BOARD OF PHYSICIAN QUALITY ASSURANCE NEWSLETTER
Volume 6, Number 1
PHYSICIANS HOTLINE FOR PAIN MANAGEMENT STARTS MARCH 1
Physicians may access a free consultant with expertise in pain management by calling 1-800-492-3805 after March 1, 1998. This service is being offered to assist physicians facing difficult pain management decisions who may feel uncomfortable prescribing medications for patients in pain because they lack expertise and training in pain management.
The idea of a toll free hot line grew out of the recognition that many patients may receive inadequate pain control because of physician reluctance to use medications such as morphine, even when clinically indicated. Studies have shown that pain management is a primary issue in palliative care and that patients often fear the pain of the dying process more than dying itself.
With these issues in mind, Dr. Michael Gloth obtained an unrestricted educational grant from Purdue Frederick Company, and organized physicians from around the state who were Board Certified in Hospice and Palliative Medicine to serve as a resource to physicians who wish immediate consultation on pain management in palliative care.
Dr. Gloth will be the "first call" physician for the first month of the program to iron out any problems that arise. Physicians calling can expect to be called back by the on call physician within 15 minutes. Physicians who respond through the Emergency Medical Resource Center will be covered by the Good Samaritan law. Should the program be a success, efforts will be make to continue the program and expand it to other states. "We plan to collect some information on the nature of each call," says Dr. Gloth. This basic data on the type of pain problems being addressed and some demographic data will be used to help assess the effectiveness of the program.
Mr. Jack Schwartz of the Office of the Attorney General for the State of Maryland points out that the Supreme Court has emphasized the right of patients to obtain adequate control of pain even when the treatment may shorten the patient's life. The Board of Physician Quality Assurance is also concerned that fear of sanction by the licensing board may deter physicians from meeting their patients' needs for relief from pain. By alerting physicians of the hot line resource, the BPQA is demonstrating its strong support for physicians dealing with difficult problems in pain management.
Dr. Gloth is the Medical Director for Carroll County Hospice and Chief of Geriatrics at Union Memorial Hospital. He is certified in Hospice and Palliative Medicine by the American Board of Hospice and Palliative Medicine.MARCH 98 NEWSLETTER
ALLIED HEALTH INFORMATION
On October 1, 1997 the regulations governing the Writing of Medication Orders (COMAR 10.32.03) expired. In their place, Health Occupations Section 15-302(d) was implemented. Of particular note to PAs who wish to apply to write medication orders is a change in the CME requirement.
As of October 1, 1997 the provisions of Section 15-302(d)(1)(iii) require that Physician Assistants who apply for authority to write medication orders under an approved job description must provide evidence of:
1. Certification by the National Commission on the Certification of Physician Assistants, Inc. within the previous 2 years; or
2. Successful completion of 8 CME Category I hours in pharmacology education within the previous 2 years.
Documentation of NCCPA certification or CME hours must accompany the application form.
The Physician Assistant Advisory Committee meets the second Wednesday of the month at 4:00 PM. If you would like an item placed on the agenda, please submit the item in writing two weeks in advance of the meeting. Items received after the deadline will be placed on the next month's agendaMARCH 98 NEWSLETTER
MEDICAL RADIATION TECHNOLOGISTS and
NUCLEAR MEDICINE TECHNOLOGISTS
Subsequent to the recent certification renewal, a random audit of CME hours is being performed. In the event that you are audited, you will be required to show documentation of 24 hours of relevant continuing education earned during the 2 year period preceding the renewal.
Relevant continuing education means inservice programs at a hospital or related institution or HMO certified by the State. Additionally, programs relevant to the practice of medical radiation technology or nuclear medicine technology which have been approved by any of the following organizations are acceptable: American College of Radiology or its chapters; Maryland Society of Radiologic Technologists; Maryland Association of Nuclear Medicine Technologists; Maryland Society of Nuclear Medicine; American Medical Association; and Medical & Chirurgical Faculty of Maryland.
The Medical Radiation and Nuclear Medicine Technology Advisory Committee meets the third Wednesday of the month at 4:00 PM. If you would like an item placed on the agenda, please submit the item in writing two weeks in advance of the meeting. Items received after the deadline will be placed on the following month's agenda.MARCH 98 NEWSLETTER
May 1998 is renewal time for respiratory care licensees. Recently enacted legislation, supported by the profession, authorized the licensure of Respiratory Care practitioners. This authority has resulted in a change in fees. Regulations effective August 25, 1997 changed the renewal fee to $135.00
The August 1997 regulatory changes also affected the continuing education requirement. Current regulations require 16 Category I hours. However, for the 1998 renewal only, 8 hours of Category 1 and 8 hours of Category II CME's will be accepted. Following the renewal, the Board will perform a random audit of CME hours. In the event you are audited, you will be required to show documentation of the required CME hours.
Category I CME means programs approved by the MD/DC Society for Respiratory Care, American Association of Respiratory Care, Medical and Chirurgical Faculty of Maryland, or other organization or institution having requirements equivalent to the above organizations as recommended by the Committee and approved by the Board. Category II CME means in-service training at a hospital or related institution or a HMO certified by the State. The continuing education requirement applies to all renewal applications after the first renewal.
