Licensed to Pill

On July 31, 2019, Dr. Michael Lapaglia appeared before the Tennessee Board of Medical Examiners. It was not the first time the board had considered a disciplinary case involving the then forty-seven-year-old internist from Knoxville, but the fourth.

His first brush with the board—the state agency that has the final word on who can practice medicine in Tennessee—was in 2014, after he was arrested by law enforcement for dealing opioids, benzodiazepines, and marijuana out of his home. When the state board learned that he’d pled “no contest” to the charges in that criminal case, it placed his license on probation and ordered the doctor to attend weekly Narcotics Anonymous meetings. The federal government, for its part, revoked his Drug Enforcement Agency registration and thus his ability to legally prescribe controlled substances.

His second encounter with the licensing board came in January of 2019, when the board summarily suspended Dr. Lapaglia, in absentia, from practicing medicine after learning what he had done while his license was on probation. In early 2018, he met a doctor named Charles Brooks at one of his board-mandated NA meetings. Both doctors had restricted licenses, but Dr. Brooks had something Dr. Lapaglia did not—a valid DEA registration.

Later that year, the two doctors teamed up to form L&B Healthcare, a clinic with no brick-and-mortar presence, just a prescription pad with Dr. Brooks’s DEA number and Dr. Lapaglia’s phone number. Dr. Lapaglia used the pad to prescribe dangerous combinations of benzodiazepines and Suboxone, an addiction medication but itself an opioid with significant street value. Dr. Lapaglia sold the prescriptions for $300 cash out of his house, at patients’ homes, and, once, in a McDonald’s parking lot. When federal law enforcement officers found out about L&B, they charged Dr. Lapaglia with trafficking narcotics and fraud. He pled guilty to both felonies in late 2018, and currently awaits sentencing.

Dr. Lapaglia’s third brush with the Tennessee medical board was a few months later in 2019, when he testified at Dr. Brooks’s disciplinary hearing and admitted to his part in L&B. He acknowledged that he’d used Dr. Brooks’s DEA number to circumvent his own inability to prescribe narcotics. The board members found that these encounters were “transactions” and not the practice of medicine. (Yet the panel allowed Dr. Brooks, too, to keep his license.)

Finally, Dr. Lapaglia was subject to board proceedings that fourth time. At a hearing to determine the fate of his license in the aftermath of L&B and his federal pleas, he again admitted to the forgeries and the convictions. In response, the board restored his ability to practice medicine. The panel praised his commitment to helping his patients, and laid down a path back to his full licensure.

After the hearing, I spoke with Dr. Lapaglia. He was pleased with the result. “All I really wanted today was to get my license off suspension,” he said, “so I could go make some money.”

*

The opioid crisis has claimed the lives of more than 400,000 Americans. The scale of this epidemic is hard to grasp, exceeding by multiples the number of Americans who have died to date in the Covid-19 pandemic. In 2018, the most recent year for which data are available, one in five Americans had an opioid prescription filled. An investigation by NPR last week found that, according to a CDC report released in May, doctors commonly ignored federal guidelines and were still prescribing powerful opioid medications instead of other, better treatment options. In some rural counties, enough prescriptions are written each year for every single inhabitant, including children, to have one.

Fatal overdoses now exceed deaths from car accidents or gun violence; overdose is the leading cause of death for Americans under fifty, lowering the life expectancy of Americans for the first time in decades. Tennessee, where I live and work, is one of the hardest-hit states, ranking third in the nation for prescribing rates.

As the opioid crisis evolved, many states passed laws to deter and punish dangerous prescribing. But medical licensing boards, which have the final say in whether a doctor will be allowed to continue to practice and prescribe, are treating cases of unethical prescribing with a leniency that’s at odds with the scope of the crisis.

