Forensic

Looking for an Investigative Reporter to Question MRO—-Procedural, Ethical and Legal Justification Needed

mllangan1 13 Comments

As the Medical Review Officer (MRO)  for the Massachusetts state Physician Health Program (PHP), Physician Health Services, Inc. (PHS, inc.), Dr. Wayne Gavryck’s responsibility is simple.  He is supposed to verify that the chain-of-custody  in any and all drug and alcohol testing is intact before reporting a test as positive.

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Note Dr Gavryck is: 1. Certified by ASAM; 2. A .Certified Medical Review Officer (MRO) who “serves PHS in this capacity.” Although Dr. Gavryck serves PHS I would beg to differ on the MRO function. Accessed from PHS Website 1/15/2015 http://www.massmed.org/Physician_Health_Services/About/PHS_Associate_Directors/#.VM1dZlXF-hY

Dr. Gavryck evidently did not do that here.  In fact for more than a year he helped cover up an alcohol test that was intentionally fabricated at the behest of PHS Director of Operations Linda Bresnahan (who told me when I confronted her with the fact that I have never had or ever even been suspected of having an alcohol problem “you have an Irish last name–good luck finding anyone who will believe you!”

It took a formal complaint with the College of American Pathologists to get the truth out.  The whole fiasco can be seen here and here.

What Gavryck and his co-conspirators did is egregious and ethically reprehensible.  It shows a complete lack of moral compass and personal integrity.  What was done from collection to report to coverup  and everything in-between is indefensible on all levels (procedurally, ethically, and legally).

The documentary evidence shows with clarity that this was not accident or oversight.  It was intentional and purposeful misconduct.  I think everyone would agree that there should be zero-tolerance for forensic fraud in positions of power.    Any person of honor and civility would agree.

Transparency, regulation, and accountability are necessary for these groups.   It is an issue that needs to be acknowledged and addressed not ignored and covered up.

If Dr. Gavryck can give a procedural, ethical, or legal explanation of what was done then I stand corrected. Just one will suffice.  I’ll erase my blog and vanish into the woodwork.  But If he cannot then this needs to be addressed openly and publicly.   And whether he was involved in the original fraud or not is irrelevant. As the MRO for PHS it is his responsibility to correct it–however late the hour may be.

Perhaps Dr. Gavryck needs to see some of the damage he has caused in order to take this responsibility. Known as a “bag man” who simply rubber stamps positive tests at the request of Sanchez and Bresnahan (much like Annie Dookhan)  he does not see the damage that is caused. Forensic fraud has grave and far reaching effects and in this case has severely impacted many people and include patient deaths.

Perhaps Dr. Gavryck needs to take a “moral inventory” and see that this this type of behavior causes real damage to real people and put a face on it.

Perhaps Gavryck needs to be asked these questions directly from an investigative reporter.

It is people just like this who are killing physicians across the country.   The body count is vast and multiple. This has recently been underscored by the horror stories mounting in recent Medscape and KevinMD articles associating PHP programs like this one with the recent epidemic of suicides in doctors.

These people have removed themselves from accountability.  One way they do this is by withholding information and suppressing the truth.  This is facilitated by willing sympathizers and apologists who refuse to acknowledge or investigate wrongdoing.   Gavryck believes he is beyond reproach and is complacent that his friends will protect him and insulate him from harm.  The evidence, however, is not going away. Neither am I.

Those who are caught doing dirty deeds such as this need to be held accountable.  This requires the provision of information, justification for actions and the ability to be punished by outside groups.

I have the information.  Gavryck needs to provide justification for his actions and held accountable for them.  Perhaps an investigative journalist could interview him and ask him directly.

Help me get this exposed, corrected, and rectified.  The doctors of Massachusetts and the doctors of this entire country deserve better than this.

via Integrity and Accountability—Defend the MRO Procedurally, Ethically or Legally and win 100 Volumes of the Classics in Medicine Library and Salk and Sabin Autographs!.
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The MRO Code of Ethics--Seems like Dr. Gavryck's breaking them in sequential order!

The MRO Code of Ethics–Seems like Dr. Gavryck’s breaking them in sequential order!

Mandating Drug-Testing of Unknown Validity while removing the procedural safeguards of forensic drug testing: The plan to Introduce Laboratory Developed Tests into Mainstream Healthcare

mllangan1 19 Comments

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Chain-of-Custody refers to the document or paper trail showing the collection, control, transfer, analysis and disposition of laboratory tests.  It is the written documentation of a specimen from the moment of collection to the final destination to the review and reporting of the final results.   The multi-part chain-of-custody form or “custody and control” form is part and parcel of this process. It contains stickers to sign and seal the specimen so that it cannot be tampered with and the form itself is signed by the appropriate parties as the test specimen travels from place to place. Information is added to the form as it travels from person to person.  It has been given the status of a legal document as it has the ability to invalidate a specimen with incomplete information.  Once the sample is analyzed it is reviewed by a Medical Review Officer (MRO) for final review. In the case of a positive test it is the responsibility of the MRO to ascertain an intact  chain-of-custody, determine whether an alternative explanation exists for the positive test such as a prescribed medication, and then and only then report the test as a “true positive.”

The MRO looks for what are called “fatal flaws” and,  should one be present, invalidates the test.  A fatal flaw requires the test be rejected as it were never drawn.  It invalidates it and it cannot be used. screen-shot-2013-12-19-at-12-20-46-pmAny and all drug testing requires strict  chain-of-custody procedures. It documents not only the whereabouts of the specimen at any given time but the management and storage of the specimen. This is important because time and temperature can influence the results of certain tests.  One such test is alcohol.

Specimen integrity is critical in forensic drug testing, but so too is the integrity of the people involved.

Forensic Versus Clinical Drug Testing

According to the ASAM White Paper on Drug Testing, clinical drug-testing “employs the same sound procedures, safeguard, and systems of information management that are used for all other health-related laboratory tests, tests on which life-and-death medical decisions are commonly made.”  In the box below they describe the multiple safeguards in place and requirements demanded of “forensic” drug testing but do not mention the reason these uncompromising and multiple specifications exist is to protect the donor from a false accusation of drug or alcohol use.  They proceed to define “clinical drug testing” as “part of a patient examination performed for the purposes of diagnosis, treatment, and the promotion of long term recovery” noting that clinical testing “must meet the established standards of medical practice and benefit the therapeutic relationship, rather than meeting the formal legal requirements of forensic testing.”  The authors then state that the “majority of drug testing done today” includes both forensic and clinical elements using individuals on parole and probation as examples.

