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Fill-in doctors for Gosy gain appreciation of pain patients, practice and problems

The three doctors saw more than 200 of Dr. Eugene Gosy’s patients on their first day of filling in.

The patients came in walkers and wheelchairs, some connected to oxygen tanks and others to pain pumps. Several arrived hours before the 7 a.m. opening.

“It looked like Lourdes, except no one was throwing away crutches,” Dr. Robert Milch said of the broken and painful bodies.

Milch and two other doctors – Nancy Nielsen and Christopher Kerr – did not know what to expect on May 16, the day they stepped in as temporary fill-ins for Gosy. Federal prosecutors three weeks earlier accused Gosy of operating a criminal conspiracy, issuing more than 300,000 illegal prescriptions over four years.

When his office closed, 9,500 patients were left without their pain doctor, and many were dependent on or addicted to narcotic painkillers. They were panicked over the prospect of withdrawal and who would treat them. The fill-in doctors’ encounters with Gosy’s patients have led them to question their preconceptions.

“I thought I was going to see 35-year-old guys on workers’ comp who didn’t want to go back to work,” Nielsen said. “That is not what I have seen.”

On that first day, the fill-in doctors worked 10 hours, along with the eight nurse practitioners and physician assistant in the office.

Patient after patient told the doctors they were grateful for the help.

“Some of the things we saw were inspirational,” Milch said.

Some things weren’t.

The doctors encountered several patients trying to scam them for drugs. One patient ranted at the staff out of frustration. Another, angry over the closure of the practice, threatened to harm Gosy.

Three weeks since they arrived, the three fill-in doctors are impressed with Gosy’s practice and the safeguards he put in place to spot drug seekers.

And they have gained a better understanding of the scope of the opioid problem, which Erie County Health Commissioner Gale R. Burstein last month called “a public health crisis.”

The problem

Gosy was the repository for all the cases doctors in the community didn’t want. The patients are legitimate and have nowhere else to go. Given the shortage of addiction treatment services, they can’t just be told to get off the drugs.

“These patients are really refugees in the medical system, unable to find a home,” said Nielsen, who played a key role in arranging the short-term fill-ins to keep open Gosy’s practice.

“The patients had no warning, had no ability to find alternative arrangements,” she said. “This is a 75-day plan. What we’re doing is putting a tourniquet on the bleeding.”

The three doctors who are filling in are medical veterans.

Kerr is chief medical officer at the Center for Hospice & Palliative Care. Milch is the organization’s co-founder and former medical director.

Nielsen is the senior associate dean for health policy at the University at Buffalo’s Jacobs School of Medicine and Biomedical Science. She also ran a private internal medicine practice for nearly two decades, worked as the chief medical officer of Independent Health, served as an officer in the state Medical Society, and in 2008 served as president of the American Medical Association, the nation’s largest physician organization.

They had to adapt quickly to unfamiliar surroundings and patients they didn’t know.

“We were so unknowledgeable. We had to tell the staff to walk us through everything,” Kerr said. “I’m more than a little impressed by the quality of the practice. The nurse practitioners – they are really, really good.”

The pace didn’t let up. Front office employees worked 17-hour days until 11 p.m. At one point, the volume of calls – 900 people on hold – crashed the phone system. “The staff has been trying its best,” Nielsen said.

Every day that Gosy’s office was closed meant more of his patients were running out of medication. Many rationed their prescriptions and tried in vain to squeeze into the packed offices of other pain specialists in Western New York. They began to show up in emergency rooms. One former patient went into a Lockport hospital with two rifles demanding drugs. Concern grew that it was only a matter of time before patients turned to the street to buy narcotics.

The doctors are not commenting on Gosy’s legal case. But they have a lot to say about the patients.

“A contradiction exists between the way these patients have been characterized and how they actually appear,” Kerr said. “What is most impressive is that we have yet to see a case that is not striking in its authenticity.”

The patients

On that first afternoon, the doctors were running 90 minutes behind, so Milch went out to the waiting room to explain and apologize. The 20 waiting patients applauded.

Milch visited the waiting room again after 5 p.m., when a woman apologetically told him she couldn’t wait any longer because her daughter was graduating from nursing school and the ceremony was set to start in 30 minutes. Two people gave up their place in line for her.

Certain patients stick in their minds. They include the man with four failed back surgeries who talked about how pain treatment allows him to spend time with his grown children. An older woman described struggling into compression stockings every morning before she can get out of bed. They saw one man who has been on an opioid for an unheard of 30 years because of a painful injury. He has built up tolerance over that time, meaning the drug is less effective, and he self-induces his own abstinence program to show that he can periodically go off the medication.

