NC Medical Board Dr. Rashid A. Buttar Transcript - Page 9 of 16
my ‑- my synopsis of the case or ‑-
QOh, I want you to tell the Board what you recall about Patient A.
APatient A was an end-stage cervical cancer patient who presented to me in late July of 2006. She was diagnosed in 2003. She had a history of a radical hysterectomy and bilateral salpingo‑oophorectomy and node dissection sometime in 2003. Late 2003, she had ‑- if I remember right, she had one or two out of 14 nodes that were positive.
By September of 2003, I believe she had completed about 25 or 27 some radiation therapies. And after completion of the radiation, the patient had regular checkups for the next few months or was scheduled for checkups every six months.
I don't believe she went a full six months because in April she began having some pain. In 2004, I believe it was, she started having some pain on her right side and she ended up seeing a family physician. They had some scans done, some CAT scans and an ultrasound done and they found that she actually had a recurrence with metastatic disease to her lung and her liver. Her hepatic metastasis I believe was not as extensive as her lung metastasis was.
She was referred to M.D. Anderson. She had chemotherapy which included carboplatin treatments I believe she had it twice, it's all in the record. She completed her last treatment sometime in June of 2006.
Was seen in July of 2006 again by M.D. Anderson who noted that her liver enzymes were beginning to become elevated and they told her that she had basically failed everything and they referred her to hospice.
QCould you turn to Exhibit 11 in our ‑- in our book please?
AYes, ma'am.
QIs Exhibit 11 a medical note regarding Patient A as to her last visit at M.D. Anderson?
AYes, ma'am, it is.
QAnd is that part of the medical records that you reviewed to ‑- to get that summary?
AYes, ma'am, it is.
QAnd does that reflect that as of July 13th, 2006 she was being denied further treatment at M.D. Anderson?
AYes, ma'am, it does.
QFollowing ‑- following her last visit to M.D. Anderson, did she then seek you out?
AYes, ma'am, she did.
QOkay. And do you know if you saw her the first time she came to the office?
AI saw her, but I saw her ‑- I stepped into the room. I did not do the office visit myself because our computer program for scheduling had been down and I remember that there was a out-of-country patient there that they were leaving the next day, so I went ahead and saw that patient and Jane saw Patient A and then I stepped in and talked with her and her husband briefly.
QDo you ‑- first of all, the person you referred to as Jane, who ‑- who is that?
AThat's Jane Garcia, she's my nurse practitioner.
QAll right. And how long has Ms. Garcia worked for you? We can turn to Exhibit 5 and that might refresh your recollection.
AIt's been years, I'm not sure, five maybe.
Exhibit 5, ma'am?
QYes. Is Exhibit 5 the collaborative practice agreement between you and ‑- and Ms. Garcia?
AYes, ma'am, but I think I started her ‑- I think she started before this.
QOkay. The earliest date on that is 2003. Is that ‑-
AOh, 2003. I only saw a 2004.
QYeah.
AYeah, 2003 sounds right, about five years.
QOkay. And so ‑- so as of 2006 Ms. Garcia had been practicing with you for at least three or four years?
AYes. Yes, ma'am.
QOkay. And tell the Board about your working relationship with Ms. Garcia.
AWell, the joke is that I'm lucky she's not 20 years younger because I may be having an affair with her. That's how much time I spend with her.
I have a very, very good working relationship with Ms. Garcia. I interviewed ‑- I went through an extensive number of people before I found somebody that I trusted enough to take care of my patients with me to help me take care of my patients.
QAnd have you trained Ms. Garcia yourself?
AExtensively.
QAnd ‑- and describe the access Ms. Garcia has to you.
AWell, Ms. Garcia is ‑- has 24 hour access to me anywhere in the world at any time she needs.
Ms. Garcia also spends ‑- well, just this week the clinic closed at 5:30, she and I were in the clinic until about 8:45.
We spend a lot of time together going over various things. We have set once a week, I guess you would call it mini-rounds where we review charts, but that's just what we have set aside time. Throughout the week, any time she needs me for anything.
She has become a very trusted member of my staff. The most trusted when it comes to clinical aspects. She is anal retentive. She constantly second guesses herself when she has shown to be very proficient and it's only because she's that anal retentive. She's a fantastic nurse practitioner and I would not ‑- I would not be ‑- (becomes emotional) -- I would not be able to do everything that I need to do without Jane's help.
QDo you want a drink of water, Doctor?
AYes, ma'am.
QNow, let's ‑- let's go to Exhibit 6 in our ‑- in our book and again there's been redaction to that, but I'll represent to you that that is the set of consent forms that Patient A signed.
AI'm not sure what you mean by redaction.
QOh. The personal -- the identifying information has been removed ‑-
AOh, I see.
Q‑- for the privacy of Patient A, so her name is not on there, so it's ‑- you can't say ‑- I have to tell you what it is. That's the only way in this ‑- it can work in a public hearing setting.
AYes, ma'am.
QAnd Exhibit 6, I will represent to you is a set of consent forms that was signed by Patient A.
AYes, ma'am.
QThe first one is just an intake form with information on it. The second page is the Consent for Treatment.
AYes, ma'am.
QDo you recognize that Consent for Treatment?
AYes, ma'am.
QAnd is that Consent for Treatment used with the patients consistently in your office?
AWith every patient that comes into our office.
QOkay. And if the patient has any questions about the consent forms, are there people that they can ask about that?
