Charges against David S. Buscher, M.D. Dismissed
Stephen Barrett, M.D.
David Buscher, M.D., operates the Northwest Center for Environmental Medicine in Redmond, Washington. In 2014, Washington's Medical Quality Assurance Commission charged him with unprofessional conduct in connection with his management of two patients. The statement of charges (shown below) alleged that he fell below the standard of care by:
- Inappropriately diagnosing both patients with illness due to mold exposure
- Ordering unnecessary and costly testing
- Prescribing expensive non-indicated antifungal medications that caused both patients to have adverse reactions that were very costly and psychologically damaging
In 2015, following a hearing, the Commission concluded that Buscher "has a practice of ordering potentially unnecessary and certainly unusual laboratory tests." It also expressed doubts about some of his treatment practices. However, it decided that his use of non-traditional treatment in these two cases did not amount to unprofessional conduct and therefore dismissed the charges.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
MEDICAL QUALITY ASSURANCE COMMISSION
In the Matter of the License to Practice
STATEMENT OF CHARGES
Filed JULY 7, 2014
The Executive Director of the Medical Quality Assurance Commission (Commission) is authorized to make the allegations below, which are supported by the evidence contained in file number 2012-7950. The patient referred to in this Statement of Charges is identified in the attached Confidential Schedule.
1. ALLEGED FACTS
1.1 On November 9, 1978, the state of Washington issued Respondent a license to practice as a physician and surgeon. Respondent is board-certified in family medicine. Respondent has also received training in environmental medicine, and practices at The Northwest Center for Environmental Medicine in Redmond, Washington. Respondent's license is currently active.
1.2 During July/August 2012, Respondent diagnosed Patient A and Patient B with illness due to mold exposure. Respondent ordered unnecessary and costly testing and prescribed expensive non-indicated antifungal medications with little apparent benefit. Respondent's inappropriate antifungal treatment caused Patient A and Patient BV to have moderate to severe reactions, which were not Herxheimer reactions, and resulted in very costly and psychologically damaging experiences for both patients.
1.3 On or about May 27, 2012, Patient A visited a basement storage locker at her mother's condominium. Patient A reported immediately experiencing burning nose, ears and throat, and a sensation that her throat was swelling. Patient A went to the ER and was placed on a Z-Pak and prednisone 20 mg taper over three days, from which she reported' an immediate and complete resolution of her symptoms. About two weeks later, Patient A entered the storage locker again and all the symptoms returned. Patient A was treated with a higher dosage prednisone taper, experienced a psychotic episode as a result, and was seen in the ER twice on June 17, 2012. On the last ER visit, a CT was done.
1.4 On June 18, 2012, Patient A presented at Bellevue Ear Nose and Throat complaining of dizziness. Patient A reported experiencing vertigo from a few seconds to hours in duration, worse when walking. She described being constantly light-headed, having swollen sore lymph nodes, and neck pain and headache that require her to take Vicodin. She also thought she was having problems hearing. The provider's medical record noted that Patient A "does have a history of allergic rhinitis and knows mold is an allergy for her .. She has been taking antihistamines and anticongestants with Tylenol and they do not help." The provider's assessment listed vertigo, headache and allergic rhinitis, other. The provider reviewed the normal CT findings with Patient A and recommended that she obtain a consultation from neurology to explain the vertigo and headaches.
1.5 Patient A had an environmental assessment done on the storage locker. A report dated July 18, 2012, from NVL Laboratories, Inc., (NVL) documents the Baseline Mold-Indoor Environmental Quality Assessment of the basement storage locker. The report concluded:
- "The airborne mold spore concentrations in the sample collected from inside the storage locker is lower than the concentration of the outside sample. This is considered normal and typical for an indoor environment.
- Additionally, no fungal genera (types) were found in the sample taken from the subject area which were not also present in the outdoor sample. This is considered normal and typical for an indoor environment."
