Journal of Medical Licensure and Discipline(Vol82N2)

VOLUME 82
NUMI3ER 2
1995
66
Information for Authors
67
President's Message
70
Editorial: Itifi?rwcd Discre:tirirr
72
Medical Futility: An Evolving Ethical and Clinical Concept
■ Rrabert E. Porter, NID
■ Carl 1. Selociiberger, NID
80
The United States Medical Licensing Examination, Step 3: the First Year
■ John H. ]Iiorton, MD
■ Saneini G. Sc,Udnian
83
What Do the Certificates on Your Doctor's Wall Reailv Mectn?
90
Report of the American Medical Association and the Federation of State Medical
Ad Hc)c Committcc. to Studv aNfr1 Proposals
Boards: Ethics and Q uality of Care
Rcgar(iiiig State Medical Societieti and []ualit)r af Ca:e Issues: ltot,crt E. Portcr, A'II7, Ciair
94
Remedial Education in Prescribing Controlled Da.ngerous Substances
■ Williaii: Vilcnskt', RPh, 170
98
101
Commentary: Mr'rfieal 1-'rstility: A Coframeslt ■ Thoni.ts Wnj. Mayo, ID
From O ur International Exchanges: New South IVales, .3ustra.lia; On tario, Crcrrarla;
(Jrr ilzrl Kiir.arlrtw
From Our Member Board Exclt,tnges: Arizemri, Arkansas, ICentlrcPtM1, Lauisicrua,
_lfaaylezrtd, NeFwrla, f])-e,qiyya, Rlxir•lc Island, tiVyar3ai7rrt
115
Medicolegal Decisions
117
Review: A ltc'rrtatin' :'blee'ficine: Ftpatadiykq _'41crficrrl Hwlizrms
Letters to the Editor: Rcsponse lr, Dr. Wecd's Questions a rid
119
iLlertzcitm Robert W. UreLick ,
0
EL7C13 A1Clallder,
Jr, A1D
ATlSwF7:V" (1?I RL'rT!/fYFIGL'1't9'!^q
MD; Dr. Weed RE:spunds to Dr. 1-'rcliek , Lawrence L. Weed, NID
FEDERATION BULLETIN
THE JOURNAL OF MEDICAL LICENSURE AND DISCIPLINE
Published Continuously Since 1913
Volume 82
Number 2
1995
All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do
not reflect the official policy of the Federation of State Medical Boards of the United States or the institutions or
organizations with which the authors are affiliated unless clearly specified.
Editor
Linda C. Chandler, MA
Editors Emeritus
Ray L. Casterline, MD
Dale G Breaden
Editorial Board
Ronald C. Agresta, MD
2990 Johnson Road
Steubenville, OH 43952
Ruth Horowitz, PhD
401 Rockwood Road
Wilmington, DE 19802
Patrick W. Russell, DO
Elkhart Clinic
PO Box 201
Elkhart, IN 46515
Barbara S. Schneidman, MD, MPH
American Board of Medical Specialties
1007 Church Street, Suite 404
Evanston, IL 60201
Thomas J. Scully, MD
1400 Ferris Lane
Reno, NV 89509
Daniel J. West, PhD
RD #1, 101 Birch Street
Gouldsboro, PA 18424
Contributing Editors
David S. Citron, MD
Bryant L. Galusha, MD
John H. Morton, MD
Deborah Lewis Rodecker, JD
Editorial Assistant
Linda F. Vernale
The Federsataoaa Bulletin: The Journal of
Medical Licensure and Discipline (ISSN
0014-9306) is published quarterly by
the Federation of State Medical Boards
ofthe United 5tares, Inc; 400 Fu11er Wser
Road; Suite 300; Euless, TX 760393855. Telephone 817-868-4000. Fax
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Journal of Medical Licensure and Discipline, 400 Fuller Wiser Road, Suite 300,
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Federation Officers
President: Robert E. Porter, MD*
President Elect: James E. West, MD*
Vice President: Susan M. SpauIding*
Treasurer: Bruce H. Hasenkamp, )D*
Secretary: James R. Winn, MD
Federation Board of Directors
Gerald J. Bechamps, MD*
Leroy B. Buckler, MD*
Ray Q. Bumgarner, JD
William H. Fleming, Il:l, MD
John T. Hinton, DO, MPH
Philip M. Margolis, MD
Dinesh Patel, MD
Alan E. Shumacher, MD
George Van Komen, MD
*Executive Comrnittee
Federation Executive Staff
Executive Vice President:
James R. Winn, MD
Deputy Executive Vice President:
Dale L. Austin, BSN, MA
Assistant Vice President, Exam and
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I. ICathryn Hill, MEd
Assistant Vice President, Public
Relations/Pub licati ons/Education:
Carol A. Clothier, BA
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of the society but the people themselves;
and if we think them not enlightened enough
to exercise their control with a wholesome discretion,
the remedy is not to take it from them,
but to inform their discretion by education.
-Thomas Jefferson (1743-1826)
The Writan8s of Thom cssjefferson, vol. 10
Information for Authors
The Editorial Board accepts original manuscripts for consideration of publication in
the Federation Bulletin: ne joaarraal ofMedieal Licensure and Discipline. The Bulletin
is a refereed journal, and all manuscripts are reviewed by Editorial Board members
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66
FEDERATION BULLETIN
PRESIDENT'S MESSAGE
Making the Commitment
Amid Changes and Challenges
ROBERT E. PORTER, MD
I stand before you as the 74th president of this outstanding organization. I
am humbled, honored, challenged, and excited about the tasks at hand. I stand
on the shoulders of the dedicated men and women who have gone before
me-people like Morton, Cramblett, Galusha, Clark, Godinez, Sage, Jacott,
McQuarrie, Cortese, Behrens, Yohn, Schneidman, Sigel, Rassekh, and last but
not least, my good friend and leader this past year, Jerry Bechamps.
And looking to the future, with the advice and support of people like Tom
Bowles and Don Melnick and their National Board staff and Bob McAfee, Bill
Jacott, and the AMA team, and with the strong liaison established between the
Federation and AIM, under the leadership of Ray Bumgarner, how can we lose?
With a committed Federation Board, outstanding Federation staff under the
capable leadership of Jim Winn, our new headquarters facility, and electronic
technology that will take us into the 21st century, how can we fail?
I'll tell you how. Despite the best efforts of staff, your board of directors,
and your elected officers, any complacency, any failure of commitment, any
lack of understanding of your state boards' responsibility to your constituents-the public---cvuld cause the state board structure to disappear, the
Federation to dissolve, and licensure and disciplinary activities to become
federalized and administered with the same bureaucratic mindset that brought
us $1000 toilet seats and $500 hammers.
A remote possibility? Maybe. But let me read to you a summary profile of
last session's House of Representatives Bill 4856-The Patient Safety Act of
1994-introduced by Gerald. Nadler (D-NY): "The Patient Safety Act applies
to any health care professional who provides services requiring a license to
perform. Its purpose is to improve the nation's health care by creating a
comprehensive medical malpractice prevention program through the creation
of independent, publicly accountable state medical boards and more stringent
licensing procedures."
Whose responsibility is it to meet challenges to our role as overseers? All of
ours. But remember, we do not represent a constituency of physicians-that's
Vol 82, No 2 1995
Robert E. Porter, MD.
^''resident, Federation of State
Medical Boards of the United
States, Inc.
67
the American Medical Association's responsibility. Nor are we consumer
advocates for any particular group. We are health care professionals and public
members, a unique mix, who have been appointed, hired, or elected to protect
the public's interest. That is our primary charge.
In carrying out this responsibility, we must provide competent practitioners
and process applications in a timely fashion_ Four to six months to process
any application for licensure sounds more like bureaucratic red tape than
consumer protection. I urge those Boards that have problems to give a little
in terms of requirements unique to your state that may be archaic or that slow
down the process unnecessarily. The Federation's Endorsement Committee
has recommended a uniform core of key information for initial licensure and
subsequent portability, and their suggestions offer a means of accelerating the
process without compromise of quality review. Similarly, a backlog of consumer complaints and provider review requiring more than a year's time for
processing from initiation to resolution is inexcusable.
Boards should recognize when there is a problem. Don't make excuses, such
as limited funding, staff constraints, or legislative roadblocks. As board
members, be positive and aggressive in finding answers to problems. Do not
expect your executives to do the work you should be doing. You are charged
with protecting the public's interests. Don't become a part of the logjam.
Executives, make sure that you are educating your board members regarding
their responsibilities. Their lobbying for changes to the Medical Practice Act
will help your board carry out its mandate.
We don't want another Congressional bill like H.R. 4856 to resurface. It
shouldn't if you get the necessary support to do your jobs well.
What can the Federation do to help individual boards carry out their charge
more effectively? How can the Federation best serve you?
First, we are providing to the National Governor's Conference a packet of
information for each participant, which will remind the governors of the role
of the Federation and the interaction between state medical boards and state
government. The public is demanding quality care and quality providers.
Every Board needs dedicated appointees, sufficient funds, and the independence to carry out the charges stated in its Medical Practice Act. With a
few exceptions, boards can generate sufficient income to be self-supporting if
permitted by law.
Your Federation is already providing technical support. Through its future
computerized network, state medical boards will access more easily the
Federation's licensure repository information, examination results, disciplinary data, or other information. As the Federation designs future systems,
needs of the State Medical Boards must be foremost. Boards are the
Federation's "customers." If it means that a uniform hardware and software
package be supplied to each member board, with the necessary instruction,
then that approach must be considered.
Signing on to the Federation BoardNet should be as easy as turning on the
coffee pot in the morning. My own medical center is on-line-my desktop
computer goes on with my light switch. Inpatient and outpatient notes and
data are at my fingertips. All boards should have a computerized service that
is just as convenient.
68
FEDERATION BULLETIN
State medical boards are unusual hybrids-composed of members from the
professions and the public sector appointed by the governor, frequently administered by state employees, and supported by a nonprofit Federation that
provides examination administration, information, and other services. The medical board process of examination and licensure is the final qualifying hurdle to
becoming a provider in the world's best system of professional medical care. We
cannot fail to fulfi]I our responsibilities. Medical schools and other provider
programs produce a product, but it is the Boards' job to evaluate and affix the
stamp of approval. Computer technology should facilitate the process without
quality review compromise. Use it and discover what a powerful aid it can be.
The Federation can be a resource in disciplinary cases. Every state board has
examples of unfit providers, as indicated in the Federation's recent press release
documenting last year's disciplinary actions. These wayward individuals must
be dealt with justly and expeditiously. Although some people look only to the
number of license revocations as the mark of a board's effectiveness in dealing
with these cases, head counts alone are superficial indices. While revocation is
a necessary tool, it can, in some cases, represent a failure of early intervention
and remediation.
The Federation, the American Medical Association, the National Board of
Medical Examiners, and some innovative state boards are positioning themselves
to meet the challenges ofevaluation and remediation. The Federation, in support
of state boards, must be in the forefront of this activity. We must provide support
to help boards deal with the thorny aspects oflicense limitations, revocation, and
legal challenges. We must continue to press for in-depth evaluations and for
focused, high quality reeducation programs when appropriate.
In closing, I want to stress that we must leam to deal efficiently with our
day-to-day responsibilities, so that time may be devoted to tomorrow's
problems. I encourage you to think more globally about your board's
functions. Medical care today knows no state boundaries. Many large national
managed care groups already exist. Interstate telemedicine is a fact. International health care consortiums are being developed by people like Bob
Buchanan, ex-CEO of Massachusetts General Hospital. These developments
present unique licensure problems.
The Federation is positioning itself to be ready to aid state boards as new
situations arise. Our long-range plan, our new initiatives, our future network,
and our growing, dedicated staff are all geared to answer the needs of the future.
Do we have a big challenge ahead of us? Yes. Can it be successfully met? I
strongly believe so, or I assure you I would not be investing the time and
energy this job will demand over the next year. The payback to all of us who
do Federation work is the satisfaction of a task well done, the camaraderie that
comes out of intense weekend-long committee retreats, and the friendships
that develop with board members, executives, staff, and members of other
professional organizations, all working together to ensure that our medical
board system remains the best that it can be.
I urge you to sign up for committee assignments with your state board.
Advocate for improvement. Volunteer for service to the Federation. After all,
it is your organization. Your advice is needed, your support is necessary, and
your stewardship is essential.
Vo182, No 2 1995
69
EDITQRIALS
Informed Discretion
State medical boards are charged with protecting the public interest. For
many years, only physicians served on medical boards. Those board members
had the responsibility to oversee the actions of other physicians, monitoring
ethical obligations to the public. But with the growth of consumerism, public
members were added to medical boards. The consumer movement not only
brings a public perspective to boards but also rejects the paternalism of
physicians' decision making.
Paternalism in medicine said, "We know what is best for you." Consumerism
says "Give me the information and allow me to make my own choices." This
distinction is similar to what Jefferson wrote about self-determination in a
democratic society. His conclusion was that if the people do not know enough
to make informed choices, the solution is not removing their right to choose
but educating their uninformed choices.
At no time is our "wholesome discretion" challenged more than when we
deal with life/death decisions for ourselves or our loved ones. We cannot
expect to eliminate the power of emotion at such times of crisis. Family
members and guardians as well as patients struggle to make the "right
decisions," their minds often fraught with guilt, grief, remorse, and anxiety.
For all, it is a confrontation with the end of the physical life. For many, it is
also a test of philosophy or faith.
How do we alleviate the stress patients and families feet at such times? The
solution is not to make decisions for them, but to educate about these complex
concepts before they are entangled in emotion. Life/death decisions are best
made before life/death issues arise. Discussions of death and dying should be
removed from our taboo list. Information about living wills and durable
powers of attorney should be available in physicians' offices, alongside the
pamphlets about diabetes and breast cancer. Questions about these issues
should be added to the regular history taking and physical examination and
answers noted in the patient's record. Hospitals now are required to ask about
living wills and durable powers of attorney, but this opportunity comes only
when a patient enters the hospital, so elements of stress and fear can muddy
decision making.
70
FEDERATION BULLETIN
In terminal cases, when a patient wants to exercise control over his medical care,
the physician must avoid paternalism and allow the patient (or family/guardian)
to decide. The average patient will not be "enlightened enough" about the
repercussions of medical treatment options. It is the physician's duty to
explain, to educate, to offer options, but not to decide. The decisions belong
to the patient. The physician' cannot impose a personal philosophy or faith.
This applies both when the physician thinks it is too early to give up treatment
and when the patient demands continued futile treatment. If what the patient
(or family/guardian) wants is, in the physician's opinion, unreasonable or
unattainable, the physician can, and should, allow the patient to seek another
physician. Removing the decision making from the patient is not the solution.
In recent years, we have encountered another element of paternalism in the
form of managed care. In managed care, patients may be deprived of decision
making, not under the paternalistic good intentions of "father knows best,"
but under the law of averages and rules of the game. In managed care,
physicians, too, may be deprived of decision making, but they must advocate
what is best for the patient and defend patient choices, not allow decisions to
be taken from them. Decision makers in managed care entities also must be
educated.
Already, conflicts of patient-physician-managed care choices are being settled
in the courts. Ifwe continue to ignore the role of education in informed choice,
courts will increasingly be the venue of the power struggle for the right to
make health care decisions. How much better it would be to allow patients to
exercise their informed discretion in matters of their personal health!
Vol 82, No 2 1995
71
Medical Futility: An Evolving
Ethical and Clinical Concept
CARL I. SCHOENBERGER, MD
Overviem: Mediccxl faatility refers to clinical interventions that cannot result in
benefatfor the patient. Although controversies persist about bow benefst is defined
and abotat futility's quantitative aspects, the emerging consensus is that at least
some treatments in some clinical circumstances are both clinically and ethically
inappropriate. Whatever the conclusion, the debate itself has fostered among
physicians and patients closer attention to thegoals oftreatrnent and the likelihood
of achieving them. Such physician -pcttient interchange will result in better
informed decisions by patients, who will be less inclined to opt for aggressive
therapies that offer little or no potential benefit. The importance of truth-telling
and the distinctions between rnedicctl futility and medical rationing are critical
issases to consider.
Carl I. Schoenberger, MD.
President of the Medical and
Affiliate Staff, Medical
Director offntensxve Care,
and Medical Director of
Respiratory 7berapy; Shady
Grove Adventist Hospita4Rockville, Maryland.
72
From the earliest days as students and residents, physicians are taught the
twin obligations which ethicists refer to as benificence and nonmalificencethe duty always to help our patients and never to knowingly harm them. In
the explosion of medical technology which followed World War II, this
philosophy usually was equated with using in lavish amounts the latest
modalities for every patient. It was not long, however, before the adverse
effects of treatment began to dampen this enthusiasm. In the mid-19 5 Us, side
effects of radiation therapy for cancer led to one of the landmark case decisions
concerning autonomy and informed consent.' Several years later, Jick2 and
others focused attention on adverse drug reactions and pointed out the
significant number of hospital admissions and deaths that were directly
attributable to drug therapy.
During the 1980s, several other trends led to discussion of the concept of
medical futility. First was the "Outcomes Movement" spawned by the work
of Paul Ellwood3 and John Wennberg ¢ These authors encouraged physicians
to examine carefully the outcomes of therapy to be more certain about which
interventions led to superior clinical results and by what degree of magnitude.
Second, the rapidly rising costs of health care and the increasing share of the
gross domestic product devoted to it led many to look at limiting medical
interventions as a way of cutting costs. While there is a clear distinction
between futility (stopping or limiting treatment which cannot help) and
rationing (stopping or limiting potentially beneficial treatment purely for
reasons of cost), the impact of cost nevertheless encouraged attention to
FEDERATION BULLETIN
futility as a concept. Third, the field of bioethics itself has undergone an
evolution. From a paradigm of pure paternalism during the middle of the
century, ethicists began to return from the more extreme views of absolute
patient autonomy popular in the late 1970s and early 1980s toward a more
balanced view of the potential limits on patient autonomy.
History
The term futility derives from the Latin futilis or "leaky." This term was used
in the mythical tale of the 49 daughters of Danaus who conspired to kill their
husbands while they slept. As punishment, they were condemned to Hades,
where they eternally drew water from a river in leaky jars, a task which no
matter how often repeated or how expertly done, can never achieve its goal
of bringing water back to the home.' Hippocrates recognized this concept as
applied to medicine in his Art.- "Whenever therefore a man suffers from an ill
which is too strong for the means at the disposal of medicine, he surely must
not ever expect that it can be overcome by medicine." Lawrence Schneiderman,' a prolific author on the topic of futility, cites a "qualitative" allusion to
the concept from Plato's Repxablic,ft in which Asclepius placed limits on his
patients' treatment: "For those, however, whose bodies were always in a state
of inner sickness, he did not attempt to prescribe a regimen . . . to make their
lives a prolonged misery." The roots of the modern debate lie in antiquity.
When medicine has nothing to offer a patient, physicians must say so. We are
not obligated to provide and, in fact, are ethically barred from offering or
We are not obligated to provide and, in ficct, are ethically bcarrert from off'ering or
cadrninisterirag therapies whicb
we knoiv to be futide.
administering therapies which we know to be futile.
