NC Medical Board Charges Against Dr. Rashid A. Buttar
- Notice of Charges and Allegations - 1 PDF - November 21, 2007
- Patient A - Brenda W - PDF
- Patient B - Lourdes K - PDF
- Patient C - Jeff K - PDF
- Patient D - Darlene A - PDF
- Response to Charges - 1 - PDF - December 4, 2007
- CHCA Health Care Access - PDF - April 29, 2008
- Correspondence Regarding Ex Parte Communication - Link - August 8, 2008
- Memorandum Regarding Ex Parte Communication - Link - August 8, 2008
- Motion to Declare a Mistrail - Link - September 15, 2008
- Petition for Judicial Review - PDF - February 17, 2009
- Notice of Charges - 1 AMENDED - PDF - March 10, 2009
- Motion to Stay Proceedings and Response - PDF - March 25, 2009
- Attorney Letter - PDF - March 26, 2009
- Dr. Buttar's Affidavit - PDF - May 22, 2009
- Notice of Charges - 2 - PDF - September 9, 2009
- Response to Charges and Allegations - 2 - PDF - January 2010
- Consent Order - PDF - March 26, 2010
In the new notice of charges, the NCMB has dropped the clearly "false allegations" against Dr. Buttar, specifically of never having examined or visited or evaluated or seen the patients in question. These original charges, which have now been dropped, were noticeably and conspicuously inflammatory and a major alleged reason for prosecuting Dr. Buttar in the first place, based on the NCMB's premise of "patient safety”.
The first hearing and examination of the plain and simple evidence disproved their allegations, showing them to be blatantly unfounded and fabricated. The NCMB, in an obvious attempt to discredit Dr. Buttar, was in possession of and examining the medical charts in question for over 18 months before allegations were made and charges were filed and made public.
Now, after having the charts for over 3 years, they have finally dropped the only "real" evidence in this case. The same evidence that was planned to be used against Dr. Buttar (which in 18 months was never adequately reviewed), proved that Dr. Buttar was innocent of the false allegations made by the NCMB against him.
The mistrial due to ex parte is of further concern. The agenda of the NC Medical Board prosecutors, who were well aware of this departure from professional conduct yet waited to disclose it to the defense for a full 2 months after the facts were known to them, is suspicious.
Considering all this, as well as the previous 10 year history of the NCMB in persecuting Dr. Buttar based on NO complaints and NO cause, as well as Dr. Buttar's prominent role in helping pass legislation in 2003 to control the abusive power of the NCMB against doctors (Bill 886, Due Process for Physicians), the intention of the NCMB has become highly suspicious and overly concerning.
The NCMB has proceeded to prosecute this clearly non-existent case based upon 4 complaints by parties who all admitted to never having met Dr. Buttar previous to the first hearing. Furthermore, all these 4 parties have a clear financial motive. Since the filing of the original case, the NCMB has decided to drop 1 of the 4 complaints, after Dr. Buttar was awarded a financial judgment against the complainant.
In addition, all of the actual patients (not complainants) upon which this case is based are documented to have been appreciative and thankful of the treatment and care provided by Dr. Buttar, with objective evidence proving the efficacy of the treatment they received. Subjective improvements are also well documented, including that the patients outlived the prognoses given by their conventional oncologists.
Lastly, the mission and purpose of the NCMB is to ensure patient safety. The 3 remaining cases the NCMB tried were all concerning patients who were considered "terminal". There has clearly been NO patient harm, which was even admitted to by the ONLY ONE expert witness used by the NCMB. The "alleged" financial harm is even more ludicrous because now the NCMB is trying to dictate economic policy.
If Dr. Buttar's treatments were NOT effective, he would NOT be enjoying the privilege of taking care of people from 33 different countries. His practice would not be thriving and increasing in size were the allegations of the NCMB based on any fact. The lack of economic viability would have closed down Dr. Buttar's practice long ago if there were any truth to the false allegations made by the NCMB.
The blunt truth is that Dr. Buttar has exceeded the non-descript, vague, unclear and often contended upon definition of "standard of care". This has threatened the status quo, the "good old boy" network in the medical hierarchy in the great state of NC. This, along with the fact that Dr. Buttar teaches other doctors from around the world, that he protects patient and doctor rights by helping to change the law in NC, that he was President of the NC Integrative Medical Society for 6 years, and that he has been an outspoken critic against the NCMB’s abusive conduct towards good doctors and their attempts to restrict patient rights, has incited the medical hierarchy in the local region.
Under pretense of public safety, the medical hierarchy has released their GESTAPO agency, using the complaints of 4 non-patients all based on financial motive, to wage a war against Dr. Buttar who they clearly consider a threat and enemy of the NCMB and the NC Medical Society. The NCMB has used its power for a personal and professional agenda: to eliminate competition for the medical hierarchy.
This "competition" that the NCMB seeks to eliminate is more sought out by patients, provides better outcomes, has far lesser side effects and offers a better quality of life than what the traditional and obsolete medical hierarchy can provide. The evidence of this surrounds us every single day.
The NCMB gave a very clear message in response to the patients who testified to the success of their treatment under Dr. Buttar. These were patients whose conventional "standard of care" treatments had failed and who were sometimes labeled as "terminal”. This proves that the agenda of the NCMB was everything else BUT patient safety. If patient safety were the primary concern of the NCMB, they would be embracing Dr. Buttar and his colleagues, “begging" them to teach the rest of the medical providers in the great state of NC how to help more patients achieve a better outcome than they currently are receiving through the obsolete "standard of care".
BEFORE THE
NORTH CAROLINA MEDICAL BOARD
In re:
Rashid Ali Buttar, D.O.,
MOTION TO DECLARE A MISTRIAL
NOW COMES the Respondent, Rashid Ali Buttar, D.O., and moves Janelle A. Rliync,
M.D., President of the Board, for an Order declaring a mistrial of the proceedings before the Panel which heard cvidence in the above matter on April 23-24, 2008 and in support of their Motion shows to the Board as follows:
1. On Wednesday, April 23, Dr. Kirby, who is on staff with the Medical Board and
who participated in the investigation and preparation of Dr. Buttar's case, had an ex parle
comnlunication with 1-1. Arthur McCulloch, M.D. in the Board brake room during a recess in the formal proceedings. Dr. McCulloch is a member of the Panel assigned to hear evidence and to issue a recommended decision in this case.
2. Dr. Kirby gave Dr. McCulloch materials on Complimentary and Alternative
Medicine as follows:
1. Fundamentals of Complementary and Alternative Medicine by Marc S Micozzi.
2. Alternative Medicine: An Objective Assessment Edited by Phil B. Fontanarosa, MD.
3 The Duke Encyclopedia of New Medicine by the Center for Integrative Medicine at Duke University.
4. A wcbsite with the address: http://nccain.nili.~ov/clinictarila ls/alltrials.htin which lists "All NCCAM Clinical Trials" by either disease or treatment.
3. Counsel for Dr. Butiar is also informed and believe that Doctors Kirby and
McCulloch engaged in exparte discussions of the evidence in Dr. Buttar's case
4. It is evident that Dr. McCulloch reviewed the books and internet site over night
because on Thursday, April 24 he asked Dr. Wilson, an expert witness for Dr. Buttar, questions that related to some of these materials,
5. Marcus Jimison and Thomas Mansfield. Counsel for the Medical Board, became
aware of the exparte communication sometime on Thursday during the hearing. Counsel did not disclose this information to Dr. Buttar's attorneys so that it could be made a part of the record of the hearing. Mr. Jimison did cross-examine Dr. Buttar and refer to some of the same materials in his cross-examination.
6. Messrs. Jin~isona nd Mansfield first notified counsel for Dr. Buttar of the ex pane
communications between Dr. Kirby and Dr. McCulloch on May 19,2008, almost a month after the close of the hearing. In the intervening weeks, counsel for the Medical Board consulted with outside counsel and obtained an opinion that the exparie contact between Dr. Kirby and Dr. McCulloch was a violation of the Administrative Procedures Act. NCGS 150B-40 (d), which states:
(d) Unless required for disposition of an ex parte matter authorized by law, a
member of an agency assigned to make a decision or to make findings of fact and
conclusions of law in a contested case under this Article shall not communicate,
directly or indirectly, in connection with any issue of fact or question of law, with
any person or party or his representative, except on notice and opportunity for all
parties to participate. This prohibition begins at the time of the notice of hearing. An agency member may communicate with other members of the agency and may have the aid and advice of the agency staff other than the staff which has been or is engaged in investigating or prosecuting functions in connection with the case under consideration or a factually-related case. This section does not apply to an agency employee or party representative with professional training in accounting, actuarial science, economics or financial analysis insofar as the case involves financial practices or conditions.
7. The expane communications in violation of the above referenced statute were
prejudicial to Dr. Buttar because they deprived him of his right to confront and cross-examine
witnesses and evidence considered by the finder of facts in the hearing of the charges in this case
This error is in violation of the United States and North Carolina Constitutions, the law and
procedure mandated by our legislature, and the fundamental concepts of fairness rooted in our
judicial system.
8. Dr. Buttar reserves his right to file written exceptions to the Recommended Decision
of the Hearing Panel pursuant to NCGS 90-14.5, prior to a final decision by the Board in this matter.
WHEREFORE, the Respondent respectfully prays that Dr. Jenelle A. Rhyne as President of
the North Carolina Medical Board and presiding officer of the Hearing Panel grant this Motion for a Mistrial of the proceedings which took place before the Hearing Panel on April 23-24,2008 and Order that any retrial of these charges be before an administrative law judge pursuant to NCGS
150B-40 (e),
Respectfully submitted, this the 15 day of September, 2008.
H. Edward Knox
Lisa G. Godfrey
Attorneys for Respondent
FOR THE FIRM:
KIIOX, Brotherton, Knox & Godfrey
Post Office Box 30848
Charlotte, N.C. 28230-0848
Phone: (704) 372-1 360
Fax: (7041 372-7402 ~,
eknox@knoxlawcenter. corn
lgodfrey@knoxlawcenter.com
CERTIFICATE OF SERVICE
I, Lisa G. Godfiey, Attorney for Respondent, certify that I have this day served a copy of the
foregoing MOTION TO DECLARE A MISTRIAL on the following individual. a copy of same
via e-mail, addressed as follows:
VIA E-MAIL Marcus. Jimison@NCMEDBOARD.ORG
Mr Marcus B. Jimison
North Carolina Medical Board
Post Office Box 20007
Raleigh, NC 2761 9-0007
This the 15 day of September, 2008.
Lisa G. Godfrey
Attorney for Respondent
KNOX, BROTHERTON, KNOX & GODFREY
ATTORNEYS-AT-LAW
POST OFFICE BOX 30848
CHARLOTTE, NORTH CAROLINA 28230-0848
(704) 372-1360
FAX: (704) 372-7402
August 8, 2008
VIA E-MAIL Marcus.Jimison@NCMEDBOARD.ORG
& FIRST-CLASS MAIL
Mr. Marcus B. Jimison
North Carolina Medical Board
Post Office Box 20007
Raleigh, NC 27619-0007
Re: North Carolina Medical Board vs. Rashid Ali Buttar, D.O.
