I am in my second year of law school and what strikes me over and over is the lack of due process in Administrative Law. For me this became acute in my dealings with the Board of Medicine and watching colleagues around the country as they navigate their respective Boards of Medicine and the DEA. It is not just medicine and it is not just at the state level. The very foundation of this country is being mocked daily. The level of Fourth Amendment violations is astounding.

The DEA made a surprise visit to my office yesterday. This apparently was prompted because a vendor reported a suspicious order – AN ORDER THEY DID NOT COMPLETE. I tried to order a vial of ketamine to do infusions for depression.  I did this because the psychiatric hospital that was doing them, 1.5 hours away, abruptly stopped their ketamine clinic when the physician who ran the program resigned. The patient found me because I received my REMS certification for Spravato – a new FDA approved drug, a nose spray, a derivative of ketamine that is very expensive ($4700/month).  He had had a fantastic response to ketamine, which was life altering for him, after 30 years of debilitating depression from bipolar disorder. He was now overdue for an infusion, and was spiraling down, becoming more depressed with suicidal ideation. He was being treated by a nurse practitioner who was only treating him with a single agent for his bipolar disorder, which I did not feel was adequate. I agreed to treat him and told him I wanted to take over all the treatment.  I ended up ordering the ketamine from a pharmacy that also gets Spravato, we simply had the patient pay for it ($14 which covers several infusions) and they sent it to the office. The patient has had a fantastic response to the infusions. I am using the protocol most sites have used – twice weekly for one month then monthly infusions at 0.5mg/kg infused over about 1 hour. We monitor vitals (BP, 02sat, pulse). We do have an AED, ambu bags, ACLS meds, EKG, and between my RN and me are ATLS, ACLS, PALS and NALS certified, though at such a low dose, ketamine thus far has shown to be quite safe. The side effects in the studies of both ketamine and esketamine have been hypertension, dissociation and sedation. We monitor patients for 2 hours. We also have one patient recently started on Spravato and we are following the REMS protocol for that patient, who is also responding quite well.

The DEA agents came in, told me that this vendor had alerted them that I ordered ketamine, which they found “suspicious”. I laughed because the patient was upstairs in our infusion room. The agent then went on to state that she then investigated further, saw my consent agreement with the state Board and had questions about my methadone prescribing. She had allegations that were false, so I corrected her. Many notes were taken. I told them which controlled substances are on site, how we account for them, how we document, what procedures we do, and everything else. I offered to show them our narcotics cabinet and documentation, the agents declined stating that would require paperwork. I am fully aware they could come back with that exact paperwork, so their declination does not mean all is over. For those wondering, I called my attorney who was on speaker phone through all of this. I will never speak to anyone without an attorney present and advise the same for all others. No agency is your ‘friend’ in medicine. No call is innocent. Do not speak, do not answer without an attorney. Take it from those of us who made that mistake.

What really shocks me is that the vendor did not bother to contact me. If they had concerns why was there no communication? Why have they not assigned a sales person to my office? What has happened to customer service? Clearly for physicians there is none. I understand the need to report, and that everyone is doing their job but had there been any sort of communication, all of this would have been avoided.

This follows the adage of no good deed goes unpunished. The patient has offered to testify on my behalf should that become necessary. He jokingly said to bill his insurance company for a higher rate – oh if only I could. Yes indeed this is another unfunded nuisance. It happened during office hours, meant no lunch for me, and yes I went and drank at the end of the day – being the lightweight that I am 2 drinks was all I needed to rid myself of the angst from the DEA showing up at my office. Law school cannot start soon enough.

Yonden Lhatoo, a writer for the South China Morning Post, recently quoted Mike George’s ‘How to Be An Alien’ – a book from 1946. It was so on point, I decided to read it. Mr George emigrated to England and authored many books. This book is a short piece, that continues to be relevant today. I would never have found this charming example of humor, save for my younger son introducing me to Mr Lhatoo’s voice – both are an excellent addition to my repertoire.  