DeFinitions of Futility
The literature describes two principal schools of thought concerning the definition of medical futility. The first, which might be described as the more purist or
absolute in orientation, holds that an intervention is futile when it fails to achieve
any measurable physiologic effect. This stance would apply to performing CPR
on a patient already without vital signs for an hour or more or to administering
mannitol to a patient already clinically brain dead. Neither of these treatments
has any chance of effecting the desired result, and all clinicians would agree that
they are futile. The second, or relativist camp, tries to weave into its definition
the inevitable vagaries and uncertainties that are part not only of medicine, but
of all fallible human endeavor. This school, championed by Sc€xneiderman' and
others, holds that futility can be given qualitative and quantitative dimensions,
even in the absence of absolute certainty. This is sometimes referred to as a
"patient-centered" or "clinical" definition of medical futility.
Proponents of the "physiologic" definition argue that few clinical decisions
are backed by enough data to demonstrate absolute efficacy or absolute futility.
The classic example cited is pre-hospital CPR for cardiac arrest. VVhile many
studies have shown poor results of CPR in this situation, it is striking to note
that the overall "success" rates, whether measured by restoration of vital signs,
emergence from intensive care, discharge from the hospital, or return to
prc-arrest levels of function, vary considerably y Attempts to develop "predictors" of poor outcome in this setting also have yielded inconsistent findings.
Some authors have attributed such differences to the modes of organization
Vol 82, No 2 1995
Proponents of the "phvsiologic"
definition argue thratfezv
clinical decisions are backed
by enough data to demon strate absolute efficacy or
aabsolute fistilit,v.
73
the state does have a
potentical role in protectirag
incompetent iradividaeals
ivithosit advance directives
from liberal definitions of
of EMS personnel or to variations in the training of lay people in CPR.
Whatever the reasons, the fact remains that when one discovers an arrest
victim, one cannot predict with certainty the likelihood of successful CPR,
however it is defined, for that individual patient. McIntyre10 and others would
argue that it is not ethical to withhold CPR except in cases of decapitation,
rigor mortis, or other convincing evidence ofclinical death, or when a patient's
advance directives against CPR are known to the physician.
Carried to its logical extension, this is also the view held by the United States
Circuit Court" in its decision concerning "Baby K" in Virginia. This unfortunate child, born with anencephaly, was placed on ventilatory support after
several months of life on the insistence of the mother. Against all expectations,
the baby was extubated and continued under custod'zal care through several
additional bouts of respiratory failure. Convinced that such repeated life
support for a child who was clearly terminal was illogical and unethical, the
physicians and administrators of Fairfax Hospital in Virginia went to court to
obtain permission to withhold future ventilatory support.'2 Finding for the
mother, the Court ruled that because the ventilator was successful in restoring
respiration, it could not be viewed as "futile." The issue of whether the child's
entire existence was "futile" was held by the judicial opinion to be within the
realm of "values," which are decisions of the individual and not within the
purview of the courts or the physicians.' The relativist school, on the other
hand, would argue that the continued existence of an anencephalic child on
long-term or repeated life support had an intrinsic value that is below any
generally accepted community standard.
The Maryland legislature, which in 1993 passed the Health Care Decision
Act, recognized the concept of "medically ineffective treatment" (ie, medical
futility) but placed a fairly strict definition in the statute: "Medically ineffective
treatment is a treatment that, to a reasonable degree of medical certainty, will
neither prevent or reduce the deterioration of the health of an individual nor
prevent the impending death of an individual." According to an opinion letter
from Jack Schwartz, General Counsel for the Attorney General of Maryland,
Joseph Curran, the legislature took this position to prevent any wholesale
withholding or withdrawal of life-sustaining treatments from patients in the
absence of advance directives. This wording is in concert with the flavor of the
US Supreme Court decision in the Cruzan case.13 Although competent adult
patients generally are held to have an absolute right to refuse treatment for
any reason, even if that treatment is not futile, the state does have a potential
role in protecting incompetent individuals without advance directives from
liberal definitions of inedical futility, what Younger'¢ refers to as "giving
naerlicalftatility ....
opinions disguised as data." Under the Maryland statute, if a potentially
The relativist school ... zvould
aryme that the continued existencL of an aneneephalic child
on donq-terrn or repeated life
support had an intrinsic value
that is belo7.v anyAenerallv accepted corrz»atsnitr standard,
iife-sustaining treatment (such as CPR) is to be withheld or withdrawn, the
patient must be certified by two physicians to be in a "terminal" or "end-stage
condition," in effect, a condition in which death is expected to be imminent.
Therefore, futility decisions in Maryland, because by definition they involve
the unilateral withholding or withdrawal of care by the physician, must be held
to the strictest standard. The proposed intervention, even when expertly
performed, must be incapable of keeping the patient alive even for a short
time, or it is, by definition, not futile.
74
FEDERATION BULLETIN
At approximately the same time, the Roman Catholic Bishops of MarylandIs
issued a Pastoral Letter that echoed some of these concepts. Seeking to offer
spiritual guidance to patients and families of the Roman Catholic faith, the
bishops stated that because life itself was the gift of God, and the "foundation
for all his other gifts," one must never "adopt a course of action or inaction
which is intended to cause death, even if the motive is to alleviate suffering."
However, the next section of the Pastoral Letter states,
This does not mean that all possible remedies must be used in each
circumstance. Patients and their families frequently need help in
deciding which level of care is appropriate to fulfill the God-given duty
of preserving life.... No patient is obliged to accept or demand useless
medical interventions.... A medical treatment is "useless" to aparticular
patient if it cannot bring about the effect for which it is designed.
The example given is the use of an antibiotic to which an infecting organism
is resistant. The bishops go on to say that
Patients and their loved ones need to rely on health care professionals
who can help them decide which forms of treatment are effective and,
thus, useful and which are ineffective and, therefore, useless. However,
no one-including the patient, family members, medical professionals,
... the bishops stated that...
one naust never "adopt a
course oferction or inaction
which is intended to cause
death, even if the rnotive is to
alleviate satffErtng."
or members of the clergy-ever has the right to decide that a patient's
life is useless, even when a patient is no longer able to perform basic
human functions. We are stewards, not owners of the gift of human life.
The bishops are clearly in the camp of "physiologic futility" by the strict
definition and would likely agree that keeping Baby K'Z alive is required under
the moral doctrine of their Pastoral Letter.
A leading voice of the relativist camp, Lawrence Schneiderman,' argued in
1990 for defining "futility" as "any effort to achieve a result that is possible
but that reasoning and experience suggests is highly improbable and that
cannot be systematically produced." Futility judgments, in Schneiderxnan's
view, have a quantitative and a qualitative aspect. Quantitatively, he proposes
that treatments be considered futile when no success has occurred in at least
100 cases of personal or peer experience or in the reported literature. Qualitatively, certain "poor results fall outside the range of the patient's autonomy
and need not be offered as options. The clearest of these qualitatively poor
results is continued biologic life without conscious autonomy." This qualitative viewpoint also was adopted by the American Thoracic SocietyI6 in its 1991
Consensus Statement on Withholdng and Withdrawing Life-Sustaining
Therapy:
A life-sustaining intervention is fiitile if reasoning and experience
indicate that the intervention would be highly unlikely to result in a
meaningful survival for that patient. Here, meaningful survival specifically refers to a quality and duration of survival that would have value
to that patient as an individual. Survival in a state with permanent loss of
consciousness, ie, completely lacking cognitive and sentient capacity, may
be generally regarded as having no value for such a patient.
Quantitative thresholds are a difficult issue in this context. On one hand,
because every application of a treatment or intervention is an independent
event, even 100 repeated failures do not prove that the 101st trial will be
Vol $2, No 2 1995
The clearest of these qualitatively poor results is continued
biologic life without conscious
autorxony.
75
Despite Schneiderman's claim
of clear canirraunity standards
of treatment outcomes that
are so poor they "need not be
unsuccessfizl. Repeated failure merely raises the probability that each additional effort will be unsuccessful. On the other hand, many treatments and
interventions with failure rates well below 100% are placed on the scrap heap.
Qualitatively, the debate really boils down to one's personal value system.
Despite Schneiderman's claim of clear community standards of treatment
outcomes that are so poor they "need not be offered as options," our
exceedingly diverse society has not reached such a consensus. Roman Catholic
teaching as detailed above, the spiritual guide for tens of millions ofAxnericans,
comes down foresquare on the side of "physiologic futility." And any physician
who deals with terminal or end-stage illness will attest to the large number of
patients and families who believe that a "continued biologic life without
conscious autonomy" is indeed worth saving, for whatever reasons.
offered as options,"our exceedingly diverse society has not
reached such a consensus.
Doctors and patients both
need to be reminded of the
end resaalts.
Futility in Clinical Practice
A number of hospital medical staffs around the country have formulated
guidelines for making medical futility judgments. These policies typically
concentrate on the key feature of physician-patient and physician-family
communication. Our current practice climate, in which long-term relationships between physicians and patients are increasingly less common, the
application of technology is often the easiest way out of an unpleasant set of
choices, physicians' communication skills are not often nurtured during the
educational process, and physicians are increasingly pressured to see more and
more patients in order to earn decreasing incomes, serves as a barrier to
effective communication. Nevertheless, this is the key to avoiding conflict
about treatment decisions. Ideally, questions concerning aggressiveness of
therapy should occur before a crisis, in the physician's office. Studies have
repeatedly shown that patients and families are almost always receptive to
discussions about advance directives when the physician raises the subject.
When the patient's wishes are known, when clear decision-making authority
is delegated via a power of attorney, when the patient has a realistic view of
treatment alternatives and their respective likelihoods of success, unilateral
futiliry judgments by physicians rarely are needed.
Unfortunately, in many cases this scenario is not played out. Rather, a patient
presents to an emergency room acutely ill and with multiple underlying
chronic illnesses, is seen by an emergency physician or covering specialist or
resident, and is subjected to a barrage of tests and a variety of interventions
with no knowledge of his wishes. The sudden stress of acute illness makes
effective communication more difficult. Even here, though, good decisions
still can be made by reasonable patients, families, and physicians if information
is freely and honestly given. Too often, physicians focus on the organ system
or body part that is damaged or malfunctioning and suggest the knee-jerk
response of what is available to "fix" it. We fail to focus on the big picture:
Can a bowel resection really help a 90-year-old who is demented, diabetic,
hypertensive, and contracted, even if she does have colon cancer? Can a
ventilator really help an elderly patient with metastatic lung cancer who has
respiratory failure? Can CPR really help a 30-year-old septic leukemic patient
with no white blood cells who has already failed chemotherapy? Doctors and
patients both need to be reminded of the end results. A study done at the
76
FEDERATION BULLETIN
Cleveland Clinic" demonstrated vastly overoptimistic assumptions about the
success rates of CPR by the residents and attending staff of the institution.
Physicians owe it to themselves and to their patients to have realistic concepts
of the success rates for treatments recommended in each particular patient's
clinical context. In many cases, careful assessment at the beginning will clearly
demonstrate the futility of aggressive care. In others, the data are equivocal,
and the chances may be worth taking if expectations are realistic up front.
Sometimes conflicts arise despite the best efforts at communication and
realistic prognostication. For these times, a hospital medical staff policy about
tutility can be helpful. At Santa Monica Medical Center in California, futile
care is defined as "any clinical circumstance in which physicians and their
consultants, consistent with the available literature, conclude that further
treatment cannot, within a reasonable possibility, cure, ameliorate, improve,
or restore a quality of life that would be satisfactory to the patient."'x This
definition adheres closely to the philosophy of Schneiderman' and the Thoracic
Societv'6 statements.
In 1994, at Holy Cross Hospital in Silver Spring, Maryland, a Subcommittee
on Futility developed the following definition: "Physicians are not obligated to
offer treatment alternatives that will be extremely unlikely to result in a benefit
which can be appreciated by that patient or which will result in excessive burdens
to that patient." This covers a middle ground between relativist and physiologic
positions on futility. As a Roman Catholic institution, the Ethical Advisory
Committee and Board of Trustees of Holy Cross were satisfied that this guideline was compatible With the Maryland Bishops' Pastoral Letter.''
Both these hospital policies require an Ethics Committee consultation as a
check-and-balance mechanism before any unilateral action by the physician.
However, many states, including Maryland, require hospitals to offer the
patient and family a transfer of physician and/or institution if they continue
to resist the physician's decision.
Another approach is that taken by Massachusetts General Hospital, a teaching
institution in Boston. There the Ethics Committee can actually write a "Do
Not Resuscitate" (DNR) order if care is judged to be futile by the committee.
In a recent lawsuit,19 the first in which futility itself was the central theme, the
daughter of a patient who died at Massachusetts General sued for emotional
distress because a DNR order was entered without her knowledge or consent.
The elderly patient, who was too sick even to have a broken hip repaired,
suffered from Parkinson's Disease, diabetes, heart disease, and status epilepticus and had a history of stroke and breast cancer. Upon authorization of the
hospital's ethics committee, a DNR order was written. The patient died three
days later without resuscitative attempts. In its decision, the jury reached two
important conclusions: First, that had the patient been able to express her own
wishes, she would have opted for CPR, and second, that had CPR been
attempted, it would have consituted futile care, even satisfying the strict
definitions of physiologic futility.20 After all, the clinical and ethical issue was
whether this patient would have survived the cardiac arrest even with CPR
The literature amply demonstrates that an elderly patient with that constellation of problems added to an acute illness has no chance of leaving the hospital
after a cardiac arrest, with or without CPR.
Vol 82, No 2 1995
Hoivever, many states ...
require hospitals to offer the
patient cand faarnily a trccnsfer
ofphysician and/or institution if they continue to resist
the physicican's decision.
There is not universal agreement about ivhich treatments
are beneficial, so we certainly
can expect continuing disagreement about which ones
are futile.
77
We can expect more such court cases as the approach to this issue evolves.
There is not universal agreement about which treatments are beneficial, so we
certainly can expect continuing disagreement about which ones are futile.
From the ethical and
philosophical viewpoint,
economically based limits
should always be so identifaed,
so that they are not confused
xrath futility judgments.
... treatment decisions can
be made inappropriately
under theguise offutility
when, in fact, the physician
is merely fiailing to respect
patient autonomy orfailirag
to obtain informed consent.
Such conduct, in egregious
circumstances, could be
actionRble.
78
Futility and Rationing
Today it seems that almost all health care issues are viewed by some observers
through the economic prism. Articles have been written debating how many
health care dollars could be saved if futile care were avoided or if more patients
consented to limits on aggressive therapy. While we cannot ignore the
economic aspects of these decisions for individual patients, particularly those
who pay some or all of their health care bills out of pocket, we should never
confuse the philosophical bases of the concepts of futility and rationing.
Futility, by definition, connotes the leaky jar. It is care that on some level,
cannot help-the patient. Rationing, on the other hand, by definition, connotes
the doling out of a limited but useful commodity. This is true whether the
case is water during a drought or hearts for transplantation. By definition, the
number of patients who can potentially benefit from rationed care exceeds the
availability of that care. By definition, the number of patients who can benefit
(however defined) from futile care is zero.
If our society intends to make true rationing decisions for health care, such
as placing age limits on dialysis or coronary bypass operations, those decisions
must be formed in the public policy arena, not at the bedside. The now famous
Medicaid debate in Oregon is an example of this approach. There, the state's
elected officials acknowledged that certain beneficial treatments would be
withheld so that other beneficial treatments could be given to a larger group
of patients. Public consensus was sought concerning which treatments would
be provided and which would not. From the ethical and philosophical
viewpoint, economically based limits should always be so identified, so that
they are not confused with futility judgments.
Regulatory Aspects
We can expect more states to enact legislation addressing futile care. As with
most other contentious issues, medical futility decisions likely will appear on
the agendas of state licensing boards in the form of disciplinary actions. It is
conceivable that treatment decisions can be made inappropriately under the
guise of futility when, in fact, the physician is merely failing to respect patient
autonomy or failing to obtain informed consent. Such conduct, in egregious
circumstances, could be actionable. More commonly, however, the issue will
be whether the conduct in question was in concert with local hospital policies
and with applicable state law. Investigations under this heading will need to
focus on the physician's pattern of interaction with patients and the adequacy
of communication and documentation, which is doubly critical when a conflict
exists with the patient and family. The safeguards of second opinions and
ethics consultations that are in place in most institutions will help physicians
avoid such potential licensing actions.
FEDERATION BULLETIN
References
1. Salgo v. Leland Stanford, jr, University Board of Trautees. ( 1957) 154 Cal. 2d 500, 317
Pac.2d 170.
2. Jick H, Miettinen OS, Shapiro S, et al. Comprehensive drug surveiilancc. JAMA.
1970; 213:1455-1460.
3. Ellwood PM. Outcomes management: a technology of patient experience. N Eri,gl jlblecL.
1988; 318:1549-1556.
4. Wennberg JE, Mulley AG Jr, Hanley D, et al. An assessment of prostatectomy for benign
urinary tract obstruction: geographic variations and the evaluation of medical care
outcomes. JAMA. 1988; 259:3027-3030.
5. Hamilton E. Mytholog,v. Boston, Mass: Little Brown & Co; 1942:415-417.
6. Hippocratic corpus, The Art. In Reiser SJ, Dyck AJ, Curran WJ, eds. Ethics in Medicine:
Historical Perspectives and Cnnternporary Concerns. Cambridge, Mass: e'IIT Press; 1977:6-7.
7. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical
implications. Ann Intern Med. 1990; 112:949-954.
8. Grube GM, trans. Plato's Repu&lic. lndianapoiis, Ind: Hackett Publishing; 1981:76-77.
9. Rosenberg M, Wang C. Hoffman-Wilde S, Hickam D. Results of cardiopulmonary
resuscitation: failure to predict survival in two community hospitals. Arch Intern Mert.
1993; 153:1370-1375.
10. McIntyre KM. Loosening criteria for withholding pre-hospiral cardiopulmonarr resuscitation. Arch Intern Med. 1993; 153:2189-2192.
11. In the matter ofBa6y K. 16 F. 3d 590 (4th Cir. 1994) 832 F. Supp. 1022 {E.D.Va. 1993).
12. Annas Gj. Asking the courts to set the standard of emergency care: the case of Baby K.
N Engl j Med. 1994; 330:1542-1545.
13. Cruzan v. Director, Missouri Depszrtsnent of Hertlth. {1990} 497 U.S. 261, 111 L.Ed.2d
224, 110 S.Ct. 2841.
14. Younger ST. Who defines futility? JAMA. 1988; 260:2[]94-2095.
15. Marvland Catholic Conference. Pastoral Letter on the Care of the Sick and Dying fi'om
the Roman Catholic Bishops of Maryland. October 14, 1993.
16. American Thoracic Society. Withholding and withdrawing life-sustaininn therapy. Am
Rev ResPir Dir. 1991; 144:726-731.
17. Miller DL, Gorbien Mj, Simbarth LA, Jahnigan DW. Factors influencing physicians'
recommendations concerning in-hospital cardiopulmonary resuscitation. Arch Intern
Med. 1993; 153:1999-2003.
18. Hudson T. Are futile care policies the answer? Hosp Health News. Feb 20, 1994.
19. Gilgunn v. Massachusetts General Hospital. Suffolk County Sup. Ct. (iass. ) 92-4820-H.
May 1995.