1.6 Respondent's initial' evaluation of fifty-one-year-old female Patient A occurred on August 2, 2012. Respondent's report does not include a physical examination. According to Respondent's notes under "Chief Concerns," Patient A "suspects she is having health problems because of exposures to mold in the storage facility at her condominium." Respondent commented that "they had an environmental evaluation of the storage room and a combination of various fungi were found in the locker space, but less than the outside air." Respondent noted that "since the exposure, she has had chronic sinusitis and headaches, excessive thick yellow/green phlegm in her throat that she has to hack up. Tylenol Sinus medication helps reduce the headaches. Her eyes burn and sting. She has been having episodic vertigo. Came down with a vaginal infection a week ago, which she has rarely ever had." (p. 9) Respondent listed Patient A's problems as: 1) Sinusitis, 2) Headaches, 3) Hypersensitivity, and 4) Environmental exposure-probably mold. Before doing any testing, Respondent started Patient A on amphotericin 250 mg 3 times a day and nasal amphotericin 0.1 % 1-2 sprays, 2 to 3 times a day. He noted "discussed Herxheimer reaction." In addition, Respondent noted treatment with Mediclear Plus 1-2 scoops daily, and ordered urine mycotoxins. Respondent planned to start cholestyramine at the next visit and to consider allergy testing.
1.7 Respondent next saw Patient A on August 13, 2012. Respondent's report does not include a physical examination. Respondent comments that Patient A "had a setback when she started on amphotericin 250mg 3 times a day and a lot of her symptoms got magnified including abdominal cramps, diarrhea and vomiting. She called I told her to reduce amphotericin to once daily, but continue the nasal spray. She still bloated, but no longer having the vomiting, but has loose stools 80% the time. After taking the medication she broke out in a rash on her lower legs, which she's never had before. Continues to have problems with memory and cognition, which she's never had before." Respondent noted that Patient A went to Vancouver to see her mother's home, which was just fumigated. Within 10 minutes of her entry into the home she experienced burning of her sinuses and eyes and had to leave. Respondent's comments under "Assessment" state: Patient A "had a very intense initial Herxheimer reaction, but is doing better on a small dose for the time being. She has had multiple exposures over the past few months, mold, chemicals, gas leak. Even though urine test shows very little if any mycotoxins exposure, her clinical history is consistent with mold exposure. On top of that she's had the different chemical exposures that may be contributing to her condition as well." Respondent noted continuing the amphotericin 250 mg once daily and the nasal spray, adding cholestyramine 2 teaspoons daily in water, with a return visit in two weeks.
1.8 A letter dated August 23, 2012, from an infectious disease doctor to Patient A's ARNP thanks the ARNP for her referral of Patient A, and states, "We agree with your plan to immediately stop the amphotericin B, as the risk in toxicity is high. I will check her renal function and liver function studies, and hematocrit. I asked her to go the University of Washington to be seen in the Department of Occupational Medicine to decide what toxin exposure she had in Vancouver."
1.9 Respondent's treatment of Patient A was below the standard of care. Respondent treated Patient A for a systemic fungal infection without support of objective data such as physical exam and culture. Respondent's treatment put Patient A at risk, caused her emotional stress, and unnecessary financial costs for inappropriate therapy.
1.10 Prior to her first visit with Respondent, thirty-six-year-old female Patient B visited her primary care provider with the Swedish Hospital system on six occasions starting on April 18, 2012, complaining of insomnia, fatigue, decreased concentration, isolating herself, irritable, increased crying, and elevated blood pressure. On June 12, 2012 Patient B reported epigastric pain, a burning sensation, tightening in chest, pain radiating to clavicle, labored breathing, sweats at night, decreased appetite, decreased sleep. On June 15, 2012, Patient B continued to complain of chest pain with breathing, fatigue, pain radiating to the clavicle area, pain in anterior neck, and hoarse voice. On June18, 2012, Patient 8 reported that she continued to experience pain in anterior chest, painful with deep breathing, pain radiating to anterior neck. Patient B's EKG, chest xray, chest CT, and cardiac workup were all negative. Patient B expressed concern that this may be due to mold exposure, and wondered if it might be an allergy issue. Patient B's primary care provider ordered allergy testing.
1.11 Patient B saw an allergist on June 18, 2012. The allergist checked thyroid levels, CBC and sed rate, which were all normal. Patient 8'5 pulmonary function testing was also normal. Patient B's allergy skin testing showed reactivity to cat, dog, dust mites, tree pollens and grass pollens. Only one mold reacted, Alternaria was 3/8. Aspergillus was negative. The allergist also cultured Patient B's tongue, which showed no growth although the fungal smear showed occasional yeast with pseudohyphae; four-week culture was negative. The allergist diagnosed Patient B with allergic rhinitis.
