Are You Gambling On A Bad Doctor?

Physicians who break the rules can get away with just about anything. Odds are, their patients won't find out.

Susan Blake did not like what she saw in the mirror. The pretty 42-year-old, an account executive for a bank in Las Vegas, had been feeling awful for weeks. Now she was gaining weight and her hair had started falling out in clumps, symptoms of a sluggish thyroid.

She turned to her longtime doctor: Edward Hoffman, D.O., a charismatic 59-year-old whose practice, the Nevada Institute for Wellness & Longevity in Las Vegas, served as a one-stop medical shop. As an osteopathic physician, he had completed training equivalent to an M.D. and passed a comparable licensing exam but took a more holistic approach to care. From his well-appointed office, he gave cosmetic treatments such as Botox and dispensed prescription drugs as well as hormones, dietary supplements and vaccines, selling these in-house and saving patients a trip to the drugstore. In the early fall of 2004, Blake says, Dr. Hoffman prescribed her several pills in an amber bottle, claiming they would help her shed the unwanted pounds. She'd never heard of the drug, clenbuterol; the doctor's assistant flipped through a medical dictionary looking in vain for the proper spelling for the label.

At home, only 30 minutes after taking her first pill, Blake started to shake and swoon. Her pulse was racing. When she called Dr. Hoffman's office in a panic, his staff relayed his reassurance: Her body was merely getting used to the drug, and it wasn't necessary to go to the emergency room. But within an hour, Blake was worse. She was sweating profusely, and her face turned beet red. She says she called back and this time got the doctor on the phone. "Something is wrong," she told him. "I feel like I might be having a heart attack."

Dr. Hoffman assured Blake she was fine, she says, and simply recommended that next time she take half the amount. Shortly after hanging up, she felt her stomach turn: She almost didn't make it to the bathroom, throwing up so violently that vomit came out of her nose. "I thought I might die," she recalls. "I managed to climb into bed and stayed there for the next three days." Once she recovered, Blake decided to chalk up the incident to a freak reaction. After making it clear to Dr. Hoffman's medical assistant that she would never take clenbuterol again, she continued her regular appointments, including a scheduled Botox touch-up on November 29.

Two weeks after that visit, Blake's view of her doctor changed in a flash. She was working in her home office with the local news on in the background. "Investigators raided Dr. Hoffman's office," she heard, turning in shock to see footage of his locked-up doors. The state was probing whether Dr. Hoffman had given his patients drugs that the Food and Drug Administration had not approved for human use. clenbuterol, it turned out, is a veterinary drug approved solely to clear obstructed airways in horses with lung disease; its frightening side effects in humans include irregular heartbeat, tremors and interrupted breathing.

Officials also suspected that instead of Botox, Dr. Hoffman had dispensed a potentially deadly extract of botulinum toxin intended only for laboratory research. This Botox knockoff, already administered to patients by a doctor in Oakland Park, Florida, had left four people—including the physician, who had also given himself an injection—paralyzed and on ventilators from severe botulism poisoning. (All the victims survived, though one 34-year-old woman spent four months on a respirator, incapacitated and unable to speak.)

Now Blake feared that both the weight loss pills and the Botox she'd taken were in fact dangerous mystery substances. "My heart was in my shoes," she recalls. She called the Nevada State Board of Osteopathic Medicine in Las Vegas, which licenses Dr. Hoffman and whose executive director she had seen interviewed on the news. Her sobbing phone call was taken by John Hambrick, a beefy, white-haired Secret Service agent now working as the board's investigator. He quickly involved an alphabet soup of federal and state agencies. The Centers for Disease Control and Prevention in Atlanta had a botulism antitoxin at the ready, to be used if Blake developed signs of paralysis, which could freeze her muscles and in a severe case shut down her breathing. Blake got a printout of the dreaded symptoms and taped it to her bathroom mirror.

Symptoms of botulism poisoning can take anywhere from a few hours to two full weeks to emerge, and it was a month before Blake could truly relax. She returned again and again to the mirror, gazing for hours at a time at her features for any hint of drooping eyelids, frozen face muscles, difficulty swallowing or other symptoms. "It was terrifying to just not know, " she recalls. "How can you enjoy anything when you think you're going to be paralyzed at any moment?"