20. Kolata G. Court ruling limits rights of patients: care deemed futile may be withheld. The
New Yark Times. April 22, 1995:25.
Vol 82, No 2 1995
79
The United States Medical Licensing
Examination, Step 3: the First Year
JOHN H. MORTQN, MD
Overviem: The first aclrniraistratiorts of the United States Mediccel Licensing
Examination (USMLE) Step 3 occurred in June and December 1994. Failure
rates, the composition of the examinations, and the implications of fiataare
computer-bersed examinations are discussed. Candidates who perform inconsistently across the exavnzncataon's rnatr'Px and the predictability ofscw-ang fixctors in
compxaterizecl examinations are two fc^ctors that require further staaclv by the
Examination Board.
1 ltter a number of years of planning and preparation, the United States
Medical Licensure Examinations came to fruition when Step 3 was administered in June and December 1994. The first Step 3 was given to 856
candidates in June, and. 3883 individuals were examined in December.
During 1994, a number of physicians qualified for independent licensure by
successfully completing either the National Board sequence or FLEX. Part III
of the National Board examinations was administered for the last times in
March and May of 1994. FLEX Component 2 was given for the final time in
December 1993. Two extra administrations of FLEX Component 1 were
offered in June and December 1994 to candidates who previously had
successfully completed Component 2.
In 1995, no licensure examinations will be available for allopathic physicians
in the United States except the United States Medical Licensing Examinations.
For this reason, the nurnber of candidates taking USMLE Step 3 in June and
December 1995 should increase dramatically.
John H. Morton, MD.
University of Rochester Medical Center, Rochester, NY,
Past presiderat, Ferlerration of
State Medical Bocsrcls; consailtant to the Federation Examination ,8oarcd; contribxatirag
editor, Federation Bulletin.
80
Failure Rates
Medical school graduation is an eligibility requirement for Step 3. In 1994,
2284 graduates of American or Canadian medical schools were examined.
Among them were 2119 individuals who had not previously taken NBME Part
III, FLEX Component 2, or Step 3. The failure rate among these first-time
candidates was 5%, a figure consonant with the initiai projections of the
Step 3 committee before the first administration of the examination. Performance by American and Canadian first-time examinees was essentially the same
in the two administrations during 1994.
During these two administrations, 650 international medical graduates were
examined in June and 1805 in December. In this group, 392 were first-time
FEDERATION BULLETIN
candidates in June and 1195 in December. The passing rate for the first-time
examinees was 78% for each examination.
For both the American-Canadian group and the international medical
graduates, passing rates were significantly lower for those individuals who had
previously failed one of the final licensing examinations (49% of the 165
members of the American-Canadian group and 30% of the 868 international
medical graduates). When repeaters and first-time candidates are considered
together, 2078 of the 2284 American or Canadian examinees (91%) were
successful. Among the international medical graduates, 332 of 650 candidates
Thefiailure rate among these
passed in June (51%) and 1155 of 1805 passed in December (64%). Overall,
first-time candidates was 530,
approximately 75% of the 4739 examinees were successful.
In all recent administrations of FLEX Component 1 and Component 2,
American citizens studying outside the United States or Canada have had
higher failure rates than any other group. This disparity continued with the
initial administrations of USMLE Step 1. (The failure rate in 1992 for students
from US or Canadian schools was 15%, for foreign citizens trained in foreign
medical schools, 63%; and for US citizens trained in foreign medical schools,
77%.)' Because of the limited number of candidates who took Step 3 in 1994,
it is impossible to determine whether this difference persists.
afigure consonant with the
initial projections ofthe Step 3
committee before the frst
administration of the examination.
Composition of Step 3 Examinations
All items on the two-day examination were in the multiple choice format.
Examinees in June 1994 believed that the examination was too long. In
response to this complaint, the number of items was slightly reduced in
December (672 scorable items as compared to 686 in June). National Board
statisticians confirmed that this change in length would not adversely influence
examination reliability.
In an effort to make the 6xamination reflective of medical practice, each test
item was introduced by a clinical vignette. The blueprint which the committee
adopted was followed closely in a three-dimensional matrixxx. The first dimension involved the type of care, with initial workup covered by 20% to 30% of
items, continuing care 55% to 65% and emergency care 10% to 20%. The
second dimension dealt with physician tasks. Taking a history and doing a
physical examination covered 8% to 12% of items, carrying out diagnostic
studies 8% to 12%, making a diagnosis 8% to 12%, assessing outcome and
prognosis 8% to 12%, applying basic science concepts to clinical problems 8%
to 12% and patient management 409'a to 60%. Patient management was further
broken down into health maintenance 5% to 9%, clinical intervention 18% to
22%, therapeutics 12% to 16% and legal or ethical issues 4% to 8%. For the
third dimension, a mathematical model was not used, but items were selected
to evaluate several areas important in office practice. Common disorders seen
in ambulatory practice and symptom complexes related to organ systems were
included. The third dimension was included in an effort to ensure coverage of
In an effort to make the
examination reflective of
medical practice, each test
item was introduced by a
clinical vignette.
the broad range of activities encountered by a physician practicing primary care.
At present, the pass-fai.l decision is made entirely on overall examination
performance. In other words, a candidate who performs very well on continuing
care and does poorly on both initial workup and emergency care may achieve the
same grade as an examinee whose performance is even across all three areas. In
Vol 82, No 2 1995
Si
the future, the committee will decide whether it is appropriate for a candidate
to pass with markedly uneven performance across the parts of the matrix.
The USMLE Composite
Committee's strategic plan
ccslls for the eventual adoption
of a computer-based
examination.
Computer-based Examinations and Grading
The USMLE Composite Committee's strategic plan calls for the eventual
adoption of a computer-based examination. When this plan is realized, the
Step 3 Committee will face another decision. With the computer grading the
answers while the candidate is taking the examination, it may be possible to
determine rather quickly and with fewer test items that a candidate will
certainly pass or will certainly fail. Candidates at either end of the curve could
be excused when a reliable pass-fail decision is reached. On the other hand,
the examination could be extended as long as necessary to reach appropriate
pass-fail decisions for those individuals falling near the minimal pass point.
This technique, which is known as adaptive testing, was never feasible with
pencil and paper examinations, but it has been employed successfully in
examinations in national nursing licensure.
If this strategy were adopted, the committee would need to pay particular
attention to coverage in the various parts of the matrix. Uneven performance
in the separate areas would assume greater significance if passing a shorter
examination led to a license for independent medical practice.
One effect of this technique would be that only a pass-fail decision, not a
score ranking for passing candidates, would be reported. Many individuals are
concerned about the emphasis placed on the actual grade by medical schools
and residency training programs, and they would be pleased if examination
grading were abandoned. Others believe that the actual grades provide
important information about medical schools and individual physicians.
Definitive decisions on these points would be essential before adaptive testing
could be adopted.
Reference
1.
82
Skolnick AA. Government report gives Department of Education and some offshore
medical schools failing grades. JAMA. 1995: 273;1162-1163.
FEDERATION BULLETIN
What Do the Certificates
on Your Doctor's Wall Really Mean?
SANDRA G. BD0DMAN
Overview: The American Board of Medical Specialties remains the standard in
board certificcttiQn. Self-derignated boards have proliferated since the 1975 Federal
Trade Commission suit against the American Medical Association's prohibition of
plrysician advertising and more recently have been driven by managed care and
hospitRl plans. Such boards vary -avidely in their requirements. The public is easily
misled by board certification clairns ofdisreptatablepdrysicictns, andfra udulent claims
have been integrally linked to quality of care issues. Caveat emptor applies.
Like many doctors, Arlington [Va] physician Denise E. Bruner believes that
advertising her credentials is the way to attract new patients.
In an advertisement, the 42-year-old doctor says she is "the only area
physician Board Certified in Bariatric Medicine." In the 199 3 and 1994 editions
of the Washington Physicians Directory, Bruner is listed as being board certified
in internal medicine; the 1994 directory lists her subspecialty as bariatric
medicine.
What Bruner's prospective patients probably don't know is that bariatric
medicine, the study and treatment of obesity, has not been recognized by the
American Board of Medical Specialties (ABMS), the sole widely accepted
authority on board certification.
The American Board of Bariatric Medicine, an independent organization
located in a suburb of Denver, is one of more than 100 unofficial-=or
self-designated-boards that certify doctors. Bruner is one of 80 physicians
certified by the bariatric medicine board, according to its executive director.
Bruner says that if patients ask about her bariatric medicine credentials, "I tell
them quite frankly what it entails, that the exam I took was just as difficult" as
the one she took for the official American Board of Internal Medicine.
But according to records of the American Board of Internal Medicine, Bruner
has never been board certified in internal medicine. She did not return several
telephone calls after questions about her credentials arose.
As the juggernaut of managed care inexorably transforms the medical
landscape, physicians are scrambling to adapt. For many, that means getting
on lists approved by giant networks, such as Kaiser Permanente and Cigna,
that are providing both health insurance and health care to a growing number
of Americans. For consumers and corporations alike, the term "board certified" has become an essential credential that signifies quality medicine.
Vol 82, No 2 1995
Sandra G. Boodman.
Washington Post staff writer.
Reprinted with permission
from The Washington Post.
"Health. A July 12, 1 994.
23-I4, I7.
83
Once an academic distinction, certifaccrtion by an
Once an academic distinction, certification by an official specialty board is
now a rite of passage for most new specialists, particularly in urban and
suburban areas where competition among doctors is fierce and likely to
intensify. In 1973, only 46 percent of doctors were board certified; today, an
estimated 66 percent of physicians are board certified.
Known in medicine as "the boards," the grueling exams are given annually
in 24 core specialties such as internal medicine, and 110 subspecialties
including pediatric surgery, aerospace medicine and forensic psychiatry. (See
Table 1.) For decades, the only boards that certified doctors were a relative
handful of specialty groups that make up the ABMS, founded in 1933,
official specialty board is
now a rite ofpassage for
most new specialists, par-
Table 1.-Specialry Boards Recognized by ABMS
ticularly in urban and
suburban are[as....
Below are the 24 specialty boards recognized by the American Board of Medical
Specialties. Most boards also award certifications in subspecialties. To determine whether
a subspecialty is officially recognized or whether a doctor is board certified, call the
ABMS at I-800-776-2378.
Allergy & Immunology
Anesthesiology
Colon & Rectal Surgery
Dermatology
Hospitals and managed care
companies are ... refusing to
hire well-regarded physicians
who haven't passed their
boards.
84
Qrthopaedic Surgery
Otolaryngology
Pathology
Pediatrics
Emergency Medicine
Physical Medicine & Rehabilitation
Family Practice
Plastic Surgery
Internal Medicine
Preventive Medicine
Medical Genetics
Psychiatry & Neurology
Neurological Surgery
Radiology
Nuclear Medicine
Surgery
Obstetrics & Gynecology
Thoracic Surgery
Ophthalmology
Urology
In addition to the 24 specialty boards, ABMS members include the pillars of
the medical establishment: the American Medical Association, the American
Hospital Association, the American Association of Medical Colleges, and the
Federation of State Medical Boards.
Unlike a medical license, which every state requires, board certification is
entirely voluntary. Even so, doctors are finding it increasingly difficult to get
a job without it.
Hospitals and managed care companies are demanding it, sometimes refusing
to hire well-regarded physicians who haven't passed their boards. A 1992
survey by the American Hospital Association found that 95 percent of
hospitals are requiring board certification of new doctors seeking privileges;
a growing number of hospitals also are insisting on board certification before
renewing the privileges of doctors already on their stafFs. Kaiser Permanente,
the nation's largest health maintenance organization, requires that physicians
become board certified within three years of being hired.
FEDERATION BULLETIN
"Board certification has become the gold standard for doctors," says Paul G.
Ramsey, chairman of the department of medicine at the University of
Washington School of Medicine in Seattle.
Rise of Unofficial Boards
The accelerating demand for board certification by health plans and hospitals
has also led to the proliferation of unofficial, self-designated boards that certify
physicians. There are at least 126 self-designated boards, according to the
Chicago-based ABMS. (See Table 2.)
Among them: the American Academy ofAingside Medicine and Surgery; the
American Academy of Bloodless Medicine and Surgery, and the Council of
board certification . . . has
also led to the proliferation of
Non-Board Certified Physicians.
unofficial, sedf designc^ted
The accelerating demund for
boards. . . .
Table 2.-Self-designated Subspecialty Boards
Following is a list of 126 unofficial boards compiled by the American Board of Medical
Specialties. These self-designated boards certify physicians and sometimes non-physicians
as w•ell. Some have rigorous requirements. Others grant board certificates after a weekend
course. Unless otherwise indicated, each is known as the American Board of
Abdominal Surgeons
Acupuncture Medicine
Addiction Medicine
Addictionology
Adolescent Psychiatry
Aesthetic Plastic Surgery
Alcoholism & Other Drug Dependencies
(AMSAODD)
Algology (Chronic Pain)
Alternative Medicine
Ambulatory Anesthesia
Ambulatory Foot Surgery
Anesthesia
Arthroscopy (Board of North America)
Arthroscopic Surgery
Bariatric Medicine
Bionic Psychology
Bloodless Medicine & Surgery
Cardiac Catheterization & Angiography
Chelation Therapy
Clinical Dependence
Clinical Chemistry
Clinical Ecology
Clinical Medicine & Surgery
Neurology
Neurophysiology
Neurosurgery
Nutrition
Clinical Orthopaedic Surgery
Clinical Pharmacology
Clinical
Clinical
Clinical
Clinical
Vo182, No 2 1995
Clinical Polysomnography
Clinical Psychiatry
Clinical Psychology
Clinical Toxicology
Cosmetic Plastic Surgery
Cosmetic Surgery
Council of Non-Board Certified Physicians
Critical Care in Medicine & Surgery
Dermalogy
Disability Evaluating Physicians
Electrodiagnostic Medicine
El e ctroencep halography
Electromyography & Electrodiagnosis
Environmental Medicine
Epidemiology (College )
Eye Surgery
Facial Cosmetic Surgery
Facial Plastic & Reconstructive Surgery
Forensic Examiners
Forensic Psychiatry
Forensic Toxicology
Hand Surgery
Head, Facial & Neck Pain & TMJ Orthopedics
Health Physics
Homeopathic Physicians
Homeotherapeutics
Hypnotic Anesthesiology (Nat'l Board for)
Industrial Medicine & Surgery
Insurance Medicine
Int'l Cosmetic & Plastic Facial
Reconstructive Standards
85
Some self-designRted boards
have rigorous stcsrtdards
Others are membershipgroups
that provide a doctor with an
Some self-designated boards have rigorous standards. Others are membership groups that provide a doctor with an impressive-looking certificate,
suitable for framing, in exchange for a fee.
"If a doctor is board certified, a patient has a guarantee that the physician has
satisfactorily completed an approved training program under supervision, has had
practice in that specialty, and has passed a rigorous exam, usually two-part, in
that specialty. With a self-designated board, there is no guarantee they have done
any of these things," says ABMS vice president Barbara Schneidman.
"You can say you're `board certified' and have a plaque on the wall in illegible
script and consumers cannot tell the difference," says Julia M. Reade, a
physician who co-authored an article about doctors' credentials published in
the New England Journal ofMedicine in 1987.
irnpre.ssive-looking certifacate
in exchanae for afte.
Table 2.-Self-designated Subspecialty Boards (continued)
InterventionaI Radiology
Laser Surgery
Law in Medicine
Longevity Medicine/Surgery
Malpractice Physicians
MaxilIofacial Surgeons
Medical Accreditation (American
Federation for)
Medical Hypnosis
Medical Laboratory Immunology
Medical-Ixgal Analysis of Medicine
& Surgery
Medical-Legal Consultants
Medical-Legal & Workers
Comp. Medicine & Surgery
Medical Management
Medical Microbiology
Medical Preventics (Academy)
Medical Psychotherapists
Medical Toxicology
Microbiology (Medical Microbiology)
Military Medicine
Mohs Micrographic Surgery
& Cutaneous Oncology
Neuroimaging
Neurologic & Orrhopaedic Dental
Medicine & Surgery
Neurological & Orthopaedic Medicine
Neurological & Orthopaedic Surgery
Neurological Microsurgery
Neurology
Neuromuscular Thermography
Neuro-Orthop. Dental Medicine & Surgery
Neuro-Orthop. Electrodiagnosis
Neuro-Orthop. Laser Surgery
Neuro-Orthop. Psychiatry
86
Neuro-Orthop. Thor. Medicine & Surgery
Neurorehabilitation
Nutrition
Orthopaedic Medicine
Orthopaedic Microneurosurgery
Otorhinolaryngology
Pain Management (American Academy of)
Pain Management Specialties
Pain Medicine
Percutaneous Diskectomy
Plastic Esthetic Surgeons
Prison Medicine
Professional Disability Consultants
Psychiatric Medicine
Psychiatry (American National Board of)
Psychoanalysis (American Exam. Board in)
Psychological Medicine (International)
Quality Assurance & Utilization Review
Radiology & Medical Imaging
Rheumatologic Surgery
Rheumatological & Reconstructive Medicine
Ringside Medicine & Surgery
Skin Specialists
Sleep Medicine (Polysomnography)
Spinal Cord Injury
Spinal Surgery
Sports Medicine
Sports Medicine/Surgery
Toxicology
Trauma Surgery
Traumarologic Medicine & Surgery
Tropical Medicine
Ultrasound Technology
Urological Surgery
Urologic Allied Health Professionals
Weight Reduction Medicine
FEDERATION BULLETIN
Reade's study found that 12 percent of doctors listed in the Hartford, Conn,
Yellow Pages who claimed that they were specialists were not board certified.
Some lied about their credentials and claimed to be board certified by an
ABMS board when they weren't; most listed certification by self-designated
boards.
"There are some extremely reputable jself-designated] boards with very
reputable people," Reade adds. "Then there are these cranks who run these
insane diploma mills."
In most states, doctors, armed with only a valid medical license, may practice
virtually any specialty they choose. That means that a doctor with a medical
degree and no specialized training can set up a practice as a cardiologist or a
cosmetic surgeon. And while a surgeon would probably have a hard time
obtaining hospital privileges without residency training and board certification, he or she could legally perform some procedures, such as liposuction or
ner'e is some evidence that
board certified doctors are
superior to those who are not
certifed by an official specialty board.
other kinds of cosmetic surgery, in his or her office.
Link to Quality
In the past decade, health care researchers have searched for ways to measure
quality. As the University of Washington's Ramsey notes, "There's been an
increased interest in developing methods that assess doctors' performance and
are feasible, affordable, and meaningfitl." Those markers, he says, are board
certification and where a doctor trained. "After that, it becomes subjective."
There is some evidence that board certified doctors are superior to those who
are not certified by an official specialty board. A 1989 study by Ramsey found
that board certified doctors performed significantly better on written competency exams and were more highly rated by colleagues than their non-certified
colleagues. The study, published in the Annals of.Fnterncsl Medicine, involved
250 internists, 185 of them board certified within 10 years after they completed residency training.
While officials at the American Board of Medical Specialties agree that board
certification is no assurance of quality, they say it indicates that a doctor has
met standards that are higher than those required to obtain a medical license
in any state.
