Doctor Bison’s Fables: The Crowded Exam Room

By Pat Anson, PNN Editor

Dr. Mark Ibsen is a Montana physician whose license was suspended in 2016 by the state medical board for “overprescribing” opioids and poor record keeping. A state judge later reversed the suspension, ruling the medical board made numerous errors.

Ibsen has since become a strong proponent of medical marijuana and a leading advocate in the pain community. He’s published a new book, “Dr. Bison’s Fables,” using animals as lead characters in a series of stories to convey how many pain patients in the U.S. lack proper treatment and some are in crisis.

This interview with Ibsen has been edited for content and clarity.

PNN: Who is “Doctor Bison’s Fables” intended for and what is your goal? What is the message you're trying to get across?

Dr. Mark Ibsen

IBSEN: I'm not really in the book selling business. I'm in the restoration of the sacred physician-patient relationship business. But all of my screaming from the rooftops about it for the last 12 years has made little progress.  

I was talking to the publisher and he was saying if you write a book about what's going on in medicine today, the pain crisis and catastrophe of it, you'll have a readership of 50,000. If you write a book that talks about the dynamics of what's going on, and put it in the form of a parable or a fable that has a bigger meaning to it, your audience will expand.

When this approach was suggested to me, I rejected it completely out of hand. I said I just want to tell what's going on because the house is on fire. But I slowly came to look at this idea as maybe he's onto something. Maybe Aesop's Fables had some good things to say, maybe the Brothers Grimm had some good things to say. So I thought, okay, let's add some folksiness to this. Give it a Burl Ives approach.

PNN: When you tell your fables in the book, animals are the key characters. Why did you choose them?

IBSEN: The animals are the protagonists. I chose Dr. Bison because of the bullheadedness of the character. As you can see on the book cover, he's examining this cute little otter on the exam table. And the weasel guy with the clipboard is scowling at him and evaluating how he's doing his job and if he's doing it effectively or quickly enough.

The weasel is like an interloper in the exam room, which has been my persistent complaint. We have too many guests in the exam room that have a vote into what's going on between the doctor and the patient. We have an insurance bureaucrat deciding what you can or can't prescribe, and a pharmacist deciding if the prescription is legitimate.

Then there's a law enforcement officer who's looking at whether a crime is being committed. Then there's a DEA agent who may or may not have a college education, who's looking at patterns and matrices. Is Dr. Bison prescribing more than other doctors?

Then there's legislators, like the legislators in the state of Ohio that legislated exactly how much I could get for the pain in my chest after it was split open during heart bypass surgery at the Cleveland Clinic.

So it's really crowded in the exam room now.

PNN: You want to get across the point that you can't treat all patients the same way. Everyone is different. How do you communicate that in your fable scenario?

IBSEN: I think it's basically species dependent. By that I mean that different species have different personal attributes. A mouse is going to attack a problem much different than a bison would. Or an herbivore will attack a problem more than a carnivore will.

I guess you could call it a menagerie. There's a bison and a cougar. There's a possum. There's a wise llama. There's a viper in the chapter about breeding resentment. There's a coyote, the trickster who has a lawyer's briefcase and there's a crow. And then the elk. Elk handle their conflicts by keeping the herd intact, surrounding the weakest member so the wolves can't get to them.

My goal is to is to make this seemingly light and then develop it. Story development pulls them in and readers finish the story. And then they're left with curiosity about the pain crisis, rather than revulsion or rejection or resistance or argumentation.

PNN: Take us to the epilogue and the message that you really want to get across to the reader.

IBSEN:  I guess I would say that I didn't leave medicine, medicine left me. I don't want to project some righteous indignation about it. I'm sad about it more than anything else. I don't think this is limited just to the patient-physician relationship. I think it's a cultural phenomenon. And it's just manifested in medicine in this way.

We now have patients that cannot tell their doctor the truth. It's sort of like a teenager who has to lie to their parents. It's like a patriarchal system. The patriarchal system works if the patriarch supports the people in the system. But these days, if you admit that there's a family history of alcoholism, then suddenly you're not a candidate for opiates.