The case of Dr. Lapaglia is not an aberration but the norm. And Tennessee’s medical board follows the standard operating procedure of such boards around the country. For example, in 2017, the medical board in Missouri reinstated the license of an over-prescribing doctor who had violated the board’s own order five times. In that same year, when nearly a thousand Missourians died from overdoses, the board pursued only a handful of opioid-prescribing cases; most prescribers kept their licenses. A 2018 local news investigation in Ohio revealed that seven doctors indicted on drug-dealing charges for their prescribing in the state had incurred repeated disciplinary notice from the state’s medical board yet maintained their licenses. And last year, a Virginia doctor was sentenced to seven years in prison for his prescribing practices after having lost—and regained—his state medical license on three different occasions.

Meanwhile, data from the DEA suggest that the US has been flooded with about 10 billion pain pills a year, with the bulk of the drugs moving through a relatively small number of pharmacies. Likewise, most of the prescriptions for these drugs were probably written by a small number of physicians at “pill mills”—clinics, like Brooks and Lapaglia’s—that charge cash for prescriptions, with little pretense of medical treatment, although it’s impossible to know exactly how many because states treat data on how much each doctor prescribes as confidential. But we do know these clinics were good customers for companies like Purdue Pharma, the maker of Oxycontin. Purdue launched the drug in 1996, and with it a sales strategy that proved wildly successful for two decades: focus sales efforts on what Purdue called “supercore” providers—that is, pill mills.

A terrible irony is that opioid addicts, once the victims of prescribing-for-profit when seeking pain treatment, may now find themselves again victims of prescribing-for-profit when seeking treatment for their addiction. Suboxone is a long-acting opiate that suppresses cravings and eases withdrawal symptoms. Its sublingual strips can be life-saving when prescribed responsibly to recovering addicts, but it can also be abused. Some say the drug delivers a high that, while not as intense as that from heroin or Oxycontin, can also be dangerous: fifty of Tennessee’s 1,818 drug overdoses in 2018 involved Suboxone.

Suboxone is most dangerous when used in combination with benzodiazepines. Many opioid addicts are also addicted to “benzos” like Valium or Xanax, and using the two drugs in combination increases the likelihood of overdose five-fold. That’s why Tennessee law requires Suboxone clinics to wean their patients off benzodiazepines, and it’s probably why Dr. Lapaglia’s practice of prescribing both drugs together caught the attention of the DEA.

As Tennessee began shutting down over-prescribing pain clinics in 2018, a new kind of pill mill almost immediately emerged: the Suboxone clinic. These clinics can operate under the radar in ways that regular pain clinics cannot: federal law provides special privacy protections to patients seeking addiction treatment, making it difficult for Tennessee’s Department of Health to obtain their medical charts when investigating unethical prescribing. Without that evidence, the board cannot pursue complaints against doctors running Suboxone pill mills.

And these clinics can be lucrative. Dr. Lapaglia told me at his board hearing last July that each sublingual strip commands $30–$50 on the street, meaning a patient can potentially sell a one-month supply of ninety strips for as much as $2,700. Typically, about $300 is kicked back to the prescribing physician in the form of an appointment fee, for an encounter that lasts about as long as it takes to write a prescription.

*

By the time I started attending licensing board meetings for my research, in 2018, the state government of Tennessee was on high alert about the opioid crisis. Then-governor Bill Haslam had just sponsored a comprehensive legislative response called “Tennessee Together,” signing the legislation that June in a ceremony in Maryville, a small city in the eastern part of the state, in the heart of the Appalachian region that has been so devastated by the crisis. (Brooks and Lapaglia’s joint venture, in full swing at the time, also happened to have a mailing address in town.)

Maryville was also home to a pill mill known as the Breakthrough Pain Center, which became notorious when its prescribing led to federal indictments against nine providers in 2014. All except one, who apparently committed suicide while awaiting trial, pled guilty. Four years later, as I observed board meetings, I witnessed one of those providers—a physician’s assistant named Walter Blankenship—get his license back.

As the months went by, I started paying attention to similar disciplinary decisions. These cases revealed how self-regulation can go terribly awry. Even in cases of extreme overprescribing—usually for profit, and sometimes with a known body count from overdoses—board members were unwilling to bring the hammer down on their practitioner colleagues.

