VIRGINIA BEACH, Va. —
Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.
It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have ADHD, not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard's doctor to stop prescribing him Adderall, warning, “You're going to kill him."
It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.
The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for ADHD, doctors and other experts said.
Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.
Richard Fee's experience included it all. Conversations with friends, family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.
Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard's own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that ADHD practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered," said Parker, a psychiatrist in Virginia Beach. “I think it's an abnegation of trust. The public needs to say this is totally unacceptable and walk out."
Young adults are by far the fastest-growing segment of people taking ADHD medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company IMS Health. While this rise is generally attributed to the maturing of adolescents who have ADHD into young adults — combined with a greater recognition of adult ADHD in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.
“Any step along the way, someone could have helped him — they were just handing out drugs," said Richard's father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it."
The first signs of trouble
Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for ADHD.
Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any ADHD symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Rick Fee also expressed concerns about the safety of his son taking daily amphetamines for a condition he might not have.
“The doctor wouldn't give me anything that's bad for me," Rick Fee recalled his son saying that day. “I'm not buying it on the street corner."
Richard's first experience with ADHD pills, like so many others', had come in college. Friends said he was a typical undergraduate user — when he needed to finish a paper or cram for exams, one Adderall capsule would jolt him with focus and purpose for six to eight hours, repeat as necessary.
So many fellow students had prescriptions or stashes to share, friends of Richard recalled in interviews, that guessing where he got his was futile. He was popular enough on campus — he was sophomore class president and played first base on the baseball team — that they doubted he even had to pay the typical $5 or $10 per pill.
“He would just procrastinate, wait till the last minute and then take a pill to study for tests," said Ryan Sykes, a friend. “It got to the point where he'd say he couldn't get anything done if he didn't have the Adderall."
Various studies have estimated that about 8 percent to 35 percent of college students take stimulant pills to enhance school performance. Few students realize that giving or accepting even one Adderall pill from a friend with a prescription is a federal crime. Adderall and its stimulant siblings are classified by the Drug Enforcement Administration as Schedule II drugs, in the same category as cocaine, because of their highly addictive properties.
“It's incredibly nonchalant," Chris Hewitt, a friend of Richard, said of students' attitudes to the drug. “It's: 'Anyone have any Adderall? I want to study tonight,'" said Hewitt, now an elementary school teacher in Greensboro.
After graduating with honors in 2008 with a degree in biology, Richard planned to apply to medical schools and stayed in Greensboro to study for the entrance exams. He remembered how Adderall had helped him concentrate so well as an undergraduate, friends said, and he made an appointment at nearby Triad Psychiatric and Counseling Center.
According to records obtained by Richard's parents after his death, a nurse practitioner at Triad detailed his unremarkable medical and psychiatric history before recording his complaints about “organization, memory, attention to detail." She characterized his speech as “clear," his thought process “goal directed" and his concentration “attentive."
Richard filled out an 18-question survey on which he rated various symptoms on a 0-to-3 scale. His total score of 29 led the nurse practitioner to make a diagnosis of “ADHD, inattentive-type" — a type of ADHD without hyperactivity. She recommended Vyvanse, 30 milligrams a day, for three weeks.
Phone and fax requests to Triad officials for comment were not returned.
Some doctors worry that ADHD questionnaires, designed to assist and standardize the gathering of a patient's symptoms, are being used as a shortcut to diagnosis. Keith Conners, a longtime child psychologist who developed a popular scale similar to the one used with Richard, said in an interview that scales like his “have reinforced this tendency for quick and dirty practice."
Conners, an emeritus professor of psychiatry and behavioral sciences at Duke University Medical Center, emphasized that a detailed life history must be taken and other sources of information — such as a parent, teacher or friend — must be pursued to learn the nuances of a patient's difficulties and to rule out other maladies before making a proper diagnosis of ADHD. Other doctors interviewed said they would not prescribe medications on a patient's first visit, specifically to deter the faking of symptoms.
According to his parents, Richard had no psychiatric history, or even suspicion of problems, through college. None of his dozen high school and college acquaintances interviewed for this article said he ever showed or mentioned behaviors related to ADHD — certainly not the “losing things" and “difficulty awaiting turn" he reported on the Triad questionnaire — suggesting that he probably faked or at least exaggerated his symptoms to get his diagnosis.
That is neither uncommon nor difficult, said David Berry, a professor and researcher at the University of Kentucky. He is a co-author of a 2010 study that compared two groups of college students — those with diagnoses of ADHD and others who were asked to fake symptoms — to see whether standard symptom questionnaires could tell them apart. They were indistinguishable.