Or this doctor friend of mine who was recently suspended, he's a residency mate of mine. He had a mother and a daughter, both in chronic pain. I think they lived together and one was on hydrocodone and the other on oxycodone. And it turns out their medications may have gotten mixed up. They had a urinalysis and it looked bad.

But if you live in the same household, then maybe you can get your pills mixed up. I mean, you could have that chance. But do you fire somebody for having hydrocodone in their system? In my training, a lab result is something that you respond to, not something you react to. The first thing you do is you repeat the lab test. If you see something that's completely out of the ordinary, then you have to inquire about it.

But in this system, you have to fire the patient, even when there's no evidence that doing urine drug screens make any difference at all about diversion or patient care or anything. Nobody's done a placebo, double-blind controlled study about that.

I'm now seeing some pain refugees from Billings. The pain doctor there retired and the new guy came in slashing everybody’s dose and then he left. All these patients are trying to recover and none of them are oriented towards taking cannabis because they know that if they found cannabis in their urine that they would be fired. Somebody somewhere will say if you have cannabis in your urine, it's obvious that you're selling your pain pills in order to buy your cannabis. That is not obvious to me. Not even remotely

There’s a huge amount of gaslighting going on between the system and patients, that doctors are willing participants in. I mean, my younger colleagues have loans to pay off, so they are not risk takers. Right now, I am quite a risk taker. Because everything's gone. I don't have anything left.

I would say that in medicine today, the wheels are coming off and maybe they need to all come off. It doesn't operate in the same mentor-apprenticeship relationship that I was trained in. I don't know if I would last in medical training today.

I think that the internet has both good and bad things about it. And the good thing is that patients research their ailments or their symptoms and they come in with that. They come in with a differential diagnosis already. And I get to hear that and respond to it.

The great thing about that is what I call the alignment effect. If a patient comes to me and wants to do something that they read about and it's not going to kill them, if I say yes and it works for them, then they're going to be really persistent about following that therapy because it was their idea. Right? If it fails and they come back to me, then they're willing to listen to my point of view on it. And that builds trust.

If only the hospital administrator, pharmacist, insurance bureaucrat and legislator would trust our medical expertise. I think we're in a period of time where expertise is not thriving. Failing to use the expertise of our specialists is really putting us in a bad way, not only in medicine, but in the entire culture.

PNN: Thank you, Dr. Ibsen.

Suspension of Dr. Ibsen's Medical License Reversed

By Pat Anson, Editor

A Montana district court judge has reversed the suspension of Dr. Mark Ibsen's medical license, ruling that the state medical board made numerous errors when it suspended Ibsen’s license in 2016 for allegedly overprescribing pain medication.

Judge James Reynolds said the Montana Medical Board violated Ibsen’s right to due process by failing to allow expert witnesses to testify in his defense during board hearings. The board also rejected the findings of its own hearing examiner, who said Ibsen’s standard of patient care was sufficient.

“It is analogous to the selection of a jury in a civil case and then when the verdict comes in against a party, that party asking for the selection of another jury. Except in this case, it is even more striking because it is the agency who selected the hearing examiner,” Judge Reynolds ruled.

“They screwed up,” Ibsen attorney John Doubek told the Independent Record. “I think it’s a pretty sharp rebuke to a decision that was totally off-base.

“The sad thing is my client has been under their thumb now for two years. He can’t move his practice because he has this black mark against his reputation and against his license, so he’s been unable to practice medicine and this guy is a good doctor.”

DR. MARK IBSEN

Ibsen first came under investigation in 2013, when he was accused of over-prescribing opioid medication by a disgruntled former employee at his Helena medical clinic.

“I’m a little stunned that it happened,” Ibsen said of the judge’s decision. “I’m mostly angry. It could have been resolved in 10 minutes, instead of five years.”  

Although the suspension of Ibsen’s license was stayed while he appealed the board’s ruling, his professional reputation was so damaged that pharmacists refused to fill his prescriptions and he was forced to close his clinic. Ibsen’s former patients also suffered. He says three committed suicide (including the recent death of Jennifer Adams) and three others died of causes likely related to the stress of their pain not being treated. Montana has the highest suicide rate in the country.