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From the ASAM White Paper on Drug Testing

The logical fallacy here is striking.  It is comparing apples and oranges.  After detailing the specific quality assurance safeguards designed to prevent the donor of a drug or alcohol test from being falsely accused of illicit use, the authors give a general  definition and purpose of  “clinical” testing  then state that when testing for drugs the systems in place are up to snuff as they are already being used to make  “life-and-death medical decisions.”  The take-home message is that “forensic” testing is unnecessary hyperbole designed for legal challenges. The clinical lab  systems in place are used for critically  important testing and can therefore be used for drug-testing–after all, parolees and probationers don’t require it.

Forensic guidelines were developed in collaboration with occupational and environmental medicine specialists, clinical and forensic toxicologists, pathologists and others and the recommended  requirements agreed upon by this consortium exists solely to  assure validity and accuracy in the testing process.  These requirements exist to protect the donor and If the “clinical” testing context fit the bill then “forensic” testing would not have evolved.

Labs ordered clinically in the course of patient care are interpreted within the context of multiple other pieces of data.  Lab errors occur all the time and are interpreted in that context. Oftentimes a lab will not fit with the clinical picture and, when that happens, a repeat lab is ordered for verification.  Specimens get collected in the wrong tube and specimens get lost but in the clinical setting they simply get reordered and there are no consequences to patient care.   In contrast drug testing is an all-or-none one-shot test and the results have consequences. It is for that reason they must be valid.  Chain-of-custody and MRO review are critical and that is why most drug-testing programs follow the forensic protocol.  And the example of non-forensic drug-testing  parolees and probationers is misleading.   Any Employee Assistance Program that has a union or some other group looking out for their best interests uses strict “forensic” guidelines.   Parolees and probationers have no power  and have no choice.  Besides, the  National Association of Drug Court Professionals uses the Laboratory Developed Tests these same people introduced to test  individuals on probation or parole in the criminal justice system just as they do in the PHPs.

The  ASAM White Paper:

 “Encourages wider and “smarter” use of drug testing within the practice of medicine and, beyond that, broadly within American society. Smarter drug testing means increased use of random testing* rather than the more common scheduled testing,* and it means testing not only urine but also other matrices such as blood, oral fluid (saliva), hair, nails, sweatand breath when those matrices match the intended assessment process. In addition, smarter testing means testing based upon clinical indication for a broad and rotating panel of drugs”

As a physician-patient relationship renders drug testing “clinical” rather than “forensic” the consequences become “treatment” rather than “discipline.”  And that is the real reason behind all of this.    A positive “forensic” test in most employee random drug screening programs today will result in an “assessment” for substance abuse.  Most EAPs allow a choice in where that assessment takes place.  The model this system is based on, Physician Health Programs. do not allow choice as evaluations are mandated to “PHP-approved” assessment centers; a rigged game.

A positive “clinical” test will result in the same thing under the ASAM White Paper proposal.  But the assessment will be at an ASAM facility and if a Substance Use Disorder (SUD) is confirmed it will result in mandated abstinence of all substances (including alcohol) and lifelong spirituality involving 12-step recovery   And by using the healthcare system as a loophole and calling this testing “clinical” rather than “forensic” the ASAM will have successfully introduced widespread testing of a variety of Laboratory Developed Tests (LDTs) of unknown validity while removing  the safeguards provided by forensic testing including chain-of-custody and MRO review.

 

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Integrity and Accountability—Defend the MRO Procedurally, Ethically or Legally and win 100 Volumes of the Classics in Medicine Library and Salk and Sabin Autographs!

mllangan1 19 Comments

Screen Shot 2015-06-18 at 11.46.50 PMIntegrity and Accountability—The Declining State of Physician Health and the Urgent Need for Ethical and Evidence-Based Leadership.

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Sabin and Salk Autographs

“The incompetent or unprincipled physician, licensed to practice medicine by a too complaisant State, is the greatest menace to scientific medicine – as great a menace as all the cultists put together.”  —Dr. Morris Fishbein  (The Medical Follies.  New York:  Boni Liverlight, 1925 p. 71)

“There is no place in science for consensus or opinion, only evidence”  —Claude Bernard

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Sabin, Salk and the Classics in Medicine Library

Polio is nearly a thing of the past thanks to to Dr. Jonas Salk and Albert Sabin. In 1952 Salk discovered and developed the first successful vaccine for polio and combined with Albert Sabin’s 1961 oral vaccination the duo effectively obliterated the contagious polio virus.  Once a deadly threat to our  country and future there were 93,000 cases of polio reported in the U.S. Between 1952 and 1953 alone. ElaineBurnsBut thanks to Sabin and Salk the last case of naturally occurring polio in the U.S. occurred in 1979.

 
full body respirator or “iron lung” needed to treat patients whose respiratory muscles became paralyzed by polio

October 23, 2014 was the centenary of Jonas Salk’s birth and in honor of his 100th birthday I am sponsoring a contest to win framed autographs of both Jonas Salk and Albert Sabin as seen above.  In addition,  you will receive 100 volumes of the Classics in Medicine Library published by Gryphon Editions whose “mission is the preservation of the literary and intellectual heritage of the noble professions that we serve”

These are exact facsimiles of the original classics bound in leather and include works by William Osler, Harvey Cushing and Paul Dudley White.

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Background

According to British sociologist G. V. Stimson the  “impaired physician movement” is characterized by a “number of evangelical recovered alcoholic and addict physicians, whose recovery has been accompanied by involvement in medical society and treatment programs.” Their “authoritative pronouncements on physician impairment is based on their own claim to insider’s knowledge.”

In this regard Dr. Wayne Gavryck, M.D. is a prototypical example.

An ex-alcoholic with a history of malpractice, Gavryck quit drinking through Alcoholics Anonymous, became “board certified” in “Addiction Medicine” and became involved with the Massachusetts PHP,  Physician Health Services, Inc. (PHS) where he has been an Associate Director since 1988.  He serves as their Medical Review Officer (MRO).

