4-17-04 Lincoln Nebraska newspaper

Nebraska licensed Charles J. Mora even though several other states denied
him.

McCOOK - Gail Wagner caresses the colorful nail polish bottles that
sit forever unused in a bedroom drawer.

On some visits to this upstairs shrine, she fingers through clothes
in her daughter's closet, breathing in traces of a 14-year- old girl now
gone.

In one corner sit the journals in which the shy, devout Christian teen
drew up two lists: Reasons for living and reasons for dying.

On March 29, 2001, after writing goodbye e-mails to friends, Lindsay
Whittaker erased her computer files and hanged herself from a large radio
tower in the back yard of Wagner's McCook home.

Wagner feels culpable, she said in an interview, blaming her own brief
psychosis of a few years earlier for pushing the girl toward suicide.

Shortly before her death, Lindsay had asked: "Mom, if you kill yourself,
will you go to heaven?"

Wagner recalled telling her daughter, "If you have depression, it can
be treated medically."

But not long before, Wagner herself had been speaking to imaginary cats,
telepathically communicating with televisions and flying into rages. At
the time, she was taking five prescription medications a day.

"Yeah, Mom," Wagner imagines her daughter thinking. "Look at you."

Wagner blames her own psychosis on a mix of drugs prescribed by former
Kearney psychiatrist Charles J. Mora.

This is a story of one patient's bad medical outcome that is part Greek
tragedy and part soap opera. It also raises uncomfortable questions about
the standards Nebraska has set for its physicians.

In treating Wagner, Mora prescribed a mix of antidepressants that three
other psychiatrists say is counter to basic, well-known medical practice.
Mixing the drugs might be appropriate in extraordinary circumstances, said
one, but only in consultation with an expert.

In one interview, Mora claimed to have intentionally prescribed the
drugs together. In a later interview, he said he would have had Wagner
stop taking them immediately had a pharmacist warned him of the danger.

As for his qualifications, at least four states have either rejected
or questioned Mora's medical credentials. Nebraska granted him a license
in 1990, the same year New Jersey, where Mora completed his residency,
denied him a license.

Once Nebraska granted the license, state officials said, there were
no grounds to revoke it despite the actions in other states.

Why? And what has changed since 1996, when the Nebraska Legislature
required the Health and Human Services system to overhaul the state's medical
licensure system?

LAWSUIT SETTLED

Lindsay Whittaker's death was mentioned nowhere in a lawsuit her mother
settled in December with Mora and Kearney's Richard H. Young Hospital.
The settlement amount was not disclosed, and the hospital cited patient
confidentiality and federal privacy rules in making no comment.

Among the drugs Mora prescribed for Wagner were two antidepressants
that carry bold warnings about the dangers of mixing them.

In October 1998, pharmacy records show, Mora simultaneously prescribed
Prozac, a selective serotonin reuptake inhibitor, or SSRI, and Nardil,
a monoamine oxidase inhibitor, or MAOI. Many over- the-counter cold medications
commonly warn of possible reactions with MAOIs.

The prohibition against simultaneously prescribing these two antidepressants
is common knowledge, said psychiatrist E. Fuller Torrey, president of the
Treatment Advocacy Center in Arlington, Va. Torrey appears frequently on
National Public Radio and on such programs as "Oprah," "20/20," "60 Minutes"
and "Dateline."

"That is well known, that you don't give them together," he said. "You
can get severe side effects."

The effects, known collectively as serotonin syndrome, can include hallucination,
anxiety and psychosis.

Any physician, but especially a psychiatrist whose specialty includes
prescribing antidepressants, should know of the danger, said Lincoln psychiatrist
Eli Chesen, a witness for Wagner in her suit against Mora and the hospital.

In rare cases, said Dr. Carl Greiner, a psychiatrist and assistant dean
for clinical affairs at the University of Nebraska Medical Center, there
may be some justification for mixing the two drugs, but that likely would
be in done in consultation with an expert psychopharmacologist.

In a telephone interview earlier this year, Mora said the drug mix was
appropriate for Wagner and benefited her.

"These two medications were really helping this lady," he said.

He had learned of experiments mixing MAOIs and SSRIs from a drug salesman,
he said, and also had read a medical study discussing it.

But in hearings for the lawsuit, Buffalo County District Judge John
Icenogle gave Mora four months to name the salesman and produce that study.
Mora could do neither and was barred from making those statements at trial.