Ibsen told PNN that Montana has become a virtual “wasteland” for pain care, because many of the state’s doctors fear being prosecuted or losing their licenses for prescribing opioids.  Several of Ibsen's patients were former patients of Dr. Chris Christensen, a Ravalli county physician convicted of negligent homicide after two of his patients died from overdoses.

“There was a clear time there I was crying for help. I was just inundated by these pain patients that my colleagues weren’t dealing with. And I was just sort of shocked at the cruelty of the way I was treated and the cruelty of the way pain patients were being treated,” he said. “I’ve got a lot of compassion for people who don’t feel like they belong in the medical model. I’ve been shunned. They’ve been shunned.”

And after five years of legal battles, the only drug Ibsen will prescribe now is medical marijuana.

“It terrifies me to consider opening up a clinic again. They might come after me,” Ibsen said. “Things could change, but I have nothing in the on-deck circle.  I don’t have anything planned. It was just not good for me to plan anything.”

Montana Doctor to Seek ‘Medical Asylum’

By Pat Anson, Editor

A doctor whose license was suspended indefinitely by the Montana Board of Medical Examiners for over-prescribing opioids plans to seek “medical asylum” in other states or even overseas.

The Montana medical board issued its 80-page final order suspending Dr. Mark Ibsen’s license on Tuesday, the latest chapter in a three year investigation into Ibsen’s opioid prescribing practices. Ibsen was accused of over-prescribing pain medication to nine patients and keeping inadequate medical records on them, even though investigators did not cite a single case where Ibsen’s practices led to someone’s death or injury. Ibsen disputes the charges and will file an appeal.

(Update: District Court Judge James P. Reynolds on Thursday issued a temporary restraining order that prohibits the Montana Board of Medical Examiners from suspending Ibsen's license for 30 days.)

“I was kind of hoping for a Hail Mary. I was hoping they’d come to their senses, but they didn’t,” Ibsen said.

The board left the door open for Ibsen to someday get his license reinstated if he takes a class on medical record keeping and is under the supervision of another physician. Ibsen says the terms for reinstatement are “impossibly vague” and impractical, but he doesn’t intend to give up medicine.

“I’ll go wherever I can get a license. I’m considering myself a medical refugee and I’m seeking medical asylum, whether it’s in New Zealand or Australia or Canada or one of the United States,” he told Pain News Network.

In May, Ibsen plans to go to India and do volunteer work.

dr. mark ibsen

“I do have an agreement to travel with a mission to northern India in Zanskar province, with a group that’s going to help the Dali Lama open up a hospital there,” he said. “I’m going be bringing an ultrasound for them, hopefully train them how to use it, and I’m going to screen kids for congenital heart disease and rheumatic heart disease. There’s a lot of strep infections in that area. And I’ll be doing general medicine.”

Ibsen said he last visited India in 1989 and is not worried about needing a license to practice medicine there.

“I’ll treat the underserved and people who don’t get care anyway. The Indian government is not at the level of regulating licenses of volunteers,” he said.

Ibsen was one of the last doctors in Montana willing to prescribe opioids to new patients and became something of a folk hero in the pain community, treating patients that other doctors had abandoned.

In December, financial problems forced Ibsen to close his Urgent Care Plus clinic in Helena. Since then, various efforts to reopen it under new management have fallen through. Ibsen is not sure what will become of the clinic.

“Right now the business is dead and rotting,” he said.

Montana Doctor’s License to Be Suspended

By Pat Anson, Editor

The Montana Board of Medical Examiners voted unanimously Thursday to suspend the medical license of Dr. Mark Ibsen for unprofessional conduct, the latest chapter in a three year investigation into Ibsen’s opioid prescribing practices. A final order on the board’s ruling still needs to be drafted and voted on again. Ibsen has said he will appeal the decision.

The medical board accepted almost all of the recommendations made in a proposed order by Michael Fanning, Special Assistant Attorney General to the Montana Department of Labor and Industry, but it refused to consider lengthy allegations that Ibsen has “destructive psychological and behavioral issues.”