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The “impaired physician movement” has gained tremendous sway through the American Society of Addiction Medicine and the Federation of State Physician Health Programs.  The ASAM is not a valid medical specialty but a “special interest group” that represents the chronic relapsing brain disease with lifelong abstinence and 12-step recovery model of addiction and the companies that profit from it financially ( drug and alcohol testing labs,  12-step inpatient assessment and treatment centers) and politically  (Drug War advocates,  Anti -Medical Marijuana advocates).   The impaired physician movement gained a seat at the table of power in medicine by bamboozling regulatory and administrative medicine.   This illegitimate and irrational authority is in charge of almost every state PHP in the United States.     ASAM physicians joined their state PHPs, gained power, and then removed those who did not agree with the groupthink and doublethink.  Blind obedience and control  are favored over fairness, truth and evidence-base.   As with other states under the FSPHP, blindly obedient doctors are kept on while those who  question the science  and ethics of the groupthink are removed.  The  PHP-Drug Testing Laboratory and  “PHP approved” assessment and treatment center industrial complex requires a Medical Review Officer of blind faith who places the goals of the FSPHP above all other considerations including the Hippocratic Oath.  The system requires doctors who are willing to participate in “moral disengagement” of wrongdoing including professional, ethical and legal violations.    To erect this scaffold they have put in place barriers to exposure and accountability. By declaring themselves “experts” they have used logical fallacy to temporize  deflect and otherwise stifle accountability. With no oversight or regulation they are, in fact, accountable to no one.   The appeal to authority and esoteric knowledge is an effective means of  extinguishing valid concerns.  Complacent that this is a group of benevolent organizational purpose those who should know better and could do something about it rationalize their apathy and indifference.   A necessary step in exposing and addressing this  problem is imposing accountability.    If an organization is able to  engage in conduct that is the antithesis of accepted professional guidelines and standards of care,  in violation of professional and societal mores and codes-of-conduct and  is illegal then there is a systemic problem.  This problem can fortuitously be addressed by examining standards of care, conduct and criminal codes for breaches.   If a breach is found then it needs to be explained and justified.  One of the tactics of the FSPHP is to deflect criticism under the logical fallacy of appeal to authority.  We are the experts. We know better.  That is where it usually ends.   But accountability requires both the provision of information and justification of actions.  My hypothesis is that this group is committing fraud, violating ethics and flouting the law in an irrefutable manner.  If this is not true then my hypothesis should be able to be refuted.  It cannot.  And for that reason I am putting my money where my mouth is.

Accountability

In all fairness,  If Gavryck can justify his actions either procedurally, ethically or  legally and back it up by any written protocol, guideline or standard then he wins and I will refrain from any more criticisms.  In addition I will hand deliver to him the Salk and Sabin autographs and 100 volumes of the classics in medicine, apologize and remove this entire blog.

Accountability requires both the provision of information and justification of actions.  One way of examining this is to look at the body professional and ethical standards and state and federal law.   The FSPHP has blocked the provision of information regarding drug-testing.  Although it has taken over three years I have obtained the all of the information pertaining to a July 1, 2011  test that should have immediately been rejected by the MRO. It is an invalid test.

Dr. Gavryck violated every conceivable procedural guideline and standard-of-care there is for an MRO,  the Medical Review Officer Certification Council’s Codes of Ethical Conduct and both State and Federal Law.   This can be ascertained by looking at the documentation.  I have done this and found hundreds of documents that support the accusation that as an MRO Wayne Gavryck breached protocol, engaged in unethical behavior and broke the law.  Prove me otherwise with just one credible source and  the prizes are yours.

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Contest Rules

Your job is to review the documentary evidence and records from PHS, Quest Diagnostics and USDTL and assess the actions and decisions made by the MRO.S)

If you can show that  these decisions were the result of  legitimate reasoning based on published guidelines or protocol, ethically defensible or did not break any laws and cite one credible source that concurs with this point of view then you have won.

If you can show that these decisions were the product of legitimate and thoughtful reasoning in accordance with established guideline, ethical codes then I will hand-deliver the items to you.

 If you can justify, support or defend the actions of the Medical Review Officer (MRO):

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  2. Ethically; 

  3. or Legally;IMG_0577 - Version 2 

You win all of the prizes! Simple as that!

In fact, If you can support  just one of these the entire lot is yours.

If you can show Dr. Gavryck did not breach any and all published Standards-of-Care and Professional Protocols and Guidelines regarding drugs-of-abuse testing, OR that he did not violate any and all Codes of Conduct and Ethical Guidelines of the Medical Profession from Hippocrates to the American Medical Association OR that he did not violate multiple State and Federal Laws you win Salk and Sabin autographs and all of the books.

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All of the documents and details regarding the forensic fraud, concealment, coverup and deliberate misrepresentation to a state agency under color of law can be seen here:

Integrity and Accountability—The Declining State of Physician Health and the Urgent Need for Ethical and Evidence-Based Leadership.

To Review:   Any and all drug testing requires chain-of-custody.   “Forensic” drug testing differs from “clinical”drug testing because the consequences of a falsely positive test can be grave and far reaching.  Because the results of  a positive test can result in the loss of rights and liberties of the person taking the test it is essential that it be done correctly.  False-positive tests are unacceptable so strict chain-of-custody procedure and MRO review assure specimen integrity.    This provides accountability and the custody

The custody-and-control form records chain-of-custody and is given the status of a legal document as it has the ability to invalidate a test that lacks complete information.  The job of the MRO is to invalidate specimens without intact chain-of-custody.

The MRO job is fairly simple.  If a lab reports a positive test for any substance the MRO must check that the signatures, dates, times and other information on the custody-and-control form are correct and per protocol.  Chain-of-custody must be accurate and complete.   The MRO looks for “fatal flaws” on the chain-of-custody form.  If a “fatal flaw is present then the test is invalidated and the test is not reported as “positive” but “invalid.”

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The sole  job of the MRO is to ensure that the drug testing process and chain-of-custody procedure is followed to the letter.  The MRO reviews the Custody and Control form for accuracy and completeness.  The MRO also rules out any other possible explanations for a positive test (such as legitimately prescribed medications).  Only then is a test reported as positive.

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The legal issues involved in forensic testing mandate MRO review. According to The Medical Review Officer Manual for Federal Workplace Drug Testing Programs

“the sole responsibility of the MRO is to”ensure that his or her involvement in the review and interpretation of results is consistent with the regulations and will be forensically and scientifically supportable.”

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Corruption is misuse of entrusted power.  It occurs when those who have been given authority to carry out expected goals instead use their position and power to benefit themselves and others close to them. Abuse of power is particularly egregious when that person is doing the opposite of what he or she is supposed to do.

Accountability is necessary to prevent corruption and necessitates both the provision of information and justification for actions;  what was done and why?   The other defining factor of accountability is the ability of outside actors to punish and sanction those who commit misconduct or wrongdoing.    Without these constraints corruption is inevitable.

