Complaint against James R. Privitera , M.D. (2003)
The Medical Board of California has publicly reprimanded James R. Privitera, M.D. of Covina, California, for "failing to perform an adequate history and physical of a patient before commencing treatment, and for failing to maintain adcequate and accurate records of the care and treatment provided to that patient." The patient was a 71-year-old woman who in 1999 had complained of a headache while in Privitera's waiting room. According to the complaint, Privitera (a) prescribed 20,000 units of heparin (an anticoagulant) to be placed under the woman's tongue, (b) examined a blood sample with a dark-field microscope, (c) concluded that the blood specimen showed too much tendency to clot, and (d) prescribed another 20,000 units of heparin to be given under the patient's skin. Soon afterward, the patient became lightheaded, vomited, and passed out. She was rushed to a hospital. where it was noted that she was comatose and bleeding from several places. She died a few hours later, apparently as a result of a massive hemorrhage inside her head. Privitera's management of this patient was highly improper because:
- Heparin is not a rational treatment for a headache.
- In standard medical practice, heparin should not be prescribed without testing the patient's clotting status, which Privitera did not do.
- The test Privitera used—commonly referred to as live blood cell analysis—is not a valid test of clotting status.
- The amount of heparin he prescribed was excessive.
Accordingly, in the document below, the Medical Board charged that Privitera had (a) failed to properly evaluate the woman's headache, (b) had no documented rationale for administering heparin, and (c) had administered an overdose. The case was settled with a stipulation under which Privitera agreed to be reprimanded, pay $5,000 for costs, and take courses in prescribing and medical recordkeeping.
This is not the first time Privitera has gotten into trouble. In 1975, he was convicted of conspiring to prescribe and distribute laetrile and was sentenced to six months in prison. (Laetrile is a quack cancer remedy.) In 1980, after the appeals process ended, he served 55 days in jail but was released after being pardoned by California Governor Jerry Brown. Then, because Privitera had been prescribing unapproved substances for the treatment of cancer, the California Board of Medical Quality Assurance suspended his medical license for four months and placed him on ten years' probation under board supervision. During the probationary period, Privitera was "prohibited from making any representation that he is able to cure cancer through nutrition." During the probationary period, he began marketing equipment that off-beat practitioners use for recommending dietary supplements. Privitera improperly claims that live cell analysis can be used to diagnose "clot malfunction," which he claims is an underlying cause of many diseases.
DIVISION OF MEDICAL QUALITY
MEDICAL BOARD OF CALIFORNIA
DEPARTMENT OF CONSUMER AFFAIRS
STATE OF CALIFORNIA
In the Matter of the Accusation Against:
JAMES R. PRIVITERA, Jr., M.D.
Case No. 11-2001-119360
1. Ron Joseph (Complainant) brings this Accusation solely in his official capacity as the Executive Director of the Medical Board of California ("Board").
2. On August 22, 1968, the Board issued Physician and Surgeon's Certificate Number C 30445 to James R. Privitera, Jr., M.D. ("Respondent"). Unless renewed, his license will expire on February 28, 2005.
3. This Accusation is brought before the Board's Division of Medical Quality ("Division") under the authority of the following provisions of the Business and Professions Code.
4. Section 2004 of the Code states:
"The Division of Medical Quality shall have the responsibility for the following:
"(a) The enforcement ofthe disciplinary and criminal provisions of the Medical Practice Act.
"(b) The administration and hearing of disciplinary actions.
"(c) Carrying out disciplinary actions appropriate to findings made by a medical quality review committee, the division, or an administrative law judge.
"(d) Suspending, revoking, or otherwise limiting certificates after the conclusion of disciplinary actions.
"(e) Reviewing the quality of medical practice carried out by physician and surgeon certificate holders under the jurisdiction of the board."
5. Section 2227 of the Code provides that a licensee who is found guilty under the Medical Practice Act may have his or her license revoked, suspended for a period not to exceed one year, placed on probation and required to pay the costs of probation monitoring, or such other action taken in relation to discipline as the Division deems proper.
6. Section 2234 of the Code states:
"The' Division of Medical Quality shall take action against any licensee who is charged with unprofessional conduct. In addition to other provisions of this article, unprofessional conduct includes, but is not limited to, the following:
"(a) Violating or attempting to violate, directly or indirectly, or assisting in or abetting the violation of, or conspiring to violate, any provision of this chapter [Chapter 5, the Medical Practice Act].
"(b) Gross negligence.