Dear Marcus:
We are in receipt of your letter of August 5, 2008. We do not recall your discussing a re-opening of the evidence before the panel of Drs. Rhyne, Walker and McCulloch. Given the nature of the ex parte communication between Drs. Kirby and McCulloch, we do not believe that this panel is qualified to decide the proper remedy for the errors that occurred during the hearing of May 23 and 24, 2008. If you have any case law or statutory authority to suggest otherwise, please provide it to us. It would not make sense to ask those who did not follow the rules to review their own conduct.
Rather, if we are unable to resolve this matter through a Consent Order, we would propose to present testimony to the full Board regarding the improprieties that took place. We plan to call the following witnesses:
(1) Dr. Kirby
(2) Dr. McCulloch
(3) Dr. Rhyne
(4) Dr. Walker
(5) Marcus Jimison
(6) Thomas Mansfield
We would propose to present this testimony when the full Board considers the recommen-dation of the panel. As of yet, we have not seen any proposed findings of fact or conclusions of law. Under N.C.G.S. § 90-14.5(c), we will be given an opportunity to file written exceptions to the recommended decision made before the hearing panel and to present oral arguments to the Board. As we told you on the telephone, both Eddie and I have substantial conflicts for the month of September. It was our understanding that you were going to determine whether a special meeting of the Board could be called sometime during the month of October. Before you set a date for that meeting, please contact our offices to determine our trial schedules. I am currently on the Lincoln County trial calendar for the week of October 27, 2008, but do not have any other trials during that month. Eddie has a Mecklenburg County trial beginning the week of October 6, 2008.
Because we anticipate calling you and Tom Mansfield as witnesses, we wanted to give you ample opportunity to obtain outside counsel in this matter. You had indicated in an earlier telephone conversation that you had already sought the advice of an outside attorney, so I assume you have somebody who is familiar with the facts and the law of the situation and can step in to assist you.
We look forward to hearing from you regarding a proposed consent resolution to this matter in the next few days.
Very truly yours,
/S/ Lisa Godfrey
H. Edward Knox
/S/ Lisa Godfrey
Lisa G. Godfrey
LGG/kgf
MEMORANDUM
TO: HEK
FROM: LGG
RE: BUTTAR v. MEDICAL BOARD
WHAT IS THE REMEDY FOR THE EX PARTE COMMUNICATIONS BETWEEN DR. KIRBY AND DR. McCULLOCH DURING THE HEARING BEFORE THE THREE MEMBER PANAL OF THE MEDICAL BOARD ON APRIL 23 AND 24, 2008?
Facts
On May 19, 2008 we received a call from Marcus Jimison and Thom Mansfield. At that time, they disclosed to us that on Wednesday, April 23, Dr. Kirby, who is on staff with the Medical Board and who participated in the investigation and preparation of Dr. Buttar’s case, had an ex parte communication with Dr. McCulloch in the Board brake room during a recess in the formal proceedings. Dr. Kirby gave Dr. McCulloch materials on Complimentary and Alternative Medicine. At this point we do not know the content of any discussions that took place, but the materials that Dr.Kirby provided to Dr. McCulloch were as follows:
1. Fundamentals of Complementary and Alternative Medicine by Marc S. Micozzi.
2. Alternative Medicine: An Objective Assessment Edited by Phil B. Fontanarosa, MD.
3. The Duke Encyclopedia of New Medicine by the Center for Integrative Medicine at Duke University.
4. A website with the address: http://nccam.nih.gov/clinicaltrials/alltrials.htm which lists “All NCCAM Clinical Trials” by either disease or treatment.
It is evident that Dr. McCulloch reviewed these materials over night because on Thursday, April 24 he asked Dr. Wilson, an expert witness for Dr. Buttar, questions that related to some of these materials.
Counsel for the Medical Board became aware of the ex parte communication sometime on Thursday during the hearing. Counsel did not disclose this information to Dr. Buttar’s attorneys or bring it to the attention of the President of the Medical Board who was the presiding officer at the hearing. Counsel for the Medical Board did cross-examine Dr. Buttar and refer to some of the same materials in his cross-examination.
When Marcus Jimison and Thom Mansfield disclosed this information to us on May 19, they said that the reason they had waited to tell us was that they had gotten an opinion of outside counsel on whether or not the communications between Dr. Kirby and Dr. McCulloch were prohibited by NCGS 150B-40 (d). This section states:
(d) Unless required for disposition of an ex parte matter authorized by law, a member of an agency assigned to make a decision or to make findings of fact and conclusions of law in a contested case under this Article shall not communicate, directly or indirectly, in connection with any issue of fact or question of law, with any person or party or his representative, except on notice and opportunity for all parties to participate. This prohibition begins at the time of the notice of hearing. An agency member may communicate with other members of the agency and may have the aid and advice of the agency staff other than the staff which has been or is engaged in investigating or prosecuting functions in connection with the case under consideration or a factually-related case. This section does not apply to an agency employee or party representative with professional training in accounting, actuarial science, economics or financial analysis insofar as the case involves financial practices or conditions.
Marcus and Thom told us that in the opinion of their outside counsel, the communications between Doctors Kirby and McCulloch did violate the above statute.
Legal Analysis
In the case of Mission Hospitals, Inc. v. N.C. Department of Health and Human Services, 658 S.E. 2d 277 (Ct. of App. March 18, 2008), the Court addressed the prohibition on ex parte communications in the Administrative Procedure Act (APA). Mission Hospitals involved a decision by the Director of Division of Facilities Services of NCDHHS (Agency) to grant a “no-review” Certificate of Need to Asheville Hematology and Oncology Associates. Mission Hospital petitioned for a contested case hearing before the Agency. The ALJ who heard the case issued a recommended decision affirming the original Agency decision. After a hearing before the Director of the Agency, the decision was reversed.
It came to light that counsel for the Mission Hospital had some ex parte communications with the Director prior to the issuance of his decision. Asheville Hematology appealed and the Court of Appeals held:
(1) Director of Agency violated the Administrative Procedure Act (APA) by engaging in ex parte communications with hospital immediately before reversing ALJ's recommended decision;
(2) Director's actions prejudiced treatment center's substantive rights; and
(3) Agency's decision violated the APA by not stating specific reasons for not adopting certain findings of fact by the ALJ.
658 S.E. 2d 277. The Court found that the ex parte communications in violation of the statute (in this case NCGS 150B-35) constituted an error of law under NCGS 150B-51 (b). This error of law effected the outcome because it denied the opposing party the right to cross-examine witnesses or evidence offered to the decision maker in the case. As the Court reasoned:
N.C. Gen.Stat. § 150B-29 provides rules of evidence for agency proceedings. In relevant part, it states:
Evidence in a contested case, including records and documents, shall be offered and made a part of the record. Factual information or evidence not made a part of the record shall not be considered in the determination of the case, except as permitted under G.S. 150B-30.
N.C. Gen.Stat. § 150B-29(b) (2005). The referenced exception in N.C. Gen.Stat. § 150B-30 allows for official notice of certain facts provided that:
The noticed fact and its source shall be stated and made known to affected parties at the earliest practicable time, and any party shall on timely request be afforded an opportunity to dispute the noticed fact through submission of evidence and argument.
N.C. Gen.Stat. § 150B-30 (2005).
658 S.E. 2d at 283.
The remedy for this violation was to reverse and vacate the decision and remand the matter to the Agency for a new hearing. Id. The Court specifically refused to adopt the appellant’s suggestion that Court adopt the original decision in favor of the appellant.
Another recent decision that should be considered in this case is Faber v. NC Psychology Board, 153 NC App. 1, 569 S.E. 2d 287 (2002). In this case, a psychologist appealed the decision of the Psychology Board suspending his license for engaging in a romantic relationship with a patient.
Just as with the Medical Board, the Psychology Board received a patient complaint and assigned a staff psychologist (Dr Yardley). to investigate. Dr. Yardley presented a report to the Board on whether there were sufficient grounds to bring formal charges against Dr. Farber. Prior to the formal hearing, Dr. Faber filed a petition and asked that certain Board members be disqualified because they had received information from Dr. Yardley that may have prejudiced them in hearing evidence at the formal hearing. The Board denied the petition and all members heard the case in the formal hearing. They issued a decision suspending Dr. Faber’s license.
On appeal to the Wake County Superior Court the decision was vacated on the grounds that Dr.Yardley’s ex parte communications improperly commingled the investigative and adjudicative functions of the Board.
The Court of Appeals reversed the Superior Court on the grounds that the ex parte contact in this case did not specifically violate NCGS 150B-40 (d) because it took place before the Notice of Hearing on the formal charges was issued. NCGS 150B-40 (d) specifically limits the prohibition on ex parte communications to the period after the time of the Notice of Hearing.
In the Buttar matter, the ex parte communications clearly took place after the Notice of Hearing was issued. Thus, our case is distinguishable from Faber on its facts and reasoning in the Mission Hospitals case should apply.
Conclusion
Based on the facts of this case and the law cited above the possible remedies for the violation of NCGS 150B-40 (d) are:
(1) A new hearing before the full Medical Board – with the 3 members who sat on the Panel that heard the case in April excluded from the hearing and all deliberations; or,
(2) Under NCGS 150B-40 (e), if the Board determines that it can not hear the case, the Board can apply to the Office of Administrative Hearings to appoint an administrative law judge to preside over a new hearing.
BEFORE THE NORTH CAROLINA MEDICAL BOARD
In re: Rashid Ali Buttar, D.O.,
Respondent.
Reference: Patient A
Brenda WXXXXX
Date of Birth: 4/15/57
49 year old white female patient presented on July 20, 2006 with
chief complaint of stage 4 cancer, initially diagnosed in October, 2003 with
Cervical Cancer. History included
Radical Hysterectomy, Bilateral Salpingo-Oophorectomy and pelvic lymph node
dissection in August 27, 2003 with 1/14 nodes being positive.
By September of 2003, pt had completed 25 sessions of radiation therapy. After completion of radiation therapy,
pt had regular check ups every 6 months.
In April 2004, patient began having right sided pain and saw family
physician. Ultra sound and CAT scan revealed metastasis to liver and lung. Referred to MD Anderson and had
chemotherapy which included Carboplatin treatment x 2, administered every 4
months. Pt completed last
treatment June, 2006. July 2006,
reevaluated at MD Anderson, and noted to have liver enzymes elevated. Patient was referred to hospice and
recommended pain control. Pt
sought us out due to the fact she was not willing to give up. Patient was under the care of Dr.
Buttar from July 20, 2006 through August 17, 2006. Despite impending organ failure as identified by Dr. Buttar,
pt and pt’s daughter wished to continue to fight and not give up. She was admitted to the hospital on
August 17, 2006 and died August 19, 2006.
----------
Each
numbered item below is the NCMB’s expert reviewer’s
comments on the charts. Each
bulleted item is our response, with references to the medical charts showing
the facts.
-
Dr. Peterson:
1.
