Pioneer or Profiteer?
Pain Specialist Dr. Boris Pilch Fuels a SLO County Medical Controversy Unlike Any Before
BY DANIEL BLACKBURN
Ed Stewart's pocket-sized tape recorder was rolling when he died.
"God, I hope I can sleep tonight. It seems I have to take so much of this stuff to sleep even... the medicine has to work sooner or later. It's one-twenty in the morning and I'm still wide awake.... Xanax. Zocor... what else did these doctors give me? [Drinking sound] Boy, that shit tastes nasty.... I'm scared. I'm cold. It hurts. Honey, what are they doing to me?... Please don't make me take any more of these pills. I'll lie here. I want to struggle...."
After his rambling, directed in part to his girlfriend, the sound of Ed Stewart’s heavy, steady breathing can be heard, before it gradually diminishes. Then, only silence.
A coroner's inquiry would subsequently categorize Stewart's end as the result of an accidental prescription drug overdose.
Several months before his Feb. 20 death, Stewart, a 41-year-old San Luis Obispo man, started keeping an audio journal. He was recording a talking history of his chronic back pain and its progression into a health condition that had begun to dominate his every waking moment.
Following a July automobile accident in which his vehicle was rear-ended by another at a downtown SLO stoplight, Stewart began to experience severe shoulder and back pain.
His mother, Jean Stoher, a resident of Pittsburg, Calif., said her son underwent surgery for the shoulder injury "and that solved that problem." But his insurer wouldn’t cover the operation and Stewart ended up paying for it. The insurance company also balked at writing a check for additional surgery on Stewart's back, so he sought alternative relief.
In what Stoher calls "desperation" triggered by her son's incessant pain, Stewart placed himself in the care of a San Luis Obispo physician whose clinic, Interventional Pain Management, specializes in cutting-edge pain intervention.
Stewart became a frequent visitor to Dr. Boris Pilch.
Short, paunchy, balding, and bespectacled, the Russian-born Pilch, 43, is an anesthesiologist whose pain treatment techniques stir significant dissent among local medical people.
To some people–patients, employees, current and former associates–Pilch is a pioneer whose bold treatments offer rare relief to people who have found no other solution to debilitating, never-ending pain.
Others, including physicians, nurses, other patients, lawyers and private investigators, paint a vividly different, darker, picture of Pilch.
They claim he overmedicates patients for financial gain, uses surgical procedures inappropriately, exploits the state workers' compensation system, and embroils his critics in expensive litigation on little provocation.
There's one thing, however, upon which most of these professionals and laypersons agree: A very fine legal and ethical line separates contemporarily acceptable pain treatment and dispensing medicinal narcotics in much the same manner as ordinary, street-corner drugs.
Pain. So much more than simply a word, pain is the universal human experience, the common denominator, the great equalizer. Lightly or with excruciating malice, briefly or with agonizing persistence, it eventually touches all.
Is relief, as an old seltzer commercial once boasted, really just a swallow away?
A simple question with a complex answer–if, indeed there’s an answer at all. The dilemma fuels a festering controversy within San Luis Obispo County's medical community like none seen before.
* * *
Boris Pilch opened the doors to his private Casa Street clinic in late 1997 with the advertised goal of alleviating pain using a wide array of revolutionary new techniques and procedures. (The clinic is now in a Vincent Street medical center just down the street from French Hospital.)
Pilch, who specializes in non-cancer patients, treats many patients who are covered by workers’ compensation. Creating the clinic followed on the heels of Pilch’s five-year stint as a principal player in a financially successful but ultimately disbanded–and, some say, disgraced–pain management program at French Hospital Medical Center.
After relinquishing his operating room privileges at French amid rancorous, litigious dissension, Pilch, without missing a beat, signed on at Sierra Vista Regional Medical Center, SLO's largest and busiest hospital.
There, and at his clinic, his critics contend, Pilch continues a practice that has placed him squarely in the center of a most strident medical controversy.
A remarkable array of formal and informal complaints by local medical personnel against Pilch and two of his physician associates, Dale G. Kiker and Russ L. Levitan, prompted a two-year investigation by the state medical board. Completed five months ago, the investigators’ report was turned over to the state attorney general, where is has languished ever since.
Candis Cohen, a spokesperson for the medical board, declined comment, saying only that "Dr. Pilch presently is licensed to practice medicine in the state of California."