It dawned on me while starting to read ‘How To Be An Alien’, that being ‘from away’ in Maine is precisely the same thing as being described in the book. I may be American, but I will always be an alien here in Maine. I don’t need a visa to live here nor a passport to cross the border into Maine; I invested all my money to purchase land here, I came here for purely altruistic reasons, but none of that is considered by those who are native Mainers. All they recognize is that my family is not from here. We are not fishermen, farmers nor the like.  It is quite the opposite of the cities I have spent my life in, and gives me a small taste of what those who have emigrated to the United States from foreign lands have confronted. Additionally, Mainers eschew differing opinions – especially strong ones, critical ones, if you are ‘from away’. 

As  with the aliens in Mike George’s book, once ‘from away’, always ‘from away’. There are Mainers who will invite you into their homes: they collect us, like pets.  So rather than the British being nice and treating an alien with condescension, it is a Mainer who deems to be nice to one of us ‘from away’ – and of course the condescension is present. We will always be ‘from away’. We are the aliens in Maine. Just as imitating the British makes an alien more ridiculous than not, imitating Mainers is replete with the same consequences.

The irony, is that without new blood in Maine, whether American or foreign for that matter, without people from away, Maine is dying. Literally. Maine is the second oldest state in the nation. Maine will be bankrupt and die off without an influx of newcomers.

In cities, and almost everywhere I have ever lived, education is admired. Here, in Downeast Maine, education is scoffed at – one is considered arrogant for being educated. Opinions are stated as facts, and given the same weight, particularly if one is a Mainer, missing several teeth, but has relatives that date back to the Mayflower.  Truth is a relative term. Mainers will tell you their truth, which is usually not the truth at all. It will be whatever gets them what they want.

We do seem to have the same fascination with the weather here in New England as our forbearers in England did. Mr George’s chapter on the weather could almost be transplanted with some minor variations for linguistic colloquialism.   Downeast Maine, being on the coast, has separate weather from the rest of Maine, and often forgotten by the forecasters. Rather than the caste system of England, ours is geographical, determined by maritime weather and the divide of route 9. 

Downeast Mainers eat most of their food fried, or drenched in mayonnaise. Even the wonderful fresh seafood they just caught – what is the point? Here they have this lovely, fresh-off-the-boat haddock, and they treat it like it has been in the freezer for 2 years, in a block of ice, by dredging it in batter, and deep frying it, until it resembles any other deep fried fish. This is the only successful type of restaurant to be found. Lobster is turned into lobster roll – drenched in mayonnaise and put on a hot dog bun. One can no longer tell that it was just swimming in the ocean a few hours ago.  Only those of us from away appreciate the freshness of the seafood and prefer to eat our food unadulterated. Alas we must do that at home, or in the few restaurants that cater to tourists: open only in the summer months.

Perhaps because of the the remoteness of Downeast, people are unwilling to be uncoupled. They have the next relationship lined up before they have exited the last one. It is quite disconcerting to observe (even worse to see the patterns of sexually transmitted infections). Some stay in relationships while each member is allowed to have their dalliances – I supposed that is not unique to this region – however, it is done so brazenly here in a small towns, where everyone knows everyone else, or might even be related to everyone else.

The biggest tell of being from away is the lack of a Maine accent.  If you can say the word “here” as one syllable instead of two you are not a Mainer. 

The following paragraph I have to quote in its entirety. Even though written in 1946, about England, it is true today about Maine, particularly if you are a woman from away: 

“In England it is bad manners to be clever, to assert something confidently. It may be your personal view that two and two make four, but you must not state it in a self- assured way, because this is a democratic country and others may be of a different opinion.” (p. 36 How To Be An Alien)

The largest difference is, of course, that an alien can become ‘naturalized’ – they can become a citizen of their new country. The same cannot be said of a move to Maine. No matter how long I am here, no matter that I own two properties, rent a third, provide jobs, live here, work here, pay taxes here, no matter how long I reside here, to Mainers, I will always be ‘from away’. Therein lies the rub. This attitude is what keeps Downeast in particular from progress.  This lack of welcoming outsiders into the community keeps Downeast Maine from development and aid. It pushes clinicians, innovators, entrepreneurs, venture capitalists and anyone who even thinks of pouring their hard earned capital into the region from investing.