Ibsen was one of the last doctors in Montana willing to prescribe opioid pain medication to new patients, including many who drove hundreds of miles to see him. While that made Ibsen a folk hero of sorts in the pain community, it also attracted the attention of investigators who thought he was overprescribing opioids, and raising the risk of addiction and overdose.

“Opioid deaths are frighteningly common with one source estimating one death for every 500 opioid prescriptions written in America,” Fanning wrote in his 62-page proposed order, without citing a single case where Ibsen’s prescribing practices led to someone’s death or injury.

The case against Ibsen largely centered on nine pain patients and the incomplete records he kept on their treatment.

MARK IBSEN, MD

“Dr. Ibsen’s charts did not contain satisfactory evidence that he attempted more conservative care short of chronic opioid therapy,” Fanning wrote. “While the charts include occasional references to mental or behavioral health and rare references to interventional services, there was no consistent evidence that the more conservative option had been attempted and failed before continuing opioid therapy.”

Ibsen’s charts also did not include records of a written or oral contract with patients about their opioid use, which is a common requirement in pain management. Fanning said Ibsen also overlooked “red flags” in a patient’s behavior that could indicate signs of opioid abuse or diversion.

Last year a hearing officer recommended that Ibsen be put on probation for 180 days, but Fanning went much further, asking the board to suspend Ibsen’s medical license indefinitely. The board spent over seven hours reviewing the case and over 6,000 documents admitted as evidence before making its decision.  

“I just want to say that nothing has made me feel more ashamed to say that I am a Montanan born and raised than this kangaroo court in action,” said Gary Snook, who suffers from Arachnoiditis, a painful and disabling spinal cord disorder caused by botched spinal injections. He now gets medical treatment in California.   

“I am appalled by the total lack of understanding of the treatment of pain by these doctors. No wonder Montana has one of the highest disability rates in the nation,” Snook said in an email to Pain News Network.

“Overreaching is far too gentle a term for what occurred here. It felt like a witch hunt,” said Terri Lewis, PhD, a rehabilitation specialist and patient advocate.  “No doubt Dr. Ibsen, like many, has flaws, but holding this physician to a standard of perfection which exists in neither law nor practice makes no sense.  Maybe they will assign him a scarlet ‘O’ to wear on his chest.

“This is signal in the noise of our public confusion about the management of chronic pain.  This hearing process provides a good deal of insight into the conditions of care, or lack thereof, that both clinicians and patients find so challenging and threatening.”

One board member – who voted to suspend Ibsen’s license -- praised Ibsen for his compassion toward patients and said she hoped he would apply to have his license reinstated if he submits to professional oversight..

Publicity about the case and financial problems forced Ibsen last month to close his Urgent Care Plus clinic in Helena. Ibsen was arrested in November, not for opioid prescribing, but for a misdemeanor domestic assault charge. He has pleaded not guilty.

Doctor's License May Be ‘Suspended Indefinitely’

By Pat Anson, Editor

The Montana Department of Labor and Industry is recommending that the medical license of Mark Ibsen, MD, be suspended indefinitely by the state Board of Medical Examiners for unprofessional conduct.

Ibsen has been at the center of a long-running debate in Montana over the prescribing of opioid pain medication. State investigators say Ibsen overprescribed opioids, kept poor records and risked the health of his patients, while supporters say he is one of the few doctors left in the state willing to treat chronic pain patients. The Board of Medical Examiners is scheduled to meet Thursday to decide Ibsen's fate.

“Opioid deaths are frighteningly common with one source estimating one death for every 500 opioid prescriptions written in America,” wrote Michael Fanning, Special Assistant Attorney General to the Montana Department of Labor and Industry.

But in his 62-page proposed order, Fanning dos not cite a single case where Ibsen’s prescribing practices led to someone’s death. Instead he focuses on Ibsen’s alleged emotional instability and poor record keeping.

“Dr. Ibsen’s charts did not contain satisfactory evidence that he attempted more conservative care short of chronic opioid therapy,” Fanning wrote. “While the charts include occasional references to mental or behavioral health and rare references to interventional services, there was no consistent evidence that the more conservative option had been attempted and failed before continuing opioid therapy.”