Most physicians, nurses, and other medical personnel interviewed for this story requested anonymity, citing Pilch's alleged penchant for litigation.
James Duenow, an SLO attorney representing several of Interventional Pain Management's former clinical patients in malpractice and wrongful death cases, minces no words when talking about Pilch.
"Boris is a medical predator. He's making a ton of money doing what he does," said Duenow. "I've represented medical malpractice plaintiffs since 1982, and I've seen a lot of bad doctors come and go. I have never seen anybody like this guy. And I've never seen such unanimity of opinion among the medical community, across the board."
"A predator? I don't know what that means," said Pilch in an interview. "I take care of patients who come to me with pain. We have as many patients as we can handle. We do not seek patients with pain. They seek us."
Duenow wrote a letter to California attorney general Bill Lockyer earlier this month, asking Lockyer to act on the medical board's completed investigation.
"The investigators for the Medical Board of California have been vigorous in working up their case," wrote Duenow. "They have had the cooperation of numerous physicians, nurses and attorneys in verifying the cases against these doctors. They have had patient cases, 22 in number, reviewed by outstanding experts in the field of pain management. It is our understanding that the reports of those reviewing consultants were scathing in their criticism of the doctors."
Duenow criticized the state for failing to take action.
"Despite this thorough investigation and scathing reviews, these doctors continue … doing unnecessary procedures, prescribing unnecessary medication, getting patient after patient hooked on prescription drugs without any action by the state," he wrote.
Fiery words, yes, but Duenow says he passionately believes what he says.
One prominent SLO physician, who has observed Pilch for years and has been sued by Pilch, and who spoke to New Times only on the condition of anonymity, alleges "Pilch has hurt, maimed and physically injured literally hundreds of people. That may sound like a massive statement, but it's true."
* * *
Pain management is a comparatively new medical discipline. Pilot programs gained popularity nationally in the early 1990s, initially among hospitals and similar institutions whose administrators were anxious to help patients deal with pain and, at the same time, augment facility profits.
According to a 1999 policy statement by the American Association of Pain Management, "The specialty of pain medicine is concerned with the study of pain, prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain.
"Some conditions may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be conditions in which pain constitutes the primary problem, such as neuropathic pains or headaches.
"The evaluation of pain syndromes includes interpretation of historical data; review of previous laboratory, imaging, and electrodiagnostic studies; assessment of behavioral, social, occupational and avocational issues; and interview and examination of the patient by the pain specialist."
By 1995, pain units were the bright lights in many hospital profit-loss reports. Anesthesiologists and other professionals in the pain management business were raking in $750 million annually. Today, that figure easily tops $1 billion, according to industry estimates.
Several factors contributed to the sudden success of pain management programs, according to Douglas G. Merrill, chairman of the pain management committee of the American Society of Anesthesiologists (ASA).
Rapid technological advances have occurred, both in medication variety and delivery systems, coupled with a surge in availability of equipment for drug-dispensing pump implants.
Private manufacturing companies subsequently began to target anesthesiologists as "a lucrative audience," said Merrill in a recent paper he prepared for the ASA.
"This in turn has led to a proliferation of company sponsored 'certification' and 'education' programs, spurring greater acceptance of the techniques... and perhaps decreasing the clarity with which some physicians analyze the value of the procedures themselves," he wrote.
More and more anesthesiologists are leaving the venue of the operating room [in hospitals], he added, and are attempting to supplement or replace that practice with pain management activity.
And finally, wrote Merrill, fellowship training in pain management is more accessible and enticing now, helping fulfill additional training requirements for the resident in anesthesiology.
As the pain management business began to bloom, so too did the lust for participation by profit-conscious health management organizations (HMOs).
For French Hospital and its HMO, Summit Health Ltd., a new pain management program was just what the doctor ordered. Summit introduced pain management programs in all of its hospitals, almost overnight. Tom Salerno, chief operating officer of French Hospital at the time, bought into the program in 1991.
After the program's first director departed after only six months, the hospital began a search for a replacement.
In early 1992, Dr. Boris Pilch, a young physician from San Bernardino, joined the pain management team at French Hospital. Pilch had trained at San Bernardino's Pain Management Center under its director, Dr. Francis Comunale.
Comunale told New Times that Pilch was a graduate of the University of Miami and during the time he was the pain management center (1990—91) Pilch "excelled" at both pain management and anesthesia.