On Sept. 19, 2003, Icenogle wrote, "Again it appears that Dr. Mora in
his deposition conveniently recalls information which supports his treatment
decision, and even more conveniently is unable to produce those sources."

Asked about that, Mora said months later, "I'm in the middle of moving
my house. I do not have time to dig this junk up."

AN EDUCATION REVEALED

Of the states that rejected Mora's attempts to gain a medical license,
at least two faulted his education.

Mora counters that he is eminently qualified, saying he not only meets
all Nebraska physician requirements but also has more than sufficient expertise
to correctly prescribe psychiatric medications.

Before denying Mora's license, New Jersey investigators chronicled his
unusual journey into medicine.

After graduating from a Texas high school in 1965, Mora attended East
Los Angeles Junior College in 1966-67, withdrawing from 21 courses and
earning two Ds and an F, according to a New Jersey licensure report. He
next attended the University of California, Berkeley, from 1969 to 1973,
receiving seven more Ds and fives Fs en route to a bachelor's degree in
psychology.

In 1979, Mora entered the American University of the Caribbean School
of Medicine, a startup for-profit medical college that then was not associated
with a teaching hospital. In the late 1980s, several states, including
New York, were closing their doors to graduates of such medical schools,
whose entrance requirements were notoriously low, said Professor Edward
Salzberg, who runs the Center for Health Workforce Studies in Albany, N.Y.

Traditionally, medical students complete a series of rotations as part
of their internship.

With his medical degree in hand after 16 months of classroom study,
Mora arranged his own intern rotations.

The New Jersey Medical Board report, however, describes some of these
not as formal internships but "clinical experiences," similar to shadowing
a doctor. Further, the report said, some hospitals at which Mora claimed
to have completed internships have no record of him.

On his New Jersey license application, Mora indicated he performed various
rotations at the University of Southern California from Sept. 2 to Nov.
20, 1981. A letter from that school said it had no record of Mora between
those dates.

Mora also wrote he performed a psychiatry rotation at Metropolitan State
Hospital in Norwalk, Calif. But that hospital advised New Jersey investigators
that while foreign students had informally spent time there, pains had
been taken to explain they were not being provided a formal rotation.

While they may not have been formal rotations, Mora said, "I did the
preceptorship with that doctor."

Mora blames New Jersey officials for all of his licensure troubles.

"The people in New Jersey never bothered to check that I had done my
clerkships, and two of those hospitals had gone out of business and they
could not get the records," he said.

"But I passed all of my examinations for licensure, my internship, residency
training, everything."

Michigan disagreed that his training had qualified him to be a doctor.

In a May 9, 1990, letter from Michigan denying Mora's license request,
regulators wrote: "Since four out of five of your clinical clerkships were
completed at hospitals or institutions that were not teaching hospitals,
nor are they JCAH (Joint Commission on Accreditation of Hospitals) approved,
you do not meet the requirements."

Mora defends his education. Unlike most physicians, he said, he completed
four years of residency when most do three. The record bears him out.

In 1984, Mora gained entry to an internal medicine residency program
with Trenton Affiliated Hospitals in New Jersey. Not recommended for advancement
after his first year, he transferred to a nearby state mental hospital
and completed a three-year psychiatric residency in 1988. He had a job
waiting there if he could obtain a medical license, according to the New
Jersey report.

One big barrier for Mora was passing the necessary medical exams. Over
a period of eight years, he took licensing tests nine times in five states,
passing the second of two required exams with bare minimum scores in March
1990, according to Nebraska Health and Human Services System records.

Recruited by Richard Young Hospital in Kearney, Mora got his Nebraska
license that same month. He received a West Virginia medical license one
month later. That next year, after obtaining the report on Mora from New
Jersey, West Virginia asked Mora to return that license.

Records show he also failed in an attempt to gain a Pennsylvania license.

On Dec. 26, 1990, the New Jersey State Board of Medical Examiners refused
to grant Mora his license on the grounds his medical education was inadequate
regardless of whether he passed the licensure tests.

Mora had appeared before the New Jersey board to discuss the matter
during deliberations, an event that became significant when West Virginia
officials demanded in June 1991 that he surrender his license there.

The West Virginia application form had asked Mora if he had ever been
denied a license to practice medicine or been ejected from any medical
examination.

He answered no.

It also asked: "Have you ever been called before or appeared before
any board or panel for discussions or questions that concern violations
of the law or rules pertaining to the practice of medicine or for unethical
conduct."