Kerr added, “The patients we see in hospice are trying to find their way to grace and comfort. These patients are struggling with function in the face of adversity. They are trying to be parents, trying to be employed.”

Getting Nielsen, Kerr and Milch in place to oversee Gosy’s practice on an emergency basis was no simple thing.

“Mountains were moved to get this done,” said Dr. Timothy Gabryel, president of the Medical Society of the County of Erie.

The response

After Gosy’s indictment, officials recommended that patients consult with their insurance company, primary care physician or health centers for assistance in finding new pain treatment.

But any expectation that other doctors could or would take on Gosy’s patients turned out to be unrealistic.

The remaining pain-management specialists in the region are saturated with patients. Primary-care physicians, usually the first stop for common medical problems, are increasingly reluctant to prescribe opioids.

Chronic pain can be difficult to diagnose and treat. Experts say more training is needed. And the prosecution of physicians has had a chilling effect.

That’s why more than 2,000 physicians in the Buffalo area referred chronic pain cases to Gosy & Associates, according to his attorney, Joel Daniels.

As Kerr put it, “Gosy never said no. His practice became a repository for the symptoms others didn’t want to look at.”

Alarmed by the size of Gosy’s practice and the potential for a crisis, officials at the Medical Society began to reach out to state agencies, health insurers and others in hopes of finding alternatives for the patients.

The medical society encouraged primary-care physicians to assist patients who had been seeing Gosy.

The Health Department secured a 30-day waiver, with the potential for an extension, to allow non-authorized doctors to treat and bill for Workers Compensation patients. The medical society also received assurances from the agency that doctors who prescribe controlled substances for Gosy’s patients will not fall under increased scrutiny if their usual prescribing pattern suddenly changes.

Dr. Paul Updike, a pain medicine and addiction specialist at Sisters Hospital, pulled together educational material to guide doctors in the management of chronic pain and addiction.

But even if the region’s doctors tried to absorb the material and the patients, they could never do it soon enough. So talk turned to finding a way to rely on the expertise of the nurse practitioners and physician assistant at Gosy’s practice. They knew the patients. Their office held the records.

The office staff

But obstacles stood in the way. BlueCross BlueShield removed Gosy & Associates from its participating network after the office closed without a contingency plan for the health insurer’s members, and state regulations require that nurse practitioners at a minimum maintain a collaborative relationship with a physician. On top of this, no pain-management specialist was about to ride to the rescue and supervise a practice under a cloud of suspicion.

So, Nielsen enlisted Kerr and Milch.

The two use opioids to relieve pain – in different circumstances – and were willing to help.

BlueCross BlueShield reinstated the practice in its network. Medical credentialing and malpractice insurance were speedily arranged.

Nielsen praised the cooperation of insurers and government agencies to get things done.

“Good people exist,” she said. “People didn’t know exactly what to do, but they knew something needed to be done.”

The next steps

To Kerr, the unfolding events underscored a deeper problem. Doctors don’t want to treat chronic pain, he said.

From his own experience, he noted that half of the calls to hospice result from physicians’ unwillingness to write opioid painkiller prescriptions for patients at the end of life or suffering from terminal illnesses.

“There is no consequence for not treating pain,” Kerr said. “And, there’s no equivalent in medicine. You can’t say you won’t treat hypertension or diabetes.”

The doctors remain worried about what will happen after the relief effort at Gosy’s office ends later this summer.

An extension is possible. Others hope primary care doctors provide the pain-management treatment for more of Gosy’s patients.

But the problem is not solved, said Gabryel, president of the Medical Society of the County of Erie.

Gosy’s attorneys have said Gosy is looking at ways to keep the practice open, including a sale or partnership. But some of the nurse practitioners have left for other jobs, and more may go.

One proposal getting attention is to create a regional pain-management center tied to the UB medical school that employs a multi-disciplinary approach, balancing opioid medications with non-opioid pain-relievers, cognitive and physical therapies, exercise, acupuncture and other non-drug methods. But that is years away, and to become reality will require funding, changes in reimbursement and someone shepherding such a project to fruition.

Nielsen wrote a letter about what happened here to the current AMA president, Dr. Steven Stack. In it, she warned that if law enforcement authorities ramp up actions against doctors related to painkillers, steps must be taken to enlist other physicians to help patients left in the lurch.

“Having no plan is a true public health crisis, as patients will end up in the hospital, on the street buying heroin, or dead,” she wrote.