"Board certification guarantees that if you go to a doctor who says he's a
surgeon, he really is a surgeon," says the ABMS's Schneidman.
"As a public health or consumer protection matter, it's really important, but
personally I wouldn't use it as a benchmark," says Reade, coauthor of the New
England ]oasrnctl study. "Every doctor knows someone who's not boarded
and is very good. Board certification doesn't tell you whether a doctor is
empathic or a good clinician."
Lack of board certification, however, may reflect a serious problem with a
doctor's training, competence, or character.
A report prepared for the Medical Board of California, the state agency that
polices physicians, found that of 69 doctors disciplined since 1991 for the
most serious offenses-ranging from rape to gross negligence that resulted in
a patient's death- -f 8 were not certified by an ABMS board.
Board certification doesn't
tell you whether a doctor is
empathic or agood clinician.
"It's an irrefutable statistic," said Dixon Arnett, executive director of the
California board.
Vol 82, No 2 1995
87
Advertising and the Law
The clamor for doctors' credentials was fueled in 1975 when the Federal Trade
Commission successfully sued the AMA, charging that it unlawfully barred
advertising by doctors.
Once the courts allowed doctors to advertise, all these pseudoboards started
What makes it even more
confiasingfQr consumers
is that the names of many
self-designated boards are
strikingly similar to those of
the official boards.
forming" that attracted "people who weren't able to make it within the
existing boards," says Mark Gorney a past president of the California Society
of Plastic Surgeons.
"What you're looking at is the very peculiar American phenomenon of
entrepreneurism by practitioners who cannot be players in a big pond," says
Gorney, a former official of the American Board of Plastic Surgery. "This, of
course, results in enormous confusion in the public mind."
What makes it even more confusing for consumers is that the names of many
self-designated boards are strikingly similar to those of the official boards. The
American Board of Neurology, for example, is a self-designated board; the
official board is the American Board of Psychiatry and Neurology. The
American Board of Radiology and Medical Imaging is an unofficial board.
The American Board of Radiology is the ABMS group.
In all but three states-California, Florida, and Colorado-there is no law
that bars doctors certified by self-desig.nated boards from calling themselves
specialists or from advertising that they are "board certified."
In California, the primacy of the ABMS is being challenged by several groups,
including the American Academy of Pain Management, a self-designated
board based in Modesto.
"Nobody says the ABMS model is not good, but it fails to recognize a
multi-disciplinary approach," says executive director Richard M. Weiner. "It's
an economic guild issue.... The public should be allowed to make its own
informed decisions about specialists" and should be able to assess the
credibility and competence of boards without government intrusion.
"The ABMS has no acupuncture board, no herbalist board," Weiner adds.
"When $1 out of every $3 is spent on alternative medicine, it would indicate
that the ABMS is missing the boat."
Academies, Societies, Fellowships, Etc.
Deciphering the meaning of
such terms as "fellow of,"
`diplomate," and "baard
certified" ... is no easy task.
88
Board certification is not the only confusing credential. Most consumers find
the arcane terminology and alphabet soup of initials after doctors' names both
mystifying and impressive. Deciphering the meaning of such terms as "fellow
of," "diplomate," and "board certified" (the last two are synonymous) is no
easy task.
In addition to board certification, many doctors advertise their membership in
a professional specialty society. The standards ofthese societiesvary considerably.
Being a fellow of the American Academy of Pediatrics, for example, may
sound exalted, but it merely means that a pediatrician is board certified and
has submitted two letters of recommendation from other fellows.
A fellow of the American Academy of Family Physicians need not be board
certified. Becoming a fellow of the American College of Surgeons is considerably more difficult. A doctor must be board certified, must have practiced
in one location for at least two years, and must have a hospital appointment
FEDERATION BULLETIN
in good standing. Candidates also arc required to submit a year-long list of
all procedures performed, as well as detailed reports of several cases.
Determining whether a doctor's credentials are genuine can be daunting:
Many physicians directories, Washington's included, print the information a
doctor submits without verifying it. While it is uncommon, doctors do lie
about their credentials.
A 1988 study of 773 doctors who submitted clinical credentials to Humana
found that 39 presented false credentials; 10 said they were board certified
when they weren't. A 1987 congressional audit of 650 Veterans Administration Hospital physicians found that 1 I 5-nearly 18 percent-said they were
board certified when they weren't. Officials of the American Board of Internal
Medicine have uncovered 19 cases of fraudulent board certification since 1980
and arc currently conducting a multi-specialty study of faked credentials.
"The whole area of credentials is largely unregulated, and some of these
self-designated boards are very troubling," says Julia Reade. "For a layperson,
it's very hard to get access to information about doctors-who's good and
who's not-that physicians have. Board certification guarantees a minimal
level of training and experience."
Taking the Boards
To be eligible to take the official specialty board exams, a doctor must have
successfully completed one of the 7200 accredited American residency training
programs. Graduates of foreign medical schools are eligible if they complete a
US residency; doctors who successfully finished a residency in Canada or England
may be exempt from this requirement. Residencies vary in length: Most are three
years, although some surgery residencies can last seven years.
Each specialty board sets its own rules governing when a new doctor is eligible
to take the exam. Many specialties-psychiatry, internal medicine, pediatricsallow candidates to take the tests within a year after finishing a residency. Eight
boards, most of them surgical, require that candidates practice for several years
and perform a specific number of procedures as a prerequisite.
Requirements established by the American Board of Plastic Surgery are
among the most rigorous in medicine: Candidates must have completed five
years of training, must have practiced plastic surgery exclusively for two years
and must pass both a written and an oral exam.
For years, the boards have inspired particular trepidation among doctors.
Passing them is a badge of honor, and horror stories-about candidates who
broke down in the exams or flunked repeatedly-are common among
physicians. Swapping stories will undoubtedly become more commonplace;
19 boards now require newly credentialed doctors to take recertification exams
every seven to 10 years.
Failure rates vary among the boards. In internal medicine, the most popular
specialty, about 60 percent of candidates pass the exams. Each board decides
how many times a doctor who fails may retake the test.
Vol 82, No 2 1995
Mccny pdrysicia nsdirectories
... print the information
u doctor submits without
yerifying it-
... 19 boards now require
newly credentialed doctors to
take recertifaccation exams
every seven to 10 years.
89
Report of the American Medical
Association and the
Federation of State Medical Boards:
Ethics and Quality of Care
Overview: The Ad Hoc Committee to Study AMA Proposals Regarding State
Medical Societies and Quality of Care Issues was established in 1992 as a result
of an AMA proposal offering the assistance of state medical societies to state
medical boards for the evaluation of quality of care complaints.
This committee last met in December 1994. AMA representatives agreed to
support the Federution's position that investigation of quality of care issues, as
legislated in medical practice acts, is the responsibility of state medical boards.
The report printed here represents the conclusions of the meetings and outlines
areas ofcontinued cooperation between medical societies and state medical boards.
It was approved by the Federation's House of Delegates in April.
Committee members:
-FSMB: Robert E. Porter,
MD, Chair; Gerald J.
Becharnps, MD; Leroy B.
Buckler, MD; Peter E. Dans,
MD; Bruce H. Hasenkamp,
jD; Earle M. .L.eVernois, MD;
Deborah L. Rodecker, JD;
Stephen I. Schabel, MD;
SusQn M. Spaulding.
AMA: MichRellle, JD;
William E. jcacott, MD;
Kirk johnson, jD;
James S. Todd, MD
90
1 lt its Interim Meeting in 1991, the American Medical Association (AMA)
House of Delegates adopted Board of Trustees Report BBB: Council on
Ethical and Judicial Affairs - Enforcement of the Code of Ethics. Among other
things, that report called on the AMA to
work with the Federation of State Medical Boards (FSMB) to (a) make
a uniform part of the licensure examination knowledge by physicians of
their unique ethical responsibilities, as described in the Principles of
Medical Ethics and the Current Opinions of the Council, and (b) expand
those medical society programs whereby, under the supervision of the
state medical board and with its attendant investigating powers and civil
suit immunity, medical societies examine and report to the boards with
regard to quality of care complaints referred to the boards.
Beginning in early 1992, the AMA and the FSMB held a series of meetings
designed to explore ways in which these goals could be accomplished. The
FSMB appointed an Ad Hoc Committee for this purpose, and the AMA was
represented by a member of its Board of Trustees as well as senior stafF The
most recent meeting of this group took place on December 15, 1994. The
purpose of this document is to summarize the conclusions reached in this
process and to identify prospects for continued cooperation.
Quality of Care Cases
State medical boards are charged by state law with the ultimate responsibility
for assuring the quality of care provided by licensed physicians. The boards
are directly accountable to the public for this activity. Most boards are made
up of both physician and public members, and are served by full-time staff to
investigate quality complaints. Yet the boards do not have on staff the wide
FEDERATION BULLETIN
variety of expertise needed to review the quality of all medical care provided
by physicians today. Moreover, the boards are not in complete control of their
resources. As state agencies, the boards are subject to the vagaries of the budget
process. They may find themselves lacking full funding and staff complement.
As a result of these factors, the boards necessarily rely on practicing physicians
both to report colleagues who are not meeting the standards of the profession
and to assist in reviewing quality of care complaints by serving as expert
consultants. By participating in the process of the boards, physicians meet a
fundamental obligation of members of the medical profession. One of the
basic tenets of the profession is the duty of self-regulation, which is based on
the unique qualifications physicians possess to evaluate the clinical performance of their colleagues and on the enduring commitment of physicians to
safeguard the welfare and trust of the public.
The medical profession has a long history of comprehensive peer review.
Collegial review is part of the medical education process that begins in medical
school and continues throughout every physician's career. As practitioners,
physicians participate in, and are subject to, peer review as members of hospital
medical staffs, medical societies, and increasingly, integrated health care
delivery systems. Physicians spend countless additional hours in the development of practice parameters and related efforts to improve the quality of health
care delivered today.
State medical boards may not now be a regular part of these activities. The
boards should reach out to the physicians who make up the profession's
self-regula[ory infrastructure and rely, to the extent necessary and appropriate,
on these expert peer reviewers. Likewise, state medical societies should work
to assure that the peer review efforts of practicing physicians are extended to
the assistance of state boards. Cooperative ventures between state boards and
medical societies, such as with impaired physician programs and focused
continuing medical education, may assist in this regard.
By participating in the
process of the boards, physicians meet a fundamentRl
obligation of members of the
medicQl profession.
Making Appropriate Reports to the Boards
The Council on Ethical and Judicial Affairs described a key aspect of this duty
in a December 1991 report: Reporting Impaired, Incompetent, or Unethical
Colleagues. That report, and the ensuing ethical opinion, require that
physicians notify state boards of incompetence that poses an immediate threat
to the health of patients as well as behavior that is potentially injurious to
patients and continues despite remedial efforts. In sum, "Physlcians who
receive reports of incompetence have an ethical duty to critically and objectively evaluate the reported information and to assure that identified deficiencies are either remedied or further reported to the state licensing board."
State medical boards generally find that physician reports of incompetence
State medical boardsgenerallyjnd that physician reports
of incompetence by colleagues
are among the most infrequent and yet the most reliable of the guality of care
complaints received.
by colleagues are among the most infrequent and yet the most reliable of the
quality of care complaints received. It is critical that boards receive appropriate
reports from physicians in a timely manner. As the 1991 CEJA report makes
clear, this obligation extends beyond reporting incompetence that poses an
immediate threat to the public. If other peer review actions, such as hospital
medical staff remedial plans, faii to correct incompetent practice, then a report
must be made to the medical board. This obligation takes on greater importance
vol 82, No 2 1995
91
as medical practice moves increasingly outside the hospital setting, and
traditional peer review opportunities become less available. State medical societies
can, and should, facilitate reporting by physicians in their communities.
Collectively, the physician
community provides an invaluable potential resource
which remains underused or,
in some Jaarisdictions, largely
untapped.
It is time to ensure that staadents have an adequate
knowledge of medical ethics
when they sitfor the examination reguired for licensure
throughout the United
States, the USMLE.
92
Participating in Quality of Care Review
The quality of the review process undertaken by state medical boards is
determined in large part by the resources available to them. The most essential
resource is physician review. Physicians possess the training and experience
which uniquely qualify them to review the competence of their colleagues.
Without access to an adequate supply of qualified physician reviewers, the
boards simply cannot do the job they are mandated by law to do.
State medical boards are a key element in the peer review system. The boards
are accountable by law to identify and respond appropriately to the most
serious quality of care complaints. They can do this most effectively by relying
on the unmatched competence and experience of practicing physicians.
Collectively, the physician community provides an invaluable potential
resource which remains und.erused or, in some jurisdictions, largely untapped.
The boards regularly report difficulty in securing practicing physicians to serve
as peer reviewers. Whether this is caused by a lack ofunderstanding of the boards'
role, suspicion oftheir activities, or some other cause, it is a condition that should
be corrected. The AMA and the FSMB believe that state medical societies and
state boards have a duty to establish a cooperative relationship that will foster
better understanding of the role of each entity and provide an environment in
which practicing physicians regularly incorporate work on behalf of the boards
into their other peer review activities. Specific recommendations about how this
might be accomplished are set forth at the end of this report.
Ethics
It is a fundamental obligation of the medical profession that its members have
knowledge and appreciation of the principles of medical ethics. Indeed, one
of the basic requirements of accredited medical schools is that [S]tudents
"must be encouraged to develop and employ scrupulous ethical principles in
caring for patients, in relating to patients' families, and to others involved in
the care of the patients." The medical practice act in most, if not all, states
requires that physicians behave ethically in order to acquire and maintain a
medical license. It is time to ensure that students have an adequate knowledge
of medical ethics when they sit for the examination required for licensure
throughout the United States, the USMLE. The legal profession requires that
all applicants for the bar pass a specific legal ethics examination, which is based
on the American Bar Association's ethical code.
To facilitate education and examination in ethics, the AMA will make its
Code of Ethics available to every student entering medical school each year
as well as to every student sitting for the USMLE. It can be an indispensable
tool for discussing and addressing the central ethical issue faced by physicians
today, and examination questions can be drawn from the code's opinions.
The FSMB recognizes the importance of medical ethics in guiding the
development and practice of physicians, and the vital role that ethics can play
in protecting the public interest. The FSMB endorses the proposal that an
FEI]@R,e4TIQN BULLETIN
increased emphasis be placed on the examination of prospective licensees with
respect to their knowledge of medical ethics.
Recommendations
The AMA and the FSMB recommend that the following specific actions be
undertaken where feasible and that the state medical societies and state medical
boards seek other means of improving the quality of care review of physicians as
well as physician knowledge and appreciation of medical ethics in general.
1. State medical societies should disseminate widely the CEJA report
"Reporting Impaired, Incompetent, or Unethical Colleagues" and
should otherwise strive to make physicians aware of this obligation.
2. State medical societies should inform the boards of new ethical statements
by CEJA, such as reports and opinions as they are published.
3. State medical societies and boards should facilitate reporting by
physicians, for example, by assuring to the greatest extent possible the
confidentiality of reports.
4. As prescribed by state law, state medical societies should forward quality
of care complaints and the other alleged infractions to state boards.
Complaints within the jurisdiction of the medical society should be
resolved according to the AMA Guidebook for Medical Society Grievance
Committees and Disciplinary Committees. Each state board and state
medical society should develop a system for identifying and routing
complaints to the appropriate entity.
5. State medical societies and boards should foster better communication
and understanding among their members, for example, by a report from
the board to the medical society's annual meeting, the joint sponsorship
of continuing medical education activities, and the attendance of board
meetings by medical society representatives.
6. State medical societies should assist the boards in securing physician
reviewers for quality of care cases, perhaps by making the roster of its
standing peer review committee available to the board or by developing
and maintaining a list of physicians able and willing to serve as reviewers
when requested to do so.
7. State medical societies and boards should discuss legislative issues of common interest and reach agreement, to the extent possible, of a desirable
course that will protect the public and the rights of physicians under review.
8. State medical societies should provide to the appropriate agency a list of
possible state medical board members from the society who demonstrate the
qualities of honesty, faimess, impartiality, integrity, and dedication to the task
9. State medical societies and boards should cooperate with respect to
impaired physician programs, remedial continuing medical education,
and related matters.
State
medical societies and boards should work together to address the
10.
issue of credentialing physicians who change their practice specialty after
residency training is completed or who relocate their practice from one
state to another.
Vol 82, No 2 1995
State medical societies and
boards should facilitate
reporting by physiciRn s, for
example, by assuring to the
greatest extent possible the
confidentiality of reports.
State medical societies and
boards should cooperate with
respect to impaired physician programs, remedial
continuing medical education, and related matters.
93
Remedial Education in Prescribing
Controlled Dangerous Substances
WILLIAM VILENSKY, RPh, DO
Overviezv: Problem physicians who prescribe cQntrolled dangerous substances may
never have had proper education about their use. Better medical school education
could help prevent injudicious prescribing. The educational, remedial "rrtiniresidency" program described herein has had an exceptional success rate over its
12-year history. It is not a rehabilitative or therapeutic program for impaired
plrysicians but works closely with boards that choose to mandate the course as part
of disciplinary actions.
T
William Vilensky, RI'h, DO.
Clinical Associate Professor of
Family Medicine and Director of Controlled Dangerous
Substances Programs, University of Medicine and Dentistry of New Jersey, Robert
Wood johnson Medical
School. Camden, New Jersey.
94
he injudicious prescribing of controlled dangerous substances (CDS) by
health providers continues to be a significant problem. Many factors contribute to the issue. Medical schools fail to provide appropriate curriculum.
Physicians' inadequate knowledge make them gullible and easily manipulated
by drug-seekers. Impaired physicians may stoop to bartering drugs for sexual
favors (sexual exploitation), sharing prescriptions written for patients, or
distributing CDS. Physicians who have practice problems with CDS may be
dated, deceived, dishonest, or disabled.
One basic solution to the CDS prescribing problem would be for medical/
osteopathic schools to include focused courses, including examinations, about
alcohol and substance abuse pharmacology; clinical recognition, diagnosis, confrontation, and intervention; and treatment or treatment referral. Prescribers
need sharper cognitive skills to recognize the drug-scammer and to handle these
patients without scorning their illness. The physician who prescribes inappropriately may become involved in malpractice litigation, sanctions from licensing boards, and/or felony charges for insurance or Medicaid and Medicare fraud,
illegal distribution of CDS, or sexual exploitation.
The concept of a mini-residency in the proper prescribing of controlled
dangerous substances was approved by the New Jersey State Board of Medical
Examiners in 1982 to aid in providing consumer protection and a positive
option for physicians with problems in over- or misprescribing. It was initiated
under the auspices of the University of Medicine and Dentistry of New Jersey
(UMDNJ). Since 1994, the course has been cosponsored by the Forensic and
Educational Consultants in Alcohol and Drug Abuse and Kennedy Memorial
Hospital-University Medical Centers, a teaching affiliate of the UMDNJ.
The course is held in a comfortable hotel in the Atlantic City-Philadelphia
area and is conducted in a positive, friendly informal classroom setting. Many
FEDERATION BULLETIN
state boards do not choose to award continuing medical education (CME)
credits for this course or to reward enrollees for required participation in
remedial and/or disciplinary actions. Because a majority of state medical/
osteopathic boards in the United States require CME for relicensure, it is
believed that awarding CME credits for this course would allow doctors to
circumvent at least some new CME courses intended as relicertsing criteria.