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Although Gavryck may serve PHS, it is not in the capacity of a certified medical review officer; by my count  the documentary evidence alone shows that he violated four of the seven Medical Review Officer Certification Council Codes of Ethical Conduct.  In addition to violating the MRO  Ethical Conduct he violated every other code I can think of from the Hippocratic Oath to the AMA Code of Ethics. and everything in between.

As the MRO for PHS Gavryck’s responsibility is simple.  He is supposed to verify that the chain-of-custody  of the sample was intact before reporting a test as positive.

This is indefensible on all levels (procedurally, ethically and legally). The documents show with clarity that this was not accident or oversight, but intentional and purposeful misconduct

There should be zero-tolerance for forensic fraud of this sort.   Those of integrity and moral compass would agree.     Transparency, regulation, and accountability are necessary.  It is an issue that needs to be acknowledged and addressed not ignored and covered up.

If Dr. Gavryck can give a procedural, ethical, or legal explanation of what was done then I stand corrected. Just one will suffice. If he cannot then this needs to be addressed openly and publicly.   And whether he was involved in the original fraud or not is irrelevant. As the MRO for PHS it is his responsibility to correct it–however late the hour may be.

Perhaps Dr. Gavryck needs to see some of the damage he has caused in order to take this responsibility. Known as a “bag man” who simply rubber stamps positive tests at the request of Linda Bresnahan, much like Annie Dookhan, he does not see the damage that is caused. Forensic fraud has grave and far reaching effects and in this case has severely impacted many people and include patient deaths. Perhaps Dr. Gavryck needs to take a “moral inventory” and see that this this type of behavior causes real damage to real people and put a face on it.

Please help me get this exposed, corrected, and rectified. The physicians of Massachusetts deserve better than this.

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Anatomy of a Forensic Fraud: The Reality of Drug and Alcohol Testing

mllangan1 16 Comments

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The juxtaposed documents in and of themselves reveal a number of red flags.  How does one “revise” a chain-of-custody”?    If you do a google search you will not find “chain-of-custody” as an object of the verb revise. It is an oxymoron.  A document or opinion can be revised.  A chain-of-custody, by its very definition, cannot.  This collusion to fabricate a positive test has coined a new oxymoron—“revised chain-of-custody.”     Go ahead and look it up. It is a novel one.     As it should be.

What these documents show is, in fact, indefensible ethically, procedurally and legally.  The first document signed by Dr. Luis Sanchez, past President of the FSPHP and past Medical Director of Physician Health Services, Inc.  (PHS) was sent to the Board of Registration in Medicine on December 11, 2012 and is notable for two statements.   The letter from Dr. Sanchez asserts that “Yesterday, December 10, 2012, Physician Health Services, PHS received a revision of a laboratory test result,” but it did not matter because PHS was {unaware} ” of any action taken by the Massachusetts Board of Registration in Medicine as a result of the July 28th, 2011 report.   However, based on the amended report, PHS will continue to disregard the July 21st PEth test result.”

The second document, addressed to Dr. Luis Sanchez, is dated October 4, 2012 (67 days earlier) and shows the first document to be a bald-faced lie.

On July 28h 2011 Dr. Luis Sanchez reported to the Medical Board that I had a positive alcohol test.

Although I knew that Dr. Sanchez had fabricated the test I  had no way of proving it. I requested the “litigation packet,” which records “chain-of-custody” from collection to analysis in August of 2011.  At first they  refused.  PHS then tried to dissuade me (“it will be costly, involve attorneys, etc). Finally they agreed but threatened me with “unintended consequences.”

I was finally able to get a copy of the “litigation packet”  in December of 2011.  Remarkably, it  showed that Sanchez had requested my ID # and a “chain-of-custody” be added to an already positive specimen. I reported this to the Board but they ignored it. I also filed a complaint with the College of American Pathologists.Screen Shot 2014-11-06 at 11.17.32 PM

On October 23, 2012 Sanchez reported to the Medical Board that I was “noncompliant” with requirements with A.A.  meetings that I was supposed to go to as a direct result of the positive test and my license to practice medicine was suspended as a result in December 2012.

On December 10, 2012 I contacted the College of American Pathologists who told me the test was “amended” from “positive” to “invalid” on October 4, 2012. I confronted Sanchez and PHS and they said they did not know anything about it.

The following day, December 11, 2012, they sent out a letter saying that the test was invalid but that they were “unaware of any action taken against my license as a result of the test.”  

The documents show that on  July 19th, 2011 Sanchez requested my ID # 1310 and a “chain-of-custody” be added to an already positive specimen and on October 4th 2012 the test was “appended” to “external chain of custody not followed per standard protocol.”

Please note again that  Dr. Sanchez stated on December 11, 2012 that he “just learned” about this on December 10, 2012. He reported me to the Board as “noncompliant” on October 23, 2012 and my license was suspended in December 2012.   These documents show he had full knowledge that the test was invalid and as an agent of the Board this is under “color of law.”   Both he, and PHS, need to be held accountable for this.

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Lies, Lies, and More Lies

10:19:12-Verbal Compliant Noncompliance f:u written 10:19:12–BORM Complaint Committee

The contradictory documents from Sanchez alone constitute a crime (withholding information in concealment and providing false information to a state agency).  But what he did is far far worse.

I just obtained the October 4th document. Although I knew it existed, PHS suppressed it and refused to acknowledge it.   But in response to a complaint I filed against PHS and the labs it was revealed by USDTL that the test in question (phosphatidyl-ethanol) was not sent as a “forensic” specimen but collected as a “forensic” specimen, then changed to a “clinical” specimen at the request of PHS Program Director, Linda Bresnahan.   The specimen was kept at the collecting lab (Quest) for 7 days as a  “clinical” specimen, then sent to the analyzing lab (USDTL) with specific instructions from Quest to process it and report it as a “clinical” specimen.  PHS then used it as a “forensic” specimen by reporting me to the Board of Registration in Medicine and  requesting I undergo an evaluation for alcohol abuse.

As a “clinical” specimen it is rendered “Protected Health Information” (PHI) and thus under the HIPAA Privacy-Rule.   So with the help of the College of American Pathologists I requested my PHI from both Quest and USDTL. Quest refused (for obvious reasons) but USDTL complied.   And that is how I was able to obtain the October 4th document revealing that Dr. Sanchez lied to the Medical Board.     I would love to hear him, or PHS MRO Wayne Gavryck, defend the indefensible (and unconscionable).

Dr. Sanchez is correct when he pleads ignorance of any action taken by the Board as a result of the July 21st PEth result.   It was his report to the Medical Board  that I was “noncompliant” with attending AA meetings (that I was supposed to go to as the direct and sole result of the positive test)   that he reported to the Board just two weeks after the October 4th appended test.