There are over two hundred professional licensing boards that regulate controlled substance prescribers in the United States, and almost all of them are required by state law to comprise mostly members from the profession they are tasked with regulating. They govern millions of health-care providers, yet very little is known about how they operate or about the quality of their regulation.

These boards typically enjoy no state funding beyond the fees they charge licensees, resulting in under-funded investigations that can take years to bring a prescriber to discipline. Cases are brought by state government staff (in the case of Tennessee, by employees of the Department of Health), but the ultimate decider is the board—a rotating panel mostly comprising physicians, who must make unpaid time in busy professional lives for the bi-monthly board meetings. These constraints on time hamper investigations, while the churn on the panel undermines the consistency that greater institutional memory would bring. The combination of these factors leads to board decisions that are almost entirely ad hoc and often lacking crucial information.

The typical medical board has about twelve seats, and they are filled by appointment by their state’s governor, who usually draws from the leadership of the state professional association. Board members told me that when they joined, they had to “change hats,” as they pivoted from advocating for their profession to protecting the public. But it can be difficult for even the most well-meaning board members to set aside their identities as professional advocates.

Boards usually also have a few “public” members from outside the profession, who tend to be acquaintances of the governor or people owed a political favor. These public members typically have no experience in medicine or regulation and their influence on the board is weak. A public member of the Tennessee Board of Medical Examiners told me that, early in his term, a physician board member pulled him aside and said that when it came to discipline cases, he should “save a doctor” when possible.

Board members often mention the shortage of primary care providers, especially in rural areas, as a reason for “saving” a doctor in a discipline case. But saving a doctor often means shunting the most problematic providers toward the most vulnerable populations.

Board members are keenly aware of the professional consequences that flow from discipline. Significant sanctions often mean a practitioner will lose hospital privileges, as well as the ability to take private insurance. State board discipline can cause a doctor to lose his federal license to prescribe controlled substances, as it did in Dr. Lapaglia’s case (doctors must have permission from both the DEA and their state medical board to prescribe controlled substances). Public health insurance programs, like Medicaid and Medicare, also consider disciplinary information, but they tend to have higher thresholds than private insurers for what triggers a dismissal.

Employment opportunities for doctors with a disciplinary history are limited but not nonexistent. In Louisiana, for example, 60 percent of the doctors in the state prison system are under disciplinary orders, in part because the state board itself refers them for employment there. But most doctors with serious discipline on their records must work for themselves or small clinics specializing in procedures for which there is a cash market: Botox injections, testosterone therapy, cosmetic surgery, medical weight loss, pain pills, and—because it is not adequately covered by health insurance—addiction treatment. Board discipline thus drove Dr. Lapaglia’s career switch from hospital physician to self-employed prescriber.

Many board members I talked to assured me that what looked to me like light discipline was really the end of that physician’s career. In practice, though, many providers go on to long careers in the medical profession’s less prestigious underbelly.

In rural Tennessee, medical providers are scarce, and so is adequate health insurance. Practice as a family doctor in a small town for cash-paying patients puts food on the table, especially if you are willing to prescribe pain pills at a brisk clip. Doctors who maintain status with, for example, Medicare and Medicaid, can make about $50 for each visit to refill a prescription, which, by law, must occur every month for controlled substances. At just five to ten minutes each, these visits can add up to a solid professional income.

And when the opioid epidemic took hold, such doctors learned they could skip the insurance altogether and charge $300 cash to each pain patient every month. At that point, board discipline simply stopped being any impediment to a high-earning medical career.

*

In 1980, the American Medical Association proposed a framework for understanding why doctors over-prescribe. The “4D Model” placed overprescribing doctors in four categories: duped, dated, disabled, or dishonest. The model provided a blueprint for how licensing boards should handle allegations of overprescribing. It also helped establish a narrative about overprescribing that allowed doctors sitting on boards to avoid directly blaming their colleagues for unsafe prescribing.