Table I. -Program Participants by Profession and Gender
Profession:
Male:
Prescribers need sharper cognitive skills to recognize the
Total:
Female:
these patients without scorning their illness.
M.D.
251
12
263
D.D.
67
2
69
D.D.S./D.M.D.
33
2
35
4
(voluntary) I
1
D.P.M.
4
R.N.
R.Ph.
D.V.M.
P.A.
drug scarmrner and to handle
1
1
(record keeping only) 1
1
1
1
(Physician Assistant)
375
The format, a unique, step-building curriculum, was designed with a faculty
of experts to deliver an all-encotnpassing 50-hour seminar comprising six full
days and one clinical evening. Classes are held twice a year, in May and
November, and are limited to 25 enrollees. The intent is to provide rerrted'zation for doctors who need to upgrade their general knowledge, whose licenses
are subject to sanctions by a professional licensing board or quality assurance
committee of such boards, or who are trying to retain or regain their licenses.
Although the original and primary audience is MDs and DOs, registration has
expanded to include 35 dentists, four podiatrists, a physician assistant, a nurse,
a pharmacist, and a veterinarian. (See Table 1.)
As a disciplinary action, this course work is a positive prophylaxis for repeat
infractions and an alternative to imposing only negative penalties, fines, and
suspended/revoked licenses. The course assumes that participants have never
been appropriately taught, or have forgotten, issues of substance misuse and
abuse. Therefore, all participants start at the same level. Some may have never
learned newer concepts regarding CDS and prescribing.
The course objectives are:
1. to ascertain the participants' level of knowledge of CDS prescribing before
and after the course
2. to heighten the knowledge of the practicing physician or other health care
provider about prescribing CDS
Vol 82, No 2 1995
As a disciplinary action, this
course work is ... an alternRtive to imposing only negative
penalties, fines, and
suspended/renoked licenses.
95
3.
4.
5.
6.
This program is intended to
educate health professionals.
It does not attempt to provide
therapy or rehabilitate the
i»apaired physiciara.
7.
8.
9.
to educate doctors and other participants in the most modem concepts
of pharmacology of CDS
to train participants in the pharmacology, diagnosis, and treatment
options for chemical dependency and addiction to CDS
to develop sensitivity to the patient who legitimately requires CDS for
pain or anxiety
to educate the health provider with a comprehensive knowledge of diagnosing and treating medical problems that involve the use and prescribing
of narcotics for acute and chronic pain management, sedative/hypnotics,
tranquilizers, stimulants, steroids, and drug combinations
to make health providers aware of the psychology of the drug abuser and
the dependent personality and the psychiatric component of substance
abuse
to stimulate the health provider in the evaluation of ethical values of the
prescriber, dispenser, and user
to assess physicians' prescribing habits, as they are affected by their own
stress and by drug, physical, or emotional impairments
10. to elucidate state and federal laws regulating the prescribing and use of
.., the fRculty has been serzsitized to the psychological
aspects of working with this
special8roup ofstudent
professionals•
96
drugs in the categorized schedules under the federal Controlled
Dangerous Substances Act of 1970
11. to help participants understand the role of regulating and licensing
agencies that are consumer advocates
12. to convey the successful completion of this training program to state
licensing and law enforcement agencies at the request of the participant
This program is intended to educate health professionals. It does not attempt
to provide therapy or rehabilitate the impaired physician. Over the years,
however, approximately 15% of the participants in the course have had some
alcohol and/or drug impairment due to their lack of knowledge of the effects
on their own bodies. Both the provider and patient can benefit from the
provider's experience in this course.
The faculty is composed of experts in the fields of pharmacology, pharmacy,
primary care, pain management, anxiety/depression, sleep disorders, obesity
control, steroid abuse, psychiatric disorders associated with substance abuse,
bioethics, medical record-keeping, addiction, the drug-seeking patient, state
and federal controlled drug laws, and board rules and regulations. To reduce
embarrassment and resistance, the faculty has been sensitized to the psychological
aspects of working with this special group of student professionals.
A pretest on the first day of the course identifies the weaknesses in knowledge
of the participants. Although it is compared to the post-course exam administered on the sixth day, the major value of the test is to have this
information to communicate to professional schools in the hope that education related to these deficits can be included in the core curriculum. For
medical students, such information would be most appropriate in the fourth
year, after they have finished courses in general pharmacology and are treating
patients, and may be exposed to the drug-seeki.ng patient. The history of this
course since 1983 shows that the dentist, podiatrist, physician assistant,
pharmacist, and nurses all benefit equally and can assimilate the material and
pass examinations as well as physicians, and in some cases, score higher.
FEDERATION BULLETIN
The course methods include formal lectures, interactive group discussions,
slide and overhead presentations, video tapes, panel discussion with recovering
addicts, and case study presentations. The broad-based educational program
provides highly qualified experts; offers a comprehensive, individualized program in a learning environment; allows participants to make a constructive
contribution to their community; and eliminates financial burden to the state
or taxpayer because the tuition is paid by the participant. The program has
become an important positive segment of disciplinary action used by 31 states
and the College of Physicians and Surgeons of Ontario. (See Table 2.) It has
been instrumental in the partial or total licensing and reinstatement of 99% of
the 375 participants in the course to date. Of this number, only two of the
physicians have been recharged with similar offenses as of May 1995.
It has been instrumental in
the partial or total licensing
and reinstatement of 99% of
the 375 participants in the
course to dcate.
Table 2. -Participants by State, through 25 Mini-residencies in CDS
Arizona
2
Maryland
8
Pennsylvania
18
Alabama
2
Massachusetts
2
Rhode Island
2
California
5
Michigan
I
Tennessee
3
Colorado
10
Mississippi
7
Texas
2
Utah
2
Vermont
5
Virginia
46
Delaware
3
Missouri
4
Florida
2
Nebraska
I
Georgia
23
New Jersey
Illinois
3
New York
5
Kansas
19
2
North Dakota
1
Kentucky
Louisiana
4
Ohio
Oklahoma
143
2
Wisconsin
Ontario (Canada)
8
25 ,
IS
Total Number of States (and Canada): 31
. . . state medical boards
It is not surprising that doctors who have been mandated by their boards to
take this remedial course question the level of knowledge about CDS of those
board members. In May 1995, the New Jersey State Board of Medical
Examiners sent its medical director to this course. He attended the entire 50
hours, took and passed the exam, and participated in all activities so that he
can better assess doctors whose prescribing habits are matters of concern, now
and in the future, to that state board.
Statistics indicate that prevention through education is a successful approach.
It should further indicate that state medical boards could implement a
mechanism by which the public can be assured that licensees are knowledgeable and have at least minimal competency in the prescribing of CDS before
they are licensed. Such programs would lead to the practice of better medicine
and could prevent future sanctions.
Vol 82, No 2 1995
could implement a
mechanisrra by which the
public can be assured that
licensees . . . have at leQst
minimal competency in the
prescribing of CDS before
they are licensed.
97
COMMENTARY
Medical Futility: A Comment
THOMAS Wm. MAYO, JD
Associate Professor of Law, Southern Methodist
University School of Law; Adjunct Associate Professor
of Internal Medicine, University of Texas Southwestern Medical School; Counsel, Haynes and Boone,
LLP; Dallas, Texas.
The debate over medical futility has touched a raw
nerve in the medical profession for many of the reasons
mentioned by Dr. Schoenberger in his useful discussion
of this topic. He is surely right that part of the reaction
is a backlash against the perceived excesses of proponents
of patient autonomy-most notably the courts and
legislatures that have embraced that notion enthusiastically, if somewhat uncritically,''2 in the context of
informed consent.
More promising, however, is Dr. Schoenberger's
suggestion that outcomes research and the current
drive to rein in ever-increasing health care costs have
focused attention as never before on the dilemma
created by patient demands for interventions resisted
by their physicians on futility grounds. Whether a
physician responds to an outcomes-oriented professional ethos, to the abstract demands of society to make
medicine more efficient and less expensive, or to the
explicit financial incentives created by managed care
contracts to reduce the costs of patient care, there is
not much room these days for futile care.
Dr. Schoenberger's attempt to distinguish the concept
of futility from the rationing of health care is a useful
analytical point that seems doomed to failure in a clinical
setting. His distinction would limit the label "futility" to
those interventions that provide no benefit, while "rationing" would refer to the self-conscious decision to withhold "a limited, but useful commodity." Since futile care
is never usefiil, he reasons, a decision to withhoid it can
never amount to rationing.
98
The problem with this distinction is that it turns on
the slippery notion of "benefit," and there is no end to
the mischief that is caused by that word in the current
debate over futility. When the focus of the futility
debate shifts to benefit, as it inevitably must, it raises
many serious questions. Who defFnes what is beneficial
and what is not? This question turns on the answer to
a related question: Who establishes the goals for treatment, against which the benefit will be measured?3 The
touchstone for Dr. Schoenberger's distinction between
futility judgments and rationing-whether an intervention is beneficial or not-obviously depends on a
great many clinical variables and the personal values
through which those variables are processed. Put simply, a treatment may be beneficial to me, but not
beneficial in the eyes of my physician. Withholding or
withdrawing that treatment, far from being a treatment
decision based upon futility, will appear to me to be
rationing.
This is a subjective view of the matter, and it might
be argued that there must be a better answer to this
dilemma than "it's in the eye of the beholder." The
quest for a more objective standard, however, is an
illusory one. Once we try to move past an essentially
physiologic or quantitative standard for futility, we are
in the realm of "one's personal value system,"4 and, as
Dr. Schoenberger points out, even the quantitative
standard is subject to that criticism.
The difficulty inherent in the quest for "objective"
value judgments is illustrated by the problem of DNR
orders for patients in a persistent vegetative state. For
Schneiderman, Jecker, and Jonsen,5 as well as for
others,6 this is an easy case, an obvious instance of a
futile intmention because, even ifspontaneous breathing and a pulse can be restored, there is no benefit to
the patient. Dr. Schoenberger's own hospital ethics
subcommittee's definition, which emphasizes "a
benefit which can be appreciated by the patient,"
would seem to point in the same direction. But this is
not the standard of care for many physicians who treat
FEDERATION BULLETIN
such patients. The chairman of the medical ethics
committee at Columbia Presbyterian Medical Center
in New York was presumably speaking for them when
he recentlywrote, in the context of a discussion ofDNR
orders, "[T]he definition of futility should most certainly not be applied to comatose patients who can
survive for long periods with supportive care. To do so
would be to start sliding down the slippery slope of
explosive and arbitrary judgments as to what constitutes 'useful' or 'quality' life."' The American Heart
Association$ and the A.iVfA Council on Ethical and
Judicial Affairs appear to agree, as well.
I am not arguing that the views of the AHA and the
AMA should trump the American Thoracic Society and
Lawrence Schneiderman, simply that there is precious
little agreement within the profession and within
society, even when the case is a relatively straightforward one. This is betause, as Beauchamp and
Childress1Q write, "Professional standards in medicine
are fashioned for medical judgments, but decisions for
or against medical care, which are nonmedical, are
rightly the province of the patient." These decisions
can be made with the assistance ofphysicians, and often
they are intelligible only with that assistance. But it is
a conceptual and practical mistake, except in the narrowest of circumstances and the rarest of cases, to take
these decisions out of the hands of patients through
unilateral decisions by the physician.
What gives the futility debate bite is that this unilateral
right to force a particular result, which is an essentially
coercive right, is met by the patient's claim to an equally
coercive right based upon a demand that "everything
be done." The futility debate is, thus, a struggle over
power, and as long as the struggle is over foundational
matters that are defined by bedrock personal and
professional values, the power struggle is a draw. As
Haavi Morreim" has suggested, the resolution of this
struggle is not likely to be found in anyone's answers
to the basic questions of whose values and whose goals
for treatment are worthy or unworthy, but rather in a
model for dispute resolution that minimizes the coercive effect of the claims of both sides to the dispute.
Dr. Schoenberger's emphasis, therefore, on
physician-patient communication and joint decision
making is most welcome. In many cases, this is all that
is required to produce a treatment plan that is acceptable to the patient (or surrogate) and physician. The
plan may include a time-limited trial that tests the
accuracy of the physician's predictions at the same time
it gives the patient (or family members) time to adjust
to new clinical realities. It may also include an agreement that certain interventions, including attempted
resuscitation, will not be tried, while others will be.
In the event that agreement cannot be reached, the
requested interventions ordinarily should be provided,
Vo182, No 2 1995
assuming they are capable of producing the physiological effect for which they are intesaded. On this assumption, the physician may still believe that a particular
intervention is "futile," but in the more qualitative
sense favored by Schneiderman. Discussions should
continue, often with the assistance of social workers,
pastoral care, or an ethics consultation team, until one
of three likely outcomes occurs. Over time, the patient
^or surrogate) may change his mind and agree that a
particular intervention is probably nonbeneficial in a
sense that is meaningful to the patient. Alternatively,
changed clinical circumstances may require an adjustment in the futility analysis, for or against the intervention, and require further communication and new
decisions. And, particularly in the case of end-of-life
decisions, the death of the patient may render the issue
moot, unless the issue concerned a DNR order.
This type of interdisciplinary support for and communication with the patient (or surrogate) may be
costly both in financial and emotional terms, but it
should be continued throughout this period. It
promotes the autonomy of the patient, either directly
or through a surrogate decision maker, at a relatively
low cost to provider autonomy. It does require, however, that the physician be willing to recast the patient
conflict and the apparent impasse. Rather than a bipolar
dispute in which physician and patient (or surrogate)
are adverse parties in a winner-takes-all contest, the
parties must understand themselves to be partners in
search of a treatment plan that is acceptable to both,
recognizing that neither party likely will have his position totally vindicated by the process. This approach
recasts the dilemma in terms of ongoing patient and
provider education about the patient's condition, options, values, and goals in a cooperative, rather than
adversarial, process.
It sometimes will be difficult to tell whether an
intervention is futile in the physiologic sense or only in
the value-laden, qualitative sense. In other cases, probabilistic analysis of the disputed intervention may involve a clash of values, as well, if physiologic effect
cannot be categorically ruled out and the care is deemed
futile because the physician believes that the burdens
of treatment far outweigh the benefits. To clarify the
reasoning involved in futility judgments, an
institution's policies might require that all futilitybased overrides be preceded by second opinions from
physicians in a relevant specialty, consultation with the
ethics committee of the hospital, and complete
documentation in the patient's record.12 In addition to
avoiding potential licensing actions (as Dr. Schoenberger suggests), these policies also would make it
impossible to reject a patient's (or surrogate's)
autonomous treatment choices without an institutional
airing of the reasons for the override. These procedures
99
not only provide the patient's interests a measure of
protection but also help to clarify institutional and
individual provider's values and to establish a standard
of care within the institution and the community.
These procedural safeguards may provide some legal
protection in the courts, as well. In the case discussed
by Dr. Schoenberger involving Massachusetts General
Hospital, it is far from clear whether the futifity argument relied upon by the physician and the hospital
ethics committee was based on lack of physiologic
effect or the more qualitative judgment that survival
that falls short of discharge from the hospital was not
worth the burden of the attempt. The judge's instruction to the jury, for example, required them to "balance
[the patient's] preference [for continued ventilator
support and CPR if she were weaned] against the
medical judgment to withdraw such treatment in the
context of not whether, but for how long, and at what
cost, her life might be extended."13 Nonetheless, the
jury found in favor of the physician and the hospital,
presumably in part because the careful process by which
consultants were involved, the ethics committee was
consulted, and the decisions were made and documented in the patient's record helped to establish the
reasonableness of the defendants' conduct in the minds
of the jurors.
References
3. Capron AIM. In re Helga Wanglie. Hastings Center
Report. 1991; 21 [5]:26-28.
4. Schoenberger Cl. Medical futiIity: an evolving ethical
and clinical concept. Fed Bull: J Med Licensure Discip.
1995; 82:70-77.
5. Schneiderman LJ, Jecker NS, Jonsen AR. Medical
futility: its meanings and ethical implications. Ann
Intern Med. 1990; 112:949-954,
6. American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med. 1991;
115, 478-485.
7. Prager K. When medical treatment is futile. Wall
Street jonrnal. June 27, 1995: A16.
8. American Heart Association. Ethical considerations in
resuscitation: guidelines for cardiopulmonary resuscitation and emergency cardiac care, part 8. JAMA.
1992; 268:2282-2288.
9. AMA Council on Ethical and Judicial Affairs. Guidelines for the appropriate use of do-not-resuscitate
orders. JAMA. 1991; 265:1868-1871.
10. Beauchamp TL, Childress JF. Principles of Biomedical
Lthics. 4th ed. New York, NY: Oxford University
Press, Inc; 1994:148U.
11. Morreim EH. Profoundly diminished life: the casualties of coercion. Hastings Center Report. 1994;
24 (1 ):33-42.
12. Sadler JZ, Mayo TW. The Parkland approach to
demands for "futile" trearment, H.E.C. Forum.
1993; 5{ 1 }:35-38.
Schuck PH. Rethinking informed consent. Yale Law
joaarnsal. 1994; 103 (4):899-959.
Veatch RM. Abandoning informed consent. Hastings
Center RePort. 1995; 25 {2):5-12.
100
13 Ellernent J. Jury sides with doctors on ending
vmman's life support. Boston Globe. April 22, 1995;
Metro/Region:18.
FEDERATION 'SUT,LETIN
FROM OUR INTERNATIONAL EXCHANGES
NEW SOUTH WALES, AUSTRALIA
GRADUATES OF THE YMP AIR1VLENT
PROGRAM
Most impaired doctors can continue to practise
medicine, subject to appropriate restrictions which
protect the public. The Board takes the view that its
primary responsibility to protect the public can be met
at the same time as the doctor is rehabilitated. The
Board's rehabilitation program encourages doctors to
take reponsibility for their own health. Where this is
demonstrated, along with a successful treatment program, supervision by the Board may eventually be
discontinued. Many practitioners who have adhered to
their conditions for several years and who no longer
need supervision are now ready to leave the program.
From the Medical Board Newsletter
of the New South Wales Medical Board
March 1995
An example is Dr B., who came to the Board's
attention in 1991 following long-term problems associated with the self-administration of narcotics. He
agreed to continue treatment with a psychiatrist of his
own choice, to regular review by a psychiatrist
nominated by the Board, and to thrice-weekly
urinalysis.
Reports from the Board-nominated psychiatrist documented steady improvement in his overall condition
and his cessation of narcotic abuse. The psychiatrist
noted improvement in the doctor's style of practice, in
the management of his own illnesses, and in relationships with his family. The doctor developed an understanding of his vulnerability and of his propensity to
use narcotics when stressed.
At his last interview, the Board concluded that he
should take responsibility for his own well-being and
that supervision should cease. The Board also recommended a return of his authority to prescribe narcotics.
Vol 82, No 2 1995
Early detection, prompt intervention, and ongoing
support will assist an impaired doctor in following his
or her career. Over 100 doctors with psychiatric
problems, self-administration of drugs, or alcohol
problems are currently under Board supervision. Over
the past seven years, the profession has become increasingly aware of this rehabilitation program. Reporting
of impaired practitioners by their colleagues is steadily
increasing, now that it is seen that the Board is acting
positively in assisting these doctors.