The test was sent as a “clinical” specimen intentionally. PHS is not a clinical provider but a monitoring agency. They cannot send clinical samples.   But since clinical samples are “protected health information” and under HIPAA the lab had to give me the records and here you have them.

The distinction between “forensic” and “clinical” drug and alcohol testing is black and white.  PHS is a monitoring program not a treatment provider.  The fact that a monitoring agency with an MRO asked the lab to process and report it as a clinical sample and then used it forensically is an extreme outlier in terms of forensic fraud.  The fact that they collected it forensically, held it for 7 days and changed it from “forensic” to “clinical” to bypass strict “chain-of-custody” requirements  deepens the malice.  The fact that they then reported it to the Board as a forensic sample and maintained it was forensic up until now makes it egregious.   But the fact that the test was changed from “positive” to “invalid” on October 4th, 2012 and Sanchez then reported me to the Board on October 23rd 2012 for “noncompliance,” suppressed it and tried to send me to Kansas for damage control makes it wantonly egregious.   (they didn’t think I’d ever find out).

Add on that the fact that I’ve been questioning the validity of the test since day 1 and they violated the HIPAA Privacy Rule over and over and this is reckless and major health care fraud.

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Fax from PHS to USDTL on July 19th, 2011 asking that my ID #1310 be added to an already positive test and a “chain-of-custody” be “updated”

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USDTL complies with PHS request to and adds my ID #1310 and a date of collection (July 1, 2011) to an already positive specimen

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No date of collection, no unique identifier linking specimen to me. Multiple “fatal flaws.”

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I file complaint with CAP January 12, 2102. CAP forces USDTL to amend test from “positive” to “invalid” which they do on October 4, 2012. PHS conceals this fact until December 11, 2012

Letter from Chief of Toxicology at MGH–Ignored by PHS, USDTL, and the BORM         11:5:12-Dr. Flood Letter–Ignored by PHS:USDTL:BORM

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A Golden Age

mllangan1 4 Comments

Golden Age

BY TIMOTHY STEELE

Even in fortunate times,
The nectar is spiked with woe.
Gods are incorrigibly
Capricious, and the needy
Beg in Nineveh or sleep
In paper-gusting plazas
Of the New World’s shopping malls.
Meantime, the tyrant battens
On conquest, while advisers,
Angling for preferment, seek
Expedient paths. Heartbroken,
The faithful advocate looks
Back on cities of the plain
And trudges into exile.
And if any era thrives,
It’s only because, somewhere,
In a plane tree’s shade, friends sketch
The dust with theorems and proofs,
Or because, instinctively,
A man puts his arm around
The shoulder of grief and walks
It (for an hour or an age)
Through all its tears and telling.

Timothy Steele, “Golden Age” from Sapphics and Uncertainties: Poems 1970-1986. Copyright � 1986, 1995 by Timothy Steele. Reprinted with the permission of the University of Arkansas Press, www.uapress.com.

Source: Sapphics Against Anger and Other Poems (1986)

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Disappointed that his grandiose proposal to test the urine of half the U.S. population for illicit drugs was declined in the 1980’s, Bob realizes such a large swath was too tall an order. Acknowledging that his dream of lifelong urine drops for each and every one of the riffraff at least once a fortnight will take time, he decides to focus his attention on specific subsets of the great unwashed such as school-children, welfare mothers, the unemployed and whatever they are calling Hippies these days.

Medical Urban Legend–The Legacy of the 4 MDs and why B.S. Needs to be Identified from the Get-Go!

mllangan1 14 Comments
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“Because I can Biotches! That’s right..because I can!” 

According to G. Douglas Talbott, rehabilitation programs that evaluate and treat the rest of the population for substance abuse issues are incapable of doing so in doctors as they are unlike any other inhabitants of our society.   Physicians are unique. Unique because of their incredibly high denial”, and this genetically inherent denial is part of what he calls the “four MDs.” Used to justify the thrice lengthier length of stay in physicians the “four-MDs” are as follows: “M-Deity”, “Massive Denial” “Militant Defensiveness” and “More Drugs.”

He states that “Impaired doctors must first acknowledge their addiction and overcome their ‘terminal uniqueness’ before they can deal with a drug or alcohol problem.”
Now some  doctors are arrogant undisciplined egotists but narcissistic personalities exist in any profession and expanding traits that may apply to a small percentage of doctors to include all doctors as a universal truth contradicts reality. Applying a stereotypical paternalistic length of treatment in doctors three times as long as non-doctors to force a “one-size” fits all treatment on them has no evidence base.

tumblr_kuwuugSEmN1qz6z0no1_500This dicto simpliciter argument can, in fact, be refuted simply by pointing it out! Sadly, no one ever did so the ASAM front-group hasbeen able to establish this caricature of the arrogant paternalistic know it all needing 3 months or more of treatment as standard of care for our profession. They did this by getting medical boards and the FSMB to accept fantasy as fact by relying on board members tendency to accept expert evidence at face value–which they always do and that is a personality characteristic that I would argue is not dicto simpliciter.

Physicians are unique only insofar as the unique elements required of the profession to become and be a physician such as going to medical school and completing the required board examinations.

