal Bureau of Investigation office built in 1995.

Outside the small downtown area, the roads snake through miles of tree-covered hills and quiet hollows dotted with a few scattered clusters of houses. The nearest big city is 100 miles away. It’s the kind of area that has a notoriously hard time attracting and keeping physicians.

For Ortenzio, though, it was perfect, and he quickly put down roots. “Two of the guys who finished residency with me went into practice together after residency, at the same time that four or five general practitioners in the area retired,” says Ortenzio. With the old guard retiring, the new clinic became an overnight success: “We set up practice on January 1st 1982, and by the second week, we had a thousand charts from these other general practitioners who closed shop,” he notes.

He and his partners soon found themselves running the pre-eminent practice in the region, with thousands of charts and a hospital census that commonly ran to 50 patients or more. The doctors also became pillars of the small community, even founding a free clinic in Clarksburg to treat the area’s poor and uninsured.

Ortenzio’s family also grew, and he juggled the responsibilities of a father of three and husband with those of a busy physician. Of course, the practice’s other partners were on the same ride themselves. “We built a building, we had a pretty good life, but we were working all the time. None of us had real balance in our life,” he says.

It didn’t take a doctor to see that the frenetic pace was taking its toll. “People kept telling me ‘You can’t work like this, doc, you’re gonna get sick,’” says Ortenzio, adding “I thought they were just jiving me.”

But one day, looking to take the edge off , he succumbed to a classic occupational hazard. Opening the practice’s sample cabinet, he took out some Vicodin (hydrocodone) and tried to medicate his troubles away. Ortenzio wasn’t the only one seeking chemical relief from the stress. “One of the other guys developed an alcohol addiction; only one of the three of us remained unscathed through the whole process,” he notes.

Unlike alcohol, though, Vicodin leaves a paper trail. He soon needed more pills, so he started writing himself prescriptions for them. To avoid drawing suspicion, he also wrote prescriptions in his children’s names, then filled them himself to feed his growing habit. Soon, says Ortenzio, “I was eating probably 40 hydrocodone a day.”

The last thing to go

Considering the stresses of the job and the ease of access to powerful narcotics, it’s not surprising that some physicians become addicts. In fact, doctors seem to suffer this affliction at about the same rate as everyone else.

“The general consensus is that physicians have the same prevalence of addiction as the general population, which is roughly one in seven people,” says Scott Teitelbaum, MD, medical director of the Florida Recovery Center at the University of Florida College of Medicine in Gainesville. Teitelbaum adds that “they have a higher prevalence of narcotic addiction with opiates, but some people might say that’s due to access and prescription availability.”

Despite the access, plenty of physicians choose non-prescription drugs as well. Teitelbaum, for example, has more than an academic interest in recovery medicine, having lost his medical license and a thriving pediatrics practice in Connecticut several years ago as a result of a cocaine habit.

Most physicians who have addiction problems manage to keep their licenses, though. While some activists and news outlets automatically assume that addiction compromises patient safety, the data show otherwise. “When you actually look at malpractice issues, there’s no greater prevalence of physicians with addiction to have malpractice claims,” says Teitelbaum. He adds that “Contrary to what most people think ... the job’s the last thing to go, because of ego and pride. Home life and spiritual life always go first.”

That was certainly the case for Ortenzio. As his practice filled more of his time, and his drug habit commanded more of his attention, his wife decided she’d had enough. “She got disenchanted with me and my lifestyle, and disenchanted with the school system, and decided that she’d move to Pittsburgh and send the kids to private school up there and I would commute,” he says.

Initially, he tried to pretend that his marriage wasn’t falling apart. Continuing to work at his practice most days, he would make the two-hour drive each way to Pittsburgh to visit his family whenever he had a weekend off . As the months of living apart stretched into years, though, he began to realize that it was over. Soon, even the pills couldn’t deaden the pain.

“I was suffering greatly, and actually was at times suicidal, and my marriage was on the rocks. I’d become very addicted and spiritually bereft,” says Ortenzio.