ONTARIO, CANADA
CONSENT TO TREATMENT AND
SUBSTITUTE DECISIONS ACTSAN OVERVIEW
MICHAEL E. DIXON, MD
Registrar, College of Physicians and Surgeons
of Ontario
The Consent to 7'reeatment, Substitute Decisions and
AdvocacyActsare to be proclctimed law on April3, I995.
Thefolloaving article offers physicians a basic overview of
some of the likely and most immediate effects of the
Consent to Treatment Act on their practices. It does not
deal with the Substitute Decisions or Advocacy Acts nor
is it intended to be a cornprehensive, all-inclu.rivegaeide
to the Consent to Treatment Act. Other aspects of these
laws will be discussed in future issues of Members'
Dialogue. Some of the ramifications of these lcaivs may
take years and several court decisions to become clear.
Basic Concepts of the Legislation
Physicians have always been expected to discuss treatment alternatives with their patients before seeking
consent for the course oftreatment recommended. The
common law as it pertains to consent has evolved over
the years as a result of a series ofjudgments which have
provided guidance to physicians as to the information
101
patients should receive prior to giving consent. However, provision for dealing with patients incapable of
making decisions on their own behalf, or means for
people to express wishes regarding treatment decisions
they would want made when they become incapable,
did not exist until the passage of this legislation.
The legislation outlines the rights of patients and the
duties of physicians. Unfortunately, its complexity,
coupled with uncertainty about the interpretation of
many sections, as well as the lack ofan adequate number
of rights advisors, will very likely cause serious delays
in the rendering of needed care to the public.
personal care, and other matters described in section 3
of the regulations made under the Consent to Treatment Act.
The legislation provides that patients who are incapable of understanding the risks and benefits of a
proposed treatment involving a controlled act must be
advised oftheir right to see a rights advisor and be given
the opportunity to challenge the physician's finding of
incapacity at a hearing of the Consent and Capacity
Review Board. All this is to take place before their
substitute is asked for a treatment decision.
Unless the incapable person is experiencing "severe
suffering" or is at risk of suffering "serious bodily
harm," no treatment may be given to them [sic] until
the appropriate substitute decision maker is found and
gives consent on the person's behalf.
Important Provisions of the Act
The elements of the common law regarding consent
are specified in the Consent to Treatment Act, which
states that the consent must relate to the treatment, it
must be informed, it must be given voluntarily, and it
must be obtained without misrepresentation. The requirements for consent to be informed are also included. (See Table 1.)
How the Consent Process Works
in a Non-emergeney Situation
Step I: Patient's capability of consenting to the
proposed treatment is determined.
The Act provides criteria to be considered. (See Table
1) If no reason exists to consider the patient incapable
of consenting, the patient is informed about the
proposed treatment and consent is requested.
From Members' Dialogue, The College of
Physicians and Surgeons of Ontario
March 1995
Table 1-Consent is Informed if,
Before Giving it,
the person received the information
about the treatment, alternative courses
of action, the material effects, risks and
side effects in each case and the consequences of not having the treatment that
a reasonable person in the same circumstances would require in order to make
decision; and
the health practitioner responded to the
person's requests for other information
about the treatment, alternative courses
of action, material effects, risks and side
effects, and consequences of not having
the treatment
The definition of "treatment" extends beyond the
usual therapeutic measures to include components of
the physical examination which are controlled acts
(such as a pelvic or rectal exam), as well as any x-ray,
blood test, or invasive diagnostic procedure. However, certain things are excluded from the definition
of treatment, such as the determination of capacity,
the controlled act of diagnosis, the provision of basic
102
Table 2-Criteria for Determination
of Capacity
The person must demonstrate an understanding of:
l. the condition for which the treatment is
proposed
2. the nature of the proposed treatment
3. the risks and benefits of the treatment
4.
the alternatives to the treatment presented
by the health practitioner, including the
alternative of not having treatment
and...
1. the person must be able to acknowledge
the fact that the condition for which the
treatment is recommended may affect
him or her
2. the person must be able to assess how
the proposed treatment and alternatives
to the treatment presented by the health
practitioner, including the alternative of
not having treatment, could affect the
person's life or quality of life
3. the person's choice of treatment must
not be substantially based on a delusional
belief
FEDERATION BULLETIN
Step 2: If patient is found to be incapable of consenting to the proposed treatment, the following actions must be taken:
1. Advise the patient who is 14 years or older that
they [sic] arc incapable.
2. Read the patient a 207 word notice of his or her
rights.
3. Give the patient the completed and signed notice.
4. Ascertain if the patient wishes to see a rights
advisor.
5. Call the rights advisor if patient requests (unless
in a psychiatric facility where a rights advisor must
be called).
Components 2, 3, 4, and 5 of this step are not
required for certain acts that are included in the definition of treatment such as the taking of blood samples,
other than testing for HIV, IV hydration, administration of a substance by injection or inhalation in some
circumstances, and other circumstances described in
Section 7 of the regulations under the Consent to
Treatment Act.
Table 3-Substitute Decision Makers
for Incapable Persons
(in order of authority)
1. Validated attorney for personal care or
appointed guardian of the person if authorized to act for the particular circumstance
2. Unvalidated attorney for personal care if
authorized
3. Representative appointed by the Consent
and Capacity Review Board
4. Spouse or partner
5. Child
6. Parent or, if under 16 years, guardian
7. Brother or sister
8. Other relative
Step 3: If a rights advisor is called, no treatment can
be given other than first aid or temporary assistance
until the patient decides whether to appeal to the
Review Board or until 48 hours has elapsed and no
appeal is requested.
Step 4: If the patient has decided not to appeal, or
the appeal process has run its course and the finding of
incapacity has been confirmed, a treatment decision can
be sought from the substitute decision maker. The Act
ranks substitute decision makers in order of authority.
(See Table 3.)
Step 5: If the substitute decision maker is a family
member, he or she must make a required statement
before giving or witholding consent. (See Table 4.)
Vol 82, No 2 1995
Table 4-Required Statement by Family
Members Before Giving Consent
(May be Made Orally or in Writing)
1. State relationship to the incapable person
2. State belief that incapable person would
not object
3. State belief that no other person claims
authority to make the decision
4. State belief that attorney for personal care
or other representative has not been
appointed
5. State belief that no famiiv member of
higher authority wishes to give or refuse
consent and is available
How the Consent Process Works in an Emergency
Situation
Step 1: Patient's capability of consenting to the
proposed treatment is determined.
Step 2: If patient is found to be incapable of consenting to the proposed treatment and
]„ is experiencing severe suffering, or
2. is at risk, if the treatment is not administered
promptly, of suffering serious bodily harm, and
3. the substitute decision maker is not readily available, then . . .
treatment may be given, pending the availability of the
substitute.
Problem Areas in the Legislation
This article is not meant to be a comprehensive guide
to the Act and, in any case, there are many areas and
situations in which the Act is ambiguous. For example:
1. While consent may be given for a course or plan of
treatment under the Act, it is uncertain which
procedures can be considered part of the plan and
which require a separate consent.
2. The determination of capacity must be done according to specific criteria which may not be possible to observe in all circumstances.
3. Informing patients who are confused, disoriented,
or unable to communicate that they are incapable
and that they have the right to see a rights advisor
and appeal the finding of incapacity will likely be
upsetting and confusing to many of them as well
as time-consuming and disruptive.
4. Whether "severe suffering" and "serious bodily
harm" exist for the purpose of deciding if the
emergency provisions apply will be difficult to
determine without clearer definitions.
103
5. It is unclear how relatives and physicians will find
out if an incapable patient has appointed an attorney for personal care.
6. It is unclear how the office of the Public Guardian
and Trustee will be able to give or withhold consent in a timely fashion when no other substitute
decision maker is available.
7. Children of any age who are deemed incapable of
giving consent can delay treatment by asking to see
a rights advisor and making application to the
Consent and Capacity Review Board.
UNITED KINGDOM
GOVEANMENT COMMITMENT
TO EXPAND GMC POWERS
On 16 March 1995, the Government introduced the
Medical (Professional Performance) Bill. By amending
the Medical Act 1983, the Bill will enable the GMC to
implement the performance procedures which it
proposed in 1992.
Most doctors are doing a good job, often under
difficult circumstances. They will not be directly af-
104
fected. However, the new powers will enable the GMC
to deal with the small number of doctors whose pattern
of professional performance gives rise to serious concern.
Currently, the GMC can investigate allegations of
serious professional misconduct or serious impairment
of fitness to practise due to ill health. But the GMC has
no powers to deal with cases where a doctor's pattern
of performance is seriously deficient.
From The GMC News Review
of the Gcnercal Nfcdicul Council
Winter I994/95
As with conduct, the new procedures will be invoked
only where the allegations are serious. Sir Robert Kilpatrick, President of the GMC, makes the point that
"the key question is whether the alleged pattern of
performance calls into question the doctor's unrestricted registration."
A wide range of organisations, both medical and
non-medical, will be consulted before detailed rules of
procedure are finalised and laid before Parliament. The
need to develop assessment programmes for each
specialty means that the first cases will probably not be
considered by the GMC before 1997.
FEDERATION BULLETIN
FROM OUR MEMBER BOARD EXCHANGES
ARIZONA
stimtilation treatmcnts, ultrasound
therapv, massage therapy, traction treat-
MEDICAL ASSISTANTS: A REVIEW
OF CURRENT RULES
nll'.nCs and applying Transcutaneous
Nerve Stimulation units and hot and cold
packs - 20 hours;
Frnsra the Arizoiia Osteopathic I3ullctin Board
Dacember 1994
On May 3, 1993, the following Administrative Rules
promulgated by the Board became effective. As such,
they have the force of law and are administered in the
same manner as are the Board's statutes. They are
reprinted here in order to remind all licensees of the
Board of their obligations with respect to the employment and use of medical assistants.
R4-22-110 Approval of Educational
Programs for Medical Assistants
A. The Board shall approve an educational progrann for medical assistants when it has
recci\=ed all of the information specified in
paragraph ($ ) { 1) or (2), as applicable, concerning the program and the Board determines that the educational program provides
at a minimum the folio^ving traitiing:
1. Cardiopulmonary resuscitation - 6 hours;
2. Patient assessment techniques, including
blood pressure, temperature, height,
,,veight, administering EKG tests and
administering pulmonary function tests
- 20 hours;
3. Injections and sterile techniques, including blood drawing and specimen collection, administering injections, and
applying and changing dressings on
wounds and injuries - 20 hours;
4. Physical medicine modalities, including
admi ni ste ring wiai ri pool tre atm en ts,
diathermy treatments, electronic galvation
Vol 82, No 2 1995
5. Medical ethics and confidentialitV recluirements - 16 hours.
B. A provider of an educational program for
medical assistants, seeking approval of its
program, shall submit the 1co11owing itcros
to the Board:
i. Copies of all course materials;
2. Class content outlines on a session-bysession basis;
3. Sample examinations for each course;
and
4. A list of all instructors and their qualifications.
C. An individual seeking approval of an cducational program for medical assistants connpleted by that individual after December 31,
1985, shall submit the following items to the
Board regarding the educational program:
1. Name and address of each educational
program provider;
2. A list of the courses taken and a description of the content of each coiirse;
3. Documentation of completion of the
educational program after December 31,
1985; and
4. Any other information which the Board
may require in order to determine that
the educational program meets the reqtiirements ofsubsection (A) and that the
applicant has completed the educational
program.
D. The Board shall not approve an educational
program for an individual if the individual
completed the program prior to Januany 1,
1986.
105
E. Approval by the Board of an educational
program for medical assistants shall remain
valid so long as the program continues to
satisfy the requirements of subsection (A).
R4-22-111 Medical Assistants-Authorized
Procedures
Procedures authorized for medical assistants
to engage in shall include the following:
1. Cardiopulmonary resuscitation;
2. Patient assessment techniques, including
blood pressure, temperature, height,
weight, administering EKG tests and administering pulmonary function tests;
3. Injections and sterile techniques, including blood drawing and specimen collection, administering injections and applying
and changing dressings on wounds and
injuries;
4. Physical medicine modalities, including
administering whirlpool treatments,
diathermy treatments, electronic galvation stimulation treatments, ultrasound
therapy, massage therapy, traction treatments, and applying Transcutancous Nerve
Sti.mulation units and hot and cold packs.
R4-22-112 Qualification of Medical
Assistants
A medical assistant shall be 18 years of age or
older and possess a high school degree or the
equivalent thereof.
R4-22-113 Regulation of Medical
Assistants
A medical assistant, when interacting with a
patient or otherwise working as a medical
assistant, shall wear a name tag which clearly
identifies the medical assistant and states that
the medical assistant is a medical assistant.
R4-22-114 Physician Responsibility
for Medical Assistants
A physician employing a medical assistant shall
ensure that such medical assistant complies with
all statutes and rules applicable to employment
as a medical assistant. A physician who utilizes
the services of a medical assistant to assist the
physician in the practice of medicine shall supervise and be responsible for all actions or failures
ofthe medical assistant relating to the physician's
practice of medicine.
There are also two specific statutory references to
medical assistants, these arc reprinted below:
106
A.R.S. § 32-1800 Definitions
14.
"Medical Assistant" means an unlicensed
person who has completed an education
program approved by the Board, who assists
in a medical practice under the supervision
ofa doctor of osteopathic medicine and who
performs delegated procedures commensurate within the assistant's education and
training but who does not diagnose, interpret, design or modify established treatment
programs or violate any statute.
A.R.S. § 32-1853.01 Use of Title by a Medi.cal.
Assistant
It is unlawful for a person to use the title
medical assistant or a related abbreviation unless the person is working as a medical assistant
under the supervision of a doctor of osteopathic medicine pursuant to rules adopted
by the board.
This information is provided in order to remind
physicians licensed by the Board of the rules regarding
medical assistants. Individuals desiring additional information regarding this topic are asked to contact the
Board's office.
BOARD PROPOSES NEW RULES
FOR SPECIALTY CERTIFICATION
In August 1992, the Board adopted as an administrative rule the following language regarding specialist
designation:
R4-22-102 Specialist Designation
A specialty board approved by the Board includes only those specialty boards recognized
by the American Osteopathic Association and
listed in the Yearbook and Directory of the
American Osteopathic Association, 1991,
page 643, or the American Board of Medical
Specialties and listed in the Annual Report and
Handbook of the American Board of Medical
Specialties, June 1994, page 103, which are
incorporated herein by reference and on file
with the Office of the Secretary of State.
In application, this rule precludes physicians who are
certified by specialty boards not affiliated with either the
A.O.A. or the AS.M.S. from advertising or holding
themselves out to be specialists, and in conjunction with
A.&S. § 32-1854(17), makes such a representation or
advertisement an act of unprofessional conduct.
Since adoption of this rule, the Board has heard from a
large number of physicians who take issue with the rule
FEDERATION BULLETIN
and who have claimed that it is unduly restrictive and
does not recognize that there may be legitimate specialty certifying boards, or entities, which are not affiliated
with either the A.O.A. or the A.B.M.S. Their arguments, upon review, have been shown to have merit,
and the Board thus sought some means of addressing
this issue. The method chosen was that of developing
amended wording for the current rule, a decision which
led to the following language being drafted:
R4-102 Approyal of Specialty Certifying
Organizations
A specialty board or certifying organization
which seeks to be approved by the board shall
comply with the following criteria and shall
submit documentation thereof to the board:
l. The organization has been granted
501 (c) status under the Internal Revenue
Code;
2. The organization has full time administrative staff;
3. The organization has bylaws, a code of
ethics to guide the practice of its members, and an internal review and control
process, including budgetary practices;
4. The organization is national in scope and
has, as a central purpose, the credentialing of physicians;
5. In granting certification, the organization shall establish and maintain procedures to ensure that any examination
administered by, or on behalf of, the
organization after the adoption and certification of this rule:
a. Is of sufficient breadth and scope to
cover the specialty field;
b. That the examination(s) and answers
thereto are maintained in a secure environment with access restricted to
persons authorized by the organization to have access thereto;
c. That a standard pass/fail grading system has been established in advance of
administration of the examination;
d. That proctoring of examinations is
done by independent proctors who do
not have any personal, professional, or
financial association with those individuals being examined;
e. That the granting or denial ofcertificadon is based upon objective performance, skill, and merit of the
candidate as determined by measured
performance on the certification examination(s);
Vol 82, No 2 1995
6. The organization has a demonstrated interest in the continuing proficiency of its
members, by requiring periodic recertifscation and/or documentation of attendance at continuing medical education
programs as well as continued practice in
the field of certification.
Interested individuals who wish to comment on the
proposed rule may send their comments to the Board
office. All comments received will be incfuded in the
Board's rule making record, and copies will be provided
to all Board members. Following review for form and
approval by the Governor's Regulatory Review Council
{G.R.R.C.}, the proposed rule will be considered for
adoption by the Board. This will be done during a
regularly scheduled Board meeting, most likely in March.
Actual scheduling of this will be set at a later date, with
notice ofthe Board's action on the proposed rule included
in the Notice of Meeting published by the Board. At that
meeting, the Board may entertain comments on the
proposed rule, prior to considering it for adoption. If the
Board votes to adopt the proposed rule, it must be sent
to the Attorney General for review, and then to the Office
of the Secretary of State for certification. Following this
latter action, the rule will be effective, and shall be
enforced by the Board.
Editor's Note: See page $3 for more information on this
subject.
ARKANSAS
PRACTICING MEDICINE IS A PRIVILEGE
W. RAY ]OUETT, MD
Member, Arkansas State Medical Board
From The Arkansas State
Medical Board Newsletter
Fall/Winter 1994
Practicing medicine is this state is considered to be a
privilege rather than a right. But, before this privilege
is granted, a physician must go through an in-depth
credentialing process. You may ask, why such an extensive search into the educational, professional, and moral
background? The answer is simple, to maintain the
high standard of health care this state has supported for
many years.
In recent months, the Board has been questioned by
physicians who are recruiting new doctors to their area as
to why the Board cannot bypass a portion of the
credentialing standard and quickly license a physician
that is badly needed in their area. This question comes
107
especially when the physician has a license in another
state. The reason is: in recent months, the Board has
been informed by the Federation of State Medical
Boards of known applicants who go throughout the
United States using fraudulent names, education,
and work experience to position themselves in unsuspecting areas of need. One such applicant who
possessed falsified credentials had no actual medical
education at all.
The benchmark of all state medical boards is its
credentialing process. How seriously it is taken, how
aggressive and how demanding the process may be, all
depend on the philosophy of the Board. The Arkansas
State Medical Board conducts its own credentiaiing
process and takes it very seriously.
from four to eight
The application process can
weeks, depending on the length of time required to
receive verifications back from the originating source.
The license application is an all inclusive packet with
instructions outlining all requirements necessary for
licensure. The applicant completes all forms and mails
them to the originating source for verification. These
verifications are mailed direct to the Board office to
eliminate the possibility of information being altered.
When all verifications have been received in the office,
the application is presented to the Board for review and
vote. The office cannot present the application to the
Board until the application is complete and all verifications are returned.
