Allegation of Complaint:
Dr. Gerald K. Lee; License # 0101057543
Nature of Complaint:
The physician prescribed narcotics and benzodiazepines to Patient A on multiple occasions over an approximate one-year period for the physician's diagnoses of chronic back pain, abdominal pain, and PTSD/anxiety without sufficient objective evidence or results of testing/studies to properly diagnose the patient and to determine the etiology of the patient's pain. The physician failed to request or attempt to obtain the patient's recrod from two prior treating providers. The physician failed to address the patient's noncompliance with the physician's referals to other providers for diagnostic tests to determine the etiology of the patient's complaints and continued to prescribe controlled substances.
The physician continously prescribed controlled substances to the patient without establishing or documenting a treatment plan and without proper monitoring. The physician failed to appropriately respond to information obtained through the physician's use of pain scales, urine drug screens, and records the physician received from the local emergency room which indicated that the patient was taking illegal substances and may have been misusing her prescribed medications.
The physician prescribed controlled substances including approximately 2,528 dosage units of hydrocodone, 613 dosage units of diazepam, 239 dosage units of alprazolam, and 56 dosage units of clonazepam despite the physician's awareness of drug-seeking behavior and information that should have indicated to the physician that the patient was abusing and/or had become addicteed to or dependent upon the medications the physician was prescribing to the patient.
The patient had no bona fide documented diagnosis to support the physician's prescribing of narcotics at the outset of treatment.
The physician could not provide the Special Conference Committee with a working etiological diagnosis for the patient nor did the phydician document one in his record.
The physician stated to the Committee that he has made changes to his patient records to make the records easier to read and provided copies of his revised pain management contract, patient intake forms, and progress note forms to the Committee. The physician has incorporated a checklist to capture at a patient's first visit what information and materials have been requested and received from prior providers. The physician has implemented a no tolerance policy on urine drug screens for his pain patients.
The Virginia Board of Medicine has placed the physician's license on Indefinite Probation subject to the following terms and conditions:
- The physician is prohibited from prescribing Schedule II controlled substances.
- The physician within twelve months shall submit satisfactory proof to the board that the physician has completed fifteen hours of board approved continuing medical education in the proper prescribing of controlled substances .
- The physician within twelve months shall submit satisfactory proof to the board that the physician has completed fifteen hours of baord approved continuing medical education in medical recordkeeping .
- The physician within twelve months shall submit satisfactory proof to the board that the physician has completed twelve hours of board approved continuing medical education in treating patients with acute and chronic pain and addiction medicine .
- The restriction as per Term #1 shall be terminated upon the physician's completion of the required continuing medical education.
- The physician within six months from the termination of Term #1, shall have an inspector/investigator from the Department of Health Professions obtain copies of ten randomly selected, complete medical records including records/reports of any other treatment providers/consultants of patients treated by the physician for acute and/or chronic pain.
July 13, 2010-Term #1 Terminated
The physician has completed all of the required continuing medical education. The Virginia Board of Medicine has terminated the restriction prohibiting the physician from prescribing Schedule II controlled substances. The physician's practice shall be subject to an unannounced inspection and records review.
March 4, 2011-Probation Terminated
The physician has complied with the terms and conditions of the 03-31-2010 Order. The Virginia Board of Medicine has reviewed the report regarding the 02-01-2011 unannounced inspection conducted of the physician's practice. The Executive Director of the Virginia Board of Medicine has terminated the probation and terms placed on the physician's license. The physician currently has a full and unrestricted license in the State of Virginia.