By Stephanie Warner

Those unfamiliar with the bird world may be unaware that certain vicious bird species have propagated unchecked and have now invaded other ecosystems to quench their ravenous hunger. One such species—Big Bad Board Buzzards—feed almost exclusively on canarius doctorensis—harmless little birds who sing sweetly. Although there are rules and laws which constrain the predators from excessive canary consumption, the predator population has become too large and hungry to care about things such as statutes, ethics and civil liberties. NO canary is safe any longer.  

And I should know, because I used to be a little bird in a hospital cage. I never thought about flying away, because I thought that all doctor canaries lived in cages. I hopped about, pecking at bird seed and chirping at my little canary colleagues. We typed long notes all day on canary-unfriendly EMRs long after we were supposed to be flying home. We never sang, because only disruptive canaries sing aloud, and because singing attracts canary predators. These scavengers cannot tolerate canary songs; in fact, they cannot abide canaries, period. They much prefer nurse “practitioners” and physician assistants, because these species either cannot sing—or they cannot sing very well.    

One day when I was quietly pecking about without making a peep, and trying very hard to be an inconspicuous  canarius doctorensis, a Big Bad Board Buzzard swooped down out of the sky–without any warning whatsoever–and snatched me from my little cage. But his vicious claws did not close around me tightly enough, and as I fell through his claws, I spread my little wings and flew away to a place where predators could not find me. And now I am as free as a bird, and I sing all day long. And all night, too. And until I draw my last little canary breath, I will sing more loudly than any canary has ever sung. And I hope my colleague canaries will take up the song and prevent the extinction of our species.   

Canary Song No. 1 “ Beware of Big Bad Board Buzzards” 

If Board Buzzards tried to eat me, then NO canary is safe. Because I am a cautious canary who has always deliberately flown beneath the radar. When that rogue Buzzard swooped down on me out of a clear blue sky on a lovely May day in 2018, I had been a successful physician for 28 years. I was board certified and current with maintenance of certification requirements. I had no history of psychiatric  problems or substance abuse. I had never been formally investigated by a board or any agency. I had no criminal record, and I do not even remember the last time I received a traffic ticket. I had no social media profile, nor did I advocate any medical opinions that could not be described as mainstream.  

Nevertheless, a birdbrained doctor I did not know told the Big Bad Board Buzzards such vicious lies, that all the Buzzards and even some of my canary colleagues thought I was either guilty or had somehow antagonized him. My protests that I did not know him—that I would not even recognize him in a perp lineup—were regarded as less than credible. I was thus doubly victimized by my inability to explain why the perpetrator had chosen to victimize me! 

The traitor bird claimed that I had a chronic benzodiazepine and a chronic opioid problem as well as a  substance induced mood disorder, which caused the Big Bad Board Buzzards to salivate uncontrollably in anticipation of a canary feast. They were too ravenous to be objective or even to follow the laws that regulate the hunting of canaries.  In spite of a preponderance of exculpatory evidence during the “investigative phase,” the board NOT ONLY proceeded against me, BUT ALSO deprived me of my livelihood by declaring “emergency action” against my license. The Board Buzzards further ignored state statutes giving me the legal right to attend such a meeting; indeed they did not communicate with me at all. They even flagrantly violated the law requiring confidentiality of proceedings prior to final determination. And they did all this under the watchful eyes of the  Board Counsel, a  raptor who was supposed to have kept her eagle eyes on the Buzzards to ensure that all canary murders conformed to legal parameters. In the absence of outside regulation those Big Bad Board Buzzards  can prey on any little canary they want, any time they want, EVEN if the little canary is just pecking away in the dirt and not bothering anyone at all—EVEN if the canary is not singing the songs all predators hate.   