NCMB
Expert’s (Dr. Peterson) opinion on Treatment – Below standard of
practice/care
·
Patient with Stage 4 metastatic ovarian
cancer, refractory to conventional therapy including:
o
Multiple rounds of Chemotherapy
o
Multiple rounds of Radiation therapy.
o
Referred to Hospice.
·
Presented with early organ failure with
impending hepatic failure.
·
Sought treatment from Dr. Buttar.
·
Patient left previous doctors because they
had “given up on me”. Patient was
looking for “a chance”.
·
Patient had failed all other therapies and
was NOT willing to simply give up and die!
·
Results clearly BEYOND the standard of care.
o
Patient requested treatment when no one else
was willing to try.
o
Treatment was administered with daughter
being fully aware that prognosis was poor due to:
§
Multiple rounds of chemotherapy, refractory
to treatment.
§
Multiple rounds of radiation therapy,
refractory to treatment.
§
Impending multi-organ system failure
o
Extended quality of life, albeit only for a
short period.
o
We helped the patient to maintain her dignity
in allowing her to make her own choice of continuing to fight rather than give
up.
2. Dr. Peterson states the patient chart does not follow the Problem Oriented
Medical Record method known as SOAP.
· C1a
– C1b: SOAP format is clearly used.
· C2a
– C2b: SOAP format is
clearly used.
· C4a, C4b: SOAP format is clearly used.
· C6a, C6b: SOAP format is clearly used.
· C7a: SOAP format is clearly used.
· C11a,
C11b. SOAP format is clearly used.
3.
“The standard of care would have been referral to
hospice for palliation.”
·
C7a:
8/14 Progress Notes clearly state that the patient was adamant about
continuing treatment.
·
Discussion between Dr. Buttar and daughter on
more than one occasion discussing reality of situation due to impending
multi-organ failure.
·
Daughter requested Dr. Buttar continue with
treatment and thanked him for continuing to try, despite dire prognosis, due to
multi organ system failure due to iatrogenic causes secondary to chemotherapy.
4.
“Dr. Buttar clearly engaged in a fruitless exercise
w/ therapy of no benefit in what appears to be nothing but an attempt to
extract money in exchange for fake hope.”
·
Dr. Peterson has clearly established he is
NOT an expert in assessing our approach to cancer.
·
Dr. Peterson’s “canned” response to each
patient shows he was either biased, did not read the charts, or is incapable of
assessing benefit of our treatment.
·
Patient clearly had benefits, exemplified
with better pain management, improved ambulation, and increased energy.
·
A1b:
No claims of a cure were ever given. Patient signed a consent which states: “no claim to cure
cancer with these therapies has been made to me”
·
C7a:
8/14 Progress Notes clearly state that the patient was adamant about
continuing treatment, even in light of her deteriorating condition.
·
By definition, there is NO such thing as
false HOPE. HOPE indicates having
the possibility of a desired outcome.
By Dr. Peterson’s indicated definition and use of the word HOPE, all
HOPE would be false.
5.
“No physician contact documented.”
·
I1:
7/26 Dr. Buttar performed an IRR treatment on patient. When ever IRR’s done, Dr. Buttar always
consults with patients and addresses any issues or questions patients have.
·
I2b:
8/3 Dr. Buttar performed an IRR treatment on patient
·
C7a:
8/14 Dr. Buttar had office visit with patient and wrote detailed
Progress Notes
·
I2a:
8/15 Dr. Buttar performed an IRR treatment on patient
·
In addition, at least 3 separate detailed
conversations with patient’s daughter regarding patients poor prognosis,
conducted while NP was seeing patient.
·
Most other office visits were with nurse
practitioner but Dr. Buttar was present for most of those visits. However, due to increased rate of
office visit for Dr. Buttar, NP would see the patient to keep charges lower and
Dr. Buttar would come in and visit with the patient. Notes were made by NP.
-
Dr. Mann:
1.
“No indication that Dr. Buttar actually saw or
examined the patient.”
·
I1:
7/26 Dr. Buttar performed an IRR treatment on patient
·
I2b:
8/3 Dr. Buttar performed an IRR treatment on patient
·
C7a: 8/14 Dr. Buttar had office visit with patient and wrote
detailed Progress Notes
·
I2a:
8/15 Dr. Buttar performed an IRR treatment on patient
·
In addition, at least 3 separate detailed
conversations with patient’s daughter regarding patient’s poor prognosis,
conducted while NP was seeing patient.
·
Most other office visits were with nurse
practitioner but Dr. Buttar was present for most of those visits. However, due to increased rate of
office visit for Dr. Buttar, NP would see the patient to keep charges lower and
Dr. Buttar would come in and visit with the patient, answer any questions, etc.. Notes were
made by NP.
2.
“Repetitive labs including serum lipids in
particular without justification or explanation of how the results were guiding
therapy.”
·
Doing complete panel with lipids was cheaper
test than separating test. Patient
was not charged for serum lipids.
·
Cancer patients as with other chronic
disease, exhibit lower serum lipids.
Increase in lipid profile appears to be a good prognostic marker for our
treatment regimen.
·
It is clear Dr. Mann is NOT an expert in the
integrative approach to treating cancer.
·
D1 – D16: Requirement for monitoring
renal function, hepatic function, electrolytes, and hemoglobin counts in a
cancer patient are HIGHLY relevant, especially when they are aggressively being
treated for a stage 4 cancer with multiple IV regiments daily.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
·
G1 –G11: Cancer panels necessary to
establish immune function, with detailed explanation in charts provided
o
G1, G10, G11: explanation of significance of level of uncontrolled
cellular proliferation monitoring in immunocomprimised pts.
o
Immune function – CD 19, CD 56 counts
o
Immune function – NKHT3 +
Immunocompetent Natural Killer Cells, NK Cell activity, NK cell activity/cell
o
G3 G4, G11: Lymphocyte
Subpopulation profile – CD2, CD4, CD8, CD 3, CD 26
o
G8, G11: Cell cycle Analysis and dsyregulation in oncogenesis
o
G6,G7, G11: Apoptosis and subsequent suppression of apoptosis in cancer
explained in detail
3.
“Notes written by NP Jane Garcia contain some
indication of guidance by Dr. Buttar toward the end of the patient’s life.”
·
C2b:
7/24: Jane Garcia’s Progress
Notes, co-signed by Dr. Buttar
·
I1:
7/26: IRR Treatment
performed by Dr. Buttar. When ever
IRR’s done, Dr. Buttar always consults with patients and addresses any issues
or questions patients have.
·
I2b:
8/3: IRR Treatment
performed by Dr. Buttar
·
C4b: 8/3: Jane
Garcia’s Progress Notes, co-signed by Dr. Buttar
·
C5:
8/8: RN Pennington notes
labs were discussed with Dr. Buttar
·
C6b:
8/10: Jane Garcia’s Progress Notes, co-signed by Dr. Buttar
·
C7a: 8/14 Dr. Buttar’s Progress Notes for an
examination he performed
·
C7b:
8/15/06 Dr. Buttar’s note of consult with consulting oncologist.
·
C10:
8/15: RN Pennington notes
patient discussed with Dr. Buttar.
Dr. Buttar gives Verbal Order for treatment.
·
I2a:
8/15: IRR Treatment
performed by Dr. Buttar
·
C11b:
8/16: Jane Garcia’s
Progress Notes, co-signed by Dr. Buttar
·
C12:
8/17: Jane Garcia’s
Progress Notes, co-signed by Dr. Buttar
4.
“Immunologic studies ordered. Results not interpreted in the record.”
·
C11a:
8/16/06 office visit, Ca Panel of 7/20/06 discussed and documented.
·
Standard policy in our office for office visits
includes:
o
Through review of all lab work with the
patient.
o
All information is explained with further
details provided to the patient of any thing the patient does not fully
understand.
o
Copies of all tests are given to the pt at
the conclusion of any office visit where tests were reviewed.
5.
“Intestinal health screen ordered and obtained. No
interpretation.”
·
The Comprehensive Diagnostic Stool Analysis had
NOT been completed by the laboratory prior to the patient’s last office visit
·
Therefore, it was not available for
interpretation or to review with the patient at the time of the visit.
6.
“Lymphatic massage ordered. No indication it was performed.”
·
B7:
A Lymphatic Massage was ordered as per reference
·
We do not perform lymphatic massage in our
clinic.
·
Patient had the treatment scheduled by our
office with the certified lymphatic massage therapist and given the time and
place to go.
·
It was up to the patient to keep their
appointment at another facility.
If the procedure was not performed, it was due to a patient compliance
issue.
7.
“Placed on Nutri-Energetics
Infoceluticals Protocol. Jusitification and results not
recorded.”
·
The Nutri-Energetics
System is an advanced biotechnology for the analysis and repair of the human
body energetic field based on quantum physics. The system integrates research from the fields of physics,
quantum biology, mathematics, acupuncture and Western and Chinese medicine.
·
H3: There are no results recorded of this treatment.
·
Patients generally request this treatment
from us.
8.
“Philbert Infra Respiratory
Reflex Procedure performed – justification, and results not recorded.”
·
I1: Procedure note with O2 saturation clearly
recorded showing Pre –Treatment and Post Treatment O2 Sats.
o
Results clearly recorded,,
showing immediate clinical response to treatment, assessed with respiratory
reserve and O2 saturations.
·
I2a:
Procedure note with O2 saturation clearly recorded showing Pre
–Treatment and Post Treatment O2 Sats.
o
Results clearly recorded,,
showing immediate clinical response to treatment, assessed with respiratory
reserve and O2 saturations.
·
I2b:
Procedure note with O2 saturation clearly recorded showing Pre
–Treatment and Post Treatment O2 Sats.
o
Results clearly recorded,,
showing immediate clinical response to treatment, assessed with respiratory
reserve and O2 saturations.
9.
“The various procedures seem in keeping with
alternative and complementary care practices and seem safe to the extent
known. Some are not described in
terms of methods and intended effects.”
·
This is a general statement made based on
speculation. It will be responded
to in a general manner, since there is nothing specific to counter.
·
In 17 years, Dr. Buttar does NOT have a
single formal patient complaint against him.
·
All complaints initiating these charges by
the NCMB have:
o
NEVER even met Dr. Buttar at any time
o
NEVER had ANY form of communication with Dr.
Buttar at any time
o
A clear financially based incentive to
complaint against Dr. Buttar, which even the NCMB investigator recognized and
acknowledged during his visit with Dr. Buttar
·
All treatment methods and effects ARE
described to the patient in implicit detail.
·
If we did NOT explain “methods and intended
effects”,
o
We would have real complaints from real
patients, not family members or other doctors.
o
We would NOT have patients coming back to us
o
We would NOT have patients referring other
patients to us.
10. “The medical record does not use
SOAP.”
·
C1a – C1b: SOAP is clearly used.
·
C2a – C2b: SOAP is clearly used.
·
C4a – C4b: SOAP is clearly used.
·
C6a – C6b: SOAP is clearly used.
·
C7a – C7b: SOAP is clearly used.
·
C11a – C11b: SOAP is clearly used.
11. Early
notes co-signed by Dr. Buttar, later notes are not.