Any and all doctors referred to a PHP for assessment will spend at least 3 months in treatment if the facility feels it is indicated. It is inevitable. No one has challenged a patently absurd generalization that has absolutely no evidence base or plausible scientific or medical explanation. Of course those sentenced to the 3 or more months have complained but by that time they are de-legitimized and stigmatized. No one to complain to.  After all, these are just redeemed altruistic non-profit  good guys protecting the public and helping colleagues forge a path to salvation!
All the ASAM/FSPHP quacks have to do at that point to deflect legitimate concerns is point out the one doing the complaining is an “addict” who is “in denial” and it is part of his “disease.”  The mere accusation of substance abuse is used to disregard the claims of the accused.
Authoritative opinion entrenched. Someone should have called B.S. long ago.  But no one did and if they had we would not be in the current situation which is only going to go from bad to worse as the ASAM plan for universal contingency-management and urine usury unfolds-–A “golden age.” And the 4MDs Talbott attributes to doctors are all wrong. There is only one MD and it is “medical license.” On second thought that may not be entirely true.  “More money” may be another. And I am not talking about a doctor’s income. I am referring to insurance and the specter of depleting home and hearth.   Fiscal annihilation. Your license or your life.   And the only true  and plausible answer that Talbott could give to justify the lengthy stay is “Because I can biotches!” And “contingency-management” sounds better than extortion doesn’t it?  And  using your medical license as “leverage” sounds a helluva lot better than holding it for ransom.
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The ‘A’ Word: Are Doctors Arrogant?
Leslie Kane
June 17, 2014
Good Doctors Have Some Bad MomentsDoctors’ personalities have become a hot topic, not only because warmth and pleasantness count toward patient satisfaction, but also because positive patient interactions have a role in better outcomes.Physicians’ personalities are under the microscope as patients post reviews of doctors on numerous Websites. In some reviews, the word “arrogant” has shown up. But calling doctors arrogant is nothing new.Are there really so many arrogant doctors? No doubt, some physicians deserve the label, but it seems to be a stereotype that has blossomed and taken on its own life.”Arrogance among doctors is not the norm”, says Marion Stuart, PhD, co-author of The 15 Minute Hour: Therapeutic Talk in Primary Care, and Professor Emeritus in the Department of Family Medicine at UMDNJ-Robert Wood Johnson Medical School. “Someone who has done the hard work and has gone into medicine because they care about people, and are interested in helping peoples’ lives and making the world a better place, is not going to be arrogant.”So how did the arrogant doctor epithet arise?In the past, doctors were considered authorities who told compliant patients what to do and treated them with a paternalistic attitude. Some doctors may retain those behaviors today.Another possibility is overgeneralizing. A patient sees a doctor who has a difficult personality and assumes that the trait is more widespread within the profession than it really is.

Arrogance or Self-confidence?

“Arrogance is totally different from self-confidence,” says Dr. Stuart. “When you’re confident, that’s your assessment of your own competence. You have the experience and the wisdom, you know what you can do, and your confidence says that. It’s your relationship to yourself and your own expertise,” she says.

Arrogance is a different ballgame. “This has to do with your judging that other people are inferior,” she says. “It has more to do with not seeing other people as being up to your standards.”

Could the confidence that comes with being accomplished and successful make someone arrogant? Typically no, says Dr. Stuart. The trait of arrogance develops or resides within a person at a much earlier stage, arising from one of two paths:

“I am indeed better.” Someone who has always lived a privileged life, feels entitled to all of the finer things, or has always been looked up to may take it as a given that he or she is better than others. “People who had a sheltered, protected existence with no perception of what the real world is like for other people may consider themselves an elite group, entitled to feel superior,” says Dr. Stuart.

“I made it, so why can’t you?” By contrast, a person who was deprived as a child and worked very hard to pull himself up by the bootstraps may then look down on others who don’t have the same perseverance or initiative to take charge of their life and create similar success.

Doctors Are Harried and Pressured; Patients Are More Demanding

Some doctors have admitted that at times it’s hard to maintain their patience, and frustration triggers a snappish response. Throw into the mix the fact that doctors may have less time to see each patient and answer questions, and you have the ingredients for a negative interaction.

“I’ve had eight years of medical education and I’ve been trying to get my patient to make healthy lifestyle changes, and he comes in with a page ripped out of a tabloid, convinced that the information is right…there’s a limit to how much time I can spend ‘educating’ or convincing them that their ‘cure’ has no scientific basis,” one physician told me.

People have come to expect the stance of “the customer is always right” and get annoyed if doctors don’t accede to all of their requests. But because of new medical practice guidelines, a doctor may not readily give the patient the test or medication they ask for. “Now, with healthcare insurers and companies setting limits on doctors, many times the patient feels that the doctor is not so much on their side, and this could be perceived as arrogant,” says Dr. Stuart.

Is There an Outbreak of Rudeness?

Barry Silverman, MD, a cardiologist and coauthor with pediatrician Saul Adler, MD, of Your Doctors’ Manners Matter: Better Health Through Civility in the Doctor’s Office and in the Hospital, says, “While most doctors are appreciated and respected by their patients, there’s a general perception that professionalism has declined.

“Patients are often more informed, ask detailed questions, and demand a high level of service, while demands on the doctor’s time increase and reimbursements fall,” says Dr. Silverman. “What patients interpret as arrogance is many times a rushed and harried doctor, not an uncaring one. Medicine can be mentally and physically exhausting, but the bottom line is that the doctor must listen and communicate with the patient to deliver quality medical care.”

Still, remaining pleasant and calm is easier for some doctors than for others. There’s no uniform physician personality; many doctors have a natural “people person” inclination, while others are more stoic.

Are doctors expected to smile and be nice in every circumstance, no matter what?

“Professionalism is not about putting on a happy face or being someone you are not; it is about providing quality care for the patient,” says Dr. Adler. “Patients are more informed and have access to more information than ever before. Much of that information is incorrect and sometimes harmful. That means that part of the professional duty is to teach as well as treat.

“Patients understand that doctors have significant restraints on their time, and it is not unreasonable for doctors to use preprinted written materials, educational resources outside the doctor’s personal office, and honest and informative Websites,” says Dr. Adler. “However, under no circumstances should the doctor be rude or abrupt; a smile and kind, considerate behavior is always appropriate.”

It would be naive to say that there aren’t arrogant doctors. But there are far more doctors trying to do their best for patients and relate to them.

Medscape Business of Medicine © 2014 WebMD, LLC

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Laboratory Misconduct in Drug Testing–Processing “Forensic” as “Clinical” to Bypass Chain-of-Custody

Asidemllangan1 23 Comments








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In “Ethical and Managerial Considerations Regarding State Physician Health Programs, ” Dr.’s J Wesley Boyd and John Knight note the significant and multiple conflicts of interest that exist between State Physician Health Programs and the referral treatment centers that they use.     They state:

“To further complicate matters, many evaluation/treatment centers depend on state PHP referrals for their financial viability. Because of this, if, in its referral of a physician, the PHP highlights a physician as particularly problematic, the evaluation center might—whether consciously or otherwise—tailor its diagnoses and recommendations in a way that will support the PHP’s impression of that physician.”

There is an obvious difference between impartially evaluating evidence in order to come to an unbiased conclusion and building a case to justify a conclusion already drawn. To consciously “tailor” a diagnosis of addiction or relapse based on anything other than the objective evidence violates the basic principles of medical ethics.

A state audit of the North Carolina Physicians Health Program that was released in 2014 documented the conflicts of interest and lack of quality assurance in referrals to out of state “PHP-approved” assessment and treatment programs.  The same centers are used in most states including Massachusetts.  and the the medical directors of the “PHP-approved” facilities can all be found on this list of “Like-Minded Docs.”  The financial and political conflicts-of-interest are obvious between the PHPs and the “PHP-approved” assessment and treatment centers.  And there is no choice in the matter.