Over the next months, as the investigation of her doctor unfolded, Blake wondered: Had there been warning signs that she overlooked? Had she put too much trust in Dr. Hoffman? Then again, what was not to trust? He had given her excellent care for 13 years and also treated her mother and brother. "He was not just someone I had picked out of the yellow pages," she says. "When you have a doctor you trust, it's not like you're in some back alley. Why would you question it?"

But as the facts emerged, Blake learned that she knew little about the doctor she'd come to rely on. Dr. Hoffman was already well known to investigator Hambrick: More than two years before the state searched his office, the Nevada State Board of Osteopathic Medicine had received a complaint that he'd had an affair with a patient, an ethical violation. These and other allegations had led the board to order him to undergo psychological evaluation and treatment. Investigating the doctor was, according to one board member's report, akin to "an archaeological dig—as each new allegation came to light, more and more violations were revealed." The scenario playing out with Dr. Hoffman was depressingly familiar: A popular doctor with a loyal following skirts trouble for years—until the risk to patients becomes too great to ignore.

State and federal prosecutors have the power to pursue doctors who break the law. But in many cases, the first line of defense in policing physicians is a state medical board. These boards are funded by state legislatures, comprise primarily physicians appointed by the governor and have the authority to investigate complaints, weigh evidence at triallike hearings, discipline doctors and, if need be, revoke their licenses. But critics say they are far too reluctant to wield this authority. "Licensing boards have become lily-livered," says attorney Philip K. Howard, chairman of Common Good, a nonprofit organization in New York City that promotes legal-system reforms. "If they allow a doctor to keep his license, few people will complain, whereas if they try to take away the license, the doctor will drag them over legal coals for five years."

Although medical boards have "great clarity" about their duty to safeguard the public and little inclination to protect bad doctors, they must also be fair, says Dale Austin, senior vice president and chief operating officer of the Federation of State Medical Boards in Dallas. A doctor's right to due process means that medical-board hearings are often "tedious, long and expensive," Austin says. Most medical boards have limited resources, so they may not be able to afford more than a few each year. The Nevada osteopathic board gets about 65 complaints a year, but only three osteopaths have lost their licenses in the state in the past three decades.

There is also an inherent conflict in the current system of doctors disciplining their colleagues, says Timothy S. Jost, a health-law professor at Washington and Lee University in Lexington, Virginia. "Doctors are reluctant to punish their peers, because they realize they make mistakes, too," says Jost, who served as one of the few nonphysician members of Ohio's medical board for five years. As a result, states rarely suspend or revoke a license after only one instance of misconduct. "You have to prove two, three, four cases of medical malpractice," he says. "You have to convince a board of doctors that this doctor is different from them."

Many of Dr. Hoffman's patients viewed him as a New Age Marcus Welby. The physician was a convincing advertisement for his own wellness regimen: He dressed with casual elegance, competed in triathlons and projected an easy charm and a competent air. The slim, bespectacled doctor also had a widespread reputation for compassion and, as several patients tell it, a kind of sixth sense as to what ailed them. Scott Dockswell, an entrepreneur in Las Vegas whom Dr. Hoffman diagnosed with advanced hepatitis C, says that even after he traveled out of state to undergo a liver transplant, Dr. Hoffman called three times a week to check on him. "The surgeons all knew there was somebody who loved me, was looking over me," Dockswell says.

So when the first charges of impropriety against Dr. Hoffman emerged, his loyal patients rallied to his defense. In September 2002, Bruce Familian, a Las Vegas businessman, filed a complaint with the osteopathic board alleging that Dr. Hoffman had an affair with his wife, Arlene, while both of them were his patients. (Familian reportedly discovered this betrayal in part because his sex life with his wife had deteriorated—and when he asked Dr. Hoffman for a Viagra prescription, the doctor refused.) Such an interaction would have been a flagrant violation of the doctor-patient relationship as spelled out by the American Medical Association and the American Osteopathic Association, both in Chicago, as well as every state medical board. "It is completely improper for doctors to have a sexual relationship with a patient, for the same reason that doctors are urged never to treat family members," Hambrick says. "Their judgment and their decisions could be clouded, maybe to the detriment of their patients."

Doctors can skirt trouble for years, until the risk is too great to ignore.