AAbsolutely. When the patient ‑- yes, ma'am.
QAnd this Consent for Treatment signed by Patient A refers to ‑- to cancer, does it not?
ANo, ma'am. It refers to everything.
QOkay. Well, why don't you read it for the Board.
AI authorize the medical and nursing staff at Advance Concepts in Medicine and Dr. Buttar to perform diagnostic tests and administer treatment plans for allergy, immune disorders, nutritional disorders, cancer, autism and public chronic medical conditions.
I fully recognize that the treatments I will receive may include nutrient, herbal, oxidative, functional, integrative, alternative, preventive and/or conventional therapies.
I also understand that: 1) the safety and efficacy of many such therapies has not been established with controlled studies; 2) specifically no claim to cure cancer with these therapies has been made to me; 3) Dr. Buttar will not be providing hospitalized care or emergency care for me from this clinic; and, 4) the therapies I receive will compliment the care I receive from my primary care physician and will not replace them.
QAnd tell ‑- tell the Board why you word your Consent for Treatment that way.
ABecause, again, I come from six generations of attorneys and my consent form that my father and my sister came up with would have taken a couple of weeks to go through, so we took the highlights and put this together.
And they told me that in our litigious society and especially with the limelight that doctors like I am that are successful in certain modalities of treatment where those other people may not be, it would be better for me to have a consent form such as this and we basically kind of condensed it down to this one before we treat them.
QWell, and is this consent form consistent with the way you represent yourself to your patients?
AYes, ma'am. But there's another consent form before we start actual treatment. This is just before I ever see them or my nurse practitioner sees them. This is just before we even sit down to talk to them. And they're given this consent form, we sit down and talk with them and then they have to sign it afterwards.
Before we ‑- there's another consent form before treatment.
QAll right. And you're talking about the IV consent form?
AYes, ma'am.
QOkay. The third page of Exhibit 6 is the Financial Policy.
AYes, ma'am.
QAnd I think we've been over that and what it says. Is that presented to each patient before ‑- before treatment?
AYes, ma'am. And we have designated staff members that that is their responsibility and it has to be checked off by a second person to make sure that they have been ‑- had adequate explanation of this policy.
QNow, during the period of time that you treated Patient A, did you have ‑- and let's turn if we can to Exhibit 7 in the book.
During the period of time that you treated Patient A, did you have occasion to refer her to Dr. John Clements at Carolina Digestive Health Associates?
AAbsolutely.
QAnd tell the Board why you did that.
AWell, when she presented to me she ‑- it was obvious that nobody had addressed her issues of jaundice. We had ‑- she wasn't ‑- she didn't ‑- her course of progression made me feel that she may have some type of a biliary outlet obstruction and I wasn't sure what was going on. I called Dr. Clements and he was kind enough to get her in right away to see what was going on.
I don't ‑- he and I talked about possibly during a ERCP on her. I don't know whether he did, I can't remember. But basically there was no biliary obstruction that he could ‑- that he could see.
QOkay. And just in general in treating your patients do you utilize other medical providers in treating your patients?
AIn all these patients you can see consultations with other doctors, oncologists and such.
QAnd in what circumstances would you particularly refer to a patient to an outside doctor?
AWhen I need help getting ‑- supporting what we're doing for the patient.
QLet's turn to Exhibit 8.
AYes, ma'am.
QExhibit 8 is the pages of the expert review sheet that Dr. Peterson filled out for the Medical Board.
AYes, ma'am.
QHave you had an occasion to review that?
AYes, ma'am.
QNow, I will tell you that ‑- I'm trying to see which order these are in. I think Patient A is the second review sheet in this sequence. I should have put them in correct order. But the 49-year-old female with cervical cancer.
AYes, ma'am.
QDo you see that one?
AYes, ma'am.
QOkay. And what I'd like to do now is go to the second page of that expert review sheet.
AYes, ma'am.
QAnd ask you to address the comments that Dr. Peterson made with ‑- with regard to your care and treatment of this patient. The first comment I'd like you to address is Dr. Peterson's opinion that your treatment was below the standard of practice or care. Can you give a reaction to that, please?
AI've never done anything standard in my life and I'm not going to practice a standard when it's ‑- to me, it's not standard. I have a patient that comes to me and they want me to help them and I'm going to do everything I possibly can to help them.
Below standard of practice. Well, that's his opinion. I chose to only do one thing and that's practice above the standard.
QAnd ‑- and why do you believe you practiced above the standard with this patient?
AWell, because we had subjective and objective improvements through her short course of therapy.
QOkay. What were some of those improvements?
AOn ‑- do you want me to specifically give the dates and ‑- and ‑-
QWell, just tell us what the nature of the improvements are.
AWell, she had liver functions that were progressively increasing and we started her therapy and her liver functions came down between July 31st and August the 3rd and she was able to sustain that improvement for about two weeks and then the liver functions started going back up.
She had ‑- she was anemic when she came to us and she had a consistent improvement in her hemoglobin and her hematocrit. In fact, her hematocrit was back up to normal within three weeks of therapy.
She was able to reduce her pain medication. In fact, eliminate her pain medication for about 12 days, 10 to 12 days, if I recall correctly.
Her nausea had improved. She was able to ambulate. She had a better sense of ‑- she had a better sense of balance and her ambulation improved.
She did start after about 12 to 14 days start showing the liver function increasing and was also followed by ‑- she became icteric and she was ‑- had mild jaundice and that's when I got Dr. Clements involved to see if there was any type of massive ‑- mass effect versus a direct obstruction of her biliary tree.