"(c) Repeated negligent acts. To be repeated, there must be two or more negligent acts or omissions. An initial negligent act or omission followed by a separate and distinct departure from the applicable standard of care shall constitute repeated negligent acts.
"(1) An initial negligent diagnosis followed by an act or omission medically appropriate for that negligent diagnosis of the patient shall constitute a single negligent act.
"(2) When the standard of care requires a change in the diagnosis, act, or omission that constitutes the negligent act described in paragraph (1), including, but not limited to, a reevaluation of the diagnosis or a change in treatment, and the licensee's conduct departs from the applicable standard of care, each departure constitutes a separate and distinct breach of the standard of care.
"(e) The commission of any act involving dishonesty or corruption which is substantially related to the qualifications, functions, or duties of a physician and surgeon.
"(f) Any action or conduct which would have warranted the denial of a certificate."
7. Section 2242 of the Code states:
"(a) Prescribing, dispensing, or furnishing dangerous drugs as defined in Section 4022 without a good faith prior examination and medical indication therefore constitutes unprofessional conduct.
"(b) No licensee shall be found to have committed unprofessional conduct within the meaning of this section if, at the time the drugs were prescribed, dispensed, or furnished, any of the following applies: .
"(1) The licensee was a designated physician and surgeon or podiatrist serving in the absence of the patient's physician and surgeon or podiatrist, as the case may be, and if the drugs were prescribed, dispensed, or furnished only as necessary to maintain the patient until the return of his or her practitioner, but in any case no longer than 72 hours.
"(2) The licensee transmitted the order for the drugs to a registered nurse or to a licensed vocational nurse in an inpatient facility, and ifboth of the following conditions exist:
"(A) The practitioner had consulted with such registered nurse or licensed vocational nurse who had reviewed the patient's records.
"(B) The practitioner was designated as the practitioner to serve in the absence of the patient's physician and surgeon or podiatrist, as the case may be.
"(3) The licensee was a designated practitioner serving in the absence of the patient's physician and surgeon or podiatrist, as the case may be, and was in possession of or had utilized the patient's records and ordered the renewal of a medically indicated prescription for an amount not exceeding the original prescription in strength or amount or for more than one refilling.
"(4) The licensee was acting in accordance with Section 120582 of the Health and Safety Code."
8. Section 2266 of the Code states: "The failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients constitutes unprofessional conduct."
9. Section 14124.12 of the Welfare and Institutions Code states, in pertinent part:
"(a) Upon receipt of written notice from the Medical Board of California, the Osteopathic Medical Board of California, or the Board of Dental Examiners of California, that a licensee's license has been placed on probation as a result of a disciplinary action, the department may not reimburse any Medi-Cal claim for the type of surgical service or invasive procedure that gave rise to the probation, including any dental surgery or invasive procedure, that was performed by the licensee on or after the effective date of probation and until the termination of all probationary terms and conditions or until the probationary period has ended, whichever occurs first. This section shall apply except in any case in which the relevant licensing board determines that compelling circumstances warrant the continued reimbursement during the probationary period of any Medi-Cal claim, including any claim for dental services, as so described. In such a case, the department shall continue to reimburse the licensee for all procedures, except for those invasive or surgical procedures for which the licensee was placed on probation."
10. Section 125.3 of the Code provides, in pertinent part, that the Division may request the administrative law judge to direct a licentiate found to have committed a violation or violations of the licensing act to pay a sum not to exceed the reasonable costs of the investigation and enforcement of the case.
FIRST CAUSE FOR DISCIPLINE
11. Respondent is subject to disciplinary action under section 2234, subdivision (b) of the Code in that he engaged in acts and omissions in the care and treatment of a patient constituting gross negligence. The circumstances are as follows:
A. Dr. Privitera conducts a private practice in allergy and nutrition in Covina, California. He began seeing patient Hilda C. [initials to protect privacy] on May 30, 1991 at which time she had an elevated cholesterol and blood sugar. The patient filled out a general history form and Dr. Privitera carried out a limited physical examination and diagnosed nutritional deficiency associated with thrombocyte aggregation, mild B deficiency, and mild diabetes. He performed dark-field microscopy and reported 4+ thrombocyte aggregation. Over the next eight years, he prescribed a number of vitamins, minerals and drugs. The patient's file contains an undated agreement signed by Dr. Privitera and the patient informing the patient that Dr. Privitera's viewpoint concerning nutrition and the need for certain nutrients was not necessarily shared by the American Medical Association, the Food and Drug Administration, the American Cancer Society, and others.