I duly flew through all the hoops recommended my attorneys. I underwent an evaluation by the state Physicians Health Program (PHP) which was quite comprehensive. The avian addiction specialist concluded that there were NO past or present “substance use” problems—meaning that the Buzzards had no grounds to devour me. Even though the PHP is the organization charged with the evaluation and monitoring of canaries with  substance abuse problems, the Buzzards were so eager for a canary morsel that they claimed that the PHP  “must have missed something.”  I sang to my colleagues to appeal to the Buzzards to spare my life, and even though they risked personal dangers by attracting the raptors’ attention, more than a  dozen wrote to those Buzzards to refute their specious allegations. I spent hundreds of hours responding to those Buzzards and their Complaints. I underwent a neurological consult to prove that I was  not a bird brain and was “cognitively fit to practice medicine.” But the Vultures were SO hungry that they tossed legalities and good sense to the wind; they were too starved to think about anything but eating me alive and spitting my little bones out.  

The Buzzards subpoenaed medical records, pharmacy records, called former supervisors, and still could not find any evidence. Every subpoena and inquiry effectively notified the recipient that I was a “bad canary,” and this served their purpose of condemning me by insinuation without any evidence. I was forced to exhaust my savings to pay for legal counsel, unnecessary “evaluations” and the usual bills. I even had to liquidate retirement assets, because I had no income. I cried, and hopped frantically up and down and ruffled my little feathered wings in anguish, despair and total panic. Those Board Buzzards dismantled my life piece by piece–forcing me to watch helplessly as they stripped me of dignity, destroyed my personal and professional reputation, and robbed me of my savings and retirement income. I regretted the day that I had been hatched into this World! 

Four months after they declared “emergency action” against my license, those vultures were so desperate to find an excuse to eat me alive that they voted not to consider all the exculpatory evidence until I underwent  a 3-day “evaluation” at a Center for Bad Canaries, which was a humiliating and thoroughly terrorizing experience. I had to fly over 1,000 miles and across many state lines to find the Center for Bad Canaries, where they demanded most of my few remaining seeds for the privilege. Fortunately, as miserable as the experience was, those bloodhounds sniffed out the truth, and three months later their report shocked the Buzzards and the bird world: there was NO evidence that would allow the Board Buzzards to legally gobble me up. No signs of mental illness, dementia or substance abuse or even avian flu. NADA. I wish I could have seen the looks on those predators’ faces when they read that report, which exonerated me and indicted them. The report specifically referred to  the “emotional trauma” I had sustained as a result of the “lengthy board proceedings.” The Board’s elite evaluators condemned them, not me!  

Eight months or so after snatching me from my little cage, the Big Bad Board Buzzards dismissed all charges. Although they had no canary for dinner, those Buzzards cackled with evil glee, because they knew that they had ensured my demise by robbing me of the seeds I needed to survive the coming winter.  They further knew that no little cage administrator would welcome a canary that even Buzzards would not eat. And so the Buzzards turned their loss into a celebration. They sat at the Board table—greedily shoving more Danish into their caws and washing the pastries down with stale coffee—and congratulated each other for breaking another canary heart, for destroying the financial means of another canary family, and  for striking fear into other canaries who would surely learn how they had unlawfully gotten away with the annihilation of another canary—just because they could. No canary should every doubt that Board Buzzards are heartless scavengers who answer to no higher bird authority. 

And although I know that I shall surely starve without any bird seed or be attacked by a larger bird without the protection of my cage, the exhilaration of freedom pushes such thoughts right out of my little birdie head. Even if I sing alone, I will sing anyway, just because I can. And before I am done, Buzzards will be a joke in bird circles. 