QOkay. Now, Dr. Peterson's next comment is that he states the patient chart does not follow the problem oriented medical record methods of SOAP. So can you give your reaction to that, please.
AWell, I'm not sure which charts he was looking at because I can give you the specific dates in the chart, one, two, three, four, five, six, seven, at least eight entries where the SOAP note was used.
I use a SOAP note the same way learned how to use it at M.D. Anderson. We don't label the plan as a plan, we use ‑- we label it as AP, assessment plan, and where the assessments only go through where you write it as an impression. So we have subject, objective, impression and assessment of the plan, but that's ‑- that's how I learned it in my training and it's the same way that everybody else uses it, but it's right there in the chart.
QAnd turn if you will to Exhibit 9.
AYes, ma'am.
QAnd I'll represent to you that those are the progress notes and treatment plan for Patient A.
AYes, ma'am.
QNow, the first two pages are the initial note; is that right?
AYes, ma'am. This is her first time.
QOkay. And who took the history?
AJane did.
QOkay. And did you review that?
AYes, ma'am.
QAnd are the notes that were made mostly made by Jane in here?
AIn this whole chart or just ‑-
QIn this ‑- in this section.
AIn these two sheets?
QYes.
AYes. Jane ‑- Jane made these notes.
QOkay. And did you then review and countersign them?
AI reviewed the notes with her the same day actually, that's when I stepped in with the patient.
QOkay. And then as the treatment progressed, did you continually review the notes that were made?
AThe ones that I wasn't in there with her, I reviewed and co-signed; otherwise I did the notes myself or I did review them myself or whatever.
QOkay. And does the chart show your co-signature on that?
AYes, ma'am, after the slash.
QAnd let's go back to Dr. Peterson's comments. His next comment is the standard of care was to refer ‑- to refer this patient for hospice ‑- to hospice for palliation. Could you give your reaction to that?
AShe was already referred to hospice. I'm not ‑- she came to me from hospice, so I'm not sure why I would send a patient that came from hospice back to hospice if she was already referred to hospice.
QOkay. And what did you note ‑- and I'll turn your attention to the progress notes. What did you note about this patient's desires to go to hospice as opposed to continuing treatment with you?
AIn ‑- well, I know that the family was very adamant. I know that they were ‑- they had already done their homework. They had already checked out certain things and unfortunately sometimes the things that they were relying on may not be as reliable, but they had a lot of information. They were well versed.
They knew that they were out of options on the conventional side. I asked them if they had talked with their oncologist -- (inaudible) -- providing clinical trials and they said that they had no ‑- they had no other options and that that's why they came to us.
QAnd what did you ‑-
AI'm sorry ‑-
QWhat did you observe yourself about this patient's desires as far as ‑- herself as far as continuing treatment?
AWell, I remember that when it became clear to us that she was failing our supportive therapies and her immune system was not responding or if it was responding, it was a little too late because she was already in multi-organ system failure. I had ‑- she was actually in the IV suite, she was getting an IV and I asked Robin my nurse ‑- and the only reason I know it's Robin is because when you work at the office and you find out who it was because I couldn't remember who it was.
When one of my nursing staff members went to get her from the IV suite to bring her into the exam room, she refused. She did not want to come to the exam room. And I was in the exam room, the daughter was in the exam room and I asked Robin, what's going on.
And Robin said, Dr. Buttar, she doesn't want to come in here.
And Marie, her daughter, went out and came back in in tears and she said, Dr. Buttar, she doesn't want to come in here because she thinks that you're going to stop her treatment and she cannot handle that. She will not stop treatment.
And then I had this discussion that's documented on August 14th with her daughter at that time.
QAnd is that documented in Exhibit 9 at page C7?
AC7A, yes, ma'am.
QC7A?
AYes, ma'am.
QOkay. And, again, whose writing is that?
AIt's mine, ma'am.
QOkay. And what did you document at that time?
ADo you want me to read the note?
QSure.
AI discussed with daughter the issue of evaluation with Dr. Clements showing no external biliary obstruction, deteriorating LFT, with increasing alkaline phos. and bilirubin indication of progression of tumor and increasing need of narcotics to control pain, further indication of progression of disease. However, hemoglobin and hematocrit actually improving.
Daughter states mom wishes to continue treatment and the daughter nor myself wish to take hope away from that patient ‑- from the patient. Daughter states her mother is adamant about continuing treatment.
Abdominal ultrasound, enumerable hepatic lesions consistent with extensive metastatic disease with no extra biliary obstruction.
And I've got her lab values documented there and what we were going to continue doing.
QOkay. And in this patient what was the influence as far as ‑- as ‑- well, let me withdraw that and try to restate it another way.
In this patient why did you continue treatment?
AWell, one was because I have ‑- I'll try to be succinct with this, but I'll --
QPlease do.
AWell, I've taken a lot of fire in service to my country to ensure freedom and I do not see why that freedom that I have potentially given my life for that I come back home and that my patients don't have that freedom to make a choice they want or I don't have the freedom to try to help them if I think that I can possibly help them.
QAnd at this point, had you given up hope?
AWell, I never give up hope, but I could see the writing on the wall. At this point, her detoxication and her immune colliquation was not the issue. She was already in organ failure. And unfortunately once you're in organ failure, there's nothing that could be done because now you've got the organs that necessary to up regulate if you want to detox by somebody they've already failed, so there's no way to get rid of the toxicity.