B. On June 5, 1991, the patient had hair analysis performed which assertedly showed both excessive and deficient concentrations of different elements.
C. Dr. Privitera saw the patient again on August 9, 1991, September 10,1991, September 12, 1991, and October 6, 1997.
D. On October 14, 1997, Hilda presented to respondent at his medical clinic complaining of the left eye "not functioning at all." Hilda reported a hospital discharge three weeks prior, but the reason for her hospital stay was not documented. Respondent examined Hilda's weight, blood pressure and visual field, but did not document a legible differential diagnoses, plan of treatment, or an assessment of the medication she was using since her hospital discharge.
E. Hilda's final visit with Dr. Privitera occurred in the late afternoon of Wednesday, March 3, 1999. She was at that point 71 years of age and weighed 106 pounds with a documented history of diabetes and hypertension, cardiomyopathy, atrial fibrillation, and rectal bleeding. She also had been having left arm pain for the past few days. She went to Dr. Privitera's office for an appointment in the company of her cousin, Rev. Gerald Lord and a friend, Ms. Frances Ferrari. The patient's weight (106), blood pressure (160/80), and glucose (259) were recorded. While in the waiting room, Hilda complained of a pain in her head and asked the office staff for a Tylenol. A medical assistant named Rosemary Ghalbomjian reported the complaint to Dr. Privitera who told her to place the patient in a room and to check her blood pressure. She was then advised to give Hilda 20,000 units of the blood thinner heparin sublingually, which was done. A blood sample was then evaluated by Ms. Ghalbomjian using a technique referred to as "dark field microscopy" which assertedly showed "moderate (3+) thrombocyte aggregation" (clotting). Fifteen-to-twenty minutes later, Dr. Privitera ordered Ms. GhalbouIjian to administer another 20,000 units of heparin, this time subcutaneously, which was done. Hilda then experienced dizziness, lightheadedness and vomiting. Soon after, the patient lost consciousness. Right arm blood pressure was measured as 190/110. The office called "911" for paramedic help.
F. Upon their arrival, paramedics described the patient as unresponsive, with blood pressure of 220/140. Hilda was then taken by paramedic ambulance to Citrus Valley Medical Center' s Inter-Community Campus at 210 West San Bernardino Road, Covina, where she arrived in full arrest, comatose and bleeding from several orifices. She never regained consciousness. At the hospital, she was treated by Dr. Zahida Bhutto. Thirty minutes after Hilda's arrival at the hospital, her PTT level was 75, indicating that she was fully anticoagulated, and therefore unable to use her own coagulation proteins to stop the bleeding in her head. She was declared clinically brain dead.
G. She died early the following morning, Thursday, March 4, 1999 from a massive hemorrhage in the head. The consulting neurologist, Dr. Abdullah Haroon, interpreted a CT scan of Hilda's head to show "Acute massive left hemispheric intra cerebral hemorrhage of lobar type with ventricular extension and midline shift, probably provoked by anticoagulation."
H. At his office visit on March 3, 1999, Dr. Privitera failed to take a history which documented the severity of Hilda's headache, its duration, location, frequency, and associated signs and symptoms. The only physical exam documented was the patient's weight, blood pressure, and blood sugar. Respondent did not perform a physical examination of Hilda's head, eyes, ears, nose, throat, abdomen, neurological system, or mental status. Respondent did not conduct an assessment or provide a differential diagnoses to rule out possibly life-threatening causes for her symptoms such as a stroke, aneurysm or other intra-cranial bleed, or meningitis, which require emergent testing prior to treatment, or less serious problems such as migraine or tension headache. Further evaluation could rule out the serious types of headaches. For example, a sedimentation rate can help rule out Temporal Arteritis [inflammation of the artery or arteries], and an MRI can be used to rule out stroke or an intra-cerebral bleed, and a blood test can help rule out meningitis. Respondent has admitted that he did not note a history, physical examination, assessment, or rationale for treatment in his records for Hilda, and admitted that he did not obtain a blood test result for blood coagulation prior to ordering the administration of heparin. When interviewed, Respondent stated that he had been accustomed to treating headaches with Heparin on a routine basis and believed this gave prompt relief.
I. Heparin, a potent anticoagulant (i.e., blood thinning agent), is used to prevent and treat thromboembolic disorders (i.e., venous thrombosis), but is contraindicated for patients in whom suitable blood coagulation tests cannot be performed at appropriate intervals, or in patients with uncontrollable active bleeding (e.g., hemorrhagic strokes). A pre-use assessment of coagulation proteins, not platelets, is essential. Heparin is not effective by oral administration, but should be given only by IV or deep subcutaneous injection.