Again, no.

West Virginia claimed Mora answered falsely.

Says Mora:"I had never been disciplined."

In a June 12, 1991, letter, West Virginia offered Mora an opportunity
to surrender his license or have it revoked. Mora replied he had never
intended to apply for a full New Jersey license and that officials there
had required him to fill out an application for full licensure even though
he knew he was not ready.

He surrendered the West Virginia license July 15, 1991. He says he did
so to avoid a fuss.

NEBRASKA ALERTED

In spring 1993, Kearney attorney William Wright was hired to point out
deficits in Mora's education to Nebraska Health and Human Services officials.

Contacted recently, Wright couldn't recall who had hired him. In letters
to state officials, Wright wrote he represented an anonymous client.

In any event, Nebraska officials took no action after receiving Wright's
letters outlining Mora's credentials.

Speaking hypothetically, state officials said recently they would not
have had any grounds for an action. Unlike New Jersey, Nebraska has no
requirement for a "thorough and satisfactory" course of instruction in
medicine and surgery.

Unlike West Virginia, Nebraska's application did not - and still doesn't
- ask applicants if they have ever been turned down for a license elsewhere.

Mora met the state's requirements of a medical degree and passing scores
on the medical exams.

Had Nebraska known of the actions by other states before granting Mora
a license, things might have turned out differently, officials suggested.

"In a (license) denial, you shift the burden of proof," said Helen Meeks,
credential division administrator with Health and Human Services. Applicants
must prove they have the necessary qualifications. In disciplining a license,
however, the burden of proof falls on the state.

Courts require that a pattern of negligence be demonstrated - it's a
high standard to meet.

A CLEAN RECORD

In his years of practicing psychiatry in Nebraska, Mora said, he has
had not one malpractice judgment against him.

Lincoln attorney Sally Rasmussen, who represented Gail Wagner in her
action against Mora, said her search of records in several states also
revealed no judgments.

Mora points to this record as the ultimate proof of his qualifications.

"If any of that stuff was true, I would have had lawsuits left and right,
and I haven't," he said.

Other psychiatrists say a clean record may not prove competency.

Especially in psychiatry, where most scars are invisible, an incompetent
doctor could see patients for years without developing a file full of lawsuits.

"It's not only possible," said Dr. Torrey of the Treatment Advocacy
Center, "it happens."

As part of his practice, Mora toured nursing homes in Kearney and North
Platte, monitoring the medication of dementia patients.

Said Rasmussen: "His patient base is a group consisting of mentally
ill patients, who are probably the least likely to advocate for themselves."

BURNED-OUT RECEPTORS

In Wagner's case, Mora said, he prescribed the two drugs together because
she was unresponsive to traditional treatment.

Short of sending her away with unresolved problems, he said, the mix
of Nardil and Prozac was the only thing that could relieve her depression.

But Wagner said that immediately after she began taking the two drugs
together on Oct. 29, 1998, she experienced dizziness, jerking, confusion,
hallucinations, slurred speech, loss of coordination, hysteria, memory
problems, aggression, rage, insomnia and paranoia, plus she started to
drink again.

In mid-February 1999, Wagner said she attempted to refill both prescriptions
in McCook, and that's when a pharmacist called Mora to question him about
the potentially dangerous mix.

Mora disputed this account in an interview.

"The pharmacist never called me. It was I who called them."

In a second interview, Mora blamed pharmacists for not alerting him
earlier to the possible dangers of a drug interaction.

"The drugstore that received the prescriptions for Wagner should have
caught the problem immediately," he said. "In the four months, if there
had been one objection, I would have stopped the medication immediately."

SEEKING HELP

Wagner, 45, went to Mora after finding his name in a phone book. When
she began seeing him in 1996, Wagner was earning $50,000 a year as business
manager at Lee Janssen Chrysler Plymouth Dodge in McCook. Over the next
two years, Mora prescribed stimulants, anti- anxiety medication and antidepressants.

In October 1998, he prescribed Prozac. Two weeks later, Wagner said,
he banged his hand down on the desk and said, "'I know what it is: You
are borderline (have a borderline personality disorder).'"

Then he got down a textbook, she said, and read that Nardil is used
to treat borderline personalities.

"He took the dosage right out of the book."