“Duped” doctors are well-meaning healers manipulated by drug-seeking patients into prescribing ever more controlled substances. Elvis Presley’s doctor, George Nichopoulos, invoked this defense when the Tennessee Board of Medical Examiners brought disciplinary action against his license for prescribing ten thousand pills to Presley in the twenty months leading up to his death. In the same year the AMA came up with its model, the Tennessee Board found that Dr. Nichopoulos’s prescribing constituted gross malpractice, but the board kept him in practice until 1993 when it learned that he had spent the interim serving as a “Dr. Feelgood” to hundreds more patients. About his over-prescribing, he said, “I just cared too much.” 

“Dated” providers are those who received inadequate training in proper prescribing, and discipline usually involves continuing education in prescribing practices and record keeping. Rehabilitation plays a greater role for the “disabled” doctor, who is addicted to alcohol or pills himself. Addiction is prevalent among doctors facing discipline, especially those accused of overprescribing. In 2014, when the medical board disciplined Dr. Lapaglia’s license over his state drug-dealing charges, the doctor used the “disabled” narrative to negotiate for probation rather than revocation. While the police said they found forty-five quart-sized jars of marijuana, one hundred and twenty-seven marijuana pipes, a digital scale, a sales ledger, two guns, and a large collection of prescription drugs, including fentanyl and morphine, in his home, the board order was more elliptical in its statement of the facts. It simply said that Dr. Lapaglia “possessed marijuana and 52 pills of Diazepam… for his personal addiction.”

For a remedy, the board conditioned Dr. Lapaglia’s ability to practice on attendance of twelve-step meetings and frequent drug tests; he complied and kept his license—at least until his federal indictment. But Dr. Lapaglia told me that the meetings did nothing for him. “I don’t have a problem,” he said.

The fourth “D”—dishonest—refers to the doctor who overprescribes for profit or another ulterior motive. Many disciplinary cases I saw, including Dr. Lapaglia’s, involved facts that indicated dishonest or criminal conduct. But boards tend to resist the narrative of a “dishonest” doctor.

Some board members I have seen in the course of my research questioned whether criminal conduct was even relevant to board discipline. In relicensing a physician who pled guilty and was sentenced to federal prison for a million-dollar medical insurance fraud scheme, one board member remarked: “I don’t see what a federal charge and conviction over a billing matter has to do with us giving him a license to return to practice.”

*

Last year, the Tennessee legislature passed a bill that created the Opioid Minimum Discipline Taskforce, modeled on criminal “mandatory minimums.” The statute instructed this taskforce—comprising one member from each board that licenses prescribers—to establish a minimum punishment for opioid overprescribers. Absent a decision from the taskforce within a year, the statute mandated its own mandatory minimum: loss of opioid-prescribing authority for five years.

At a hearing on the bill, state Senator Ferrell Haile made clear that the bill should be interpreted as a warning. “We are expecting the boards to begin acting in good faith,” he said. “If you want to serve on these boards, we expect disciplinary action. That’s what you’re there for.” Yet the taskforce settled on a rule that would have all but the most egregious repeat-offender overprescribers back to prescribing in six months.

In another attempt to rein in the boards, the state’s Department of Health appealed the disciplinary decision for Christina Collins, a nurse practitioner at Bearden Health Associates in Knoxville—a clinic associated with at least five board orders for over-prescribing. Nurse Collins prescribed one patient 51 pills a day; for another, she tripled his dose of morphine after he was hospitalized for an overdose. The Department described the nursing board’s discipline, which amounted to a reprimand and order for continuing education, as “a slap on the wrist.” The state judge hearing the appeal agreed, but without the authority to take or restrict a license directly, all he could do was order a retrial in front of the same board that had already put her back in practice.

The state’s most public rebuke against the boards has been indirect. Tennessee, like Oklahoma and Ohio, has filed a high-profile, high-stakes suit against Purdue, alleging that the company fraudulently marketed addictive drugs like Oxycontin directly and aggressively to pill mill prescribers. Tennessee’s complaint argues that Purdue failed to adhere to its promise in the 2007 settlement agreement that it would identify over-prescribers and place them on a do-not-call list. For several providers, Tennessee’s complaint identifies a history of board disciplinary measures—short of removing prescribing authority—as a red flag that Purdue should have recognized as a sign of over-prescribing.