Recovering addicts call it “bottoming out.” It’s that moment of grim realization that the addiction has finally consumed everything of value, leaving nothing but a bleak moonscape of despair extending to the horizon. For educated professionals in general, and physicians in particular, it can be a particularly hard scene to contemplate.

“You’re trained to be self-sufficient and not show vulnerability, you’re trained not to ask for help; these things—although they’re part of medical training—are not really conducive to getting well,” says Teitelbaum. He adds that the prestige of a medical career can also interfere: “If I’m successful as a surgeon, or I’m successful as a pediatrician, how sick can I be? That adds to the denial. All addicts and alcoholics have denial, but the professional success in some ways leads to the denial of how sick they are.”

Besides denial, doctors with drug or alcohol problems must overcome their own local obstacles. Like virtually everything else in healthcare policy, addiction treatment for physicians is a 50-state patchwork of approaches, each enmeshed in its own local politics.

Progressive states, says Teitelbaum, take a “carrot-and-stick” approach. “So, the carrot is that if they get the help they need, they’ll still be able to practice, provided nothing horrendous has happened with patient care, and the stick is that if they don’t follow directions and get the help, they won’t; those are the successful programs.” Besides allowing physicians to continue practicing while they’re in treatment, progressive programs typically require longterm follow-up with random urine tests and periodic hair samples to detect any relapses.

It appears to work well. Pointing to Florida as an example, Teitelbaum says the state’s five-year success rate for treating addicted physicians approaches 90%, far higher than the recovery rate for the general population.

What about less progressive states? While he declines to name them, Teitelbaum says a few medical boards still take a strictly punitive tact, reflexively suspending or revoking addicted physicians’ licenses rather than trying to treat them. Unsurprisingly, that makes other doctors less likely to intervene when colleagues are in trouble. “You’ll have what we call a conspiracy of silence. Physicians will know of addicts—they'll say ‘he drinks too much, he has a problem,’ but they won’t refer, they won’t do anything about it, because they don't want to ruin the guy’s career,” says Teitelbaum.

Regardless of their medical board’s approach, doctors with drug or alcohol problems often turn to, or are referred to, a standard “twelve-step” recovery program. At least one national organization, International Doctors in Alcoholics Anonymous (IDAA), helps provide information about these programs specifically for physicians. The group takes the anonymity of its approximately 6,000 members very seriously, even refusing to provide general background data on physician addiction in response to a reporter’s questions.

Ortenzio, living in the buckle of the Bible Belt, found a different path out of addiction. As his marriage dissolved, he began dating a nurse who convinced him to attend her church. “She led me to the Lord, and I got saved; I had a religious salvation experience, and it wasn’t three months later that I was able to get off drugs,” he says. Adding that he has no objection to twelve-step programs for other people, he states emphatically that “I am not a recovering drug addict. I was healed from addiction by the Lord and I have been drug free for five years.”

Besides finding God, he also found a psychiatrist who helped treat his depression. By the end of 2004, he seemed to have gotten his life back in order. “Things were hunky-dory. I’d been able to control the practice to some extent and live drug free and be really involved in my church on a spiritual level,” says Ortenzio.

Then, one February morning in 2005, the office manager from his practice called in a panic. Thirty armed federal agents had just burst in, raiding the office and confiscating all of the records: charts, billing, and, of course, prescriptions.

One in three

The prescription records quickly revealed Ortenzio’s prior drug problem, but from a legal standpoint, there was a much more serious issue lurking in the billing files. “My notes had gotten really sloppy, because I was seeing too many patients, doing too much, writing down too little, but billing,” says Ortenzio. Soon, he was facing federal felony charges for Medicare fraud and abuse.

It’s a trap that also ensnares many doctors without addiction problems. While Federal regulators insist that they can distinguish between sloppy recordkeeping and genuine fraud, the line between the two is often blurry. In addition, the law makes no allowances for the kinds of strategic billing many physicians consider acceptable.