Four months later, in March 1999, Wagner was admitted to a Kearney hospital
for symptoms of psychosis, possibly related to a drug interaction. Mora
was not her treating physician. He had voluntarily surrendered hospital
privileges two months earlier.

Chesen, Wagner's expert witness, believes she suffers post- traumatic
stress related to her drug-induced psychosis.

"If you've never had a psychotic episode and you're thinking the television
is talking to you, it's not just disconcerting, it's frightening," he said.

Mora said Wagner does not have post-traumatic stress disorder.

"Soldiers who come back from the war, heroes, those are people who have
PTSD."

After she began taking the antidepressants together, Wagner also lost
her job. She now works in telemarketing.

As for Mora, who will turn 58 in July, he plans to continue working
in Nebraska but is winding down his practice.

"I'm going to be hitting 60," he said. "I need to start thinking of
retirement soon. I've been doing this for 14 years."

WHAT'S NEXT

The story is over for Mora and Wagner, but changes are just beginning
for Nebraska's medical licensure laws.

Some changes to the state's elaborate medical licensing process since
Mora received his license would add steps to a new applicant with an identical
background. Additional changes are coming.

After the Nebraska Legislature mandated reform of the credentialing
system in 1996, health officials dealt first with medical facilities before
turning to the licensing of individuals.

In 1999, a committee recommended 144 changes to the state's licensure
laws, said Meeks of Health and Human Services. Reform is expected to occur
piecemeal. This year, the state will begin requiring physicians to take
50 hours of continuing medical education every two years.

The end goal is for physicians to demonstrate continued competency,
Meeks said, but it's difficult to impose that on a longtime physician who
previously had no requirement for keeping current.

Torrey of the Treatment Advocacy Center would require all physicians
to be board-certified in psychiatry before calling themselves psychiatrists.

"Some of us have argued that you shouldn't be able to call yourself
a psychiatrist until you have passed your boards and have demonstrated
at least once that you knew how to prescribe medications," he said.

Mora isn't board-certified in psychiatry. All any state requires for
him to call himself a psychiatrist is a medical license. That's true for
any medical specialty.

Mora refers to himself as board-eligible, a term certification boards
describe as meaningless.

Physician licensure reform seeks a difficult balance, Meeks said. Competency
requirements must be high enough to protect patients but not so high as
to worsen rural physician shortages.

Torrey said the politics of this balancing act often lead to lower physician
standards. Because well-trained psychiatrists can take their pick of jobs,
he said, rural areas end up taking any warm body.

Then there are towns, he said, that implicitly or explicitly lobby state
legislatures not to raise physician standards.

"We need bodies, and you're putting rules in that prevent it. And the
state Legislature, by and large, will not interfere," he said.

Some doctors go from state to state looking for ways to get a license,
he said. They keep going until they find a state that will take them.

Many states probably do a better job at regulating the quality of their
physicians than Nebraska, said Greiner, assistant dean at UNMC.

Nebraskans tend to favor less regulation, he said, and the result is
that while most physicians do a good job, "There's probably about 2 to
3 percent of physicians who are highly problematic."

One or two decades ago, Greiner said, Nebraskans probably would have
been satisfied with a system that works well 97 percent of the time. Today,
we want a 99 percent system, he said.

Other experts, meanwhile, argue that Nebraska has benefited from a nationwide
tightening of the medical credentialing system that has occurred since
the early 1990s.

Today's international medical students must pass the Educational Commission
for Foreign Medical Graduates, which tests cognitive and clinical skills
as well as English proficiency, said Dale Austin, deputy executive vice
president of the Federation of State Medical Boards. There's also been
significant standardization in licensing exams across states, he said.

Other improvements include electronic reporting, which makes it easier
to discover when another state has acted against a doctor's license.

Still, Greiner thinks Nebraska regulators could have exercised better
judgment with Mora's application.

Regulators in New Jersey looked thoroughly at his credentials, he said,
perhaps because he was a product of their system.

"I would have hoped Nebraska would have had a higher index of suspicion,"
Greiner said, noting that Mora came to Nebraska after living in at least
three other states.

"Physicians don't move a lot," he said. "It's the 'duh factor.' A red
light might not go on, but a yellow light ought to."

Reach Mark Andersen at 473-7238 or mandersen@journalstar.com.

REGULATING, LICENSING NEBRASKA DOCTORS

The Nebraska Department of Health and Human Services Regulation and
Licensure Credential Division both issues medical licenses and disciplines
doctors.