At his new residency at French, Pilch readily passed muster with his peers, although some doctors and nurses believed he was being afforded special privileges by hospital management.
"We thought, well, if we've got to have a pain management program, this guy might be as good as it gets," said one physician who has observed Pilch closely for over five years. The physician, who has been sued by Pilch in the past, spoke to New Times only on the condition of anonymity.
"[Pilch] started out doing some anesthesia and some regional [pain nerve] blocks, and he did know how to do some blocks that the other guys didn't know how to do," said the doctor.
But soon, despite a sudden burst in profits for the hospital, dark clouds were gathering over the pain management unit.
Pilch's increasingly bold techniques and "his abrasive, pushy Eastern European personality were beginning to grind on people," said the doctor.
Then an intense rivalry developed between Pilch and two young staff anesthesiologists, who subsequently declined to work with Pilch.
"Pilch lobbied to take over the [pain management] program completely, but he never could. But his contract was so iron-clad Pilch could do pretty much what he wanted to."
After a year or so, Pilch started getting "very aggressive in what he was doing. He hired nurse anesthesiologists to work with him, and he started bringing in more and more patients," the doctor added.
Soon French Hospital was tallying $2 million a year in new revenues directly attributable to the pain management unit.
At the same time, Pilch was notching up the level and frequency of surgical procedures for pain management in non-cancer patients.
One longtime SLO anesthesiologist said he was "startled" when Pilch "started doing continuous epidurals on his patients, claiming that they needed to be monitored constantly and demanding that the hospital place them in the heart wards." Epidurals are drugs administered through the spinal fluid.
An intensive care (ICU) nurse employed at French Hospital described complications subsequently created in the hospital's "step-down" unit. Step-down unit beds are usually occupied by cardiac patients–people who have had a heart attack or who are recovering from heart surgery.
"These people need peace and quiet for recovery," said the nurse.
Despite that, she said, "Pilch would order all these loads of medications for his pain patients, who were very disruptive in the ICU. We'd call Dr. Pilch to tell him these patients were demanding more drugs even though they could barely keep their eyes open. They were pounding on the walls when they walked out to smoke their cigarettes."
When nurses in ICU would suggest to Pilch that "perhaps" the patients were getting too much drugs, said the nurse, "He'd tell us that we didn't know what we were talking about, that these patients could handle the drugs, that we should just give them more and don't bother him again. Soon it got to the point where nurses simply were not allowed to call Pilch when he was not in the hospital."
Nurses began to decline to care for Pilch's patients.
Dr. James Skow, a member of French Hospital's governing board at the time, summed up the situation. "These patients were demanding, they wanted their narcotics on the clock. They were disruptive and not typical of cardiac ward patients. Most doctors would call these people habitual users, and here they were, placed right next to some 70-year-old solid citizen who just had a quadruple bypass. It was a terrible mix. We were beside ourselves."
The ICU nurse said that on one occasion a floor nurse walked into a room in the step-down unit and discovered a female patient of Pilch's shoving a hypodermic needle into her own arm, aided by her boyfriend, even while hooked up to an intravenous drip painkiller prescription.
"We knew the word of mouth among patients–who by the way were almost all walk-ins, rather than physician referrals–was that 'there's this guy who will give you drugs if you tell him you have a pain. And you can get all the drugs you want,'" said the ICU nurse.
There were legitimate patients whose suffering was genuine, and who were helped by Pilch, said the nurse.
"But the large majority [of Pilch's patients] were the hype-type. These people were doing physical things that people with real pain or injury couldn't be doing. What's that make you think?" she asked.
It was not only Pilch's techniques and procedures that were being called into question by this time. His underlying pain treatment philosophy, and in turn his professional ethics, also generated concern among his associates.
According to his clinic's frequent advertisements in local newspapers, Pilch believes that people "don't have to live with pain."
But the "accepted" practice teaches something quiet different.
"No [doctor] I know of would deny the terminal patient any kind of pain-killing drugs he or she needs to be comfortable during their last days," said SLO physician George Ward, a long-time observer of Pilch. "But essentially none of Pilch's patients are that kind of patient."
Chronic pain management, on the other hand, "requires a multi-faceted approach. It is [a medical] art form in itself."
The usual principle of chronic pain management is to teach a patient to maximize their function while dealing with the reality of their pain problem and to reduce their level of pain as much as possible, he said.