“With college students," Berry said in an interview, “it's clear that it doesn't take much information for someone who wants to feign ADHD to do so."
Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: “reading books — read 10!" her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, “Okay rewrite."
Richard filled that prescription later that afternoon. It was his third month's worth of medication in 43 days.
Richard scored too low on the MCAT in 2009 to qualify for a top medical school. Although he had started taking Vyvanse for its jolts of focus and purpose, their side effects began to take hold. His sleep patterns increasingly scrambled and his mood darkening, he moved back in with his parents in Virginia Beach and sought a local physician to renew his prescriptions.
A friend recommended a family physician, Dr. Robert Woodard. Woodard heard Richard describe how well Vyvanse was working for his ADHD, made a diagnosis of “other malaise and fatigue" and renewed his prescription for one month. He suggested that Richard thereafter see a trained psychiatrist at Dominion Psychiatric Associates — only a five-minute walk from the Fees' house.
With eight psychiatrists and almost 20 therapists on staff, Dominion Psychiatric is one of the better-known practices in Virginia Beach, residents said. One of its better-known doctors is Dr. Waldo Ellison, a practicing psychiatrist since 1974.
In interviews, some patients and parents of patients of Ellison's described him as very quick to identify ADHD and prescribe medication for it. Sandy Paxson of nearby Norfolk said she took her 15-year-old son to see Ellison for anxiety in 2008; within a few minutes, Paxson recalled, Ellison said her son had ADHD and prescribed him Adderall.
Ellison met with Richard in his office for the first time on Feb. 5, 2010. He took a medical history, heard Richard's complaints regarding concentration, noted how he was drumming his fingers and made a diagnosis of ADHD with “moderate symptoms or difficulty functioning." Dominion Psychiatric records of that visit do not mention the use of any ADHD symptom questionnaire to identify particular areas of difficulty or strategies for treatment.
As the 47-minute session ended, Ellison prescribed a common starting dose of Adderall: 30 milligrams daily for 21 days. Eight days later, while Richard still had 13 pills remaining, his prescription was renewed for 30 more days at 50 milligrams.
Through the remainder of 2010, in appointments with Ellison that usually lasted under five minutes, Richard returned for refills of Adderall. Records indicate that he received only what was consistently coded as “pharmacologic management" — the official term for quick appraisals of medication effects — and none of the more conventional talk-based therapy that experts generally consider an important component of ADHD treatment.
His Adderall prescriptions were always for the fast-acting variety, rather than the extended-release formula that is less prone to abuse.
Tension and disturbances
Regardless of what he might have told his doctor, Richard Fee was anything but well or calm during his first year back home, his father said.
Blowing through a month's worth of Adderall in a few weeks, Richard stayed up all night reading and scribbling in notebooks, occasionally climbing out of his bedroom window and onto the roof to converse with the moon and stars. When the pills ran out, he would sleep for 48 hours straight and not leave his room for 72. He got so hot during the day that he walked around the house with ice packs around his neck — and in frigid weather, he would cool off by jumping into the 52-degree backyard pool.
As Richard lost a series of jobs and tensions in the house ran higher — particularly when talk turned to his Adderall — Rick and Kathy Fee continued to research the side effects of ADHD medication. They learned that stimulants are exceptionally successful at mollifying the impulsivity and distractibility that characterize classic ADHD, but that they can cause insomnia, increased blood pressure and elevated body temperature. Food and Drug Administration warnings on packaging also note “high potential for abuse," as well as psychiatric side effects such as aggression, hallucinations and paranoia.
A 2006 study in the journal Drug and Alcohol Dependence claimed that about 10 percent of adolescents and young adults who misused ADHD stimulants became addicted to them. Even proper, doctor-supervised use of the medications can trigger psychotic behavior or suicidal thoughts in about 1 in 400 patients, according to a 2006 study in The American Journal of Psychiatry. So while a vast majority of stimulant users will not experience psychosis — and a doctor may never encounter it in decades of careful practice — the sheer volume of prescriptions leads to thousands of cases every year, experts acknowledged.
When Kathy Fee noticed Richard putting tape over his computer's camera, he told her that people were spying on him. (He put tape on his fingers, too, to avoid leaving fingerprints.) He cut himself out of family pictures, talked to the television and became increasingly violent when agitated.
In late December, Rick Fee drove to Dominion Psychiatric and asked to see Ellison, who explained that federal privacy laws forbade any discussion of an adult patient, even with the patient's father. Rick Fee said he tried unsuccessfully to detail Richard's bizarre behavior, assuming that Richard had not shared such details with his doctor.