1.12 On June 22, 2012, Patient B returned to her primary care provider. Patient 8 complained of back pain, white tongue, pain in posterior neck, lower abdominal pain, urinary burning, cough low grade fever, shaking, and walking has become exhausting. Her primary care provider noted that she has had a complete cardiac workup including negative stress echo, EKG, GI workup including normal EGO, and an allergy workup as well. He suggested she consult with rheumatology.
1.13 On June 24, 2012, Patient B reported to the ER at Swedish Issaquah. Her chief complaints included neck pain, headache, and eye problems, blurring with spots in her visual fields. Patient B also complained of very sore arm pits, throat pain, dry lips, chest pain, occasional palpitations, back pain, leg and arm pain fatigue, insomnia, shakiness, anxiety, decreased balance, and burning wrist pain. Studies included a normal CT scan. The report states, "At this time, the etiology of all her symptoms are unclear. She will require additional outpatient workup and management." Diagnosis: 1) headache, 2) myalgia. Patient A followed up with her primary care provider on June 27, 2012.
1.14 On July 5, 2012, Envirospect Northwest tested Patient B's home where she is no longer living and reported that the living room sample returned elevated levels of Penicillium/Aspergillus. After receiving this report, Patient B arranged an appointment with Respondent.
1.15 All the records referenced in paragraphs l.10 through 1.13 were requested by and sent to Respondent on July 9, 2012. On that date, Patient B saw Respondent for her first visit. Respondent lists Patient B's chief concerns: generalized body pain, chest pain, fatigue, sleep disorder, and mold exposure at home and work place. Under "Assessment" Respondent states Patient B "has been thoroughly evaluated by various specialists for a multitude of medical conditions without any major significant findings or effect of treatment. Both her home and work environment have excessive levels of mold due to water damage. She has been practically constantly exposed to mold allergens, mycotoxins and VOCs from one place or the other for some time now, both at home and work. She has been feeling better since she moved out of the home and stopped going to her workplace. She has been most likely sensitized to mold and probably has fungal colonization of her mucosal system." Patient B "has been in previously excellent health until fairly recently. In my opinion she does not appear particularly depressed or overly anxious. Her present health problems are due to underlying toxic/allergic environmental exposures and not of a psychological origin." Before doing any testing, and ignoring the June 18, 2012 test results from Patient B's allergist, Respondent started Patient B on cholestyramine 2 teaspoons in water 3 times a day "to bind mycotoxins for elimination," Mediclear Plus 2 scoops daily to support basic detoxification pathways, in one week intraconazole 100 mg daily one week, then 100 mg twice a day for potential fungal colonization.
1.16 Results of testing ordered by Respondent and done on Patient B on July 9, 2012 for the Aspergillus fumigatus antibody, IgG were negative.
1.17 On July 26, 2012, Patient B had her second visit with Respondent. Respondent noted under "Subjective" that Patient B was not doing well. "She is in a lot of pain, migratory burning pain in her neck, chest, left side, arms. Having a killer headache along with neck pain. Vicodin every 4 hours helps somewhat. She is coughing a lot. Feeling worse since she increased the dose of itraconazole. She ran out of cholestyramine. Not sleeping because of the pain and she feels her adrenal glands are over active. Having a lot of sinus pressure." Under "Objective" Respondent recorded: "Elevated urinary Ochratoxins" [Mycotoxin Panel from Real Time Laboratories, Inc. Carrollton, TX, dated July 16, 2012], Skin tests positive for molds, dust, dust mites and Aspergillus [Allergy Testing record dated August 2, 2012], Normal thyroid antibodies, Venous blood gases-low Pa02 and extremely low oxygen saturation, acid pH." Under "Assessment" Respondent recorded Patient B "is having Herxheimer reactions from mycotoxins, which are probably aggravating some of her symptoms. She has metabolic acidosis and cellular hypoxia, which are probably contributing to her migratory pains." Respondent had Patient B start back on cholestyramine, reduce itraconazole to 100 mg daily for a week or so and then back up to 200 mg, start nasal amphotericin 0.1 % two sprays each nostril three times a day, Oxygen therapy at home 4-6 L/minute 30 minutes, 2-3 times daily to reverse acidosis and hypoxemia, phosphatidylserine two capsules at bedtime for sleep, Vicondin 5/500 one every 4 hours when necessary for pain, #100. Respondent also noted, "Consider EECP and IV therapy if no improvement in the next few weeks."