Tennessee’s argument is striking because it amounts to a public admission that its own state boards are unable or unwilling to take dangerous prescribers out of practice. It’s also unlikely to be successful since Purdue can persuasively counter that it is proper to market drugs to prescribers who have their state’s blessing to prescribe them.

Perhaps the most direct control that the state can exert over its own boards is in the appointment process. In Tennessee, as in most states, board members are appointed by and serve at the pleasure of the governor. When I met Dr. Stephen Loyd in July of 2019, he had just been appointed to the board after serving for two years as the state’s “opioid czar,” advising the governor on opioid-prescribing policy and addiction treatment. I learned that he is nationally renowned for his work in addiction medicine and gives talks around the state to raise awareness about the crisis. He told me that his passion for that work—and for his work on the board—came from personal experience: he is himself a recovering pill addict.

When I learned of Dr. Loyd’s appointment, his résumé gave me hope that Tennessee’s governor had recognized the connection between board discipline and the opioid crisis. But when I saw Dr. Loyd reinstate Dr. Lapaglia’s license at his first board meeting, I learned that even the best appointments can’t make a broken system work. 

*

On April 16, 2019, the Department of Justice’s Appalachian Regional Prescription Opioid Strike Force announced fifty-three new indictments against health-care professionals, alleging fraud and drug-trafficking. Thirty of the accused were opioid prescribers in Tennessee. Among them was Dr. Brooks, who is now facing up to fifteen years in federal prison for allowing Dr. Lapaglia to use his name and DEA registration in exchange for half of L&B’s profits.

Some of the April indictments were against providers who, like Dr. Brooks, had prior board discipline for related conduct, though eighteen of the indicted doctors from Tennessee had no history of public discipline on their medical licenses. Yet, when I attended the medical board meeting following the indictments, none of those doctors was even on the agenda. And so it was with the meeting after that, and the one after that.

By my count, at the time of writing, half of the Tennessee providers named in the April 2019 indictments have no reported discipline on their licenses whatsoever. One such provider, Dr. Samson Orusa, is accused of having written about two-hundred-and-fifty controlled substance prescriptions a week without an examination or diagnosis, and of forcing patients to receive unnecessary injections to drive up his insurance billing. He petitioned the judge in his federal case to allow him to continue prescribing controlled substances while awaiting trial, reasoning that if the state licensing board felt he was a safe prescriber, so should the federal court. The judge declined.

When the indictments came down, I asked an assistant US attorney if he thought that the federal criminal prosecutions were a vote of no-confidence in board regulation. He didn’t answer that question directly, but did note that there “seems to be a disconnect” between the federal criminal perspective on overprescribing and state board discipline.

Many board members I spoke to subscribed to the view that, for the worst prescribers, the criminal justice system, not the board, is best-placed to act. But leaving licensing discipline to the criminal justice system is problematic. Convictions require proof beyond a reasonable doubt—a high bar designed to protect the constitutional rights of the accused. Board regulation, in contrast, places a lighter burden of proof on the state authorities, on grounds that public safety is the higher priority. And criminal proceedings can be lengthy. To date, only two of the April 2019 indictments have been resolved.

Most fundamentally, professional regulation and criminal justice ask two different questions. Professional regulation is supposed to protect the public by asking whether a provider has the minimum level of competence and judgment to practice safely. The criminal justice system asks whether the accused’s conduct is so antisocial as to justify incarceration.

Former DEA agent Daniel Rousseau wanted to bridge this disconnect between law enforcement and the boards. I met him at the first medical board meeting after the April indictments, where he was introduced as the new head of investigations for the Department of Health, the office that oversees all board discipline investigations. Rousseau had a hard-headed law-and-order attitude toward overprescribing: “What’s the difference between Leroy standing on the corner handing crack, getting money, handing crack, getting money, and Dr. Sanchez, handing a prescription, getting money, handing a prescription, getting money?”

He told me he was hired to shake things up at the department, and in particular to facilitate information-sharing between the boards, other state agencies, and the federal authorities. He had already gotten criticism for being from out of state, and he suspected that while he had the support of the governor, he was making too many waves with the boards and the Department of Health. By the time of the next medical board meeting, he had already quit.