“I can't talk to you," Rick Fee recalled Ellison telling him. “I did this one time with another family, sat down and talked with them, and I ended up getting sued. I can't talk with you unless your son comes with you."
Rick Fee said he turned to leave but distinctly recalls warning Ellison, “You keep giving Adderall to my son, you're going to kill him."
Ellison declined repeated requests for comment on Richard Fee's case. His office records, like those of other doctors involved, were obtained by Rick Fee under Virginia and federal law, which allow the legal representative of a deceased patient to obtain medical records as if he were the patient himself.
As 2011 began, the Fees persuaded Richard to see a psychologist, Scott Sautter, whose records note Richard's delusions, paranoia and “severe and pervasive mental disorder." Sautter recommended that Adderall either be stopped or paired with a sleep aid “if not medically contraindicated."
Rick Fee did not trust his son to share this report with Ellison, so he drove back to Dominion Psychiatric and, he recalled, was told by a receptionist that he could leave the information with her. Rick Fee said he demanded to put it in Ellison's hands himself and threatened to break down his door in order to do so.
Rick Fee said that Ellison then came out, read the report and, appreciating the gravity of the situation, spoke with him about Richard for 45 minutes. They scheduled an appointment for the entire family.
Ellison stopped Richard Fee's prescription — he wrote “no Adderall for now" on his chart and the next day refused Richard's phone request for more. Instead he prescribed Abilify and Seroquel, antipsychotics for schizophrenia that do not provide the bursts of focus and purpose that stimulants do. Richard became enraged, his parents recalled. He tried to back up over his father in the Dominion Psychiatric parking lot and threatened to burn the house down. At home, he took a baseball bat from the garage, smashed flower pots and screamed, “You're taking my medicine!"
Richard disappeared for a few weeks. He returned to the house when he learned of his grandmother's death, the Fees said.
The morning after the funeral, Richard walked down Potters Road to what became a nine-minute visit with Ellison. He left with two prescriptions: one for Abilify, and another for 50 milligrams a day of Adderall.
According to Rick Fee, Richard later told him that he had lied to Ellison — he told the doctor he was feeling great, life was back on track and he had found a job in Greensboro that he would lose without Adderall. Ellison's notes do not say why he agreed to start Adderall again.
Richard's delusions and mood swings only got worse, his parents said. They would lock their bedroom door when they went to sleep because of his unpredictable rages. “We were scared of our own son," Rick Fee said. Richard would blow through his monthly prescriptions in 10 to 15 days and then go through hideous withdrawals. A friend said that he would occasionally get Richard some extra pills during the worst of it, but that “it wasn't enough because he would take four or five at a time."
One night during an argument, after Richard became particularly threatening and pushed him over a chair, Rick Fee called the police. They arrested Richard for domestic violence. The episode persuaded Richard to see another local psychiatrist, Dr. Charles Parker.
Kathy Fee said she attended Richard's initial consultation on June 3 with Parker's clinician, Renee Strelitz, and emphasized his abuse of Adderall. Richard “kept giving me dirty looks," Kathy Fee recalled. She said she later left a detailed message on Strelitz's voicemail, urging her and Parker not to prescribe stimulants under any circumstances when Richard came in the next day.
Parker met with Richard alone. The doctor noted depression, anxiety and suicidal ideas. He wrote “no meds" with a box around it — an indication, he explained later, that he was aware of the parents' concerns regarding ADHD stimulants.
Parker wrote three 30-day prescriptions: Clonidine (a sleep aid), Venlafaxine (an antidepressant) and Adderall, 60 milligrams a day.
In an interview last November, Parker said he did not recall the details of Richard's case but reviewed his notes and tried to re-create his mindset during that appointment. He said he must have trusted Richard's assertions that medication was not an issue, and must have figured that his parents were just philosophically anti-medication. Parker recalled that he was reassured by Richard's intelligent discussions of the ins and outs of stimulants and his desire to pursue medicine himself.
Kathy Fee was outraged. Over the next several days, she recalled, she repeatedly spoke with Strelitz over the phone to detail Richard's continued abuse of the medication (she found nine pills gone after 48 hours) and hand-delivered Sautter's appraisal of his recent psychosis. Parker confirmed that he received this information.
Richard next saw Parker on June 27. Kathy Fee drove him to the clinic and waited in the parking lot. Soon afterward, Richard returned and asked to head to the pharmacy to fill a prescription. Parker had raised his Adderall to 80 milligrams a day.