Just to make sure, I mean, I called Dr. ‑- one of the oncologists that I work with who is in my opinion probably the leading oncologist in the country and talked with him too and discussed the case. I don't know whether it's documented in here or not, but I did. I remember talking to him.
QTurn to the next page.
AYes, ma'am.
QPage 70.
AYes, ma'am.
QWhat does that document?
AThat's discussed with Dr. Holbert in details ‑- in detail. And basically I was ‑-
QAnd who is Dr. Holbert, just ‑-
AHe's a hematologist oncologist and he ‑- as I understand it, he's got board certified in nine specialties, but I'm not sure if that is correct.
QAnd so you called to discuss this patient with Dr. Holbert?
AYes, ma'am, I did.
QAnd ‑- and based on your discussion with Dr. Holbert, did you believe you could still continue the ‑- there was some chance you could help him?
ADr. Holbert and I were of the same conclusion. He said you're doing everything you can for Patient A and keep on going.
QOkay.
AI mean, basically he told me that, you know, if she's already been turned away by everybody else, what are you going to do, dump her in the street. That was pretty much the words that he used.
QOkay. And ‑- and, again, this note, the 15th of August was how long between that note and death at this point?
AI believe the patient was ‑- it was ‑- it was the same week, I believe.
QThe last criticism by Dr. Peterson on this patient is no physician contact documented. We just looked at a note that you wrote. Did you have physician contact with this patient?
AI had ‑- I made notes based on the chart. I don't know where they are here, but I know the dates that I saw the patient.
QOkay.
AI saw the patient on July 26th. I performed an intra-respiratory reflex on the patient. I'm the only who does that, so there was no way the patient could have received that treatment without having contact with me and the note is in the chart.
On August the 3rd, I performed IRRs on the patient. She was having problems with breathing and she had a documented improvement after the IRRs within about 25 seconds to a minute, it's in the chart.
On August the 14th, I had a long visit with the patient.
On August the 15th, I did IRRs on the patient. In addition, at least three separate detailed conversations with the patient and the daughter regarding the whole prognosis while Jane was in the office dictating while I was talking to the patient.
And pretty much with all my cancer patients I see them every day they're in the office. I just don't make a note perhaps, but I stop by and talk to them, see how they're doing, how they're appetite is. I may check for edema. It's not a hard and fast rule because I may be tied up with other patients, but I see them virtually ever day.
We only charge for an office visit when I sit down for an hour with them or an hour and a half, but, you know, five minutes, ten minutes, there's no ‑- there's no charge for it and sometimes it's not documented.
QNow, let's turn if we ‑- if we can to Patient B and I want to go back to Dr. Peterson's criticisms of your treatment of Patient B in Exhibit 8. That would be the next expert review worksheet starting with a 51-year-old, metastatic ovarian cancer. Do you see that?
AYes, yes. Wait a second. Did you say it was the third one?
MR. KNOX: Yeah, the third one.
QYeah, third one right after Patient A.
AYes, ma'am.
QFirst of all before we address Dr. Peterson's comments, could you give us an overview of your treatment of Patient B?
AYes, ma'am. She was 51-year-old white female who presented April 29th. She was in Stage IV ovarian cancer referred to us by her primary care physician. Her initial diagnosis was in August of 2002 of having carcinoma of the ovary with staging done in 2002 and she was staged at 3C at that time. She went for a suboptimal bilateral salpingo‑oophorectomy of the tumor could also be done. The patient's history included a total abdominal hysterectomy in July with the ovaries that had been left, but that was later resected.
After the diagnosis with the ovarian cancer she underwent chemotherapy with carboplatin and Taxol and until about April 2003. Her CA 125 continued to rise. I went from 202 up to 715. The CAT scan showed persistent mixed radio dense masses on the bladder.
By June of 2003, cancer markers had risen to 1292. They changed her chemo and changed her to weekly doses. I can't remember what the chemo was.
In August of '03, repeat CAT scans revealed that she now had lesions in her liver.
By September, chemotherapy was again changed. This time was to Doxil. All in all, she had 16 months of chemotherapy before she presented to us.
QAnd what was your treatment plan with this patient?
AOne of the things about this lady that I remember, she was ‑- she was a very sweet lady. But she had ‑- she basically was referred to hospice when she came ‑- well, she was referred to hospice when she came to us, but she hadn't had any conventional treatments since December of the preceding year, so she hadn't had any treatments for about five months before coming to us.
And one of the things I wanted to do was get a CA 125 on her and her last CA 125 had been around 5,000. And she said, well, I had one done in December.
And I said, well, we need to do another one and she didn't want to do it because she didn't believe in ‑- one of my experiences is when patients have failed everything, they don't believe in anything that the doctor says.
So I just told her, I cannot do anything with you until I get a baseline to see where CA 125 is. And we ‑- we obtained that before we initiated any treatment with her.
QOkay. And before you initiated any treatment, what was her CA 125?
AWell, she came to us on April 29th, we ‑- I'm sorry, yes, I believe that was right, yes. We did a CA 125 on her which was done on ‑- CA 125 was done April the 15th. Actually, I guess she came to us before then, but we didn't start any treatments. The CA 125 was done, 10,000 ‑- it was 10,000 ‑- 10,028.1.
QOkay. Turn if you will if this will help you to Exhibit 14.
AYes, ma'am.
QTurn if you and this will help you, to Exhibit 14.