*

Before Dr. Lapaglia’s July board hearing, the doctor and his lawyer could be seen pacing and smoking in front of the featureless Department of Health building in an office park in North Nashville. I was there, waiting to learn who would be on the three-member panel—drawn from the full twelve-member board—to hear his case. One of the scheduled panelists disclosed a conflict of interest, and his seat was assigned to the new board member, Dr. Loyd, the former opioid czar.

By then, I had learned more about Dr. Lapaglia’s past. As an emergency room physician in Oak Ridge, Tennessee, he was known among local police for his willingness to medically paralyze suspected drug dealers with succinylcholine and perform warrantless body cavity searches. He settled two lawsuits over the practice, and was the subject of a Sixth Circuit decision in 2013 that said his searches “shocked the conscience” and violated the Constitution.

I searched Dr. Lapaglia’s licensing history online and found that as a psychiatry resident during 2001–2002, he’d initiated a personal relationship with a sixteen-year-old psych patient who had been admitted to the hospital where he was working. He’d told her that he was a psychiatrist and had continued to call her after she was discharged from the hospital. He was dismissed from his residency and denied licensure in two other states over the incident.

I was curious to see how these details would influence the board’s decision about what to do with Dr. Lapaglia’s medical license. They were never mentioned.

Instead, the state lawyer charged with prosecuting Dr. Lapaglia in front of the board, Andrew Coffman, focused his case on L&B Healthcare. When Coffman questioned the doctor about the origins of L&B, Dr. Lapaglia explained that when the board put his license on probation in 2014, he lost the ability to work at a hospital or accept health insurance. Finding it hard to earn a living outside the cash-only sector of medical care, he went to work for a Suboxone clinic known as EHC.

At EHC, Dr. Lapaglia’s inability to take insurance and his lack of DEA registration didn’t matter because patients paid with cash and there were doctors on staff with valid DEA registrations who actually wrote the prescriptions. When I spoke with him during a break at the hearing, he broke down the math for me: with roughly 8,000 patients needing monthly prescriptions for Suboxone at $400 a visit, EHC clinic was potentially grossing millions of dollars a month.

It was while Dr. Lapaglia was working at EHC that he met Dr. Brooks, who was also under board discipline. (Dr. Brooks’s license was on probation because he’d had sex with a patient after giving her a sedative, “believing the clandestine circumstances of the encounter to have caused [her] to experience anxiety.”) Dr. Lapaglia introduced Dr. Brooks to the owner of EHC, and they worked there together for a few months before teaming up to form L&B.

Dr. Lapaglia testified that L&B Healthcare was born out of a need the doctors saw among their Suboxone patients at EHC. Most were addicted to both opioids and benzodiazepines, but as a Suboxone clinic, EHC was required by state regulations to wean patients off benzodiazepines. This left an unmet demand that L&B intended to supply. The doctors began referring EHC patients to L&B to obtain benzodiazepine prescriptions on the side. Eventually, L&B became a one-stop shop offering prescriptions for Suboxone and benzodiazepines, saving patients from having to pay for two monthly appointments.

At the board hearing, Dr. Lapaglia admitted to using Dr. Brooks’s DEA number to prescribe controlled substances. He admitted to the cash payments and the encounter in the McDonald’s parking lot. He also stated that he had never been accused of trafficking in narcotics. Yet, just thirty-five minutes earlier, the prosecutor had admitted as evidence the two criminal cases—one state, one federal—in which Dr. Lapaglia had admitted to using his medical license to deal drugs.

The board prosecutor did not confront Dr. Lapaglia about his lie; he later told me it was because he thought Dr. Lapaglia deserved leniency for his cooperation with the administrative investigation into L&B. Rather, Coffman began his closing argument: “Dr. Lapaglia did something that was dumb.” He asked the board to protect the public by limiting, not revoking, his license.

Dr. Loyd, though new to the board, led deliberations. “My charge was to protect the health, safety and welfare of the citizens of the state of Tennessee. Do I believe taking Dr. Lapaglia’s license does that? Actually, I don’t,” he said. “Hopefully, I’m a decent judge of somebody’s heart. I saw somebody that cares.”