The requirements of a Nebraska medical license include proof of academic
degrees, passing scores on some of the many medical exams that are available,
references, proof that medical competency has been maintained. Also required
is a copy of the Drug Enforcement Administration Certificate. Graduates
of foreign medical schools also must pass a test by the Educational Commission
on Foreign Medical Graduates. Applicants must answer 17 questions directed
at whether they have ever been disciplined or placed on probation, broken
the law, abused a controlled substance or had mental illness.

The complete list of requirements is available online at http://www.hhs.state.ne.us/crl/medic...sur/physur.htm

The process for disciplining a Nebraska medical provider can take several
paths. As events proceed, a license holder is given repeated opportunities
to voluntarily surrender a license. The full range of possible outcomes
can be found at www.hhs.state.ne.us/crl/ discproc.pdf

NEBRASKA DOCTORS

Nebraska has about 7,000 licensed physicians. Some 3,600 of them have
Nebraska addresses. Many obtain Nebraska licenses but live and practice
elsewhere.

A Journal Star analysis of data from 1976 to spring 2003 shows disciplinary
actions have been taken against 55 doctors with Nebraska addresses. Twenty-eight
of them had more than one. Of those, 18 graduated from Nebraska medical
schools, five came from other U.S. medical schools, three came from Caribbean
medical schools and two came from other foreign medical schools.

Any Nebraska resident can file a complaint against a physician by calling
402-471-0175.

Information about actions taken against doctors with Nebraska medical
licenses can be found at www.hhs.state.ne.us/lis/lis.asp

Caption: 1. Gail Wagner lost her daughter, Lindsay, when Lindsay committed
suicide at age 14. Wagner thinks that if she hadn't had psychosis a few
years earlier, Lindsay might be alive today. MARK ANDERSEN Lincoln Journal
Star 2. Lindsay Whittaker committed suicide at age 14 after writing goodbye
e-mails to friends and erasing her computer files. COURTESY PHOTO 3. Many
cold medicines warn of the danger of reactions with MAIO drugs. b/w head
photo of Charles J. Mora b/w illustration of documents

Credit: Lincoln Journal Star

__________________
Moderator - State Licensing Forum

Still skeptical after all these years.
This is it. There are no hidden meanings.WYSIWYG

http://www.internetmedicalschool.homestead.com

http://www.chiropractormds.homestead.com/index.html

Wow, an SSRI and a MAOI together?? Damn, that was lesson number 1 in basic psyciatric pharmacology!!

__________________
BTS4202
St. Christopher's COM
4th Year
http://www.mdparadise.com

"If there really is a God, He has a lot of explaining to do"
- Dennis Leary

total moron. I wonder when the limit on taking the USMLE was started. G

__________________
AUC Class of '99
Bored certified
I may be a jerk, but I'm a Jedi jerk like my father.

Some say I look like Buzz Lightyear....
(They're right)

DISCLAIMER: I have no financial stake in ValueMD, or any medical school.

C'mon, Get a Life! Do you really want to accuse or blame the Doctor when the problem is obviously with the gal who had suicidal tendancies and the careless mother? Give me a break! That mother should have known better, and should not blame her daughter's death on a Doctor's prescription. That is absolutely absurd...! The mother should have taken responsibility for her life and her daughter's. Period End.

who knows what really happened but why prescribe two medications like this?

eitehr way blame can shift either way. meds aren't a cure all so a pt is on a medication and is chronically depressed, on a psychotic episode decides to commit suicide and the meds and the doc who prescribed it are blamed....advantage lawyers. another pt is chronically depressed psychiatrist refers to psychotherapy and pt commits suicide, doctolr is blamed for not medicating the pt....advantage lawyers. anyone see a pattern?

these conditions are unpredictable as it is but to add these meds without proper training is just a bad choice and it is too bad that auc's name is involved. we also don't know what happened during the interview, i find it funny that the mom finds it odd that the doctor had to look up a dosage in a book, where else would you find it? hehe

__________________
OBGYN PGY II
I see light at the end of the tunnel!!!...wait a minute its just another freakin tunnel!

This guy's record is pretty shocking to say the least.

-He's asked not to return to his IM program after his PGY1 year
-He is NOT board certified
-He prescribes an irreversible MAOI along with an SSRI for a possible BPD on a outpatient basis

However, blaming him for her daughter's death is outlandish (sounds like a BPD).