Analgesics are only one of the modalities employed in any such treatment, Ward added. However, "long-term narcotics are usually –except for a few, infrequent exceptions–not part of it.
"But long term [narcotics] are the mainstay of treatment in virtually 100 percent of the patients Pilch lays hands on."
Narcotics prescriptions shouldn't replace the basics of accepted pain management, Pilch’s critics maintain.
Those accepted practices include education, physical therapy, and active participation by patients in the treatment of their pain.
In these mainstream programs, a patient is typically taught first "to take over the pain." They learn to take control of it through education, exercise, job retraining, and family education, as well as utilization of pain procedures and drugs.
According to pain management specialists interviewed by New Times, the educational portion of any patient's program is, in many ways, the most important. The process is takes a lot of the physician’s time, however, and is said to be economically unrewarding to physicians.
Pain has many faces.
"You have to remember," Ward said, "that virtually 100 percent of people who have chronic pain also have as a component of that, and usually as a major component of that, severe depression, based upon an altered serotonin metabolism. And serotonin-mediated neurons affect pain perception. Thus, dealing with depression effectively is critical for long term success with these patients."
That means that everyone perceives pain differently, and is affected differently by it. Response range from physical and emotional irritation to complete inertia. Perception of pain is greatly impacted by the patient's state of mind.
That also means that a given specific medical treatment or procedure–or even application of a placebo–may result in actual physiological relief of pain or may simply be triggering a psychological "solution."
* * *
Even as the atmosphere among French Hospital's medical staff began to sour on the matter of the pain management unit, Pilch began using a particularly controversial procedure called "epidural endoscopy."
A definitive study by two Yale University professors, published in the February 1996 issue of Connecticut Medicine, described epidural endoscopy as "a minimally invasive technology that is now active in clinical trials. This new [fiber optic] technique allows the operator to visualize directly the epidural space... thus allowing detailed examination and better understanding...."
One of Pilch's own clinic advertisements today calls the procedure "the most exciting and effective technique for diagnosing and treating certain causes of low back pain."
The ad describes the technique in more detail: "An instrument is inserted into the spinal canal through the opening in the tail bone. Once inside the canal, the scope can be maneuvered until the scope visually identifies the source of the pain."
Then, the ad promises, "Most patients require about two hours to recover, and then they go home."
Pilch's literature suggests that "given the right clinical setting, flexible fiberoptic spinal endoscopy has proven to be a valuable tool in diagnosing and treating chronic low back pain."
That's far from the truth, said one of the French Hospital doctors interviewed for this story.
"I'm not aware of anyone who thinks epidural endoscopy an indicated procedure," said the physician, who also said he once witnessed Pilch doing the procedure.
Pilch "just looked around in there," said the physician. "Nothing I saw on the [monitor] screen looked like pathology to me." The physician, who was part of the hospital's peer review board at the time, said nurses who worked in the operating room with Pilch filed official reports claiming he never did anything "except maybe squirt some steroids in there. Which you can do without sticking that scope into the spine."
Along with his controversial procedures, Pilch would use the professional services of numerous people with whom he was associated during operating room procedures.
"He would put the scope in, then he'd include a partner who was an 'assistant surgeon,'" said the physician. "Then he'd have a nurse anesthetist who would administer a 'conscious sedation,' which is a term used for anything that makes a patient oblivious to what's going on. And then, there must be an anesthesiologist present.
"Naturally, there is a nice accompanying fee for all those extra medical personnel."
Another procedure touted by Pilch during his tenure at French Hospital and now, is "epidural corticosteroid injections" for treatment of sciatica. According to the New England Journal of Medicine, decades of studies of the procedure have shown that "the benefits, if any, of epidural corticosteroid injections for sciatica are only short term."
The injections "had no effect on functioning or the need for subsequent surgery," the Journal reported.
Additionally, the report noted, "The natural history of back pain and sciatica is such that most patients have spontaneous improvement over time."
Perhaps the biggest generator of controversy during Pilch's five years at French Hospital was his enthusiastic embrace of a powerful pain-fighting mechanical device commonly called the "morphine pump." The pump can deliver a dose of morphine (or another drug) to a patient on a regular schedule. Implanting a pump into a patient’s body is considered by many medical practitioners to be a radical treatment that should be used judiciously.
For example, the ASA's Merrill, who operates a pain management center in Phoenix, has more than 3,000 patients, many of them terminally ill with cancer. Fewer than 10 of his patients have implanted pain pumps.