J. Respondent engaged in multiple acts of grossly negligent conduct in his care and treatment of Hilda as follows:
(1) He failed to perform an adequate history and physical examination to assess the headache; and/or failed to document same.
(2) He failed to formulate a differential diagnoses of the patient's complaint of headache, and failed to recognize the urgency of obtaining an accurate diagnosis before initiating treatment; and/or failing to document same.
(3) He administered Heparin sublingually without medical indication; and/or failed to document a medical indication supported by history and physical examination findings.
(4) He administered Heparin by subcutaneous injection without medical indication; and/or failed to document a medical indication supported by history and physical examination findings.
(5) He overdosed his patient with heparin, resulting in harm rather than benefit.
SECOND CAUSE FOR DISCIPLINE
(Repeated Negligent Acts)
12. Respondent is subject to disciplinary action under section 2234, subdivision (c) of the Code, in that he engaged in repeated negligent acts in his care and treatment of Patient Hilda C. The circumstances are as follows:
A. The facts and circumstances stated in Paragraph 11 are incorporated by reference as though fully set forth.
B. Dr. Privitera engaged in multiple departures from the standard of practice in his care and treatment of Patient Hilda C. as follows:
(1) By failing to legibly document an adequate history, differential diagnoses and plan of treatment when the patient presented with vision loss on October 14, 1997.
(2) By failing to perform an adequate history and physical examination to assess the headache; and/or failing to document same on March 3, 1999.
(3) By failing to formulate a differential diagnoses of the patient's complaint of headache, and failing to recognize the urgency of obtaining an accurate diagnosis before initiating treatment; and/or failing to document same on March 3, 1999.
(4) By administering heparin sublingually without medical indication; and/or failing to document a medical indication supported by history and physical examination findings on March 3, 1999.
(5) By administering heparin by subcutaneous injection without medical indication; and/or failing to document a medical indication supported by history and physical examination findings on March 3, 1999.
(6) By overdosing his patient with heparin, resulting in harm rather than benefit.
THIRD CAUSE FOR DISCIPLINE
13. Respondent is subject to disciplinary action under section 2234, subdivision (d) of the Code, in that respondent demonstrated incompetence in his treatment of Patient Hilda C. The circumstances are as follows:
A. The facts, circumstances and opinions stated at above paragraphs 11 and 12 are incorporated by reference herein as if fully set forth.
B. Dr. Privitera failed to perform and document the fundamental components of patient evaluation, including history, physical examination, assessment and plan. His statement to investigators after the fact that the need for prompt treatment overruled the possibility of doing a history and physical shows a complete disrespect for patient safety.
C. Dr. Privitera failed to recognize the different causes of headache and to perform the appropriate diagnostic studies or to take the appropriate action.
D. Dr. Privitera failed to understand the mechanisms of blood clotting and the medications that affect blood clotting.
E. Each of the foregoing demonstrate a lack of knowledge and ability in discharging professional medical obligations and subjects patients to possible severe harm.
FOURTH CAUSE FOR DISCIPLINE
(Prescribing Without Indication)
14. By reason of the facts set forth in Paragraphs 11 and 12, Respondent is subject to disciplinary action under sections 2234, subdivision (a) and 2242 of the Code, in that respondent prescribed and administered a dangerous drug without a good faith prior examination and medical indication therefor.
FIFTH CAUSE FOR DISCIPLINE
15. By reason of the allegations previously set forth in Paragraphs 11 and 12, Respondent is subject to disciplinary action under sections 2234, subdivision (a) and 2266 of the Code because he failed to maintain adequate and accurate records of his care and treatment of Patient Hilda C.
WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged, and that following the hearing, the Division of Medical Quality issue a decision:
1. Revoking or suspending Physician's and Surgeon's Certificate Number C-30445, issued to James Privitera, M.D.;
2. Revoking, suspending or denying approval of his authority to supervise physician's assistants, pursuant to section 3527 of the Code;
3. Ordering him to pay the Division of Medical Quality the reasonable costs of the investigation and enforcement of this case, and, if placed on probation, the costs of probation monitoring;
4. Taking such other and further action as deemed necessary and proper.
DATED: March 31, 2003
Medical Board of California
Department of Consumer Affairs
State of California
This page was posted on February 21, 2005