Because verifications are accepted from the originating source, credentialing of graduates of foreign medical schools takes a longer period oftime due to the poor
communications and mail service in those countries.
Direct
regarding medical education and
postgraduate training is essential and cannot be substituted.
Temporary permits are given on occasion after the
application has been completed and is waiting to be
presented to the Board at the next meeting. That
permit is good only until the close of the next meeting.
There is one admonition that every recruiting physician
and applicant should give special attention. NO API'LICANT IS GUARANTEED A LICENSE even if
they have been given a temporary permit. A license can
only be granted by a vote of the full Board. It is for this
reason, when you are recruiting a physician, you are
warned to encourage them not to put themselves in
debt before a license has been granted. We have had
several physicians who have moved their family and
purchased a home only to be denied a license. No one
wins in this situation, the Board, the applicant, and you,
the recruiting physician and community.
The Board does not wish to appear unsympathetic,
but licensing an individual as a physician to practice
medicine and treat the citizens of Arkansas is not taken
108
lightly. Unfortunately, the credentialing process, not
by choice, will become even more restricted.
When you are recruiting physicians to your area, keep
this in mind. Plan ahead, ask the physician to contact
the Board office in their initial interview with you
and/or your hospital. Remember to consider the
credentialing process before making your schedule for
the new physician to begin seeing patients and making
rounds.
The process is not difhcuit; however, it is time consuming.
KENTUCKY
NEW CONTINUING MEDICAL
EDUCATION REGULATION
From the Kentucky Board of Medical
Licensure Newsletter
Winter 1995
Since the mailing of the 1995 Annual Renewal Forms,
the Board's office has received many phone calls from
physicians or their staff requesting information on the
new CME regulation. To highlight the most frequently
asked questions, the Board is providing the following
information:
When does the cycle begin? The first cycle began
January 1,1994, and will end December 31,1996. The
next cycle will begin January 1, 1997.
Will CME credits acquired before January 1, 1994,
be acceptable? No, credits must be earned during the three
(3) year cycle, January 1, 1995-December 31, 1996.
What are the new CME requirements? Sixty {60}
hours of CME every three years, with thirty (30) hours
being certified in AMA Category I by an organization
accredited by the Accreditation Council on Continuing
Medical Educarion and thirty (30) hours ofnon-supervised
personal learning activities. These can include selfinstruction, audio-visual materials, television and radio
broadcasts, programmed medical education materials,
consultation, use of databases and other computerbased materials, patient care review, self-assessment,
teaching, articles, publications, books, exhibits, and
CME lectures and seminars. Two (2) hours of the total
sixty {60} must be acquired in HIV/AIDS courses
approved by the Cabinet for Human Resources pursuant to 902 KAR 2:I fi0.
What documentation should I send to the
Board? Do not send documentation to the Board
unless requested, although it is important that you
have documentation on hand to provide if you are
audited.
Do retired physicians have to comply in order to
maintain an active license? Yes, all physicians holding
FEDERATION BULLETIN
a current Kentucky license are required to complete the
sixty (60) hours of CME.
Should I call the Board with questions concerning CME category approval? No, the KBML is not
responsible for Category approval and does not maintain this information. For category approval, please
contact the Kentucky Medical, Association's CME
Department (502) 426-6200 or the American Medical
Association (312) 464-4672. For a list of HIV/AIDS
approved courses, contact the Cabinet for Human
Resources,AIDS Program Education (502) 564-6539.
Other inquiries may be submitted to the Board's headquarters office.
LOUISIANA
THE MEDICAL RECORD-CHANGING,
ALTERING, AND DESTROYING
HENRY K. THREEFOOT, MD
Physician Consultant, Louisiana Medical Mutual
Insurance Company (LAMMICO)
From the Losaisiranca State Board
ofMedical Examiners Newsletter
Febrrsasy 1995
Although lawyers are frequently accused of being the
primary cause of lawsuits, the medical record in many
cases is the determining factor. Patients will ask an
attorney to review the medical record when they have
an adverse outcome or an unexpected complication.
The lawyer searches the record for errors, omissions, or
commissions. He or she is not necessarily looking for
negligence but for items that may influence a judge or
jury or make the physician's case easy to attack or
difficult to defend. The defense attorney depends on
these records to defend the physician. With good
medical records, the lawyer can often have the case
dismissed. The Louisiana State Board of Medical Examiners also has to rely on the medical record to make
decisions.
Changes and alterations in the record are important
items that the plainriffattorney looks for in the pursuit
of a malpractice claim.
■ What is the difference between maldng "changes" and making "alterations"? In medical
malpractice risk management jargon, there is a
great difference. Changes are corrections made
prior to any filing of a lawsuit. They are acceptable
and may be helpful. Alterations are any corrections or additions to the medical record after a
malpractice claim has been filed. They are completely unacceptable.
Vo182, No 2 1995
• What is the correct way to change a statement
in the record? Simply draw a single line through
the wording you wish to change. Enter the new
wording, date it, and initial it. Do not obliterate
the previous wording. Do not black out, white out,
cut out, or erase anything previously recorded. An
addendum to the record may be made by adding
the desired information and referring to the previous
data you v6sh to correct or expand upon. Date and
sign the addendum.
• When can a correction be made? A correction
can be made at any time if it is beneficial to the
care ofthe patient. However, corrections can never
be made after a claim has been filed. It then
becomes an alteration of the medical record.
■ Who alters medical records? Most physicians who
alter medical records have no fraudulent intentions.
They are well-meaning physicians who want to clariii,
the content, making it more understandable to
readers such as the judge, jury, or Board of Medical
Examiners. Often, when the physician reviews the
record, he or she realizes that others will be unable
to decipher the meaning of the record. There are also
physicians who may panic and alter their records
based on feelings of anxiety. Either way, the alterations lead to dire consequences.
• What are the consequences of altering the
record? Regardless of any circumstance, altering
the record is the most damaging action a physician
can take against his defense. A case that was defensible may suddenly become indefensible, causing
all to be lost for the physician.
• How should medical records be handled after
a suit is filed? Physicians should copy, sequester,
and secure the originat record. They should not
add, delete, or change anything.
■ How long must medical records be kept?
Louisiana law requires office records to be kept for
a minimum of six years from the date of the last
treatment and graphic materials to be kept for at
least three years. Hospitals retain records for at
least ten years.
■ How should medical records be destroyed?
Medical records must be destroyed by shredding
or incinerating.
Imagine yourself sitting in a court room. A ten-foot
screen rolls down from the ceiling, and your medical
record is projected onto that screen. Think about this
scenario every time you or one ofyour office staffmakes
a new chart and when you make entries into the record.
If you do, you may never need to change your records
or make amendments, and you will likely never be
tempted to alter one.
The medical record is your legal guardian. Take care
of it so that it can take care of you.
109
NEVADA
PHYSICIAN ASSISTANT PRESCRIBING
From the Maryiand BPQA Newsletter
ofthe Maryland $oard ofPlrysician
Qua.lity Assrcrance
March 1995
The authority for Physician Assistants to write medication orders in an institutional setting came under question in March 1992. Since that time, several attempts
have been made to correct this through the legislative
process, the last being House Bill 1527 introduced in
the 1994 legislative session. This legislation was
defeated, and the legality of PAs' being permitted to
write medication orders remained in limbo. The BPQA
has always maintained that it has the ability to delegate
this function by regulation; however, to make certain
that there was a legal basis for this, BPQA asked Nelson
Sabatini, past Secretary ofHealth and Mental Hygiene,
to request a formal opinion of the Attorney General.
Opinion #95-004 dated February 1, 1995, in summary
states: "The Board has authority to adopt a regulation
specifying the circumstances under which the job description of physician assistants may incl.ude prescribing. A
regulation may not authorize physician assistants to dispense prescription medicines, however."
Accordingly, BPQA, through its advisory committee,
has begun the process of promulgating regulations to
permit physician assistants to be able to write medication orders in a hospital or state/local correctional
facility.
Initially, it is likely that prescribing authority will be
granted for PAs working in hospital and institutional
settings where there are multiple levels of oversight
inherently in place. Unless the PA's job description
specifically allows for prescribing authority, the
physician supervisor may not delegate this aspect of
medical care to a PA. As has always been the case, PAs
may not legally use presigned prescriptions. Our goal
is to have these regulations in place by July 1995 in
order for BPQA to begin processing the expanded job
description applications for those PAs who wish permission to write medication orders. In the interim, and
until these regulations are in place, there is no express
authority for PAs to be prescribing in any circumstance.
In addition, PAs may not give out prescription medications to patients, including samples of medications.
110
CONTINUING MEDICAL EDUCATION
REQUIREMENT
The Nenada State Board
of Medical F_xaminers NEWSI.ETTEA
April 1995
Each physician licensed after the beginning of a period
of biennial registration must, if he was licensed during
the:
(a) First six months of the biennial period of registration (July 1, 1993, through December 31, 1993),
complete 40 full hours of continuing medical education;
(b) Second six months of the biennial period of
registration (January 1, 1994, through June 30,1994)
complete 30 full hours of continuing medical education;
(c) Third six months of the biennial period of
registration (July 1, 1994, through December 31,
1994) complete 20 ful.i hours of continuing medical
education; or
(d) Fourth six months of the biennial period of
registration (January 1, 1995, through June 30,1995)
complete 10 full hours of continuing medical education.
Any physician licensee who has completed a full 12
months of residenry or fellowship any time during the
period for biennial registration immediately preceding
the submission of the application for biennial registration is exempt from the requirements above-
oxEGON
THE BME AND PRBSCRFBIl;TG
HARVEY KLEVIT, MD
Medical Director, Oregon Board ofMedical Examiners
From the BME REPORT
ofthe Qregvn Board ofMedical Examiners
Spring 1995
This rarticle will rrddress the Board's crsrrent position with
regard to the use of controlled sacbsaances in: 1) cbronic
"non-malignarat" paitr; 2) pain resulting from pnalignancy and in terminally ill patients; and 3) appetite
control in the treatment of obesity.
FEDERATION BULLETIN
The Use of Controlled Substances in Chronic
Non-malignant Pain
The Oregon Medical Practice Act defines inappropriate
prescribing as follows:
"Prescribing controlled substances without a
legitimate medical purpose and without fnllowing
accepted procedures for examination of patients
and record keeping."
In the'80s and early'9Us, inappropriate prescribing
of controlled substances represented the Board's leading investigative and disciplinary problem. This is no
longer the case and probably represents a combination
of a change in physician prescribing behavior and an
increase in the number of other types of public complaints, particularly quality of care and physician/
patient relationship issues.
The BME Report has not dealt with the issue of
prescribing controlled substances since 1992, following a conference held in Portland, "The Rational Use
of Controlled Substances in the Management of Pain."
Kathleen Foley, MD, a nationally recognized authority
in pain management, stated that "patients can obtain
comfort from prolonged opiate use; most patients will
have unchanged or improved function, it is uncommon
for patients to experience adverse efFects, and while
patients may demonstrate physical dependence, it is
very different from addiction." She reassured that
physicians need not shy away from chronic use of
opiates because of fears that cognitive function will be
impaired. She suspects that physicians have been eschewing chronic use of opiates for fear of regulation
and concern about effectiveness and adverse pharmacologic outcomes.
The Board holds that in general it is inappropriate to
treat pain of non-malignant origin with narcotics on a
routine basis, but accepts the fact that there are certain
patients who will benefit and not be harmed from judicious long-term opiate use. It is imperative with these rare
patients to have a clear diagnosis utilizing appropriate
specialist consultation when necessary. Close monitoring
of the patient and meticulous attention to record-keeping
goes without saying. It is important to bear in mind that
most patients suffering chronic pain can be successfully
weaned from their medication." . . .
When the Board investigates complaints of inappropriate prescribing of controlled drugs for chronic
non-malignant pain, they are interested in several important areas:
• What is the diagnosis and how well was the patient
studied?
■ Have other medical, surgical, and ancillary treatments failed prior to instituting opiate treatment?
• Is there an attempt to maintain the patient on the
lowest dose possible to achieve relief and improve
function?
Vol 82, No 2 1995
• Is there frequent and regular follow-up?
■ Is there good documentation of refills on the
medical record?
• Is there an attempt to ascertain if the patient is
receiving prescriptions for controlled substances
from other physicians?
• Have medical reports been requested from previous physicians?
• Has a referral to a specialist in pain management
been considered?
When the Board explores the above, it sometimes
finds the physician to be "rusty" in other areas of
medical practice. It is not unusual for the Board to
order a competency examination when this is the case.
Pain Management in Acute Conditions
and in Terminal Illness
In their zeal to avoid "over-prescribing" of opiates in
patients with chronic non-malignant pain, some
physicians have inappropriately limited narcotics in
individuals with other medical and surgical conditions.
Concern about iatrogenic addiction and scrutiny by the
Board should not preciude adequate postoperative pain
control. The Board encourages physicians to hone their
skills in the latest techniques for control of acute
self-limited episodes of pain.
Moreover, the BME firmly believes that physicians
have a duty to provide maximal comfort levels and
alleviate suffering in their dying patients in a skillful and
compassionate manner. This may require large doses of
narcotics that should not be withheld on the basis of
physiologic parameters such as falling blood pressure,
altered consciousness, and diminished respiration.
The BME is concerned that fear on the part of
physicians may result in ineffective pain control and
unnecessary suffering in terminal patients.
The Use of Appetite Suppressing Drugs
Recent changes have been made in the Administrative
Rules governing the use of controlled anorexogenic
agents. These drugs are Schedule IV and are sympathomimetic amines related to the amphetamines.
Recent studies have indicated that they may be useful
temporary adjuncts to the treatment of exogenous
obesity. They include phentermine (Ionamin and Fastin) and diethylpropion-HCL (Tenuate).
The salient features of the revised "Bariatrics Practices" are as follows:
■ Schedule II or III controlled substances may not
be utilized for weight control.
• A Schedule IV appetite suppressant may be used
for purposes ofweight reduction for the treatment
of exogenous obesity as part of a program including dietary restriction, behavior modification, and
prescribed exercise, if weight exceeds by 20% the
111
upper limits of national weight/height standards
and/or the excess weight represents a threat to the
patient's health.
• For continuation of treatment with a Scheule IV
appetite suppressant beyond three months, there
must be documentation of an average weight loss
of two pounds per month during active treatment
of maintenance of goal weight.
The Board expects that clinicians employing these
agents will perform a proper history and physical examination and appropriate studies to determine ifthere
are any contraindications to the use of any of these
agents.
RHODE ISLAND
NEW LAW AND REGULATIONS IMPACT
"UTILIZATION REVIEW"
BRUCE W. McINTYRE, JD
Board Counsel, Rhode Island Board of Medical
Licensure and Discipline
From the Rhode Island Department of Health
Bulletin Board of Medical Licensure
and Discipline
Fall 1994
Managed health care plans are required by Rhode
Island law to employ a medical director to make final
decisions regarding the prospective or concurrent
"utilization review" ofa health care provider's services.
By law and regulation, the Department of Health has
established jurisdiction over both the entities conducting utilization review and the professional licensees
conducting the review.
A dramatic expansion of utilization review agents
nationally and in Rhode Island led providers and
patients to seek regulations which standardize certain
requirements for "gatekeepers" (medical directors who
approve or deny payment for provider services) and
their managed care employers. The primary purpose is
to protect patients and providers by ensuring that
review agents are qualified to perform utilization
review activities and to make informed decisions on the
appropriateness of medical care. Another goal is to
ensure that a mechanism is in place for enrollees to
appeal adverse decisions.
Bitter disputes have erupted between two major
groups. On one side are managed care staff reviewers
(who approve or deny payment in the first instance)
and medical directors (who review the decisions, usually denials, of staff reviewers). The other group are
health care providers and their patients. Providers and
112
patients have complained that the reviewers lack the
expertise and training to conduct the utilization reviews
properly. They also state that decisions are made capriciously, especially in the area of psychiatric services.
Some highlights of the utilization reveiew statute,
R.I.G.L. 23-17.12-1 et. seq., and rules and regulations
(R23-17.12-1-UR), are noted below.
The law mandates that all persons conducting utilization review must obtain a certificate to do so from the
Department of Health. Those review agents who have
been conducting such activities before the filing of the
Department of Health's rules and regulations may
continue to review utilization of services pending the
procesing of an application (filed prior to January 1,
1994) and approval of the review agent.
Notification of prospective or concurrent adverse
determinations for coverage must be communicated to
the patient and to the provider of record within one
business day of the receipt of all the information necessary to complete the review. The notice shall include:
a) the principal reasons for adverse determination;
b) the procedures to initiate an appeal of the determination;
c) the name and telephone number of the person to
contact with regard to an apeal;
d) information in avr itira8 to the patient and provider
on the right to an appeal within a reasonable period of
time after otherwise communicating to them their right
to an appeal.
The statute and the regulations specify two levels of
"internal" (ic, conducted within the utilization review
agency itself) appeals process for the patient and
provider. In both cases, the physician reviewer is
responsible for determining the outcome, documenting and signing the determination. Expedited reviews
must be provided at the initial and second level appeal
by the review agency if the case is deemed an "emergency" as defined by regulation. "Emergency" means
the unexpected onset of symptoms of an injury, condition or illness which, if not treated immediately, could
result in a serious impairment or loss of life.
Such new and significant regulatory requirements
pose problems of understanding and implementation.
An important contribution to clarification has been
provided by the American Medical Association's Council on Ethical and Judicial Affairs, which issued a report
in July of 1994 concerning "Ethical Issues in Managed
Care." The paper discusses many important considerations such as the patient-physician relationship, ethical
concerns in conflicts among patients, preserving the
physician's role in managed care, and patient autonomy
and responsibility. An important ethical concern is the
patient's physician's responsibility to recommend treatment and advocate for the patient's right to treatment
where material benefit to the particular patient would
FEDERATION BULLETIN
result. This means that physicians ought to challenge the
denial of care and argue for the provision of treatment in
a specific case. Similarly, if the managed care guideline is
unfair in its general operation, the Council says that it is
the physician's duty to advocate for a guideline change at
the health plan's policy-making level. The statute requires
that such guidelines be developed with the input of
practicing physiaans.
Obviously, it is difficult to act as doctor, appeal
advocate, and health care policy maker with every
patient. Some managed health care entities have made
practicing advocacy more difficult by "deselecting"
providers who have complained "too much" about the
managed care entity's decisions.
The Board of Medical Licensure and Discipline has
determined that the activities of the medical director or
a licensed medical review agent constitutes the practice
of medicine as defined by R.I.G.L. 5-37-1.1. The
Board retains jurisdiction over the professional activities of licensed physicians conducting utilization
review. A physician's fai.lure to conform to the requirements of the utilization review statute or the rules and
regulations of the Department of Health regarding
utilization review may be considered "unprofessional
conduct" and may be grounds for discipline.
Anyone conducting utilization review is urged to
become familiar with the rules and regulation and
statute regarding this process. Licensees are expected
to be familiar with the standards in the area in which
they practice, including utilization review.