AYes, ma'am.
QI will represent to you that Exhibit 14 are the blood work done for cancer work -- and I guess his brother ‑-
AYes, ma'am.
Q‑- just was a patient.
AYes, ma'am.
QAnd is there a chart in here that measures the progression as far as her CA 125?
AI believe there was one that she did herself or her ‑- her boyfriend did. It was ‑- it was referred to the letter, it really wasn't a letter, but it was somewhere in here, I believe.
QIt's the last page.
AYes, ma'am, the last page.
QG27?
AYes, ma'am.
QAnd is that the chart that they presented to you ‑-
AYes, ma'am.
Q‑- with her progression on C 125 ‑-
AYes, ma'am. We just ‑-
Q‑- CA 125?
AYes, ma'am. We just put it in the chart.
QAnd then is it also noted on that chart her ‑- her measures during treatment with you?
AYes, ma'am.
QWhat does it show?
AIt was 10,028 and after ‑- well, it's important to note that she really didn't initiate IV therapies until sometime in May and she was ‑- she was under ‑- she only had IV treatments for about three and a half weeks. And on June 11th which was her last, I believe ‑- well, that was when we got the next CA 125, the CA 125 was down 6,219.
QOkay. And with regard to your treatment of this patient, turn if you will to Exhibit ‑- Exhibit 12.
AYes, ma'am.
QAre these the same consent forms that we looked at earlier with regard to Patient A?
AThere's ‑- yes, ma'am. They're slightly different because at that time the ‑- I mean, the wording is the same, it's just on the same piece of paper, the intake form instead of the other side.
QOkay. And were these ‑- these consent forms, as far as Patient B, signed to your knowledge?
AYes, ma'am, they were.
QOkay.
AIt's checked before we do any kind of treatment.
QAnd with regard ‑- turn if you will to Exhibit 13.
AYes, ma'am.
QAnd I'll represent to you that Exhibit 13 is a set of progress note to this patient?
AIt's ‑-
QOkay.
AYes, ma'am.
QAnd who saw the patient when she first came?
ABoth of us did.
QBoth of us who?
AJane Garcia and myself. Jane Sprite.
QOkay. And ‑- and who ‑- who co-signed the note?
AIt's mine.
QOkay. And did you ‑- you yourself meet with this patient?
AYeah. I was telling Jane what we were going to do. I'm talking to the patient and Jane was just writing everything down.
QOkay. And then a physical exam was performed on this patient on May 11th?
AYes, ma'am. Before we start IV treatments, we have to do our own exam.
QAnd who performed the physical exam?
AI did.
QOkay.
AI mean, we do an exam all the time, but this is a form -- (inaudible) -- through the exam.
QOkay. And are there more notes by you on the 11th of May?
AYes, ma'am.
QOkay. Summarize if you will the course of this patient with your clinic.
AYou mean, how many times I saw her?
QWell, not necessarily how many times you saw her, but what happened during the course of treatment.
AWell, each time I would visit with her or we do the IRRs, she was obviously responding to treatment, but the problem was that she was very non-compliant.
She was under the impression that if she came for the IVs, which she was very religious about doing, that she would get better and that's simply not the case. It's just one part of the treatment.
And so I kept on telling her she had to do ‑- she had to watch what she was eating. She would come in with those crackers and cheese that you pick up at gas stations that are laden with all sorts of preservatives and half the stuff is all synthetic and she was still putting that stuff in her body.
She wasn't doing the liver packs which ‑- and the coffee enemas that are necessary to help pull some of these body burdens and as an stringent she wasn't doing that stuff. She wasn't ‑- she just overall wasn't doing what she was supposed to do.
She was under the impression that if she just did the IVs that she was going to get better.
QAnd as a result of her non-compliance, what ‑- what decision was made with regard to her further treatment by your practice?
AI told her that if she wasn't willing to do what was necessary to get better, I was not going to watch her die.
QAnd ‑- and ‑-
AI gave her the choice to see if she was going to change and she didn't and I had a conversation with Jane and then we had a conversation and we felt that it was best to discharge the patient from our practice.
QAnd ‑- and was that accomplished?
AThat was accomplished and it was ‑- she was referred back to her primary care physician.
QNow, with regard to ‑- going back to Exhibit 8 and the pages of Exhibit 8 that deal with this patient, can you tell us your response to Dr. Peterson's criticisms of your practice? The first one being she was treated by Dr. Buttar with alternative therapies without success.
AWell, he thinks that a drop of 4,000 in CA 125 after three weeks and three days of IVs is no success, then I guess he's entitled to his opinion.
QWhat about ‑-
AI fought the -- (inaudible) -- part of it is -- for his freedom of choice as well, so.
QOkay. And his ‑- his assessment that your care was below the standard of practice?
AWell, Ms. Godfrey, I think you know what they say about opinions, everybody has one.
QOkay. What about his reference to your failure to use SOAP notes?
AWell, it's documented. I'm not sure what he means by that because each one of these charts has SOAP notes. It was ‑- if a person knows how to read English, then he can read the SOAP notes, but I don't know what ‑- how to comment. He obviously didn't read the notes -- or I'm not sure.
QAnother comment by Dr. Peterson is like the three prior patients, there's no evidence that Dr. Buttar or any physician at his clinic ever interviewed or examined Patient B.
AI've got my own exam in there. I've got notes in there. I can tell you exactly which days I saw her, what dates they were performed, it's all documented in the chart. The Medical Board has had this information since sometime in 2006.