Parker recalled that the appointment was a 15-minute “med check" that left little time for careful assessment of any Adderall addiction. Once again, Parker said, he must have believed Richard's assertions that he needed additional medicine more than the family's pleas that it be stopped.
“He was pitching me very well — I was asking him very specific questions, and he was very good at telling me the answers in a very specific way," Parker recalled. He added later, “I do feel partially responsible for what happened to this kid."
'Paranoid and psychotic'
The 911 operator answered the call and heard a young man screaming on the other end. His parents would not give him his pills. With the man's language scattered and increasingly threatening, the police were sent to the home of Rick and Kathy Fee.
The Fees told officers that Richard was addicted to Adderall, and that after he received his most recent prescription, they allowed him to fill it through his mother's insurance plan on the condition that they hold it and dispense it appropriately. Richard was now demanding his next day's pills early.
Richard denied his addiction and threats. So the police, noting that Richard was an adult, instructed the Fees to give him the bottle. They said they would comply only if he left the house for good. Officers escorted Richard off the property.
A few hours later Richard called his parents, threatening to stab himself in the head with a knife. The police located him and took him to the Virginia Beach Psychiatric Center.
Described as “paranoid and psychotic" by the admitting physician, Dr. John Riedler, Richard spent one week in the hospital denying that he had any psychiatric or addiction issues. He was placed on two medications: Seroquel and the antidepressant Wellbutrin, no stimulants.
Unwelcome at home after his discharge from the psychiatric hospital, Richard stayed in cheap motels for a few weeks. His Adderall prescription from Parker expired on July 26, leaving him eligible for a renewal. He phoned the office of Ellison, who had not seen him in four months.
The 2:15 p.m. appointment went better than Richard could have hoped. He told Ellison that the pre-psychotic and metaphoric thinking back in March had receded, and that all that remained was his ADHD. He said nothing of his visits to Parker, his recent prescriptions or his week in the psychiatric hospital.
At 2:21 p.m., according to Ellison's records, he prescribed Richard 30 days' worth of Adderall at 50 milligrams a day. He also gave him prescriptions postdated for Aug. 23 and Sept. 21, presumably to allow him to get pills into late October without the need for follow-up appointments. (Virginia state law forbids the dispensation of 90 days of a controlled substance at one time but does allow doctors to write two 30-day prescriptions in advance.)
Virginia is one of 43 states with a formal Prescription Drug Monitoring Program, an online database that allows doctors to check a patient's one-year prescription history, partly to see if he or she is getting medication elsewhere. Although pharmacies are required to enter all prescriptions for controlled substances into the system, Virginia law does not require doctors to consult it.
Ellison's notes suggest that he did not check the program before issuing the three prescriptions to Richard, who filled the first within hours.
About a week later, Richard called his father with more good news: A job he had found overseeing storm cleanup crews was going well. He was feeling much better.
But Rick Fee noticed that the more calm and measured speech that Richard had regained during his hospital stay was gone. He jumped from one subject to the next, sounding anxious and rushed. When the call ended, Rick Fee recalled, he went straight to his wife.
“Call your insurance company," he said, “and find out if they've filled any prescriptions for Adderall."
An insurance representative confirmed that Richard had filled a prescription for Adderall on July 25. Rick Fee confronted Ellison in the Dominion Psychiatric parking lot.
Rick Fee told him that Richard had been in the psychiatric hospital, had been suicidal and had been taking Adderall through June and July. Ellison confirmed that he had written not only another prescription but two others for later in August and September.
“He told me it was normal procedure and not 90 days at one time," Rick Fee recalled. “I flipped out on him: 'You gave my son 90 days of Adderall? You're going to kill him!'"
Rick Fee said he and Ellison discussed voiding the two outstanding scripts. Rick Fee said he was told that it was possible, but that should Richard need emergency medical attention, it could keep him from getting what would otherwise be proper care or medication. Rick Fee confirmed that with a pharmacist and decided instead to drive to Richard's apartment and try to persuade him to rip up the prescriptions.
“I know that you've got these other prescriptions to get pills," Rick Fee recalled telling Richard. “You're doing so good. You've got a job, you're working. Things with us are better. If you get them filled, I'm worried about what will happen."
“You're right," Rick Fee said Richard replied. “I tore them up and threw them away."
Rick Fee spent two more hours with Richard making relative small talk — increasingly gnawed, he recalled later, by the sense that this was no ordinary conversation. As he looked at Richard he saw two images flickering on top of each other — the boy he had raised to love school and baseball, and the desperate addict he feared that boy had become.
Before he left, Rick Fee made as loving a demand as he could muster.
“Please. Give them to me," Rick Fee said.