Dr. Hoffman's lawyer, Michael J. Rovell of Chicago, says that Dr. Hoffman's only indiscretion was to date Arlene Familian 10 months after he'd treated her for a broken toe, when she was no longer his patient. "This is supposed to be Sin City, and—news flash—two people who weren't married [to each other] had sex," he says, adding that Dr. Hoffman was "by all accounts an extremely fine and dedicated doctor." When Dr. Hoffman told Blake that a disgruntled husband was trying to take his practice away, she sent the osteopathic board a letter supporting her doctor. She was one of 75 patients to do so. "At that point I was thinking, Poor Dr. Hoffman. He never had any problems, and now this person is trying to ruin his career," she says.

But behind the scenes, the osteopathic board was turning up far more troubling reports of impropriety: that Dr. Hoffman had been sexually inappropriate with several female patients, even exploiting his relationships by prescribing medications in return for sexual favors. One patient told investigator Hambrick that she had dated Dr. Hoffman while in his care. His advances were not always welcome: A former patient told Hambrick that on one occasion, Dr. Hoffman "asked me to kiss him." When she refused, "he asked me for at least a hug."

One former girlfriend of Dr. Hoffman's who was not his patient (and who asked SELF not to identify her) describes Dr. Hoffman as unstable and unethical, saying he had gone "absolutely crazy" from injecting himself with testosterone and human growth hormone. (Dr. Hoffman has said he needed shots for "diminishing testosterone levels.") And one of Dr. Hoffman's three ex-wives, Carol Gibbons of California, says he left her for a patient. Gibbons, who also worked in Dr. Hoffman's office for a time in the early '90s, describes him as kind, attentive and full of fun with his patients. But, she says, he was also sexually compulsive and unconstrained by any authority but his own. "He doesn't think he has to do things the way everyone else does," she says. "He decides with his own judgment what he can do." For his part, Dr. Hoffman questions Gibbons's credibility, saying they broke up under completely different circumstances and that other employees have found his office behavior to be exemplary.

In 2003, the osteopathic board filed its initial complaint against Dr. Hoffman, accusing him of having sexual relations with two patients. (The panel decided proof was not strong enough to charge him with bartering drugs for sex, a claim he strongly denies.) In January 2004, the board expanded its investigation to include attempted bribery, after Dr. Hoffman allegedly contacted the board's executive director, Larry J. Tarno, D.O., and, with the investigation ongoing, offered him a lucrative business opportunity. Board members did not ultimately bring bribery charges, however, and by April 2004, they had amended their complaint: They reduced the charges of sexual misconduct to one count and added new charges of professional incompetence, making a false statement on a license-renewal application and failing to report a complaint for medical malpractice.

To assess Dr. Hoffman's potential to cause harm to patients—and the likelihood he would change his behavior—the board required him to have a psychological evaluation. Dr. Hoffman traveled to Lawrence, Kansas, to the Professional Renewal Center, a facility treating troubled professionals. Its patients, 90 percent of whom are doctors, arrive with problems such as substance abuse, disruptive behavior or sexual and ethical violations, explains CEO Kirsten Judd. The center, which Judd founded in 2000, treats about 150 doctors each year. Some are facing discipline by medical boards; others are sent by physician-health programs designed to intervene and help doctors with behavioral problems before it's too late.

Treatment programs targeting troubled doctors have expanded in recent years, with growing recognition that health care providers are a distinct population that needs help. Hospitals and practices often put so much pressure on doctors to see as many patients as possible that they suffer burnout from the constant work, Judd says. "Doctors are the worst at taking care of themselves," she says. "They neglect themselves first, their families second, and it becomes a train wreck once they start to lose control." Most doctors who undergo psychological treatment become committed to changing their behavior and rebuilding their life, Judd says.

In Dr. Hoffman's case, the center's four-day assessment by a psychiatrist, psychologists, doctors and social workers found that he had significant narcissistic traits and could not practice medicine safely. The evaluation noted his "illogical rationalizations," "very poor professional boundaries" and "tendency to overlook ethical matters." On a positive note, the center's experts deemed him "far too naive to be a predator" and estimated that he would be a good candidate for rehabilitation. They recommended an intensive, residential program of psychological treatment.

The analysis distressed Dr. Hoffman. "They sent me to some small town in Kansas where this guy hated me," he told SELF, referring to one of the clinicians. Although the center's psychologists were supposed to do an unbiased evaluation, Dr. Hoffman argued, they relied only on information from people who disliked him. Nonetheless, he agreed to follow the recommendations as part of a settlement with the board in the spring of 2004. He conceded sexual misconduct and agreed not to practice medicine until he had completed the recommended treatment program to address his boundary issues and had gone before the board again so its members could decide whether to put restrictions on his license. The board dropped all other charges.