QDr. Peterson also stated she was treated with alternative therapies consisting of vitamins.
AYes, ma'am, she had ‑-
QShe had vitamins, IRR injections ‑-
AYes, ma'am.
Q-- all unproven. This is clearly not the standard of care. What is your opinion of that statement?
AHe's right, it's not the standard of care, it's beyond the standard of care.
QAnd do you ‑- do you believe your therapies had the ability to help this patient?
AI believe that any therapy that eliminates a burden, a toxic burden in the body, is going to help the patient.
It's already been established now in the field of quantum physics where the quantum coherence field is being interrupted by some type of signal. And essentially what I'm trying to do is achieve zero point. Zero point being defined as maximal output with minimal expenditure.
To me, the human body is the most perfect piece of machinery because it's the only piece of machinery that I know of, the more you use it, the better it gets, but there's some reason that it's starts to deteriorate.
And the reason it's deteriorating is because of the level of toxicity that we are being exposed to on a constant level.
So any therapy that is going to remove that burden, whatever that burden is, will have a substantial improvement at helping the person's system. And if their system is up-regulated and their immune system is up-regulated, and their detox, then obviously the patient is going to do better.
QDo you ‑- do you feel like during the time you treated this patient you had a good relationship with her. Well, what was the nature of your relationship with this patient?
AShe was a very sweet lady. I formed an attachment to her. I knew that she was going to not do well because she just wasn't listening. She wasn't becoming compliant.
And her fiance was very supportive and actually was probably an instrumental part of her support system that tried to help encourage her, but he even told me that she just ‑- when she goes home, she doesn't do what you're asking her to do.
QNow, during the course of her treatment with you, did you receive a gift from Patient B and her fiance?
AYes, ma'am.
QAnd I can't part with this because we only have one copy of it, but could you ‑- could you tell the Board what this is? And it's designated as Exhibit 15.
AIt's ‑-
QBut I couldn't get a copy of it.
AShe was an antique collector and she had gone out and tried to find an antique for me which I thought was very sweet. It was ‑- it's a medical dictionary that's over 100 years old.
QOkay. And did she or ‑- or her fiance, I'm not sure which, inscribe something in that?
AYes, ma'am. Yes, ma'am. For Dr. Buttar from Alex and XXXXXX (Patient B), May 17th, 2004.
QAnd that was received by Patient B ‑- or ‑- okay, never mind that. Withdraw that question.
AShe gave it to me, yes, ma'am.
QShe gave it to you. I'll get it right.
AYes, ma'am.
QWhen Patient B left your care, was there a balance owing?
AI don't really know. I don't deal with that part of the practice, ma'am. I think there may have been, I'm not really sure.
QOkay. Do you know ‑- well, do you know if your practice ever collected from her estate?
AI know that there was ‑- I don't know whether she had a balance then. I don't know what the details were, but I know that nothing was pursued.
I didn't know when she passed on. She had been given ‑- I believe she had been given just a couple of months to live, but she lived five ‑- five months or maybe six months.
And when she passed on, when she transitioned, there was no further effort from my staff because they know that if something like that happens, you know, we send a card. And that's what we did, we sent a card. I don't know what else Libby does or ‑-
QOkay. Now, with regard to Patient C ‑-
AYes, ma'am.
Q‑- could you describe your ‑- your overview of Patient C for us?
AIs it a he?
QYes.
AYeah, okay. I thought you said she, I'm sorry.
QIt's a he.
APatient ‑- the last patient we just discussed and this patient we're about to discuss, I've actually presented these as case studies in a couple of different conferences.
Patient C and I ‑- Patient C and my entire staff developed a very close relationship and I think that's just because of a function of time that he spent with us.
He was a patient with adrenal carcinoma initially diagnosed in 2003. Status post a cervical resection that was done in October with a left-sided nephrectomy, adrenalectomy and splenectomy. He had extensive lymph node dissection done and he presented to me with a 59 pound weight loss after having had ‑- well, he presented with a 59 pound weight loss after his radiation therapy.
He had a history of a prior diagnosis of cancer. He had abdominal surgery done in October of 2002 with resection of his lower ‑- excuse me, of his sigmoid colon with greater than 4 centimeters removed. He had a colostomy and then a few months later had a colostomy take-down done.
Subsequent to that, he underwent 16 treatments of radiation and he was advised to have, I think, twice that many or close to that, I think 30 treatments or so, but he only underwent 16, maybe 18 because he couldn't tolerate it and he was becoming very sick and that's the period that he had that weight loss.
He was told by his oncologist that chemotherapy would not be an option and was reported to have less than six months to live. His 2004 ‑- February 13th, 2004 post-operative scan showed questionable lesions in multiple sites including new ‑- new lesions in the liver, lesions in the lungs.
He presented with Stage IV adrenal cancer to us in February of 2004.
QOkay. And what regimen did you prescribe for this patient?
AThe regimen that I prescribed was the same thing as the -- you know, detoxifying his system that each one of the patients ‑- if there's one particular toxicity that we see that is different from somebody else's, then we deal with that on a different level.
But our fundamental approach is to reduce the ‑- reduce the heavy metal burden, to stimulate the immune system, to improve the nutritional components and get the weight back for this patient.
This particular patient's weight was a big issue because he was tachypneic and he was ‑- he was very close to ‑- he was very close to demise when he came to us.