1.18 At Patient B's third office visit on August 16, 2012, Respondent noted under "Subjective" that Patient 8 "has been having abdominal pain. After starting the itraconazole she developed gradually increasing problems with abdominal bloating and distention especially by the end of the day. Although we discontinued the itraconazole the bloating has continued. [Cf: July 26 medical record, says reduce itraconazole to 100 mg daily for a week or so and then back up to 200 mg] Other than the above overall . she is doing better. The EECP is helping, having improved energy and sleeping better." [Cf: July 26 medical record says consider EECP] Under "Objective" Respondent noted "Comprehensive stool analysis-Rhodotorula 1 +, moderate growth of Klebsiella pneumoniae, low total secretory IgA, slightly elevated alpha antichymotrypsin and markedly elevated intestinal lysozyme. Borderline low chymotrypsin." Respondent's "Assessment" reads: "Suspect that her increased GI symptoms are probably related to fungal/yeast exposure and hypersensitivity to mold along with Herxheimer reaction from antifungal treatment. She has extreme elevation of inflammatory marker lysozyme, which is likely correlated with her bloating." Respondent placed Patient B on Broad-spectrum complex one capsule 3 times a day 20 days to decrease Klebsiella, Gil Encap 1-2 capsules 3 times a day to decrease GI inflammation and symptomatic relief, Glutamine 5000 mg twice a day, TherBiotic Complete 1 capsule twice a day 30 days, then 1 daily to begin to restore normal bowel flora. Respondent added, "If no improvement consider using cromolyn, Ketotefin, NTFactors."
1.19 On August 22, 2012, Patient B presented to Respondent with additional complaints. Respondent noted under "Subjective" that about five days ago Patient B "started having chest pain and difficulty breathing again. It basically hurts to breathe. Having a lot of discomfort and pressure in her neck and central chest region. The symptoms are similar to what she had several months ago. She feels nauseated and had one episode of vomiting a few days ago. Has no appetite and feels bloated. Normal bowel movements." Under "Objective" Respondent noted, "Does not appear to be in any acute distress, only somewhat anxious. Temperature 98.6. tongue still heavily coated with thick white exudate .: Neck supple without adenopathy. Chest clear. Heart rate regular. Abdomen-generalized tenderness." Under "Assessment" Respondent recorded the following: "When she was treated with itraconazole 200 mg she had similar symptoms, which only decreased slightly when. the dose was reduced to 100 mg. When we stopped it symptoms resolved. Most likely she has been having Herxheimer reactions from antifungal treatment. She was taking cholestyramine during this time. I think she needs to be further treated for low grade fungal infection mainly because of the extensive long-term exposure history, hypersensitivity to fungi, elevated mycotoxins and elevated intestinal inflammatory markers." Respondent had Patient B discontinue itraconazole for now, continue glutamine and GI Encap, but discontinue Broad-Spectrum Complex. Start amphotericin powder 1/16 teaspoon 3 times a day and gradually titrate up to 1/4 teaspoon, recheck venous blood gases.
1.20 Respondent's treatment of Patient B was below the standard of care. Respondent treated Patient B for a systemic fungal infection without support of objective data such as physical exam and culture. Respondent's treatment put Patient B at risk, contributed to her anxiety, and resulted in unnecessary financial costs for inappropriate therapy.
2. ALLEGED VIOLATIONS
2.1 Based on the Alleged Facts, Respondent has committed unprofessional conduct in violation of RCW 18.130.180 (4), which provides:
RCW 18.130.180 Unprofessional conduct. The following conduct, acts, or conditions constitute unprofessional conduct for any license holder or applicant under the jurisdiction of this chapter:
(4) Incompetence, negligence, or malpractice which results in injury to a patient or which creates an unreasonable risk that a patient may be harmed. The use of a nontraditional treatment by itself shall not constitute unprofessional conduct, provided that it does not result in injury to a patient or create an unreasonable risk that a patient may be harmed; . . . .
2.2 The above violation provides grounds for imposing sanctions under RCW 18.130.160.
3. NOTICE TO RESPONDENT
The charges in this document affect the public health, safety and welfare. The Executive Director of the Commission directs that a notice be issued and served on Respondent as provided by law, giving Respondent the opportunity to defend against these charges. If Respondent fails to defend against these charges, Respondent shall be subject to discipline and the imposition of sanctions under Chapter 18.130 RCW.
DATED: July 7, 2014.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
MEDICAL QUALITY ASSURANCE COMMISSION
COLIN CAYWOOD, WSBA #40779
ASSISTANT ATTORNEY GENERAL
This page was revised on May 22, 2016.