Dr. Hoffman chose to undergo his treatment at Professionals at Risk Treatment Services, a center in Elmhurst, Illinois, similar to the one he attended in Kansas. But the doctors there were not impressed with his progress: Dr. Hoffman frequently fell asleep in group therapy and dropped out after eight and a half weeks of the 10-week program. He would later say that he suffers "a mild form of narcolepsy" and that, as in Kansas, the staff in Illinois was unfairly hostile to him. The program's medical director and Dr. Hoffman's case manager wrote in their joint discharge summary: "Dr. Hoffman's narcissism is profound. This, coupled with his need to use others' vulnerabilities to foster their dependency upon him, presents a major obstacle to patient safety.... He remains at risk for committing boundary violations as he was reluctant to fully accept responsibility for his actions."

Theoretically, Dr. Hoffman's practice of medicine should have ended there: He had failed to meet the medical board's requirements. But the board relies mostly on the honor system to make sure its orders are followed. In August 2004, Dr. Hoffman returned to Las Vegas and resumed his practice—without another hearing as the board had mandated. "When I agreed not to practice osteopathic medicine," Dr. Hoffman later testified, "I didn't apparently understand that I was supposed to close my doors and fire three girls, two of which are single moms."

One of those "girls" is Diane Lagpacan, who had worked for three years as a medical assistant to Dr. Hoffman. She, too, had signed a letter of support to the board when he faced the allegation of sexual misconduct, believing he had the best intentions. But Lagpacan, who did not return numerous calls for comment, would eventually become an important witness against Dr. Hoffman. Before and after he returned from Professionals at Risk, she would testify to the board, the doctor was purchasing deeply discounted and unapproved medicine over the Internet and from unscrupulous companies and dispensing it to his patients at a considerable markup. He continued these treatments even after patients complained about side effects, she said.

It was during this time that Blake went to Dr. Hoffman for a weight loss consultation and emerged with clenbuterol. Dr. Hoffman has testified that, contrary to Lagpacan's and Blake's version of events, he wasn't in the office that day, and that Lagpacan dispensed the drug without his approval. The steroidlike compound is so dangerous that in Spain in 1990, 135 people were hospitalized after eating beef liver from cows who had been given clenbuterol. Today the FDA limits its use to horses, who take it in liquid form, because they are not food-producing animals. Although clenbuterol's purported fat-burning powers have spurred an online black market for the drug in pill form, Hambrick says, "it is not authorized in this country, period."

Any doctor selling drugs from his office is suspect, one expert says.

Blake had found it convenient that her doctor sold the nutritional supplements, hormones and weight loss medicine he recommended. But internist Robert Baratz, M.D., president of the National Council Against Health Fraud in Peabody, Massachusetts, argues that doctor-to-patient sales can be dangerous and coercive. "In most states, doctors are not allowed to profit from selling drugs in their office," Dr. Baratz says. The practice is legal in Nevada. Nevertheless, says Dr. Baratz, "these rules came about to prevent coercion and conflict of interest. Any doctor who is dispensing drugs from his office is suspect, and if this drug is not in a package with an FDA label, it should be very suspect."

In the fall of 2004, Dr. Hoffman purchased $6,080 worth of botulinum neurotoxin type A from Toxin Research International in Tucson, Arizona. It wasn't his first purchase; he'd heard doctors affiliated with the company extol its virtues at a seminar a year earlier. One told him the product "was a generic form of Botox," as Dr. Hoffman later testified. It was not. The doctor purchased the substance at a significant discount compared with brand-name Botox and his practice gave it to some 30 patients, charging them the same price as for the authentic injections, according to Lagpacan's testimony. Dr. Hoffman said he never saw the vials or sales receipts, both of which were labeled "not for human use." (The doctors who sold him the fake Botox pled guilty to numerous charges in a federal court last year, and three of them received jail time.)

The Internet offered further financial opportunity. That November, Dr. Hoffman set up a website, IndecentSex MD.com, on which he sold impotence drugs such as Cialis and Viagra. Lagpacan said she filled at least three orders through the website. Dr. Hoffman also took advantage of a nationwide shortage of flu vaccine: He purchased and gave at least 36 patients Canadian-made vaccine that was not approved by the FDA for use in the United States. The vaccine arrived at his office in a plastic bubble envelope with a handwritten mailing address, Lagpacan told investigators. By contrast, legitimate flu vaccine arrives carefully packaged in dry ice.