Dr. Loyd crafted a disciplinary order aimed at what he believed was the root of Dr. Lapaglia’s troubles: his prior drug abuse. Dr. Loyd suggested more NA meetings and drug monitoring. “I ask my students: Who is the most important person in the room, the patient or the doctor?” he said. “They always think it’s the patient, but it’s the doctor, because if I’m not OK, you don’t have a chance.”

In the end, the board imposed discipline on Dr. Lapaglia that was nearly identical to the discipline he had been under when he formed L&B Healthcare. The only significant difference was a lifetime, not a five-year, monitoring contract with Tennessee Medical Foundation, the nonprofit that connects doctors with addiction treatment and monitors their compliance. (Dr. Lapaglia seemed untroubled by this difference; after the hearing, he assured me that he could have the TMF requirement lifted in a few years.) The order said that the “[r]espondent’s willingness to accept responsibility for his actions and his willingness to engage in the rehabilitative process allows us to provide a path to regain full licensure.”

*

I met Dr. Loyd a month later over a cup of coffee. He was dressed in jeans and sneakers, wearing a purple “overdose awareness” pin on his T-shirt. The conversation began with his telling me about his work to promote understanding and reduce stigma about opioid addiction in Tennessee. He told me he was grateful for the second chance he’d received from TMF and his professional community when he’d confronted his addiction and sought treatment. “You don’t always get a second chance,” he said.

When I asked him about Dr. Lapaglia’s case, he said that as soon as he and the other panel members had handed down the decision, he’d regretted it. He told me that it was immediately after the hearing, when Dr. Lapaglia shook his hand in thanks, that Dr. Loyd first considered the idea that Dr. Lapaglia was something other than a well-intentioned, but troubled, practitioner. Dr. Loyd told me he’d since lost sleep over the idea that he had been conned by the doctor. “It’s eating me alive,” he told me.

That was before he knew about the paralyzed body cavity searches and the relationship with a sixteen-year-old patient. When I told him the full story of Dr. Lapaglia’s past, he grew quiet. When he finally spoke, there was a catch in his voice: “How come I don’t know that?”

Part of the answer lies with the board prosecutor who pursued the case with a faint heart. But Dr. Loyd was presented with enough facts in the hearing to see that Dr. Lapaglia was a doctor undeserving of further chances at a medical career. He was handed copies of two criminal judgments against Dr. Lapaglia for using his medical license to deal prescription drugs. He knew the latest scheme was hatched while the doctor was under a board disciplinary order. And he knew the prescriptions were forged.

I asked Dr. Loyd whether he noticed that Dr. Lapaglia had lied at the hearing, when he denied ever being accused of drug-dealing. He’d failed to notice that, he said, pointing out that it was his very first board meeting. He hadn’t adjusted to thinking of himself as a regulator; he saw things as a physician. “I have experience in being a doctor,” he said. “It’d be like me bringing you into my clinic and you know, you’re a lawyer, you don’t know anything about what I’m doing.”

By the end of the interview, Dr. Loyd was beside himself. If he had read all of the evidence presented to him, he might have caught Dr. Lapaglia’s lie. But as he said, he had failed to see Dr. Lapaglia from a regulator’s perspective: as a threat to public safety. Rather, he saw him, at some level, as a fellow troubled physician. About the case, Dr. Loyd later said: “I was appointed by the Governor to protect the health safety and welfare of the people of Tennessee. I didn’t do that.”

*

Dr. Lapaglia’s sentencing hearing for his federal criminal case is scheduled for September 28. With the board’s order in place, incarceration is the only way to keep him out of medical practice. But he avoided serving time for his 2013 state charges, and he told me he thought he had a shot at a similar deal from the feds: he’d provided the DEA with information about EHC and similar Suboxone clinics running a high volume of patients—information he thought would be useful in future prosecutions. He hoped this might be enough to get him probation on the felony counts.

“Man,” he said to me, “could you imagine me in prison?”