· C2b: 7/24 Jane Garcia’s Progress Notes, co-signed
by Dr. Buttar
· I1: 7/26 IRR Treatment performed by Dr.
Buttar
· I2b: 8/3 IRR Treatment performed by Dr.
Buttar
· C4b: 8/3 Jane Garcia’s Progress Notes,
co-signed by Dr. Buttar
· C5: 8/8 RN Pennington notes labs were
discussed with Dr. Buttar
· C6b: 8/10 Jane Garcia’s Progress Notes,
co-signed by Dr. Buttar
· C7a: 8/14 Dr. Buttar’s Progress Notes for an
examination he performed
· C7b: 8/15 Dr. Buttar notes patient discussed
with Dr. Holbert,
·
C10:
8/15 RN Pennington notes patient discussed with Dr. Buttar. Dr. Buttar gives Verbal Order for
treatment.
· I2a: 8/15 IRR Treatment performed by Dr.
Buttar
· C11b: 8/16
Jane Garcia’s Progress Notes, co-signed by Dr. Buttar
· C12: 8/17 Jane Garcia’s Progress Notes,
co-signed by Dr. Buttar
Reference: Patient B
Lourdes KXXXXXX
Date of Birth: 7/12/52
51 year old W female
who presented to Dr. Buttar’s clinic on April 29,
2004 with chief complaint of stage 4 ovarian cancer. Initial Diagnosis was made on 8/13/02 of adenocarcinoma
of the ovary, with staging in 2002 being Stage III-C. Patient underwent a suboptimal BSO with tumor debulking.
Pt’s history included a TAH in July 2000 with ovaries were left. After dx with
ovarian cancer, patient underwent 8 treatments of chemotherapy (Taxol/Carboplatin) from 9/9/02 until 4/3/03. Ca 125 continued to rise from 202 to
715. CAT scans showed persistent 2.5.cm mixed radio dense mass on the bladder. By 6/25/03, CA 125 marker had risen to
1292. On 7/25/03, chemotherapy was
changed to weekly doses of Topotecan. In 8/03, repeat CAT scan revealed
lesion in liver
In 9/03, chemotherapy was again changed, this time to Doxil on a monthly schedule. By 12/03, chemo was discontinued because of no
significant improvement and also due to patient experiencing and unable to
tolerate side effects. By 4/15/04,
CA 125 markers had been elevated to 10,028 (normal 0-35). That same month, 2 weeks later, on
4/29/04, patient presented to us after family physician referred patient. Pt began treatments at Dr. Buttar’s clinic on May 17, 2004 and received less than 1
month of treatment using Dr. Buttar’s protocol.
Patient was discharged from our practice due to
noncompliance and failure to make payments and was last seen in Dr. Buttar’s clinic on June 11, 2004. Despite patient being non-compliant with treatment schedule,
diet, etc., CA 125 markers dropped from 10,028 in April to 6,219.3 in May,
clearly establishing efficacy of Dr. Buttar’s
treatments. Arrangement and
scheduling for patient to return to her primary care physician were made and
documented. Patient reportedly
died sometime in November, more than 5 months after we had seen her.
----------
Each
numbered item below is the NCMB’s expert reviewer’s
comments on the charts. Each
bulleted item is our response, with references to the medical charts showing
the facts.
-
Dr.
Peterson:
1.
“Treated by Dr. Buttar with alternative therapies
without success.”
·
Above statement is FALSE.
·
B3a:
Patient presented with a history of Stage 4 metastatic ovarian cancer,
with most recent Ca 125 level of 10,028.1 documented during initial
history.
·
D1: LabCorp Test : Cancer Antigen (CA) 125 - 10,028.1 on
April 15, 2004.
·
A1:
Patient requested and signed consent for treatment on April 29, 2004
·
J1:
Patient started Dr. Buttar’s IV treatment
protocol on May 17, 2004 after full evaluation to assess ability to tolerate
treatment.
·
D20:
LabCorp Test CA 125: 6,219.3,
Dated June 11, 2004
o
Clearly, patient was refractory to ALL
previous chemo administered over almost 2 years.
o
In LESS THAN 4 weeks, patient’s CA125 drops
by almost 4,000. This is objective
proof that our treatment worked better than ANY other treatment the patient had
previously undergone.
2.
NCMB Expert’s (Dr. Peterson) opinion on Treatment
– Below standard of practice/care
·
Largest drop in Ca 125 after Dr. Buttar’s treatment
o
Before Dr. Buttar’s
treatment: Ca 125 of 10,028.1
o
After Dr. Buttar’s
treatment: Ca 125 of 6,219.3
·
Reference: D1, D20, D27
o
Clearly, above and beyond the standard of
care
3.
NCMB Expert’s (Dr. Peterson) opinion on Records
– Below standard of practice/care, because SOAP not used.
·
SOAP
notes are clearly used throughout the medical record.
·
Reference:
o
C1a, C1b, C2: SOAP is clearly used.
o
C3a – C3b: SOAP is clearly used.
o
C5a – C5b: SOAP is clearly used.
o
C6:
SOAP is clearly used.
4.
NCMB
Expert’s (Dr. Peterson) Overall Opinion – Clearly below standard of
practice/care.
·
Non-compliant patient with Stage 4 metastatic
ovarian cancer, refractory to conventional therapy. Referred to Hospice.
·
Sought treatment from Dr. Buttar. Results clearly show significant drop
in cancer markers in LESS THAN 4 weeks (treatment from May 17, 2004 until June
11, 2004), when conventional chemotherapy CLEARLY failed over a sixteen month
period.
·
Results clearly BEYOND the standard of care.
·
Dr. Peterson indicates he does NOT know what
this treatment is. By his own
admission, he is not an expert on this subject and therefore is NOT qualified
to make a peer review in this case.
·
Failure for the “expert” to recognize a drop
of 4000 points in CA 125 as significant evidence of
5.
Dr.
Peterson states the patient chart does
not follow the Problem Oriented Medical Record method known as SOAP.
·
C1a – C1b: SOAP is clearly used.
·
C3a – C3b: SOAP is clearly used.
·
C5a – C5b: SOAP is clearly used.
·
C6:
SOAP is clearly used.
6. “Like the prior 3 patients, there is no evidence that Dr.
Buttar or any physician at his clinic ever interviewed or examined Ms. KXXXXXX.”
·
B3a:
4/29 Jane Garcia’s notes countersigned by Dr. Buttar
·
B5a – B6: 5/11 Dr. Buttar conducted a physical examination & wrote
detailed Progress Notes
·
H2:
5/11 Dr. Buttar made notes on a bone density scan
·
C1b:
5/19 Jane Garcia’s notes countersigned by Dr. Buttar
·
I1a:
5/19 Dr. Buttar performed an IRR treatment on patient
·
C3b:
5/27 Jane Garcia’s notes countersigned by Dr. Buttar
·
I1b:
5/27 Dr. Buttar performed an IRR treatment on patient
·
I2a:
6/3 Dr. Buttar performed an IRR treatment on patient
·
C6:
6/21 Dr. Buttar had office visit with patient & wrote detailed
Progress Notes
·
I2b:
Dr. Buttar performed an IRR treatment on patient
·
C7:
6/25 Dr. Buttar gave a verbal order concerning patient to Nina Wall.
·
C10:
6/30 Dr. Buttar engaged in an email consult with Jane where he gave
treatment orders
7. “She was treated with alternative therapy consisting of vitamins, IgG (?), IRR injections (?). All unproven. This is clearly not the standard of
care.”
·
Dr. Peterson indicates he does NOT know what
this treatment is. By his own
admission, he is not an expert on this subject and therefore is NOT qualified
to make a peer review in this case.
·
Treatment of this patient was NOT conducted
with vitamins.
·
Vitamins and other substances are used to
SUPPORT the patients.
·
We do NOT treat patients with vitamins. We use them to SUPPORT them while they are
undergoing detoxification.
·
We use vitamins to maintain good physiology
and give the patient what they need but are lacking in their diet.
·
This statement shows Dr. Peterson’s ignorance
of integrative medicine.
·
All principals and protocols used are covered
in the following courses:
o
AMESPA (Advanced Medical Education and
Services, Physician Association) Course– AMA Cat 1, CME course, of which
Dr. Buttar has been a faculty member since it’s inception in 2005
o
ABCMT (American Board of Clinical Metal
Toxicology of which, Dr. Buttar currently serves as Chairman of the Board)
– Introduction to Clinical Metal Toxicology Course, of which Dr. Buttar
has been a faculty member sine 1999,
o
ACAM (American College for Advancement in
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
ICIM (International College of Integrative
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
AAEM (American Academy of Environmental
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
·
Reference article published in Life Extension
2/03 Title: Anti-Cancer Foods and
Supplements, paragraph 4 “The National Cancer Institute (NCI) issued an
unprecedented number of press releases in the year 2002 stating that the diet
has a major impact on cancer.”
Page 61 of same article states the following “Supplements versus
food” “Food contains all the
nutrients the human body needs.
And if we eat the right kind of food, we’ll get them. The problem is we don’t.” “Benefit of supplements. They are concentrated and you know how
much you’re getting (if the supplement is from a reputable company). The vitamins we recommend are pharmaceutical
grade vitamins.
·
Reference Case Studies in Advance Medicine by
John C. Cline MD, BSc, Applying functional medicine in Clinical Practice. “When
the advanced medicine practitioner begins to treat the chronically ill patient,
one of the most important treatment strategies is to optimize nutrition in
order to provide support for the body’s natural detoxification mechanisms.”
o
AMESPA (Advanced Medical Education and
Services, Physician Association) Course– AMA Cat 1, CME course, of which
Dr. Buttar has been a faculty member since it’s inception in 2005
o
ABCMT (American Board of Clinical Metal
Toxicology of which, Dr. Buttar currently serves as Chairman of the Board)
– Introduction to Clinical Metal Toxicology Course, of which Dr. Buttar
has been a faculty member sine 1999,
o
ACAM (American College for Advancement in
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
ICIM (International College of Integrative
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
AAEM (American Academy of Environmental
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
8.
“She
was treated with alternative therapy consisting of vitamins, IgG (?), IRR injections
(?). All unproven. This is clearly not the standard of
care.”
·
Dr. Peterson indicates he does NOT know what
this treatment is. By his own
admission, he is not an expert on this subject and therefore is NOT qualified
to make a peer review in this case.
·
IgG 2000 DF,
a Xymogen product, from product insert, “represents a breakthrough in immunoglobulin
supplementation. It is a highly
concentrated non-dairy source of serum-derived immunoglobulin antibodies and
immune-proteins. It possesses 3
times more IgG and total immunoglobulin than colostrums and has twice as much
cysteine, an important amino acid for maintaining glutathione levels. It also
delivers 15 times the level of transferrin and Lactoferrin than colostrums
alone and one daily dose supplies over 2000mg of IgG”
o
AMESPA (Advanced Medical Education and
Services, Physician Association) Course– AMA Cat 1, CME course, of which
Dr. Buttar has been a faculty member since it’s inception in 2005
o
ABCMT (American Board of Clinical Metal
Toxicology of which, Dr. Buttar currently serves as Chairman of the Board)
– Introduction to Clinical Metal Toxicology Course, of which Dr. Buttar
has been a faculty member sine 1999,
o
ACAM (American College for Advancement in
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
ICIM (International College of Integrative
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
AAEM (American Academy of Environmental
Medicine) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
9. “She was treated with alternative therapy consisting of
vitamins, IgG (?), IRR injections (?). All unproven. This is clearly not the standard of
care.”