On November 18, a local news channel aired a segment about Dr. Hoffman's office doling out the unapproved vaccine. (Investigators believe the tip to the news program may have come from inside Dr. Hoffman's office.) Angry patients began calling, concerned about their health. Unfortunately for Blake, she missed the TV segment and would remain in the dark, at least for a few more weeks, about her doctor's lapses. But someone else was watching: By now, the medical board was awakened to the fact that Dr. Hoffman was still practicing medicine, in defiance of its orders.

In the spring of 2005, Dr. Hoffman and his lawyers gathered in a Las Vegas conference room for an administrative hearing, where a jury of fellow osteopaths would decide whether to revoke his license.

It seemed certain that Dr. Hoffman's luck had run out. Privately, one of the board members predicted that Dr. Hoffman would lose his license. This time he was facing charges of administering unapproved medicine to patients and violating the original settlement with the board. And Blake, furious over her treatment, had agreed to testify against him. She proved to be a composed witness on the stand, only showing flashes of anger when grilled by his lawyer. All along, she had thought Dr. Hoffman was an excellent doctor, she explained, until she learned that "I was being used as a guinea pig."

The accused doctor appeared alternately defiant and sorrowful. At one moment during a break, he regarded the inelegant necktie of the board's executive director, Dr. Tarno, and joked, "I'd send him a new tie, but then he'd accuse me of bribery." At another point he tearfully pleaded with Dr. Tarno, "What can I do to put this to one side?"

Misunderstandings, betrayals by his staff and errors in judgment had led to his current predicament, he told the board. His defense asserted the violations were technical and not substantive and that, on his return from the Professionals at Risk program, he was not truly practicing medicine but merely referring his VIP patients to other doctors. He alleged that his accusers had ulterior motives: that Lagpacan was vengeful because he'd denied her a bonus and that Blake had taken other dangerous supplements and those, not the clenbuterol, had triggered her reaction. (She strongly denied this on the stand.) He even argued at one point that Lagpacan and others who worked with him had gotten hold of his prescription pad and forged his signature. Ultimately, Dr. Hoffman pleaded to keep his license, telling a silent room, "I've been a doctor my whole life. It's the most important thing that defines me."

The ruling came in late May: The board found Dr. Hoffman guilty of practicing medicine in violation of its order and of using non-FDA-approved medicine. But it did not revoke his license. Instead, the panel voted to formally suspend his license but spelled out a way for him to win it back: He would need to successfully complete another three months at least of intensive psychological treatment at a residential facility, undergo another hearing and then practice under probation for three years.

Doctors are loath to take away a colleague's only means of making a living, Dr. Tarno acknowledged; Dr. Hoffman had put in years of education followed by three decades of practice. Although he acknowledged that the board "had good reason to be a little tougher on him," he added, "I don't think that anyone felt that he should be executed." But Arthur Caplan, Ph.D., chair of the department of medical ethics at the University of Pennsylvania in Philadelphia, argues that the punishment meted out by state medical boards is often too weak, putting patients at risk. "That doctor should not be in practice," he says. "He should be working at a McDonald's by now."

Even as Dr. Hoffman embarked on yet another treatment program in Texas, he appealed the board's decision, alleging bias, and won a partial victory. The judge required the board to redeliberate its final order. In May 2006, Dr. Hoffman finally settled the case, agreeing among other conditions not to prescribe clenbuterol or any other non-FDA-approved substances, to limit his practice to medicine (rather than profit-generating weight loss, cosmetic or antiaging treatments) and to have his charts monitored by fellow physicians for three years. He is also paying the costs of the investigation and hearing, which totaled $89,000. Combined with the costs of another drawn-out case, Dr. Hoffman's saga so swamped the board that it laid off its only investigator, John Hambrick, bouncing his final paycheck. The board replaced him with freelancers.

Blake has found a new primary care doctor to treat her underactive thyroid, is feeling less run-down and is working to lose weight without the help of mystery pills. She remains furious at the medical board for its decision. Why had she bothered to testify if this outcome was even a possibility? "To me, it was a group of doctors covering one of their own," she says. "He deserves a second chance? To kill someone, I'm thinking."