In 2011 the ASAM issued a Public Policy Statement on Coordination between Treatment Providers, Professionals Health Programs, and Regulatory Agencies recommending physicians in need of assessment and treatment be referred only to “PHP approved” facilities and also that PHPs need the full cooperation of the board  if they deem a monitored physician noncompliant as “criticism or doubt could unintentionally undermine the PHP”   In addition the ASAM wants regulatory agencies to  recognize the PHP their expert in all matters relating to licensed professionals with “potentially impairing illness.”  You read that right, “potentially impairing illness.”  The  Federation of State Medical Boards House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting and approved the concept of “potentially impairing illness” and “relapse without use.”  

And what might signal a potentially impairing illness you ask? According to Physician Health Services, Inc. (PHS), not having “complete, accurate, and up-to-date records” could be a red flag as “when something so necessary is not getting done, it is prudent to explore what else might be going on.”

Boyd writes in Psychology Today that when he and John Knight published this paper, reviewers at 2 different journals said that the issues raised were very important but it “should not be published, essentially because doing so might bring unwanted outside attention to PHPs” and —one of them wrote the paper should be withdrawn and instead be presented at the national federation of PHPs’ annual meeting. Boyd recommends more state audits and national standards and that “because PHP practices are largely unknown to physicians until they themselves are referred to one, physicians who do register complaints about standard PHP practice are often dismissed as bellyaching”

On July 1st 2011 I was asked to have a blood test for alcohol. 19 days later it was reported at an impossibly high level and I was reported to the Board of Registration in Medicine and asked to have an evaluation at one of the “PHP-approved” facilities.

One potential conflict-of-interest that has not been entertained is that between the PHP and the contracting labs.  Just like the assessment and treatment centers there is a lot of money involved in drug and alcohol testing and the FSPHP is a big referral source.  In addition, some of the tests these labs are using on physicians were actually introduced by an ASAM/FSPHP doctor and developed as Laboratory Developed Tests (LDTs). LDTs do not require the stringent FDA approval process. In actual fact , you don’t even have to show that it is even detecting the substance you claim it to be testing for.  Some internal protocol has to be provided but other than that it is an honor system.  And without FDA oversight, the labs can claim anything they want as far as validity, sensitivity, and specificity.  Once these tests were developed as LDTs they were pitched to the  Federation of State Medical Boards as reliable and valid.   The PHPs then contracted with the labs to use the tests they introduced for monitoring physicians in the programs.  The EtG was introduced with essentially no evidence-base other than a small study on less than 20 psychiatric inpatients in Europe with an arbitrary cutoff of 100.  Countless lives were ruined with lost medical and nursing licenses, incarceration, loss of custody of children and most programs abandoned it in 2006. A SAMHSA advisory was issued that it was unreliable.  The Wall Street Journal wrote an article about the “flawed test.”  Most monitoring programs abandoned it. The PHPs did not and continued to use it on doctors without pause.  The PHPs put the responsibility on the monitored physicians to avoid hand sanitizer, cologned, sauerkraut, and hundreds of other products as ethanol is ubiquitous in our environment.  Irrational authority. The EtS, and PEth were also introduced by an FSPHP physician.

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It was just discovered that after 7 days and under unknown conditions my PEthStat Forensic test was changed to “clinical” with specific instructions to USDTL to run it as “clinical.” PHS then misrepresented it to the Board as forensic for  the last three years.  PHS is not a “clinical” provider.

USDTL-Litigation Packet(selected)

What we see here is a letter from Luis Sanchez reporting a positive test for phosphatidylethanol (PEth) from July 19th, 2011 to the Board of Registration in Medicine.   I have also attached documents from the “litigation packet” received from USDTL that is generated with any forensic drug test as a record of chain-of-custody.   This document ensures the integrity of the drug testing by recording the specimens whereabouts at all times.  The Medical Review Officers job is to make certain everything was done correctly by confirming that everything was documented and their were no breaks in the chain-of-custody.    If a donor disagrees with a positive test then the litigation packet is used to check the integrity of the specimen. It is a quality control measure that protects both parties.

The litigation packet contains all of the information that the MRO reviews when reporting the results of a positive specimen. If the custody and control form contains all of the information it is supposed to and confirms chain of custody then it is reported as a positive.  If the chain-of- custody contains so called “fatal flaws”  (lacking collectors signature, missing date and time, mismatched ID #’s, specimen not sealed, etc.) then it is deemed “invalid.” it must be thrown out by protocol.  That is standard operating procedure, standard of care, and required.  This is the MROs sole and simple responsibility.

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In my case I disagreed with the positive result and requested the litigation packet on the specimen.   This was at first refused by PHS.  Linda Bresnahan and the PHS attorney Deb Grausbaum then tried to dissuade me from obtaining it deeming it complicated and costly.  But I insisted on obtaining it and sent the  $500.00 fee and when I did so was told that there would be “unintended consequences” as a result of my request. I finally received it in December of 2011 and it included a “summary of results” dated December 3, 2011 and signed by the director of Laboratory operations, Joseph Jones, supporting it as a true positive. (even though it contradicts his own written protocol on forensic collection procedure.)   what he preaches apparently does not apply when it comes to pleasing a big client such as the FSPHP. $$

So what do we see here in the litigation packet?   Evidence of deliberate forensic fraud perpetrated by PHS, drylabbing, and intentional misrepresentation of lab data.  It shows clear and deliberate falsification of lab data at the request of PHS and includes a memo from Linda Breshahan on July 19th requesting that the ID# on a positive specimen with no collection date be “updated” to my ID # 1310 and that it be updated to show “chain-of-custody” be maintained.  Well that would seem highly unusual as a “chain-of-custody” cannot be backdated and “correcting” a unique identifier on forensic specimen is prohibited.  In actual fact there was no chain-of-custody and not even a  custody and  control form the collecting lab (Quest Diagnostics)!    When this   complete absence of external  chain of  custody was pointed out to PHS they pleaded ignorance but eventually produced a letter from Quest Diagnostics dated March 22, 2012 that appears to be written in language suggesting legitimacy but in actuality documents all of the fatal flaws.

A six-month investigation was done by CAP and USDTL was forced to change the test from “positive” to “invalid” on October 4th 2012.    This was reported to PHS but not conveyed to anyone else.   The Chief Investigator for CAP called me in December of 2012 to make sure the test had been corrected. It had not.  Instead PHS reported me to the Board for “noncompliance” the 2nd week of October for damage control.  They apparently did this as a pre-emptive strike thinking I would never find out!