·
Dr. Peterson indicates he does not know what
this treatment is
·
IRR’s are NOT a treatment for cancer
·
IRR is the infraspinatus respiratory reflex
treatment, as published in the American Journal of Family Practice to increase
oxygen capacity and respiratory reserve.
·
Cancer is an anaerobic metabolizer. Increasing aerobic metabolism from the
predominant anaerobic metabolism characteristic in oncogenesis has been shown
to be highly beneficial to cancer patients.
·
We are simply improving patient oxygen
utilization
·
Each IRR procedure is documented, with VS,
and O2 saturation Pre –Treatment and Post Treatment are recorded, showing
immediate results post procedure.
10. “The standard of care would
have (been) a chemotherapy trial or hospice referral.”
·
Patient underwent 16 months of chemotherapy
prior to presentation to Dr. Buttar.
·
Dr. Peterson, by this statement, indicates he
is not an expert on this subject and therefore is NOT qualified to make a peer
review in this case.
·
We practice ABOVE the “standard” of care,
which is CLEARLY shown by the results:
o
Before Dr. Buttar’s
treatment: Ca 125 of 10,028.1
o
After Dr. Buttar’s
treatment: Ca 125 of 6,219.3
11. “No physician contact documented.”
·
B3a:
4/29 Jane Garcia’s notes countersigned by Dr. Buttar
·
B5a – B6: 5/11 Dr. Buttar conducted a physical examination & wrote
detailed Progress Notes
·
H2:
5/11 Dr. Buttar made notes on a EKG
·
C1b:
5/19 Jane Garcia’s notes countersigned by Dr. Buttar
·
I1a:
5/19 Dr. Buttar performed an IRR treatment on patient
·
C3b:
5/27 Jane Garcia’s notes countersigned by Dr. Buttar
·
I1b:
5/27 Dr. Buttar performed an IRR treatment on patient
·
I2a:
6/3 Dr. Buttar performed an IRR treatment on patient
·
C6:
6/21 Dr. Buttar had office visit with patient & wrote detailed
Progress Notes
·
I2b:
Dr. Buttar performed an IRR treatment on patient
·
C7:
6/25 Dr. Buttar gave a verbal order concerning patient to Nina Wall.
·
C10:
6/30 Dr. Buttar engaged in an email consult with Jane where he gave
treatment orders
-
Dr. Mann:
1.
“The patient continued to experience progression of
her cancer despite the therapies provided by Dr. Buttar.”
·
Above statement is FALSE. Reviewer has perjured himself.
·
B3a:
Patient presented with a history of Stage 4 metastatic ovarian cancer,
with most recent Ca 125 of 10,028.1 documented during initial history.
·
D1: LabCorp Test : Cancer Antigen (CA) 125 10,028.1 on April
15, 2004.
·
A1:
Request
and consent for treatment on April 29, 2004
·
J1:
Patient started Dr. Buttar’s IV treatment
protocol on May 17, 2004
·
D20:
LabCorp Test CA 125: 6,219.3,
Dated June 11, 2004
o
Clearly, patient was refractory to ALL
previous chemo administered over almost 2 years.
o
In LESS THAN 4 weeks, patient’s CA125 drops
by almost 4,000.
o
This is objective proof, despite patient
being non-compliant, that our treatment worked better than ANY other treatment
the patient had previously undergone.
·
The issue of non-compliance:
o
C3a: Documentation under
the Subjective portion of progress note where ,
pt admits to partial compliance of parasite protocol.
o
C4: Note to chart that pt had not
started Rx for Cipro
o
C5b: Documentation under Plan of
progress note pt is counseled re non compliance
o
C6: Documentation under Subjective portion
of progress note regarding lengthy discussion re non-compliance
·
D27:
Chronological timeline from 08/13/02 - 06/11/04, showing patient’s
response to overall treatment.
o
Largest drop in Ca 125 after Dr. Buttar’s treatment
o
Before Dr. Buttar’s
treatment: Ca 125 of 10,028.1
o
After Dr. Buttar’s
treatment: Ca 125 of 6,219.3
2.
“Consistent with care provided by allopathic
practitioners using complementary modalities – generally safe, limited
evidence for efficacy.”
·
As
already referenced (D1, D20, D27), results of this patient’s treatment are
BEYOND any care provided by allopathic practitioners using any modalities.
3.
“Patient received over 200 infusions of a variety
of cofactors, trace elements and other substances of benign nature.”
·
IV treatments are administered via a protocol
established to change the underlying physiology of the patient from an acid to
alkaline state with an emphasis in increasing aerobic metabolism from the
predominant anaerobic metabolism characteristic in oncogenesis.
·
IV infusion given based on protocol, as per
the AMESPA Course, which is an ACCME approved, AMA Category 1 CME course.
·
Patient’s response to IV treatment is
documented in the nursing notes on a daily basis to assess any adverse clinical
status or side effects of treatment.
4.
“No side effects recorded.”
·
Patient’s response to IV treatment is
documented in the progress notes, as well as nursing notes by nursing staff, on
a daily basis to assess any adverse clinical status or side effects of
treatment and per protocol is brought to the provider immediately.
·
There were no such adverse effects or
clinical status change in this patient and therefore, there is nothing
documented.
·
Each subjective component in the progress
notes details the patient’s response to all
treatment.
·
C1a: Under
Subjective portion of SOAP note, documentation of pt’s response to all
treatments.
·
C3a: Under
Subjective portion of SOAP note, documentation of pt’s response.
·
C5a: Under
Subjective portion of SOAP note, documentation of pt’s response.
·
C6: Under Subjective portion of SOAP
note documentation of pt’s response.
5.
“No mention of improvement or change mentioned.”
·
Each subjective component in the progress
notes details the patient’s response to all
treatments.
·
C1a: ov of 5/19/04
under Subjective of SOAP note pt states had less pain in right side from
initial visit.
·
C3a: ov of 5/27/04
under Subjective of SOAP note pt states; Today started feeling like myself again. Woke up this am with a spark-feel like
myself again, more energy, pain on right side better (much), can now sleep on
right side. Appetite not much , but still eats,
maintained weight at 150 lbs.
·
C5a: Under Subjective of SOAP note , documentation of pt’s response.
·
C6: Under Subjective
of SOAP note, documentation of pt’s response.
·
C8: Under Subjective
of SOAP note, documentation of pt’s response.
·
As already referenced (D1, D20, D27), results
of this patient’s improvement are clearly documented.
6.
“Patient billed for 12 biofeedback treatments which
are not described in the notes as to the nature of the training, the rationale
for the therapy and the effects of the training.”
·
K1 – K21: form of treatment and effects of treatment, as well as
specific anatomical regions affected by treatment are documented.
7.
“There was no full note by Dr. Buttar.”
·
B5a – B5b: 5/11 Dr. Buttar conducted a physical examination & wrote
detailed Progress Notes
·
H2:
5/11 Dr. Buttar made notes on a bone density scan
·
C6:
6/21 Dr. Buttar had office visit with patient & wrote detailed
Progress Notes
8.
“One of Jane Garcia’s note
was not countersigned and was undated, five were countersigned by Dr. Buttar.”
·
As we understand, the NC Medical Practice Act
(during that time period) did not require NP notes to be countersigned
·
C8:
That it was undated was a clerical error that had no negative
outcome. If the date of the
Progress Note was ever in question, a quick look in our scheduling program
would clarify.
10. “Several notes by Ms. Garcia were
difficult to read.”
·
Agreed.
11. “Two forms
were included for patient self assessment of symptoms and one assessment of
clinical condition. They were
unlabelled, and one was undated, neither were signed.”
·
B1a - B1b: self assessments of the patient dated 4/22/04
·
B2a - B2b: 4/22/04, is
part of the patient’s initial package
12. “No correlation
of therapy with changes in laboratory values or clinic status during the two
months of her care with Dr. Buttar.”
·
D2 – D26: Requirement for monitoring
renal function, hepatic function, electrolytes, and hemoglobin counts in a
cancer patient are HIGHLY relevant, especially when they are aggressively being
treated for a stage 4 cancer with multiple IV
regiments daily.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
o
D20: Documentation of CA 125 for
efficacy of treatment
·
G1 –G17: Cancer panels necessary to
establish immune function, with detailed explanation in charts provided
o
G9, G10: explanation of significance of level of uncontrolled
cellular proliferation monitoring in immunocomprimised
pts.
o
Immune function – CD 19, CD 56 counts
o
Immune function – NKHT3 + Immunocompetent Natural Killer Cells, NK Cell activity, NK
cell activity/cell
o
G6, G11: Lymphocyte Subpopulation profile – CD2, CD4, CD8, CD
3, CD 26
o
G1, G9, G13: Cell cycle Analysis and dsyregulation
in oncogenesis
o
G3, G12: Apoptosis and subsequent suppression of apoptosis in cancer
explained in detail
13. “Several
forms were unlabeled as to what parameters they were recording.”
·
There was no specifics
to what the reviewer was referring to.
All lab forms are either appropriately labeled or organized in the
correct section of the chart.
14. “The
record does not use SOAP.”
·
C1a, C1b: The SOAP format is clearly
used.
·
C3a, C3b: The SOAP format is clearly
used
·
C5a, C5b :The SOAP format is clearly used
·
C6: The SOAP format is clearly used.
15. “Specific therapies
non-harmful but not fully justified.
Some therapies (biofeedback) not described or justified.”
·
Dr. Mann indicates by this statement that he
does NOT understand the physiological basis and justification of our
treatment. He is not an expert on
this subject or in the treatment of cancer and therefore is NOT qualified to
make a peer review in this case.
16. “Repetitive
testing of lipids and iron and iron binding capacity is questionable.”
·
Doing complete panel with lipids was cheaper
test than separating test. Patient
was not charged for serum lipids.
·
Cancer patients as with other chronic
disease, exhibit lower serum lipids.
Increase in lipid profile appears to be a good prognostic marker for our
treatment regimen.
·
It is clear Dr. Mann is NOT an expert in the
integrative approach to treating cancer
·
D2 – D26: Requirement for monitoring renal function,
hepatic function, Iron, TIBC, % saturation, Ferritin,
electrolytes, and hemoglobin counts in a cancer patient are HIGHLY relevant,
especially when they are aggressively being treated for a stage 4 cancer with multiple IV regiments daily.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
·
Lipids, Fe, TIBC, %saturation, Ferritin, Chem. profile ordered after 5th
anionic surfactant treatment according to standard protocol, as established by
multiple medical societies, including:
o
AMESPA (Advanced Medical Education and
Services, Physician Association) Course– AMA Cat 1, CME course, of which
Dr. Buttar has been a faculty member since it’s inception in 2005
o
ABCMT (American Board of Clinical Metal
Toxicology of which, Dr. Buttar currently serves as Chairman of the Board)
– Introduction to Clinical Metal Toxicology Course, of which Dr. Buttar
has been a faculty member sine 1999,
o
ACAM (American College for Advancement in
Medicine’s) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
ICIM (International College of Integrative
Medicine’s) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
o
AAEM (American Academy of Environmental
Medicine’s) Heavy Metal Course of which Dr. Buttar has been a faculty member in
the past
17. “Dr.