Fanning also said Ibsen overlooked “red flags” in a patient’s behavior that could indicate signs of opioid abuse or diversion, such as multiple requests for early refills of prescriptions, seeing multiple doctors, and multiple lost medications. Ibsen’s charts also did not include records of a written or oral contract with some patients about their opioid use.

Fanning’s proposed order also includes references to “erratic and unprofessional behavior” by Ibsen reported by a former spouse and medical associates. One psychological profile of Ibsen said he suffers from bipolar disorder and narcissism, and that Ibsen “fails to accept responsibility, projects blame onto others and believes that others have conspired against him.”

mark ibsen, md

The state medical board is under no obligation to accept Fanning’s recommendation of indefinite suspension of Ibsen’s license. Last year the board rejected a proposed order from a hearing officer that Ibsen be put on probation for 180 days.

"I don't think I've had fair treatment in three years with the board of medicine. They've rewritten the evidence and are redefining reality," Ibsen told Pain News Network. "I haven't been treated fairly at all. They continue to accuse me of horrible and heinous things for people that I've helped. And there's been no one harmed by anything that I've done."

Ibsen has become something of a hero to pain patients, not only in Montana, but around the country. Many have trouble finding a doctor willing to prescribe opioids.

"I've become quite an advocate for the downtrodden pain patients. I promote medical marijuana as an exit strategy for people on opiates. I may be upsetting the status quo," said Ibsen.

Publicity about his case and financial problems recently forced Ibsen to close his Urgent Care Plus clinic in Helena. Ibsen was arrested in November, not for opioid prescribing, but for a misdemeanor domestic assault charge. He has pleaded not guilty.

Under Fanning's proposed order, Ibsen would be eligible to have his medical license reinstated, provided he was under "perpetual monitoring" by a professional assistance program. Ibsen says he will appeal if his license is restricted.

Montana Clinic to Reopen Without Doctor

By Pat Anson, Editor

A Montana health clinic that closed its doors last week will reopen on Monday, but without its owner -- who says he will not write opioid prescriptions for chronic pain patients because he is "paralyzed with fear" of being arrested.

"I don't think it's safe for me to continue seeing these patients until I get some reassurance that I can do it. I'm risking my well being by going in there.," said Mark Ibsen, MD, owner of the Urgent Care Plus clinic in Helena.

Ibsen says he left behind "tapering" prescriptions for opioids at lower doses to help wean patients off the drugs and prevent them from going into withdrawal.

"I have a couple who are upset and feel abandoned. And I have a lot of them who are upset and understanding," he said. "They've seen what I am going through. They've been watching me kind of deteriorate emotionally over the last few months. And I tell my patients I can't continue to do this, you've got to find someone else. This is dangerous for me."

image courtesy of mark ibsen

Ibsen fears being arrested like Dr. Chris Christensen, another Montana doctor who was recently charged with 400 felonies, including two counts of negligent homicide, in connection with the overprescribing of opioids. Ibsen himself was the target of a lengthy investigation by the Montana Board of Medical Examiners after he started treating some of Dr. Christensen’s former pain patients.

If he keeps writing prescriptions for opioids, Ibsen worries he'll be next.

"The DEA agents that met with me five different times will not meet with me again unless my lawyer is present. My only inference from that is that they have an open investigation. I haven't been able to confirm that , but you don't know that until they walk through the door and cuff you.  I have no idea, so I am paralyzed with fear," he said.

dr. mark ibsen

Pain News Network caught up with Ibsen in Las Vegas, where he is attending PAINWeek, the nation's largest conference for frontline practitioners in pain management. Ibsen hoped going to the conference would re-energize him, but found that many of the lectures focused on opioid abuse and diversion.--. the very subjects he's grown weary of.

"All I've seen is more evidence of hysteria," he said. "Prescription drug overdose is number 22 on the list of causes of death in America. And this so-called epidemic, I mean calling it an epidemic is insane."

Like Ibsen, other doctors around the country have also stopped writing prescriptions for opioids.