QNow, Exhibit 17 is a set of consent forms. Again, are ‑- and I'll represent to you that they were for Patient C. There's a third page to Exhibit 17 which is consent for chelation therapy.
AI'm sorry, ma'am, which ‑- where ‑-
QExhibit 17.
AYes, ma'am.
QLook at the third page.
AYes, ma'am.
QOkay. Do you recognize that consent form?
AThat is an outdated consent form. We ‑- it's been updated since then, but, yes, this was the consent form at that time that we used.
QOkay. And it was ‑- and this I'll represent to you was signed by Patient C and was found in your chart.
AYes, ma'am.
QWhat are you informing them about there about chelation therapy?
ABasically, that ‑- by the prevailing standard of the double-blind placebo-control that ‑- do you want me to just read it or ‑- I mean, I ‑-
QWell ‑-
AI'm just basically telling them that there's no guarantee. This is what we observed. It's based upon guidelines from a couple of different national organizations, the American College for Advancement in Medicine, the American Board of Clinical Metal Toxicology, the American ‑- the Institute of Preventative Medicine and there's a number of other ‑- this is the same information that actually when I helped with the TACT trial, the same information that we used for consent for in the TACT trial.
QThe TAC trial, what's that?
AA trial to assess chelation therapies, a $30 million dollar grant for that and I was an investigator for that -- for that trial.
QOkay. Now, specifically, that chelation therapy, I think there were some concerns from the Board Members as to possible dangers or bad effects from that. Can you explain to the Board how you do chelation therapy and how you try to prevent or monitor the patients so that they don't have adverse effects from it?
AYes, ma'am. EDTA, that means ethylenediaminetetraacetic acid. EDTA is one-third as toxic as over-the-counter aspirin. The problem with the chelator is not that the chelator is dangerous.
The definition of chelator is that whatever goes into the body must come out intact. The only difference is, that's it's bound to ‑- to a metal ion.
The issue of safety comes in with how a physician is going to administer this. For instance, a rapid IV bolus would be dangerous because it's going to defy the -- (inaudible) -- equation, it's going to cause a rapid physiological shift that is not warranted.
But a slow, steady infusion of the ‑- whatever the chemical is, whatever the chelator is, in this particular case we use diamine sulfuronic or diaminetetraacetic acid. If done in the right way, it's completely safe.
In fact, the issue that has been brought up and the few documentation ‑- excuse me, the few documented issues that have occurred has had nothing to do with the chelator, but rather the effect that the chelator had on the heavy metal burden.
So what happens is that when you put in a chelator into the body, the chelator is going to bind to metals. If you put in a large dose of a chelator, initially it's going to bind to more metals. As it comes through the vacuoles of the renal parenchyma, the vacuoles can't handle the burden of metals.
One ‑- one issue is that the ‑- there's been studies that have been shown on post -- on post-mortem biopsies of a patient's renal parenchyma showing a greater propensity of metals in the renal parenchyma. Actually, the American College of Cardiology published data that was done in Italy showing the patients that died of -- (inaudible) -- dilated cardiomyopathy had over 20 ‑- excuse me, yeah, over 22,000 times a safe level of mercury within the myocardia compared to other tissues in the body. So there are certain tissues that are more prone to becoming susceptible and to becoming vectors if you will of holding these metals.
So in the ‑- in the renal parenchyma issue of the safety issue, what happens is one of the chelators going through the body and it's actually hitting the kidneys, the kidneys are used to seeing one part of mercury per million parts of urine, for instance, normally.
But EDTA would be used for lead, so let's use lead as an example. The kidneys would normally be seeing one part of lead per million parts urine. Now you're giving a chelator, so all of a sudden the kidneys are seeing 500 parts of lead per million parts of urine.
That's a 50,000 percent increase in the load that the kidneys are used to seeing and load is what's going to cause an issue with the patient if the ‑- if the renal parenchyma can't handle ‑- if the -- (inaudible) -- filtration can't handle the load.
Now, if done judiciously, there's absolutely no problem. And we have infused well over 200,000 intravenous therapies in my office since 1997 when I opened my office, so the last 11 years. I have never yet seen a single complication. It just doesn't happen if the doctor knows what they're doing.
It's like saying that ‑- it's like saying that a car is good because it's a mode of transportation and a gun is bad because it hurts people. But that car, if you put an alcoholic behind it, is going to kill somebody and that gun becomes very useful if somebody is breaking into your house.
So the issue is not the tool, but rather the user that's using the tool. If the physician is not competent, then of course you're going to have a problem. Just like with any medication if not given appropriately, you can have a problem.
QDo you ‑- are there certain labs you need to monitor when people are on ‑-
AAbsolutely.
Q‑- people are on chelation?
AAbsolutely.
QAnd what labs are those?
AThe most common ones ‑- one thing is always go for a very low dose challenging agent the first time because I don't know whether they will be an excreter or non- excreter and maybe we'll get into that, but that's ‑- that's a phenomena that's very crucial to this.
But if a person is an excreter, they're going to dump metals right away. This is ‑- this is depending on ‑- you know, what do I mean by excreter or non- excreter and I'll try to summarize what I told the U.S. Congress.
But essentially some patients have a genetic predisposition for the inability to detoxify. They may have a methatechrohydrocholic (phonetic) enzyme deficiency. They may have a glutathione S transfer issue. They may have a CUMT lesion. They may have some type of polymorphism. The gamuts out there, it's just ‑- they may have a methylation issue.