Buttar did not document his own examination of the patient but did countersign
most of his NP’s notes.”
·
B5a:
5/11 Dr. Buttar conducted a physical examination & wrote detailed
Progress Notes
·
H2:
5/11Dr. Buttar made notes on a EKG
·
C6:
6/21 Dr. Buttar had office visit with patient & wrote detailed
Progress Notes
Reference: Patient C
Jeff KXXXXXX
Date of Birth:
2/13/61
43 y.o. W male who presented on
Feb 16, 2004 with c/c of Adrenal Carcinoma, initially diagnosed in September
2003, status post surgical resection in Oct 2003 with left nephrectomy,
adrenalectomy and splenectomy,
along with extensive lymph node dissection. Pt presented with a 59 pound weight loss. Prior to diagnosis of cancer, patient
had significant hx of abdominal surgery in October 2002 with resection of
greater than 4cm of sigmoid colon with placement of a colostomy. Three months
later, in Feb 2003, pt had colostomy takedown.
Underwent 16 treatments of radiation, although advised to
have 28. Pt stopped after becoming
very sick and was unable to tolerate further treatments. Pt told by oncologist that chemotherapy
would not be an option and was reportedly given less than 6 months to
live. On Feb 3, 2004, the first
post operative cat scan showed questionable lesion in lung (5mm), as well as a
new lesion in the liver measuring
2 ½ cm. Patient presented
to us with stage 4 Adrenal Cancer and was under the care of Dr. Buttar from
February 16, 2004 until June 9, 2004 and was last seen in our clinic on June
11, 2004. Patient died on
September 18, 2004 from a pulmonary embolus, more than three months after
treatment had been completed by Dr. Buttar.
----------
Each
numbered item below is the NCMB’s expert reviewer’s
comments on the charts. Each
bulleted item is our response, with references to the medical charts showing
the facts.
-
Dr. Peterson:
1.
NCMB Expert’s (Dr. Peterson) opinion on Treatment
– Below standard of practice/care
·
Natural Killer Cell activity more than
doubled after treatment by Dr. Buttar
o
Before treatment: Natural Killer Cell Activity: 8.6 LU
o
After treatment: Natural Killer Cell Activity: 20.8 LU
§
A 150% increase in in
NK Cell Activity
·
Reference: G17,G18,G19,G27
·
Clearly Above and Beyond the standard of
care.
·
If Dr. Peterson does NOT understand the
relevance of increasing CD 19 and CD 56 count (NK Cell) activity in cancer patients,
he substantiates himself that he is NOT qualified to review this case.
2.
“EDTA chelation therapy has no benefit in treating
cancer.”
·
First, we do NOT treat cancer with EDTA.
·
We DO treat heavy metal toxicity with EDTA.
·
The incidence of heavy metal toxicity with
cancer is highly statistically significant.
·
If the cancer patients
shows heavy metal toxicity, as they usually do, we REMOVE the metals.
·
According to the conventional cancer
literature, 75% to 95% of cancer patients have some type of toxicity. The etiology of most cancers stems from
increase in oxidative stress due to some sort of toxicity.
·
Sample References showing correlation of
heavy metals in cancer patients – Have more than a hundred others.
o Metal Metabolism Of Neoplastic
Cells: Alterations That Facilitate Proliferation? Critical Review Oncology & Hematology, Volume 42, No. 1,
April 2002, pg 65-78
o Iron Chelation Induced Senescence-like Growth
Arrest In Hepatocyte Cell Lines: Association of
TGF-beta1 Mediated p27superKip1 Expression, Biochemistry Journal, April 11,
2002
o Antiproliferative And Apoptotic Effects Of Iron Chelators On
Human Cervical Carcinoma Cells, Gynecological Oncology Volume 85, No. 1, April
2002, pg 95-102
o Ninety Percent Reduction In Cancer Mortality
After Chelation Therapy With EDTA, Journal of Advancement in Medicine, Volume
2, No. 1-2, Spring-Summer 1989
3.
“In addition, numerous labs drawn
that are of no clinical relevance such as “urine toxic metals”,”steatocrit”,
“Lactoferrin”, “Lysozyme”.
4.
E1: Urine Toxic Metals is a urine element analysis used
for the assessment of toxic element statue, monitoring detoxification therapy,
and identifying or quantifying renal wasting conditions. The incidence of heavy
metal toxicity with cancer is highly statistically significant.
·
If the cancer patients
shows heavy metal toxicity, as they usually do, we REMOVE the metals.
·
According to the conventional cancer
literature, 75% to 95% of cancer patients have some type of toxicity. The etiology of most cancers stems from
increase in oxidative stress due to some sort of toxicity.
·
Sample References showing correlation of
heavy metals in cancer patients – Have more than a hundred others.
o Metal Metabolism Of Neoplastic
Cells: Alterations That Facilitate Proliferation? Critical Review Oncology & Hematology, Volume 42, No. 1,
April 2002, pg 65-78
o Iron Chelation Induced Senescence-like Growth
Arrest In Hepatocyte Cell Lines: Association of
TGF-beta1 Mediated p27superKip1 Expression, Biochemistry Journal, April 11,
2002
o Antiproliferative And Apoptotic Effects Of Iron Chelators On
Human Cervical Carcinoma Cells, Gynecological Oncology Volume 85, No. 1, April
2002, pg 95-102
o Ninety Percent Reduction In Cancer Mortality
After Chelation Therapy With EDTA, Journal of Advancement in Medicine, Volume 2,
No. 1-2, Spring-Summer 1989
· F2:
Steatocrit, lactoferrin,
lysozyme are part of the CDSA( Comprehensive Stool
Analysis/Parasitology x1 test which is performed to
assess many digestive and absorptive functions occurring within the
gastrointestinal tract as well as providing an overview of the microfloral
balance, intestinal ecology, immunology and general intestinal health.
·
D1 – D51: Requirement for monitoring
renal function, hepatic function, electrolytes, can hemoglobin counts in a
cancer patient are HIGHLY relevant, especially when they are aggressively being
treated for a stage 4 cancer with multiple IV regiments daily.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
·
G1 –G27: Cancer panels necessary to
establish immune function, with detailed explanation in charts provided
o
G1, G9, G18 – explanation of
significance of level of uncontrolled cellular proliferation monitoring in immunocomprimised pts.
o
Immune function – CD 19, CD 56 counts
o
Immune function – NKHT3 + Immunocompetent Natural Killer Cells, NK Cell activity, NK
cell activity/cell
o
G3,G4,G11, G12, G21,G22 - Lymphocyte
Subpopulation profile – CD2, CD4, CD8, CD 3, CD 26
o
G7, G16, G24 - Cell cycle Analysis and dsyregulation in oncogenesis
o
G5, G14, G23 - Apoptosis and subsequent
suppression of apoptosis in cancer explained in detail
5.
“The standard of care would be treatment with chemotherapy
such as Mitotane or enrollment in a clinical trial
versus palliative care alone.”
·
C2a:
Pt was told chemotherapy was not an option by oncologist.
·
Dr. Buttar’s treatment was ABOVE and BEYOND
the standard of care.
·
While under Dr. Buttar’s care, pt did not
require pain control.
·
Patient lived beyond expected and predicted
life span by oncologist
·
Patient died of a
documented pulmonary emboli, NOT cancer.
6.
“No physician contact documented.”
·
C2a:
2/16 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C4a,b:
3/24 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C5a, C5b: 4/7 Dr. Buttar conducted
examination and wrote detailed Progress Notes
·
C6a, C6b: 4/7 Dr. Buttar conducted
examination and wrote detailed Progress Notes
·
C9:
5/4 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C12a:
5/25 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C13:
6/9 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
I1b:
3/15 Dr. Buttar performed an IRR treatment on patient. When ever IRR’s done, Dr. Buttar always
consults with patients and addresses any issues or questions patients have.
·
I1a:
3/23 Dr. Buttar performed an IRR treatment on patient
·
I2b:
3/30 Dr. Buttar performed an IRR treatment on patient
·
I2a:
4/6 Dr. Buttar performed an IRR treatment on patient
·
I3:
4/14 Dr. Buttar performed an IRR treatment on patient
·
I4a: 4/20 Dr. Buttar performed an IRR
treatment on patient
·
I4b:
4/27 Dr. Buttar performed an IRR treatment on patient
·
I5a: 4/28 Dr. Buttar performed an IRR
treatment on patient
·
I5b: 5/4 Dr. Buttar performed an IRR
treatment on patient
·
I6b: 5/11 Dr. Buttar performed an IRR
treatment on patient
·
I6a: 5/18 Dr. Buttar performed an IRR
treatment on patient
·
I7b: 5/25 Dr. Buttar performed an IRR
treatment on patient
·
I7a: 6/1 Dr. Buttar performed an IRR
treatment on patient
·
I8a: 6/9 Dr. Buttar performed an IRR
treatment on patient
-
Dr. Mann:
1.
“The point of the chelation therapy is not stated
in the record.”
·
Failure of the reviewer, the NCMB or
designated “expert witness” to be up to date on the medical literature is not
Dr. Buttar’s responsibility.
2.
“Records:
This is the weakest part of the care. There are no records of justification of the treatments
given except for what appear to be pre-packaged paragraphs describing the rationale
for testing for heavy metal toxicity and immune function. This information is not described in
terms specific tests and procedures for this patient.”
·
This is correct. Since the rationale is always the same, it is pre-packaged
to save time and effort. Metals
increase oxidative stress.
Oxidative stress leads to DNA mutation and Immunosuppression. DNA mutation leads to oncogenesis. Immunosuppression leads to suppression of apoptosis. All this leads to cancer.
·
C4b:
Immune function, results heavy metal testing
·
C7b:
Immune function(Cancer Panel)
·
C12A: Immune function (Cancer Panel)
·
E1-E7b:
Urine toxic Metals
·
G1-G27:
Immune function (Cancer Panel)
3.
“There is no written assessment of the patient’s response
to the infusions and chelation therapy.”
·
C4a, C4b: Dr. Buttar documented patient’s
response to all treatments under the Subjective portion of the Soap note
·
C5a: Documentation of patient’s response to all treatments under the Subjective
portion of the SOAP note
·
C6a: Documentation of patient’s response to
all treatments under the Subjective portion of the SOAP note.
·
C7a:Jane Garcia,
NP documented patient’s response
to all treatment under the Subjective portion of the SOAP note.
·
C9: Dr. Buttar documented patient’s response
to all treatments under the Subjective portion of the SOAP note.