For example, the government considers it criminal to alter a patient’s billing diagnosis, report symptoms the patient doesn’t actually have, or exaggerate the severity of a condition in order to secure coverage for treatment. A widely discussed study in 2000 surveyed more than 1,000 physicians nationwide, and found that 39% reported using at least one of these tactics in order to provide good care (JAMA. 2000 Apr 12;283(14):1858-65).

If those findings are correct, one reader in three could be flirting with disaster. Under current federal sentencing guidelines, a conviction for Medicare fraud and abuse is usually a quick route to prison time.

As Ortenzio’s case wended its way toward trial, though, a different type of problem surfaced. Maybe from the stress, maybe from the Zyprexa (olanzapine) his psychiatrist had prescribed, or maybe from some combination of factors, he developed acute hemorrhagic pancreatitis. With a slight drawl, he gives the sort of laconic summary only a rural Southerner could muster for such a near-death ordeal: “I was on life support, got ARDS, had a ventilator and all this stuff .”

When he finally emerged from intensive care, and with his federal case still pending, he took a job at another clinic in nearby Morgantown, WV. “That was the life I needed—an eight to five job, still practicing medicine but not working myself into a frenzy. But then, sadly, my license got lifted as the conviction came out,” says Ortenzio.

In a rare bit of good fortune, his years of practicing in a small town actually helped him stay out of jail. “I had 150 letters from people to the judge requesting leniency. That had a powerful impact. I feel like I did a lot of good in the community and then it sort of all came back to help me when I needed it the most,” he says. Instead of the prison time the federal guidelines called for, he was sentenced to six months of home confinement and probation. He was also banned from billing Medicare or Medicaid for the rest of his life.

Finally, excluded from medicine, Ortenzio began working his way back up the employment hierarchy, from ditch digging to office supply sales and pizza delivery. Getting back into family practice seemed like an impossible dream. He could potentially get his state license reinstated, but the federal government is less forgiving. What future would there be for a doctor who couldn’t take Medicare?

To answer that, Ortenzio sought support from a different kind of community. After joining Sermo, an online discussion group for physicians, he posted a brief synopsis of his situation and asked for feedback. The response was immediate and surprisingly positive. “Sermo has been a huge blessing for me. I’ve been removed from medicine for a couple of years, but I heard tell and I got on the website. I blogged some and I put in my thing about losing a license, and I got tremendous support,” says Ortenzio.

Some respondents suggested applying for positions in institutions that have trouble recruiting doctors, such as prisons or even the military. But there were also several physicians who were openly envious of Ortenzio’s lifetime Medicare ban, suggesting that he simply go back into practice on a cash basis. “So many people came to me ... saying ‘man we all want to do cash practice; this is your opportunity to do a cash practice and eliminate all that hassle,’” explains Ortenzio.

However, most cash practices start out with standard insurance and Medicare billing, then move gradually to cash after they’ve built up a solid patient census. Ortenzio would have to build the cash practice from scratch. That would be difficult, as the attorney’s fees and fines from his recent legal troubles left him bankrupt, and his current jobs are unlikely to replenish his savings anytime soon.

While pondering that conundrum a few months ago, Ortenzio had another church-sponsored epiphany, this time with a group in Memphis, TN that repairs homes in the inner city. “This home repair ministry does a tremendous job in rebuilding homes, but they’re also connected to a coffee house and connected to a nonprofit grocery store and connected to a free clinic,” he says. He decided that “maybe a Christian free clinic in an urban redevelopment movement like this would be a really good thing. So I came back from that trip ... inspired that I’ve got to get a license back.”

Going from a highly successful private practice to a low-paying church clinic, by way of ditch digging and photocopier sales, might feel like a catastrophic failure to many physicians. Ortenzio sees it differently: “Even though I’m not making anywhere near the kind of money ... the quality of my life, the quality of my relationship with my family, the free time that I have now that I didn’t have before, my life is better now.”

Indeed, he even picked up a bit of wisdom from mowing the golf course, where his boss often repeated an optimistic mantra: ‘It’s all good.’ That’s my favorite expression,” says Ortenzio, adding that “It can be all good if you look at it that way.”

Alan Dove, PhD, is a freelance healthcare and science writer.