In the last five years, sources claim that Pilch and his associates have installed more than 300 of the pumps.
Pilch countered that contention, saying the number was "more like 100—120."
That would be too many to satisfy physicians advocating a more conservative treatment.
"The usual indications for implantation are for someone with malignant cancer, who maybe has three months to a year before they are going to die," said Dr. Ward. "It's right to try to make them as comfortable as possible during those last days, and yet they can avoid the use of major systemic narcotics using the morphine pump.. No one has any objection to something like that.
"But to put one in a 32-year-old chronic back pain patient is crazy. You've got an appliance in them. That appliance is then usually accessed by them every month to refill its reservoir, raising the risk of infection–and, of course, greatly increasing the revenues generated.
"More importantly, their patients generally are continued on unabated multiple systemic narcotics, sedatives and muscle relaxants, despite the pump implantation, and there's no doubt it's going to get infected.
Concluded Ward: "It's just a morally and medically wrong decision, and I don't think you could find a physician in the medical community who would disagree with that assessment–except for Pilch and his cronies."
* * *
By mid—1997, five years after Pilch arrived at French Hospital, things were spinning wildly out of control for the Pain Management Unit, despite its popularity as a profit-generator with the hospital's administration.
Nurses, particularly those assigned to ICU, were in an uproar over Pilch's alleged treatment of them.
Dr. James Skow, a peer review physician who received formal nurses' complaints, said that "no fewer than 50, maybe 55" written statements had been filed relating to Pilch's behavior.
During the same period of time, Dr. Skow added, only "one or two" such reports had been filed by the entire nursing staff against the entire roster of French Hospital physicians.
Doctors responsible for reviewing French Hospital's programs and the French Hospital medical board worried about oversight for the pain program. A pervading concern was application of procedures used in the pain program, and the number of complications related to those procedures.
There were, said all three doctors interviewed for this article, an apparently excessive number of invasive procedures, such as pump installations, epiduroscopy, and the number of nerve blocks administered to single patients.
When discussions in French Hospital peer review committees turned to quality care in anesthesiology, Pilch would become "bombastic," said, a former chairman of the medical board at the hospital.
"The executive committee at French was just paralyzed for about 18 months because at least half of each meeting was dealing with Pilch and his pain program," he said.
"Pilch would get argumentative when quality of care issues were addressed," he added. "That's one of the reasons why the anesthesia department couldn't do their own quality of care meetings–whenever an issue was raised in an anesthesia group meeting about his care, Pilch would become vocally abusive, yelling... it was not possible to hold a meeting. You couldn't do 'Robert's Rules of Order' when Boris Pilch was around."
The debate was transferred into several different peer review committees, but each time the same thing happened, according to Dr. Skow, the former medical board chairman:
Said Dr. Skow: "Pilch screwed up the whole process of doing quality assurance in the hospital."
Prodded by French's medical staff, then—chief of staff Dr. Kenneth Tway authorized the retention of Dr. Theresa Brechner, a pain management expert from Bakersfield, to examine French's pain program.
Although few people claim to have seen the report eventually produced by Brechner, Pilch described it in subsequent court papers as "negative" in relation to his pain management activities.
In the spring of 1998, a team of nationally recognized experts, including specialists from schools of medicine at Yale and USC ,was hired by the French administration to review Pilch's practice. Their report became the basis for the administration's decision to close the pain management program.
In subsequent court documents, Pilch claimed the review was performed by a lawyer named Erin Mullunberg, who Pilch contends was "never given substantial critical information and documentation necessary" to help her reach an accurate decision.
With a formal review underway, and a letter of reprimand having been placed in his permanent file, Pilch suddenly resigned his privileges to work at French on May 14, 1998.
About this time, Pilch removed between 800 and 1,000 patients' files from French Hospital. Later, he would claim the files belonged to him, and French would disagree. Lawsuits resulted, and an eventual compromise allowed French Hospital officials to copy all of Pilch's records.
Pilch reportedly used the files to help establish his practice at his new clinic. Patients and former patients of French have reported being directly solicited by Interventional Pain Management, which had their personal medical charts. Æ
NEXT WEEK: Dr. Boris Pilch responds to his critics.
Daniel Blackburn lives in Paso Robles and is a weekly contributor to New Times. He has been a newspaper editor and crime reporter for over 25 years, and is the author of "Human Harvest," published by Knightsbridge Publishing.