·
C10a:Jane Garcia, NP
documented patient’s response to all treatments under the Subjective portion of
the SOAP note.
·
C11a: Jane Garcia,NP documented patient’s response under the
Subjective portion of the SOAP note.
·
C12a:
Dr. Buttar documented patient’s response under the Subjective portion of
the SOAP note.
·
C12b: Jane Garcia,NP documented patient’s response under the
Subjective Portion of the SOAP note.
·
C13: Dr. Buttar documented the patient’s
response under the Subjective portion of the SOAP note.
4.
“Most of the notes are written by Jane Garcia, ANP,
are often out of order, are occasionally countersigned by Dr. Buttar and do not
reflect ongoing examination of the patient or observed changes in his clinical
status, linked to his therapy or otherwise.”
·
When medical records given to NCMB, records
and progress notes were in order.
·
,C12b:
Dr. Buttar either wrote or co-signed ALL but one Progress Note )
o
C2a:
Signed Progress Note
o
C4a:
Signed Progress Note
o
C5b:
Signed Progress Note
o
C6b: Signed Progress Note
o
C8: Signed Progress Note
o
C9:
Signed Progress Note
o
C10b:
Signed Progress Note
o
C11b:
Signed Progress Note
o
C12a:
Signed Progress Note
o
C13:
Signed Progress Note
o
·
C5a: Under (O) Objective of SOAP note, exam,
findings documented
·
C6a: Under (O) Objective of SOAP note, exam, findings documented
·
C7b :
Under (O) Objective of SOAP note, exam, findings documented
·
C9: Under (O)
Objective of SOAP note, exam, findings documented.
·
C10b:
Under (O) Objective of SOAP note, exam, findings documented
·
C11b: Under (O) Objective of SOAP note, exam,
findings noted
·
C12a: Under (O) Objective of SOAP note, exam,
findings documented
·
C12b:
Under (O) Objective of SOAP note, exam, findings documented
·
C13:
Under (O) Objective of SOAP note, exam, findings documented
·
C4a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C5a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C6a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C7a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C9:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C10a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C11a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C12a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C12b:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C13:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
5.
“The record does not use SOAP.”
·
C2a: 2/16/04 - SOAP note is CLEARLY used
·
C2b: 2/23/04 - SOAP note is CLEARLY used
·
C4a – C4b: 3/24/04 - SOAP note is
CLEARLY used
·
C5a – C5b: 4/6/04 - SOAP note is
CLEARLY used
·
C6a-6b : 4/20/04 - SOAP note is CLEARLY used
·
C7a,C7b,C8: 4/28/04 - SOAP note is CLEARLY used
·
C9: 5/4/04 - SOAP note is CLEARLY used
·
C10a – C10b: 5/13/04 - SOAP note is
CLEARLY used
·
C11a – C11b: 5/18/04 - SOAP note is
CLEARLY used
·
C12a: 5/25/04 - SOAP note is CLEARLY used
·
C12b: 6/2/04 - SOAP note is CLEARLY
·
C13:
6/9/04 - SOAP note is CLEARLY used
6.
“Overall:
below standard of practice/care, particularly in terms of documentation
of the attending awareness of patient status, justification for therapies
chosen, and awareness of effects of such therapies.”
·
C13:
Dr. Buttar Signed all his progress notes and co-signed all of the Mid Level
Provider’s notes.
o
C2a:
Signed Progress Note
o
C3a:
Signed Progress Note
o
C3b:
Signed Progress Note
o
C4b:
Signed Progress Note
o
C5b:
Signed Progress Note
o
C7: Signed Progress Note
o
C8:
Signed Progress Note
o
C9b:
Signed Progress Note
o
C11b:
Signed Progress Note
o
C12a:
Signed Progress Note
o
C13:
Signed Progress Note
·
C4b: Under (O) Objective of SOAP note, exam,
findings documented
·
C5a: Under (O) Objective of SOAP note, exam,
findings documented
·
C6a: Under (O) Objective of SOAP note, exam, findings documented
·
C7b :Under (O) Objective of SOAP note, exam,
findings documented
·
C9: Under (O) Objective of SOAP note, exam,
findings documented
·
C10a: Under (O) Objective of SOAP note, exam,
findings documented
·
C10b:
Under (O) Objective of SOAP note, exam, findings documented
·
C11b: Under (O) Objective of SOAP note, exam,
findings documented
·
C12a: Under (O) Objective of SOAP note, exam,
findings documented
·
C12b:
Under (O) Objective of SOAP note, exam, findings documented
·
C13:
Under (O) Objective of SOAP note, exam, findings documented
9.
“In addition to the above issues, there are several
examples of repetitive blood sampling with questionable utility.”
·
D1 – D51: Requirement for monitoring
renal function, hepatic function, electrolytes, can hemoglobin counts in a
cancer patient are HIGHLY relevant, especially when they are aggressively being
treated for a stage 4 cancer with multiple IV
regiments on a daily basis.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
10. “-weekly assessment of immune function from
2/25 – 5/10 without written comment or interpretation of the results or
adjustment of therapy.”
·
Assessment of immune function was completed 3
times in this patient
o
G1 – G8: Once prior to initiation of treatment on Feb 25, 2004
o
G9 – G17: Once during the treatment on
Apr 20, 2004
o
G18 – G25: Once towards the end of the
first phase of tx, on May 10, 2004
·
Clinical interpretation and comments are
discussed in the Assessment and Plan of the OV when tests became available for
review.
·
G27 is a running comparison that was given each time to the
patient and reviewed in detail with the patient.
·
Copy of G27 given to patient at time of
review.
11. “-intravenous
infusions 03/03/2004 to 06/11/2004 without comment on change in clinical status
or side effects or justification for further infusions.”
·
IV tx are
administered via a protocol established to change the underlying physiology of
the patient from an acid to alkaline state with an emphasis in increasing
aerobic metabolism from the predominant anaerobic metabolism characteristic in oncogenesis.
·
IV infusion given based on protocol, as per the
AMESPA Course, which is an ACCME approved, AMA Category 1 CME course.
·
Pt’s response to IV treatment is documented
in nursing notes on a daily basis to assess any adverse clinical status or side
effects of tx and per protocol, is brought to the
provider immediately
·
There was no such adverse effect or clinical
status change in this patient, and therefore, there is NOTHING documented. You can’t document something if it did
NOT occur.
·
J4 – J16 documents - All normal
evaluations documented, with vital signs, including before and after blood
pressures, weight, and pulse and respiratory rates were documented, as per our
clinic protocol.
12. “-multiple
blood draws for labs from 3/18/ to at least 6/11/2004 for electrolytes, liver
and kidney functions, iron studies and lipid levels which changed very little,
were not justified in the notes, were often out of order, and were ordered about
once per week, again without documentation or justification.”
·
D1 – D51: Requirement for monitoring
renal function, hepatic function, electrolytes, can hemoglobin counts in a
cancer patient are HIGHLY relevant, especially when they are aggressively being
treated for a stage 4 cancer with multiple IV
regiments on a daily basis.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
·
Fortunately, this patient was doing well, but
often, this is not the case.
o
We monitor all patients closely.
o
If we had NOT monitored, an adverse event
could have occurred and the NCMB would be investigating the LACK of proper
monitoring.
o
All labs are kept in order and were in order
when charts were given to the NCMB.
·
C3:
Note Documentation of Labs performed on 2/24/04, 3/17/04, 3/25/04,
4/5/04, and 4/8/04 for comparative analysis of renal, hepatic function,
electrolytes, iron levels, hemoglobin/ hematocrit
levels.
o
As stated above labs are done to monitor
patient safety, assess patient response, and assist providers in guiding
treatment of patient.
·
C4b:
Under (O) Objective of SOAP note findings documented
·
C5a: Under (O) Objective of SOAP note findings documented
·
C6a:
Under (O) Objective of SOAP note findings documented
·
C6b:
Documentation of Labs performed on 4/01/04, 4/13/04, 4/15/04, and
4/19/04 for comparative analysis
·
C7a: Under (O) Objective of SOAP note findings
documented
·
C7b: Under (O) Objective of SOAP note findings
documented
·
C9: Under (O) Objective of SOAP note findings
documented
·
C10a: Under (O) Objective of SOAP note
findings documented
·
Of labs performed on 5/3/04, 5/7/04, and
5/11/04 for comparative analysis
·
C10b: Under (O) Objective of SOAP note
findings documented
·
C11a: Under (O) Objective of SOAP note
findings documented
·
C11b:
Continuation of documented findings
·
C12b:
Under (O) Objective of SOAP note findings are documented
13. “The main deficiencies are in the areas
of documentation of justification for treatments, repetitive serum tests, and
lack of a sense of management of this patient using assessment linked with
rationale for treatment. The
standard of care is below average in this case.”
·
C2a:
There is a definite plan of treatment as listed under the A/P portion of
the SOAP note.
o
This was the patient’s initial visit.
o
Plan of treatment continued at each subsequent
office visit as documented under the A/P of each SOAP note.
o
This is definitely within the standard of
care.
·
C2b:
Documentation under (A/P) Assessment / Plan of Soap note
·
C4a - C4b: Documentation under (A/P) Assessment / Plan of Soap note
·
C5b: Documentation under (A/P) Assessment/Plan
of Soap note
·
C6b:
Documentation under (A/P) Assessment/Plan of Soap note
·
C7b,C8:
Documentation under (A/P) Assessment/Plan of Soap note
·
C9:
Documentation under (A/P) Assessment/Plan of Soap note
·
C10b:
Documentation under (A/P) Assessment/Plan of Soap note
·
C11b:
Documentation under (A/P) Assessment/Plan of Soap note
·
C12a,C12b: Documentation under (A/P) Assessment/Plan of Soap note
·
C13:
Documentation under (A/P) Assessment/Plan of Soap note
Reference: Patient C
Jeff KXXXXXX
Date of Birth:
2/13/61
43 y.o. W male who presented on
Feb 16, 2004 with c/c of Adrenal Carcinoma, initially diagnosed in September
2003, status post surgical resection in Oct 2003 with left nephrectomy,
adrenalectomy and splenectomy,
along with extensive lymph node dissection. Pt presented with a 59 pound weight loss. Prior to diagnosis of cancer, patient
had significant hx of abdominal surgery in October 2002 with resection of
greater than 4cm of sigmoid colon with placement of a colostomy. Three months
later, in Feb 2003, pt had colostomy takedown.
Underwent 16 treatments of radiation, although advised to
have 28. Pt stopped after becoming
very sick and was unable to tolerate further treatments. Pt told by oncologist that chemotherapy
would not be an option and was reportedly given less than 6 months to
live. On Feb 3, 2004, the first
post operative cat scan showed questionable lesion in lung (5mm), as well as a
new lesion in the liver measuring
2 ½ cm. Patient presented
to us with stage 4 Adrenal Cancer and was under the care of Dr. Buttar from
February 16, 2004 until June 9, 2004 and was last seen in our clinic on June
11, 2004. Patient died on
September 18, 2004 from a pulmonary embolus, more than three months after
treatment had been completed by Dr. Buttar.