Signed,
 A canary who found her voice and rediscovered her wings. 

Cathleen London, MD

Americans will not see single payer healthcare (Medicare for All or another iteration) any time soon due to greed. Too many people profit off the hard labor of clinicians, particularly of physicians. No, it is not physicians raking in the large pay checks, for that you will have to look to Chief Executive Officers of Insurance Companies, Hospitals, pharmaceutical companies, device manufacturers and healthcare systems. The profiteers. These are not the people delivering the care. They are the vultures. Physicians gave their power away decades ago, and our organizations did nothing to protect us. In fact, the larger organizations helped create the systems we now have. The only people benefitting are the executives and stock holders. Don’t expect it to improve anytime soon.

The way physicians are taught is not conducive to changing the system. Our focus is the patient, the disease process – we cannot dirty ourselves with profit and loss, or cost structures. We naively invited the business people in to do that work for us. They gleefully took over.  We have not learned. While the rest of the industrialized world enjoys universal healthcare and does not worry about how to pay for care when they are ill, Americans go broke.  Physicians are treated as commodities and squeezed harder and harder as they break. Physicians are centered on empathy and compassion and capitalism has taken every advantage.

Fewer independent physician practices now exist which is detrimental to patients (and costs). Reimbursement rates continue to decline with no recourse which puts physicians in untenable positions: stop taking insurance plans, become an employee, retire, change careers, or find additional income. This is true insanity. With at least 11 years training for each physician this is also an incredible waste of talent and resources.  Now we have midlevel practitioners  being churned out by online schools which is not a replacement for physicians nor the answer to the increasing shortage of physicians. Midlevel practitioners  order more tests, refer to more specialists clogging the pipeline for necessary care, and increasing costs. Where midlevels practice without supervision, care is often stunningly inadequate resulting in complications of chronic medical conditions that are otherwise preventable.

As long as we continue to elect politicians who are  turning America into an oligarchy our system will worsen. American medicine is but a symptom of the greater illness. The founders of the United States envisioned a Federalist Republic. They put in protections against the corruption humans are prone to. Despite this, we are witnessing our own downfall. We are watching as these checks and balances fail. 

So yes, I am painting a depressing, realistic picture. Until we as a nation hold politicians accountable for representing everyone nothing will change. Unless physicians take medicine back the spiral continues. Small starts, Direct Primary Care (physician run) are some answers to the catastrophe that has become American medicine, but the trajectory is worsening  before improvement. Despite the fact that the majority of Americans would favor a single payer system such as Medicare for All, we do not elect representation that will enact these proposals. Change takes action. Right now we have inertia.  

Is this the end of America as we know it? Has capitalism failed all but a few? Are we witnessing the fall of the Republic? Time will tell. I do think things will get worse, particularly for our patients. Treatments will become harder to afford, not because those delivering the care are being paid better, but because money is diverted to those that have learned to work the system the best. American exceptionalism indeed.

Dr London is a Family Medicine physician in remote Maine. Prior to moving to the hinterland she was in academic medicine for 20 years. She is mom to 2 sons and 4 rescue dogs

I have been a physician for 24 years. I have been a fierce patient advocate throughout my entire career. It never occurred to me that physicians do not have the same rights of citizenship that the very patients I fight for do. I always thought I lived in a democracy. Medicine is not what it used to be. Articles relentlessly speak of physician burnout as though we are responsible for what is happening but that could not be further from the truth. Other articles look for causes like the EHR (electronic health record). The problems are not the hours we put in – that we signed up for – starting with third year of medical school every physician got used to sleepless nights. Every physician has been through call and what post call days feel like. Regardless of specialty, somewhere in training there was sleep deprivation. That is not the source of burnout.

It is the progressive demoralization of our hard work to attain our degrees and position. We worked 80-100 hour weeks in training absorbing as much knowledge as we could, because we knew we were responsible for someone’s life, and after training we would be the final person in charge. That responsibility weighed heavily on us. We wanted to make sure we were optimally prepared.