"Many of them with much less provocation than he's had," said Bob Twillman, PhD, Executive Director of the American Academy of Pain Management. "You worry you're going to lose your practice and lose your livelihood by doing something you don't intend to do. And the easiest way to do that is don't go there, don't prescribe."

Ibsen says he was prescribing opioids to about200 patients when he stopped. Some have gone to hospital emergency rooms seeking more medication, while others are in search of new doctors in a state where very few are willing to prescribe to new patients.

"My patients are now being shunned by other doctors and judged by the fact that they've seen me," Ibsen said. 

Controversial Montana Doctor Suspends Practice

By Pat Anson, Editor

A Montana doctor who has been at the forefront of the debate over opioid prescribing is closing his urgent care clinic and will no longer prescribe medication to pain patients. Dr. Mark Ibsen said he didn't do anything wrong, but was tired of facing regulatory scrutiny over his opioid prescribing practices.

“The clinic is closing today. I’m going to disappear for awhile,” said Ibsen, who owns and operates the Urgent Care Plus clinic in Helena.

Ibsen said he would stop practicing medicine “in solidarity” with Dr. Chris Christensen, another Montana doctor who was arrested last week and charged with 400 felony counts, including two negligent homicide charges, in connection with the overprescribing of opioids.

Ibsen himself was the target of a lengthy investigation by the Montana Board of Medical Examiners after he started treating many of Dr. Christensen’s former patients after Christensen’s Ravalli county clinic was shutdown. Many of the patients were in opioid withdrawal and went to Ibsen because he was one of the few doctors in the state still willing to prescribe pain medication.

“I’m the last man standing in Montana, I think. I don’t know if there is anyone else who will do it. I think not. Because they were all coming to me because they were abandoned by their doctors,” said Ibsen.

Although a state hearing examiner ruled this summer the medical board “did not meet its burden of proof” in the overprescribing case against Ibsen, he has not yet been formally cleared of charges.  The examiner recommended that Ibsen be put on probation for 180 days for poor record keeping.

Ibsen told Pain News Network he was under a lot of stress and was deeply in debt from the legal cost of defending himself and treating Medicaid patients at low reimbursement rates.

“This is not a protest. This is me saying I can’t do this. I’m working in a hostile regulatory environment. And I’m stopping,” Ibsen said.

dr. mark ibsen

“I’m frightened. They’ve got me scared. The DEA said to me two years ago, ‘Dr. Ibsen you are not only risking your license, you’re risking your freedom by prescribing to patients like these.’ And I said patients like what? And they said patients who might divert their pills. And I said might? And they said yes. I said that’s a law enforcement job. My job is to treat the patient in front of me and do what I think is best for them based on what they tell me and what my testing shows.”

Ibsen said his urgent care clinic treated about 30 to 60 patients a day for a variety of conditions and he regularly prescribed opioids to a “couple hundred” patients. He said he didn’t know where they would get their pain medication now.

“I have also deeply considered whether stopping prescribing opiates sends a message that I'm afraid I've done something wrong. Let me assure you I have done nothing wrong. I have upheld my oath as long as I can. The pressure is just too much and today in particular I cannot concentrate on these complex cases. Therefore my clinic is closed and I'm going home,” he said.

"Dr. Ibsen was unfairly targeted and helped Christensen's patients wean from high doses.  Who is going to wean Ibsen's patients now?" asked Terri Anderson, a chronic pain sufferer and patient advocate who lives in Hamilton, MT.

"Pain patients are ultimately the ones who suffer.  I try to look at it from all sides and if it were my brother who overdosed then I would be upset. However it is easy to judge and my first thought is that pain patients come with risk to the prescriber, because they often suffer many other health issues besides just pain, including anxiety, depression and PTSD (post traumatic stress disorder)."  

In the last month, Ibsen said three staff members had resigned from his clinic, which he likened to a “war zone” because of the stress of treating patients who had nowhere else to go.

“Maybe I will come back. But I’m rattled. I’m too rattled to think of the right blood pressure medication to give to a patient. I can’t concentrate. I don’t want any patient injured today because my concentration is so poor,” Ibsen said. “When I am well enough, and I feel safe to practice in the way I know how, I will return.”