It does not take a forensic toxicologist or  chemist to interpret the attached documents. They show collusion to commit fraud with USDTL, collusion to cover up fraud with Quest Diagnostics, misrepresentation of facts to a State Agency, and obstruction of the truth when the test was mandated by CAP to be corrected by USDTL.  These documents show conspiracy, fraud, and corruption.  What they show is procedurally, ethically, and legally indefensible.

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The distinction between “forensic” and “clinical” drug and alcohol testing is black and white. Forensic testing is done to detect illicit substances. Pre-employment, random monitoring, or for cause drug testing is done in individuals to see if they are using drugs or alcohol when they should not be.   Because the consequences of a positive test can be significant and even permanent, forensic drug and alcohol testing requires strict procedure and protocol to prevent harming the innocent. A custody and control form documenting the chain-of-custody and review by a Medical Review Officer (MRO) before reporting a positive test are necessary to ensure the validity of the test.   It is the responsibility of the MRO to make sure no other explanations exist for the positive test (such as a prescribed medication) and check chain-of-custody. If the chain-of-custody contains any “fatal flaws” (specimen not sealed with sticker and signed by donor, missing date or collector signature, etc.) it is rejected as an invalid specimen.

A clinical test is used in patient care. Ordered by a doctor, it is use for purposes of treating a patient. A clinical test does not have the strict requirements of a forensic test.   I could send a sample of fluid from a tin of pickled herring or Jagermeister to the clinical lab for electrolytes and would still get a result back.

PHS is a monitoring program not a treatment provider.  According to PHS documentation they follow NIDA drug and alcohol testing protocol. Guidelines for both the Federation of State Medical Boards (FSMB) and the Federation of State Physician Health Programs (FSPHP) state chain-of custody and MRO review on all specimens. In addition to MRO review the guidelines also specify that the PHP Medical Director confirm all positive tests. PHS has an MRO, Wayne Gavryck.

I have multiple emails sent to Gavryck asking him to correct this and inquiring why as an ardent 12-step zealot he was not practicing what he preaches by promptly admitting his wrong and making amends for it.  He ignored me. Can’t wait to hear him have to explain his doublethink and hypocrisy publicly.

MRO Code of Ethics

The fact that a monitoring agency with an MRO asked the lab to process and report it as a clinical sample and then used it forensically is an extreme outlier in terms of forensic fraud.  The fact that they collected it forensically, found out it was collected wrong with no chain of custody and the wrong tube 7 days after it was drawn and then changed it from forensic to clinical deepens the malice.  The fact that they then reported it to the Board as a forensic sample and maintained it was forensic up until now makes it egregious.   But the fact that the test was changed from “positive” to “invalid” on October 4th, 2012 and they then reported me to the Board on October 8th 2012 for “noncompliance,” suppressed it and tried to send me to Kansas for damage control makes it wantonly egregious.   (they didn’t think I’d ever find out but the CAP investigator called me in December.  Add on that the fact that I’ve been questioning the validity of the test since day 1 and they violated the  HIPAA Privacy Rule over and over and this is reckless and major health care fraud.

Like other front groups the primary motive is profit for the drug testing and rehab industry, and “recovered” physicians like Dr. Gavryck have become “willing gulls” in all sorts of fraud and chicanery.  Ideology trumps science and control usurps conduct.  including Dr. Gavryck, are “in recovery” themselves and, having only a hammer, see everything as a nail. PHS, inc. is a non-profit NGO that has become corrupt.  This occurred under the leadership of the prior Medical Director Luis Sanchez, MD who has since retired.   The director of operations, Ms. Linda Bresnahan is engaging in fraud with apparent impunity.   Forensic (in contrast to clinical) drug testing mandates strict adherence to protocol including proper collection procedures, unbroken chain-of-custody, and Medical Review Officer (MRO)  review prior to reporting a forensic  test as a true positive.  It is held to a higher standard because the potential   consequences can be grave and far reaching.   There are no exceptions.   The Federation of State Medical Boards and the Federation of State Physician Health Programs require chain-of-custody and MRO review for any and all drug testing according to their guidelines.   PHS, inc has an MRO, Dr. Wayne Gavryck, who has holds this responsibility.  I have attached the MRO Code of Ethics and an explanation of the importance of chain-of-custody.

Medical Review Officers need to have honorable values and follow the same standards as everyone else.

If an individual’s identity is tied to a sub-group that is unregulated, unaccountable, and with no oversight, such as PHS, fraud may be committed even though they have excellent knowledge about cultural norms and values on a more general level.  So called “noble cause corruption is quite common and one someone gives up their integrity in lock step with the other members of the group, no matter how small the enticement, the potential for continued and more severe forms of corruption is increased.

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PHS provided a letter from the New England Compliance Manager, Nina Tobin, on March 22, 2012 in response to my persistence in obtaining the absent  Quest “chain-of-custody.” After going into great detail about the faxed document from PHS, she states “the collector was unfamiliar with collecting blood samples for PHS and did not have a “chain-of custody” form designed for blood tubes.” “The collector used the faxed letter request, which included the test code and the collection information, as the chain of custody form.”   This is analogous to not receiving an item you requested by express mail and having them reply the person was “unfamiliar with the postal system in the United States and did not have a postage stamp, she wrote U.S. Postal Service on a piece of paper and wrote “express mail” on the flat side and folded it into an envelope.”  The very nature and purpose of both are removed.  You cannot manufacture a chain-of-custody any more than you can manufacture a stamp.

MLLv3finalJacob Hafter Esq

ThePhysician suicide has increased dramatically across the country and as Pamela Wible observes in the Washington Post it is “often hushed up.” It is only going to get worse. Heightened perceptions of defeat and entrapment are known to be powerful predictors of suicide.

Quest lists “accountability” as one of six company values  on their corporate website claiming “as a company and as individuals, we accept full responsibility for our performance and acknowledge our accountability for the ultimate outcome of all that we do.”   Quest lists “integrity” as a value noting all  “decisions and actions ultimately are driven by integrity,”  and an  Integrity Commitment Pledge.  The Quest Code of Business Ethics includes compliance with laws, rules, and regulations. confidentiality in release of test results and protected health information (PHI), avoidance of Conflicts of Interest (COI), and fair dealing; “no person may take unfair advantage of anyone through manipulation, concealment, abuse, or privileged or confidential information, misrepresentation of facts or any other unfair dealing practice.”  Quest “actively promotes honest and ethical behavior in all its business activities,” and require employees to report violations to, among others with supervisory capacity, a “Compliance Officer.”

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