GOVERNOR SIGNS LANDMARK SEXUAL
MISCONDUCT LAW FOR MENTAL HEALTH
PROFESSIONALS
BRUCE W. McINTYRE, JD
Board Counsel, Rhode Island Board of Medical
Licensure and Discipline
Psychiatrists and other mental health professionals
are now required to report to the proper state licensing board a suspicion that another mental health
professional may have had sexual contact with a
patient or former patient. The reporting requirement
for psychiatrists or other mental health professionals
is activated when reasonable cause to suspect it is
present.
This new law, which went into effect on July 12,
1994, codifies for psychiatry a standard used by the
Board of Medical Licensure and Discipline. The Board
has always held that sexual contact between physician
and patient during the existence of the doctor/patient
relationship is "unprofessional conduct." The Board,
to date, does not have a mandatory reporting requirement for physicians other than psychiatrists.
Vol 82, No 2 1995
The duty to report is contingent on the patient's
desire to have the sexual contact reported. The law also
places a duty on those who "holds himself or herself
out to be a mental health professional" if the patient
wishes to report it. Failure to report is cause for
discipline by the state licensing board or the department of attorney general with a$5UQ fine as a penalty.
Immunity from liability for reports made in good faith
is provided in the statute. It also provides for confidentiality of reports.
Definitions of "patient, former patient" and "sexual
contact" are broad and should be reviewed carefully by
psychiatrists and other mental health care providers. As
an example, patient is defined as "a person who obtained a professional consultation or diagnostic or
therapeutic service from a mental health professional-"
"Former patient" is defined as anyone who obtained
these services within two (2) years of the sexual contact
with the mental health professional.
"Sexual contact" is also given sweeping definition and
provides that consensual sexual contact is not a defense.
It includes all types of intercourse as well as sustained
kissing on the mouth and intentional touching of
specified body areas, whether clothed or unclothed.
Also proscribed by the act is using the influence in the
provider/patient relationship to induce the patient or
former patient to engage in a sexual contact with a third
Party
The Board of Medical Licensure and Discipline
wishes to reaffirm the position of this Board and every
board nationwide that sexual contacts between doctor
and patient during the existence of the doctor/patient
relationship is "unprofes'sional conduct" and may be
grounds for serious disciplinary action.
WYOMING
INSURANCE UTILIZATION REVIEWIS A LICENSE TO PRACTICE MEDICINE
AEQUICRED?
From the Wyoming Board of Medicine
NEWSLETTER
Fiall 1994
Insurance utilization review ofinedical claims generates
daily controversy and concern for patients and
physicians across Wyoming. The process through
which insurance carriers review, analyze, and decide if
a procedure is covered under a medical liability policy
often results in patients being told their policy will not
cover a specific medical process. Patients worry that
they may not be able to afford a procedure their
physician indicates is necessary, and physicians become
113
angry and frustrated because their professional judgment is second-guessed or overridden. The problem
grows particularly acute when the individual refusing
coverage for the procedure is not a physician.
knowledge, and diagnosis, the carrier may be managing
the care of a patient or treating them, and those actions
may constitute the practice of medicine for which a
medical license is required under the statute.
To finally determine if these actions constitute the
practice of medicine, the Board seeks an appropriate
case to take to District Court on a declaratory judgment
action.
Are these reviewers practicing medicine? Should they
be licensed in Wyoming? Does the Board's mandate to
help assure Wyoming citizens receive good quality
medical care enter into such situations? The Board of
Medicine thinks the answers to these questions are
"yes" and is looking for an appropriate case to illustrate
this position.
The Wyoming Medical Practice Act deems that an
individual is practicing medicine ifhe or she "prescribes
or provides medical diagnosis or medical treatment for
human disease, injury, deformity, ailment, pregnancy
or delivery of infants;" W.S. 33-26-102 ( a)(x)(B).
"Diagnosis is defined as the art of distinguishing one
disease from another," white "treatment means the
management and care of a patient for the purpose of
combating disease or disorder."
[Such an action allows "any person ... whose right,
status or legal relations are afected by . . . a statute ...
[to] have any question of construction or validity arising under the instrument determined and obtain a
declaration of rights, status of other legal relations."
W.S. 1-37-103.] An appropriate case for declaratory
judgment requires a medical diagnosis and treatment
plan by a Wyoming physician that is then reviewed and
refused by an insurance carrier. The case requires a
patient's death as a result of the denial and documented
refusal or denial from the carrier. The documentation
can be tape-recorded or written.
The Board believes that when a representative of an
insurance carrier denies coverage ofa specific procedure
after that procedure has been recommended by a
physician whose judgment is based on patient history,
Ifyou have such a case, the Board would like to review
and discuss it with you. Please contact the Board at
307-777-6462 or at 208 Barrett Building, Cheyenne,
WY 82002.
114
FEDERATION BuLLETnv
MEDICOLEGAL DECISIONS
Recent medicolegal decisions involving or of interest to medical boards. Reprinted from THE
CI7'A7T0N:
SECTION 1: MEDICAL BOARDS
Licensure Proceeding Not Defectioe .... A claim
brought by a physician whose license had been
suspended against an administrator for the Colorado
Board of Medical Examiners and a state assistant attorney general was dismissed by a federal trial court for
Colorado.
In their ufj"aLBaL capacities, . . . the program
administrator and the prosecrsting attorney
were imtnssne frovn liability.
Since 1984, the physician, a reviewer ofinedical charts
for the Social Security Administration, was licensed to
practice medicine in the state of Colorado. In May
1992, he was informed in writing [that] the Board of
Medical Examiners had initiated a complaint against
him. He was requested to respond to the complaint and
to undergo an evaluation by the Colorado Physician
Health Program within 20 days. He responded in a
letter to the Board that his medical practice did not
involve patient care and that he objected to the charges
against him. In June, he followed up by sending the
Board a letter in which he declared his belief that his
constitutional rights were being abridged. His license
was suspended one week later. He requested a hearing,
which took place six weeks later and resulted in upholding the suspension. The physician sued, alleging his due
process rights had been violated by the Board's program administrator and by the prosecuting attorney, a
state assistant attorney general.
The trial court dismissed his claim. In their official
capacities, it held, the program administrator and the
prosecuting attorney were immune from liability. The
physician's contention [ that] the assistant attorney
general had not acted in a prosecutorial capacity in this
Vo182, No 2 1995
case had no merit in the court's view. Duties in disciplinary proceedings, the court ruled, must be considered
"functionally comparable" to duties carried out in a
court of law. - Coraraolly vs Beckett, 863 F.Supp.1379
(D.C., Co., March 23, 1994)
SECTION 2: OTHER HEALTH
PROFESSION BOARDS
Dentist Disciplined for Providing False Infortnation ... A finding by the State Board of Dental
Examiners (Board) that a dentist had engaged in
dishonorable conduct was affirmed by an Iowa appellate court.
A couple practiced dentistry together in a small town.
The Board brought disciplinary proceedings against
the wife and found she had incompetently caused 15
filling overhangs, including seven gross overhangs;
misdiagnosed decay on several patients; left behind
large amounts ofcalculus after cleaning patients' teeth;
left a large distal defect under a porcelaia-fused-tornetal crown; and ordered a partial denture to be placed
over diseased abutment of teeth. She was put on
probation for two years and ordered to complete a
comprehensive continuing education program. Before
the Board had made its decision, the husband sent out
a letter to the couple's patients informing them [that]
the wife was to be reprimanded for "a minor thing
called an overhang on a filling" even though he knew
that to correct overhangs it is sometimes necessary to
completely replace the filling under anesthesia.
The Board learned oftbe letter and detmaesinrd
that it constituted Ild%sbonorable tonduct'
on the part oftbe basband.
Additionally, he failed to mention in the letter the
other matters for which the wife was being disciplined
and misrepresented both the findings of the Board and
the opinion of the expert witness who testified on the
wife's behalf at her disciplinary hearing. The Board
115
learned of the letter and determined that it constituted
"dishonorable conduct" on the part of the husband.
After conducting a hearing, the Board took no further
disciplinary actions despite the fact such conduct was
in violation of state law.
The husband appealed, maintaining the statute which
the Board found he had violated was unconstitutionally
vague and overbroad. The court held the language of
the statute was sufficiently clear and the potential ofthe
statute for the chilling of free speech was very small in
relation to its legitimate sweep in regulating the professional conduct of licensed dentists. The court affirmed.
- Wettach vs. Iowa Board of Dental Exarnitaers, 524
N.W.2d 168 (Iowa Sup. Ct., November 23, 1994}
SECTION 3: OTHER ISSUES
OF INTEREST
Physician Guilty of Filing False Claims ... The
conviction of a physician on 18 counts of submitting
false claims to the government was upheld by a federal
appellate court for Colorado.
The physician was a licensed obstetriciangynecologist who worked at an army hospital as a
civilian partner of the Civilian Health and Medical
Program for the Uniformed Services (CHAMPUS).
According to the agreement between the partners,
CHAMPUS was to provide the physician with facilities,
supplies, equipment, and nursing staff. In exchange,
the physician agreed to bill CHAMPUS at 60% of its
prevailing rate for his treatment of service people insured under the program. At some point it was revealed
he was billing the government for procedures performed by other physicians or even for procedures
which were never performed. Eventually,. he was
charged with and convicted on 18 counts ofsubmitting
false claims to the government.
... he was billing ti6e®overnmeaatfnr procedures
by other pFiysicians or even for
procedures mbich were neyer performed.
On appeal, the physician maintained an instruction
to the jury on "deliberate ignorance" was erroneous.
The instruction stated the jury could infer the
physician's knowledge of his wrongdoing "if (he)
deliberately blinded himself to the existence of a
fact." The physician claimed he had been given the
impression by his immediate superior that his billing
practices were appropriate, and in any case he had
never tried to evade discovering whether his billing
practices were improper. The court found the
evidence did not support his assertions. Other
physicians and patients, it pointed out, had brought
objections to him on the matter of billing for services
which he did not perform.
116
Additionally, he had never discussed his billing practices with the colonel actually in charge of the administration of CHAMPUS at the army hospital,
though they did discuss on three occasions complaints
brought to the colonel alleging the physician was overly
concerned about money. Under the circumstances, the
court found the jury instruction adequate, and affirmed. - United States vs. Custodio, 39 F.3d 1121
(C.A. 10, Co[o., November 8, 1994)
Chiropractor Guilty of Medicaid Frau.d . . . A
chiropractor was guilty of Medicaid fraud but not
insurance fraud, an Ohio appellate court ruled.
In 1984, the chiropractor entered into a provider
agreement with a state welfare agency under which he
agreed to treat welfare recipients covered by Medicaid.
Shortly afterwards, he entered into another provider
agreement with an insurance company. In 1990, the
insurance company began investigating the chiropractor's billing practices. A police investigation ensued, leading to the chiropractor's arrest in January
1991 on charges of Medicaid fraud, insurance fraud,
and theft. At trial his motion for acquittal was denied.
He was convicted in March 1992 of insurance fraud of
more than $300 but less than $5000. He was found
not guilty on the theft charge. His motion for a new
trial was denied. He was ordered to pay the attorney
general's office $21,242 and the insurer $6141, and
was sentenced to concurrent sentences of one year and
one and a half years for the insurance fraud and the
Medicaid fraud.
The bulk of the clriropractor's actions took place
before the eaaractment of the insYCrance frarsd
statute under w,bich he was convicted.
On appeal, the court upheld the conviction on
Medicaid fraud, but reversed the insurance fraud conviction. The bulk of the chiropractor's actions took
place before the enactment of the insurance fraud
statute under which he was convicted. The constitutionality of finding him guilty of insurance fraud
in excess of $300 was in question. Though there was
evidence to suggest he submitted nine false claims in
the amount of $358 after the enactment of the statute,
there was never any finding at trial that all these claims
were false. The court struck down the insurance fraud
conviction. - State vs. Dolce, 637 N.E.2d 51 (Ohio
Ct. of App., December 30, 1993)
The Citation is a medicolegal digest published by
Citation Publishing Corporation, Long Grove,
Illinois. To subscribe, call 800-626-5210.
FEDERATION BULLETIIV
REVIEW
Alternative Medicine: Expanding Medical
Horizons
EBEN ALEXANDER, rA, MD
Professor Emeritus
Bowman Gray School of Medicine
This book is a gold mine of information about
alternative medicine. In 1991, the Senate Appropriations Committee appropriated $2 million for an office
"to more adequately explore unconventional medical
practices." As such, the Office ofAlternative Medicine
was established, and its first goal was to develop a
baseline of information on the state of alternative
medicine in the United States.
A series ofworkshops was held in 1992, and eventually more than 200 participants were assembled at several
meetings and editorial committees were appointed to
follow certain guidelines in publishing this comprehensive volume.
Alternative Medicine: Expanding Medical
Horizons, NIH I'ublicatim No. 94-066.
372 pages. Decem6er I994.
Although this volume is surprisingly uncritical of the
medical profession of the United States, there are
elements of criticism, such as the change of advice to
pregnant women from recommending no supplementary vitamin therapy during pregnancy to stipulating
the use of vitamins, particularly folic acid. A similar
reference notes the fact that x-ray treatment was once
considered. a form of quackery, whereas it is now well
accepted. These are scarcely strong criticisms, since, in
fact, the changes were the result of much improved
systems of treatment or the development of pieces of
equipment.
The main reference to traditional medicine's failure is
the fact that although medicine has developed some
remarkably effective forms of treatment for many illnesses, injuries, and disabilities, more than 30 million
Vol 82, No 2 1995
Americans are ftinctionally limited in their daily activities by chronic debilitating conditions such as
arthritis, allergies, pain, hypertension, cancer, depressison, cardiovascular disease, and digestive problems.
These chronic diseases are scarcely the most easily
treated, and are very commonly treated by various
forms of alternative therapy. In other parts of the
world, the excellent forms of traditional medical
therapy which are available in the United States are
scarcely available in many nations, thus, folk remedies,
herbal remedies, and various other forms of treatment
are widespread.
The organizational report broadly covers four main
subjects of alternative therapy. The first is the
psychological and spiritual category (often referred to
as mind-body) that includes practitioners who use
psychological techniques, such as mental imaging, hypnosis, and art therapy.
The second major section is diet and nutrition, including those who recommend dietary supplementation
with vitamins or minerals and prescribe specific diets
for certain conditions.
The third, the drug and biological category, comprises specialists at the use of assorted chemicals, drugs,
serums, and vaccines.
The fourth category involves treatment by physical
force and devices, including chiropractic, massage and
touch therapy, acupuncture, and practitioners of
various elecrrotherapies.
The unbiased attitude of almost all the contributing
authors who try to present the material as factually as
possible, with proper references, is impressive. However, there is one protest in Appendix B: "Comments
of the Panel on Mind-Body Interventions on the National Research Council's Reports on Alternative
Medicine" that objects to the statements made in the
text regarding these areas.
The entire volume is a well-written, easily read, and
attractive book without illustrations. There are copious
references, as many as 200 to 400 after each section,
arranged alphabetically. However, this does enhance
117
the "gold mining" potential in this volume; enough
references are made to various forms of treatment that
one can look to these references and read the material
in a subject which interests him. If one is interested in
a specific subject, it is easily found through the index,
and although there is a good deal of repetition, as must
be in the form that the book is written, it is not
aggravating and can be accommodated easily in the
reading.
One example of the usefulness is the reference to
chelation therapy for heart disease and arteriosclerosis.
Many state licensing boards have been concerned about
this treatment; it seems to have a poor scientific basis,
and it is difficult to get additional information from the
American Heart Association or from the National
Library of Medicine. However, the reference to chelation therapy in this volume (p. 163) gives an excellent
discussion of the subject, including mention of a randomized study that was terminated because of Desert
Storm; it could still be carried out. No conclusion is
made, but it is impressive that this particular information is available and that so many patients have been
118
treated in the United States with apparently some
satisfaction. Almost no form of treatment-including
ortho-molecular medicine as advised by Linus Pauling,
acupuncture, Avurvedic medicine, homeopathic
medicine, neuropathic medicine, environmental
medicine, or native-American-Indian forms of treatment-is left out.
This book has been written by educated people who
are conscientiously seeking to give information and
show rather little bias to distort the issue. From the
point ofview of an allopathic physician, it is an excellent
authoritative source for almost all alternative medicine
methods, and from the point of view of this reviewer,
it is of considerable value as a reference text.
To order, send a check or money order for S25 per
copy, or send a VISA or MasterCard number and card
expiration date to: Superintendent ofDocuments, P.O.
Box 371954, Pittsburgh, PA 15250-7954. Order must
specifv stock number S/N 017-040-00537-7. (Price
includes shipping and handling.)
FEDERATION BULLETIN
LETTER TO THE EDITOR
Response to Dr. Weed's Questions
and Answers on Reengineering Medicine
priman, care physicians who need help to
know when to refer, something that usually
To the Editor-There is no argument with Dr. Weed's
contention that current medical education and delivery
are flawed and could be improved. However, I fear Dr.
Weed's solution would not be good enough to overcome the complex challenges faced by students and
practitioners to understand and use the ever-increasing
knowledge base.
Understanding "knowledge nuggets" or "facts"
depends upon language. How many understand the
professional lingo of genetics, immunology, and computer software. An array of facts in a computer file does
not mean they can be understood and used even if
coupled, if the words used are not understood.
Guidelines for management of clinical situations are
dependent upon correct observation of such items as
cardiac murmurs, abnormal lymph nodes, the presence
of depression when it is not a complaint, macular
degeneration, and rashes, before questions can be asked
of a knowledge base. Patient variability is hard to cover
in a guideline. If guidelines try to cover all exigencies,
they often become meaningless. There is not much
information on the co-morbid conditions in the aged.
For patient outliers who do not fit guidelines, subjective
impressions from skilled specialists from different fields
of knowledge can, through an interactive concurrent
consultation, suggest helpful management options
especially when objective information is limited. Such
subjective impressions may be most important when
the end points are vague.
It would be better to seek to focus on computer
guidance for specific problem areas such as
Is there randomized trial evidence that problemoriented and organized record systems and computerbased knowledge bases have reduced morbidity or
mortality, with or without coupling? If not, can the
managers of professional health services (big health
insurance companies) be "sold" on the need to support
the development of services such as Dr. Weed is
promoting?
Apparently there is current software for coupling. Is
it available to try?
is not even taught.
1, screening for patients with variable risks for
heart attacks, stroke, or cancer
2. medical oncologists who often face different
issues because the basic diagnosis usually is
made by the time of referral and therapeutic
options become a problem
Vol 82, No 2 1995
Robert W. Frelick, MD
Consultant for Chronic Diseases,
Delaware Division of Public Health
Wilmington, DE
Dr. Weed Responds to Dr. Frelick
To the Editor-We appreciate Dr. Frelick's concerns.
Because the scope of the articles in the Federation
Bulletin did not allow for extensisve elaboration, we
suggest that, for more in-depth explanation, Dr.
Frelick refer to the book Knowledge Coupling: New
Premises and New Tools for Medical Care and Education (New York, NY: Springer-Verlag; 1991) by
Lawrence Weed and to the publication "ProblemKnowledge Couplers: Philosophy, Use, and Interpretation" (Burlington, Vt: PKC Corporation; 1982)
by Christopher Weed.
In answer to the closing question: Yes, the software
is available. Please contact the PKC Corporation, Burlington, Vt, at 802-658-5351.
Lawrence L. Weed, MD
PKC Corporation
Burlington, VT
119
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