----------
Each
numbered item below is the NCMB’s expert reviewer’s
comments on the charts. Each
bulleted item is our response, with references to the medical charts showing
the facts.
-
Dr. Peterson:
1.
NCMB Expert’s (Dr. Peterson) opinion on Treatment
– Below standard of practice/care
·
Natural Killer Cell activity more than
doubled after treatment by Dr. Buttar
o
Before treatment: Natural Killer Cell Activity: 8.6 LU
o
After treatment: Natural Killer Cell Activity: 20.8 LU
§
A 150% increase in in
NK Cell Activity
·
Reference: G17,G18,G19,G27
·
Clearly Above and Beyond the standard of
care.
·
If Dr. Peterson does NOT understand the
relevance of increasing CD 19 and CD 56 count (NK Cell) activity in cancer patients,
he substantiates himself that he is NOT qualified to review this case.
2.
“EDTA chelation therapy has no benefit in treating
cancer.”
·
First, we do NOT treat cancer with EDTA.
·
We DO treat heavy metal toxicity with EDTA.
·
The incidence of heavy metal toxicity with
cancer is highly statistically significant.
·
If the cancer patients
shows heavy metal toxicity, as they usually do, we REMOVE the metals.
·
According to the conventional cancer
literature, 75% to 95% of cancer patients have some type of toxicity. The etiology of most cancers stems from
increase in oxidative stress due to some sort of toxicity.
·
Sample References showing correlation of
heavy metals in cancer patients – Have more than a hundred others.
o Metal Metabolism Of Neoplastic
Cells: Alterations That Facilitate Proliferation? Critical Review Oncology & Hematology, Volume 42, No. 1,
April 2002, pg 65-78
o Iron Chelation Induced Senescence-like Growth
Arrest In Hepatocyte Cell Lines: Association of
TGF-beta1 Mediated p27superKip1 Expression, Biochemistry Journal, April 11,
2002
o Antiproliferative And Apoptotic Effects Of Iron Chelators On
Human Cervical Carcinoma Cells, Gynecological Oncology Volume 85, No. 1, April
2002, pg 95-102
o Ninety Percent Reduction In Cancer Mortality
After Chelation Therapy With EDTA, Journal of Advancement in Medicine, Volume
2, No. 1-2, Spring-Summer 1989
3.
“In addition, numerous labs drawn
that are of no clinical relevance such as “urine toxic metals”,”steatocrit”,
“Lactoferrin”, “Lysozyme”.
4.
E1: Urine Toxic Metals is a urine element analysis used
for the assessment of toxic element statue, monitoring detoxification therapy,
and identifying or quantifying renal wasting conditions. The incidence of heavy
metal toxicity with cancer is highly statistically significant.
·
If the cancer patients
shows heavy metal toxicity, as they usually do, we REMOVE the metals.
·
According to the conventional cancer
literature, 75% to 95% of cancer patients have some type of toxicity. The etiology of most cancers stems from
increase in oxidative stress due to some sort of toxicity.
·
Sample References showing correlation of
heavy metals in cancer patients – Have more than a hundred others.
o Metal Metabolism Of Neoplastic
Cells: Alterations That Facilitate Proliferation? Critical Review Oncology & Hematology, Volume 42, No. 1,
April 2002, pg 65-78
o Iron Chelation Induced Senescence-like Growth
Arrest In Hepatocyte Cell Lines: Association of
TGF-beta1 Mediated p27superKip1 Expression, Biochemistry Journal, April 11,
2002
o Antiproliferative And Apoptotic Effects Of Iron Chelators On
Human Cervical Carcinoma Cells, Gynecological Oncology Volume 85, No. 1, April
2002, pg 95-102
o Ninety Percent Reduction In Cancer Mortality
After Chelation Therapy With EDTA, Journal of Advancement in Medicine, Volume 2,
No. 1-2, Spring-Summer 1989
· F2:
Steatocrit, lactoferrin,
lysozyme are part of the CDSA( Comprehensive Stool
Analysis/Parasitology x1 test which is performed to
assess many digestive and absorptive functions occurring within the
gastrointestinal tract as well as providing an overview of the microfloral
balance, intestinal ecology, immunology and general intestinal health.
·
D1 – D51: Requirement for monitoring
renal function, hepatic function, electrolytes, can hemoglobin counts in a
cancer patient are HIGHLY relevant, especially when they are aggressively being
treated for a stage 4 cancer with multiple IV regiments daily.
o
Labs HIGHLY necessary to monitor patient
safety
o
Labs HIGHLY necessary to assess patient
response
o
Labs necessary to assist in guiding treatment
intensity
·
G1 –G27: Cancer panels necessary to
establish immune function, with detailed explanation in charts provided
o
G1, G9, G18 – explanation of
significance of level of uncontrolled cellular proliferation monitoring in immunocomprimised pts.
o
Immune function – CD 19, CD 56 counts
o
Immune function – NKHT3 + Immunocompetent Natural Killer Cells, NK Cell activity, NK
cell activity/cell
o
G3,G4,G11, G12, G21,G22 - Lymphocyte
Subpopulation profile – CD2, CD4, CD8, CD 3, CD 26
o
G7, G16, G24 - Cell cycle Analysis and dsyregulation in oncogenesis
o
G5, G14, G23 - Apoptosis and subsequent
suppression of apoptosis in cancer explained in detail
5.
“The standard of care would be treatment with chemotherapy
such as Mitotane or enrollment in a clinical trial
versus palliative care alone.”
·
C2a:
Pt was told chemotherapy was not an option by oncologist.
·
Dr. Buttar’s treatment was ABOVE and BEYOND
the standard of care.
·
While under Dr. Buttar’s care, pt did not
require pain control.
·
Patient lived beyond expected and predicted
life span by oncologist
·
Patient died of a
documented pulmonary emboli, NOT cancer.
6.
“No physician contact documented.”
·
C2a:
2/16 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C4a,b:
3/24 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C5a, C5b: 4/7 Dr. Buttar conducted
examination and wrote detailed Progress Notes
·
C6a, C6b: 4/7 Dr. Buttar conducted
examination and wrote detailed Progress Notes
·
C9:
5/4 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C12a:
5/25 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
C13:
6/9 Dr. Buttar conducted examination and wrote detailed Progress Notes
·
I1b:
3/15 Dr. Buttar performed an IRR treatment on patient. When ever IRR’s done, Dr. Buttar always
consults with patients and addresses any issues or questions patients have.
·
I1a:
3/23 Dr. Buttar performed an IRR treatment on patient
·
I2b:
3/30 Dr. Buttar performed an IRR treatment on patient
·
I2a:
4/6 Dr. Buttar performed an IRR treatment on patient
·
I3:
4/14 Dr. Buttar performed an IRR treatment on patient
·
I4a: 4/20 Dr. Buttar performed an IRR
treatment on patient
·
I4b:
4/27 Dr. Buttar performed an IRR treatment on patient
·
I5a: 4/28 Dr. Buttar performed an IRR
treatment on patient
·
I5b: 5/4 Dr. Buttar performed an IRR
treatment on patient
·
I6b: 5/11 Dr. Buttar performed an IRR
treatment on patient
·
I6a: 5/18 Dr. Buttar performed an IRR
treatment on patient
·
I7b: 5/25 Dr. Buttar performed an IRR
treatment on patient
·
I7a: 6/1 Dr. Buttar performed an IRR
treatment on patient
·
I8a: 6/9 Dr. Buttar performed an IRR
treatment on patient
-
Dr. Mann:
1.
“The point of the chelation therapy is not stated
in the record.”
·
Failure of the reviewer, the NCMB or
designated “expert witness” to be up to date on the medical literature is not
Dr. Buttar’s responsibility.
2.
“Records:
This is the weakest part of the care. There are no records of justification of the treatments
given except for what appear to be pre-packaged paragraphs describing the rationale
for testing for heavy metal toxicity and immune function. This information is not described in
terms specific tests and procedures for this patient.”
·
This is correct. Since the rationale is always the same, it is pre-packaged
to save time and effort. Metals
increase oxidative stress.
Oxidative stress leads to DNA mutation and Immunosuppression. DNA mutation leads to oncogenesis. Immunosuppression leads to suppression of apoptosis. All this leads to cancer.
·
C4b:
Immune function, results heavy metal testing
·
C7b:
Immune function(Cancer Panel)
·
C12A: Immune function (Cancer Panel)
·
E1-E7b:
Urine toxic Metals
·
G1-G27:
Immune function (Cancer Panel)
3.
“There is no written assessment of the patient’s response
to the infusions and chelation therapy.”
·
C4a, C4b: Dr. Buttar documented patient’s
response to all treatments under the Subjective portion of the Soap note
·
C5a: Documentation of patient’s response to all treatments under the Subjective
portion of the SOAP note
·
C6a: Documentation of patient’s response to
all treatments under the Subjective portion of the SOAP note.
·
C7a:Jane Garcia,
NP documented patient’s response
to all treatment under the Subjective portion of the SOAP note.
·
C9: Dr. Buttar documented patient’s response
to all treatments under the Subjective portion of the SOAP note.
·
C10a:Jane Garcia, NP
documented patient’s response to all treatments under the Subjective portion of
the SOAP note.
·
C11a: Jane Garcia,NP documented patient’s response under the
Subjective portion of the SOAP note.
·
C12a:
Dr. Buttar documented patient’s response under the Subjective portion of
the SOAP note.
·
C12b: Jane Garcia,NP documented patient’s response under the
Subjective Portion of the SOAP note.
·
C13: Dr. Buttar documented the patient’s
response under the Subjective portion of the SOAP note.
4.
“Most of the notes are written by Jane Garcia, ANP,
are often out of order, are occasionally countersigned by Dr. Buttar and do not
reflect ongoing examination of the patient or observed changes in his clinical
status, linked to his therapy or otherwise.”
·
When medical records given to NCMB, records
and progress notes were in order.
·
,C12b:
Dr. Buttar either wrote or co-signed ALL but one Progress Note )
o
C2a:
Signed Progress Note
o
C4a:
Signed Progress Note
o
C5b:
Signed Progress Note
o
C6b: Signed Progress Note
o
C8: Signed Progress Note
o
C9:
Signed Progress Note
o
C10b:
Signed Progress Note
o
C11b:
Signed Progress Note
o
C12a:
Signed Progress Note
o
C13:
Signed Progress Note
o
·
C5a: Under (O) Objective of SOAP note, exam,
findings documented
·
C6a: Under (O) Objective of SOAP note, exam, findings documented
·
C7b :
Under (O) Objective of SOAP note, exam, findings documented
·
C9: Under (O)
Objective of SOAP note, exam, findings documented.
·
C10b:
Under (O) Objective of SOAP note, exam, findings documented
·
C11b: Under (O) Objective of SOAP note, exam,
findings noted
·
C12a: Under (O) Objective of SOAP note, exam,
findings documented
·
C12b:
Under (O) Objective of SOAP note, exam, findings documented
·
C13:
Under (O) Objective of SOAP note, exam, findings documented
·
C4a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C5a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented
·
C6a:
Under the Subjective portion of each SOAP note, specific comments by the
patient are documented