Richard looked his father dead in the eye.
“I destroyed them," he said. “I don't have them. Don't worry."
A tragic ending
Richard generally filled his prescriptions at a CVS on Laskin Road, less than three miles from his parents' home. But on Aug. 23, he went to a different CVS about 11 miles away, closer to Norfolk and farther from the locations that his father might have called to alert them to the situation. For his Sept. 21 prescription he traveled even farther, into Norfolk, to get his pills.
On Oct. 3, Richard visited Ellison for an appointment lasting 17 minutes. The doctor prescribed two weeks of Strattera, a medication for ADHD that contains no amphetamines and, therefore, is neither a controlled substance nor particularly prone to abuse. His records make no mention of the Adderall prescription Richard filled on Sept. 21; they do note, however, “Father says that he is crazy and abusive of the Adderall — has made directives with regard to giving Richard anymore stimulants — bringing up charges — I explained this to Richard."
Prescription records indicate that Richard did not fill the Strattera prescription before returning to Ellison's office two weeks later to ask for more stimulants.
Ellison never saw Richard again. Given his patterns of abuse, friends said, Richard probably took his last Adderall pill in early October. Because he abruptly stopped without the slow and delicate reduction of medication that is recommended to minimize major psychological risks, especially for instant-release stimulants, he crashed harder than ever.
On Nov. 7, after arriving home from a weekend away, Kathy Fee heard a message on the family answering machine from Richard, asking his parents to call him. She phoned back at 10 that night and left a message herself.
Not hearing back by the following afternoon, Kathy Fee checked Richard's cellphone records — he was on her plan — and saw no calls or texts. At 9 p.m. the Fees drove to Richard's apartment in Norfolk to check on him. The lights were on, his car was in the driveway. He did not answer. Beginning to panic, Rick Fee found the kitchen window ajar and climbed in through it.
He searched the apartment and found nothing amiss.
“He isn't here," Rick Fee said he told his wife.
“Oh, thank God," she replied. “Maybe he's walking on the beach or something."
They got ready to leave before Rick Fee stopped.
“Wait a minute," he said. “I didn't check the closet."
Shock and questions
Friends and former baseball teammates flocked to Richard Fee's memorial service in Virginia Beach. Most remembered only the funny and gregarious guy they knew in high school and college; many knew absolutely nothing of his last two years. He left no note explaining his suicide.
At a gathering at the Fees' house afterward, Rick Fee told them about Richard's addiction to Adderall. Many recalled how they too had blithely abused the drug in college — to cram, just like Richard had — and could not help but wonder if they had played the same game of Russian roulette.
“I guarantee you a good number of them had used it for studying — that shock was definitely there in that room," said a Greensboro baseball teammate, Danny Michael, adding that he was among the few who had not.
Almost every one of more than 40 ADHD experts interviewed for this article said that worst-case scenarios like Richard Fee's can occur with any medication — and that people who do have ADHD, or parents of children with the disorder, should not be dissuaded from considering the proven benefits of stimulant medication when supervised by a responsible physician.
Other experts, however, cautioned that Richard Fee's experience is instructive less in its ending than its evolution — that it underscores aspects of ADHD treatment that are mishandled every day with countless patients, many of them children.
The Fees decided to go to a documentary screeing and panel discussion, “ADD and Loving It?!" in October 2012. The event was sponsored by the local chapter of Children and Adults with Attention Deficit Disorder (CHADD), the nation's primary advocacy group for ADHD patients. They wanted to attend the question-and-answer session afterward with local doctors and community college officials.
The evening opened with the local CHADD coordinator thanking the drug company Shire — the manufacturer of several ADHD drugs, including Vyvanse and extended-release Adderall — for partially underwriting the event. An hourlong film directed and narrated by two men with ADHD closed by examining some “myths" about stimulant medications.
Sitting in the fourth row, Rick Fee raised his hand to ask a question to the panel, which was moderated by Jeffrey Katz, a local clinical psychologist and a national board member of CHADD.
“What are some of the drawbacks or some of the dangers of a misdiagnosis in somebody," Rick Fee asked, “and then the subsequent medication that goes along with that?"
Katz looked straight at the Fees as he answered, “Not much." Adding that “the medication itself is pretty innocuous," Katz continued that someone without ADHD might feel more awake with stimulants but would not consider it “something that they need."
“If you misdiagnose it and you give somebody medication, it's not going to do anything for them," Katz concluded. “Why would they continue to take it?"
Rick Fee slowly sat down, trembling. Kathy Fee placed her hand on his knee as the panel continued.