Whatever the case is, they're having a problem eliminating certain types of chemicals or substances out of their body that other people seem to be able to do without much problem or they're reducing ‑- they're eliminating less than what other people can ‑- can eliminate.
So what we have to do, is we have to first determine is this person going to be dumping metals readily or are they holding on to them.
For instance, the biochemistry of an autistic patient or a cancer patient seems to be a physiology that has an inability to excrete. So with those patients, we can be more aggressive because we know that they can't dump that stuff.
But with other people, you don't want to induce too much metal, so you have to go slow. You have to give them a low dose and that's what we start with every patient just to see what the first load is.
When you're doing that, you have to monitor renal function, that's the first thing, looking at BUN and creatinine and we do that. We have a standing order that every patient that's getting ‑- going through IV treatments, they must have a BUN and creatinine on record as well as a chemistry panel, baseline as well as every five treatments.
If they have any history of renal impairment, we will actually then increase their frequency to every three weeks or two weeks.
I've even had patients that have had a kidney transplant that we've done this with and they've been phenomenal with the results, but we monitor that patient every week because we want to make sure that we don't want to have any kind of complication from that aspect.
We also do specific gravity urine. We also look at the heavy metal burden with the post-challenge test. Initially before we start any type of treatment with IVs, we also get our routine things such as 12 lead EKG.
We do ‑- bone mass has been a big issue, some ‑- some non-educated criticisms of chelation therapy has been that it'll pull the calcium out of your bones which is absolutely an untruth.
In fact, Rudolph and Madonna in Missouri have shown in a study that there was an increase of 32 percent of bone mass density in one year after a person underwent chelation therapy. And I can explain that if the Board wants me to explain it, but it's based upon parathyrodone (phonetic) and calcitonin balance. If you want me to, I can go into that.
But basically there's other tests that we do that we monitor, but basically the kidney function, the LFTs and urine specific gravity and then we do heavy metal challenges every 20 treatments to see what the burden is, whether it's going up or coming down. If it's going up, that means you are a non-excreter. If it's coming down, then obviously they're dumping the metals.
And there's other things that we do depending on what we have the patient ‑- you know, whether she's a patient to have.
QOkay. Thank you, Doctor. Turn if you will Exhibit 20.
AYes, ma'am.
QIs this documentation taken from this ‑- from ‑- I'll represent to you -- we'll do it that way. Is this documentation taken from Patient C's conventional medical treatment records with regard to his treatment by his oncologist.
AYes, ma'am.
QAnd I think the second page of ‑- of Exhibit 20, L15 is the CAT scan that was ‑- that was done in February of '04.
AYes, ma'am. That was done I think like ‑- if I remember right, that was just done shortly after ‑- within a couple of months afterwards.
QAfter what?
AAfter this diagnosis that he was given with no recurrence of disease.
QRight.
ARight.
QRight. And then at that time though there was a recurrence?
AYes, ma'am. He was ‑- he had nodules that were found in the lung, in the liver. He also had retroperitoneal adenopathy and there was some issue of left pelvic bone involvement, two small benign -- the two small benign presenting left pelvic bone -- as I mentioned are benign.
QOkay. Let's turn back if we can to Exhibit 19.
AYes, ma'am.
QTell the Board, if you will, what that is with regard to Patient C.
AThis test?
QYes.
AThis is a fundamental test that is crucial for my being able to follow a patient in seeing whether they're responding to my therapy or not.
QAnd what ‑- what ‑- what do those lab tests measure?
ANatural Killer Cell Activity. There have been multiple studies done to show that in patients with cancer or even AIDS or any other type of significant immunosuppressant ‑- immunosuppression, excuse me, that the Natural Killer Cell Activities are significantly reduced.
In fact, the comment made by Dr. John Wilson is a completely true statement that if the immune system was intact, there's no way that cancer could manifest. The problem is if the immune system has had some type of burden that has compromised it and allowed for the cancer to become rampant.
Everybody, from the day they're born, we have cancer cells in our body and I'm sure the Board is aware of this. We have cells that are constantly going into ‑- into uncontrolled cellular proliferation and our body hasn't met apoptosis that basically allows us to have normal cells to commit suicide so that it doesn't affect the whole. This is a normal thing.
Natural Killer Cell Activity and some of these other things that ‑- that are part of this, the -- (inaudible) -- response is actually showing how well their immune system is functioning and how well or how normal their cellular physiology is and that's what it's coming down to.
QAnd specifically with regard to Patient C ‑-
AYes, ma'am.
Q‑- when Dr. Peterson says that your treatment was below the standard of care, do you have any reaction to that with regard to the lab tests that we're looking at right now?
AAs far as remaining calm, there are three times we did the tests on this particular patient because he went through treatment more for well treatment than the other two because they only went through a short period of treatment.
But when he came to us, his Natural Killer Cell Activity was 8.6 milliunits.
QAnd I don't mean to interrupt you, but just for the benefit of the Board, are you looking at a chart that is the last page of Exhibit 19?
Dr. Buttar Truth Quotes
“Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods.”
—- Albert Einstein
“Truth is generally the best vindication against slander.”
—- Abraham Lincoln
"All truth passes through 3 phases: First, it is ridiculed. Second, it is violently opposed, and Third, it is accepted as self-evident."
—- Arthur Schopenhauer
"There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success than to take the lead in the introduction of a new order of things because the innovator has for enemies all those who have done well under the old conditions and lukewarm defenders in those who may do well under the new."
—- Machiavelli, The Prince