Meanwhile, businessmen and women invaded medicine. People with no training came along and decided to tell us what we could and could not do. Though we had years of training, these people, essentially practicing medicine without a license, following some arbitrary protocol on a screen in front of them, would deny the medications and procedures and referrals to colleagues, we, with our training, felt necessary. 

To add insult to injury, legislators have jumped in, also practicing medicine without a license, and codified recommendations into law. Thus creating an atmosphere of fear on top of the demoralization that has already occurred. Boards of Licensure in Medicine (BOLIM), feeling a need to “protect the public”, yield a heavy hand against any such infraction they can find. Mind you no due process exists with licensing boards and no one oversees them. What used to be a process of correction has become so punitive and arbitrary that entire careers of good, caring physicians have been ruined.

This is not burnout. This is moral injury. This is the denigration of an entire profession. No other higher level degree profession is put through this kind of scrutiny and questioned at every turn. Demoralization compounds when those who have been through BOLIM processes get dragged through the press – and when BOLIMs continue their onslaught and family ask what you did to deserve this – as though you had to do anything.   Even physicians whose complaints are later dismissed find themselves branded when they apply for positions as this information is readily available.

When a BOLIM receives a complaint, they ‘investigate’ it. They act as investigative and adjudicatory arm. They are the investigator, jury, judge and executioner. There is a huge amount of subjectivity to the process and personal animus is clear. Watching careers ruined has given me a new purpose. This is happening all through the country and needs to stop. Physicians are a balance of empathy and scientific inquiry  – the persistent attacks are designed to kill – to demoralize, punish and drive physicians to harm. That makes these licensing boards not only operating outside the law but actually culpable. Driving physicians to suicide is murder.  Misusing psychiatry, the press to achieve these ends, violating right to privacy that everyone else in society has, violating right to due process, all of these together make them arms of destruction, bodies of harm – not bodies of protection and they should be held accountable for this harm.

To fix this will take a multi pronged approach.  We need to scrap the current State Boards of Licensure in Medicine and start over. Physicians deserve an open, fair process. We deserve to be innocent until proven guilty. Not every complaint deserves an answer. There needs to be screening. Lay people have no business being on these Boards as there often needs to be careful consideration of complex medical issues.  Physicians, like every citizen, deserve due process.  Too many physicians have been harmed. 

-Cathleen London, MD

The narrative is starting to come out that physicians are not ‘burning out’, rather we are suffering from moral injury. Most of us came to medicine quite idealistic. Many of us have remained that way. We are altruistic – we truly want to help people – that is why we studied hard in school, took exams, went to college, studied more, took more exams, went to medical school where we studied harder, slept less, took more exams. We understood that when we finished we would be responsible for people’s lives. We went on to further training – residencies of 3-7 years and some to fellowships beyond that. Those years, though we had our M.D.s, we practiced under more senior, experienced physicians.

Then insurance companies, administrators, and legislators came WITHOUT medical training and overrode our decisions, questioned us and equated us together with clinicians with far less experience – all to the detriment of patients and cost to the system. We have had unfunded mandate after unfunded mandate thrust upon us – EHRs whose real task is not to improve care, but to improve billing (and in some cases legal standing) have become more important than taking care of the patient in front of us.

As though all of that were not enough, what is NOT being discussed is the other dirty little secrets: sham peer reviews, subjective Boards of Licensure of Medicine and how good, caring, compassionate physicians are having their careers and lives ruined.

Physicians are not full citizens. We are the only group that is not afforded Due Process. We are guilty of accusations and forced to try to prove our innocence but often not even given that opportunity. Personal vendettas, opinions, differences of politics, all serve to force good physicians out.

This blog is a place for these stories to come out.

Thanks for joining me!

Good company in a journey makes the way seem shorter. — Izaak Walton