The 1998 renewal form will contain two new items of importance. First, the Board will be requesting a public address and a confidential address from licensees. This is in anticipation of the allied health professions addition to the on-line directory of physicians licensed by the BPQA. See article on page 4, for a detailed explanation of the private/confidential address issue. The other new matter of importance is the inclusion of a licensee satisfaction survey. As the Board's "customers", your satisfaction with our services is important to us. We encourage you to take a moment to complete the survey because your input will help us in our ongoing efforts to improve our service to you.
Renewal applications will be mailed the week of April 20, 1998. Please keep in mind that there is no grace period. Should your license not be renewed on time, i.e. postmarked midnight May 30, 1998, you may become unlicensed.
The Respiratory Care Professional Standards Committee meets the second Thursday of the month at 2:30 PM. If you would like an item placed on the agenda, please submit the item in writing two weeks in advance of the meeting. Items received after the deadline will be placed on the following month's agenda.MARCH 98 NEWSLETTER
Questions, concerns or agenda items should be addressed to the respective committee. Mail, fax or email your requests to the Board office at 4201 Patterson Avenue, Baltimore, MD 21215, via fax at 410-328-2252; or e-mail to BPQA@erols.com. We also encourage you to visit our web site for ongoing information about your respective profession. The Board's web site address is: www.docboard.org.
BOARD DISCIPLINARY ACTIONS
OCTOBER - DECEMBER 1997
DAVID LEE JOYCE, M.D., License #D45028, Specialty: Obstetrics/Gynecology (Annapolis, MD) Summary Suspension. The Board has reason to believe that the physician is guilty of immoral or unprofessional conduct based on his relationship with a patient and that the case required emergency action. Effective 10/22/97
ARLAND PRESTON, RCP, Applicant for Certification (Baltimore, MD) Application for licensure denied. The applicant "fraudulently or deceptively" attempted to obtain a certificate. Effective 10/22/97
FELIX A. WICKREMASINGHE, M.D., License #D43618, Specialty: Family Practice (Chillicothe, OH) Suspension. The Board found the physician was not competent to practice medicine based on an order of the State Medical Board of Ohio which found that he suffered from alcohol dependency and also may represent a risk to himself or others. Effective 10/22/97
GIDEON KIOKO, M.D., License #D08283, Specialty: Obstetric/Gynecology (Washington, DC) Modified Final Order. The physician petitioned for a modification of his order of May 28, 1997, and the Board determined that the physician shall not perform outpatient abortions after eighteen (18) weeks of gestation. Effective 10/29/97
DANIEL F. KRANK, M.D., License #D07172, Specialty: Psychiatry (Silver Spring, MD) Stay of Suspension; one year of probation subject to terms and conditions. The physician has completed the conditions precedent to the stay of suspension. Effective 10/29/97
PETER A. ANYAKORA, M.D., License #D42994, Specialty: Obstetrics/Gynecology (Wauchula, FL) Revocation. The physician was found guilty in New York of refusing to treat a patient arriving at a general hospital to receive emergency treatment; two counts of falsifying hospital medical records and one count of tampering with physical evidence. Effective 11/5/97
NDUBUISI K. OKAFOR, M.D., License #D43460, Specialty: Internal Medicine (Bowie, MD) Suspension for six (6) months, effective 12/31/97, with conditions; after a stay of the suspension, probation for three (3) years subject to terms and conditions. The Board found the physician guilty of immoral and unprofessional conduct because the physician engaged in a sexual and social relationship during the course of a patient's medical treatment. Effective 11/19/97
NEAL I. ARONSON, M.D., License #D00150, Specialty: Neurological Surgery (Baltimore, MD) Reprimand with conditions. The Board concluded that the physician failed to meet standards of care with regard to seven patients in his prescribing practices in his practice of Neurological Surgery. Effective 11/19/97
VIBHAKAR J. MODY, M.D., License #D15351, Specialty: OB/GYN (College Park, MD) Suspension for six (6) months; suspension stayed; probation for two (2) years subject to terms and conditions. The Board concluded that the physician failed to meet the standards of care regarding the obstetric care provided to a patient and had further violated the medical practice act in regard to patients seen at the physician's office when the physician was not present and arrangements had not been made for another physician to cover his routine office practice. Effective 11/19/97
DONA M. ALVAREZ, M.D., License #D38801, Specialty: Orthopedic Surgery (Oakland, MD) Suspension for two (2) years with all but the first three (3) months stayed; probation for three (3) years subject to terms and conditions. The physician breached the standard of care by operating on the wrong leg and acted unprofessionally and willfully made or filed a false report or record in the practice of medicine by making changes to the patient's medical record. Effective 12/3/97
SHEO P. SHARMA, M.D., License #D22638, Specialty: Obstetrics/Gynecology (Reisterstown, MD) Reprimand; probation for one (1) year subject to conditions. The physician failed to meet the standard of care with respect to a patient in his practice of obstetrics. Surrender of License. Effective 12/3/97
SUTHAM P CHARLESTHAM, M.D., License #D19962(I) Specialty: None (Moreno Valley, CA) The surrender is in lieu of license suspension and for being disciplined in California in 1996 for excessive distribution of controlled dangerous substances. Effective 12/17/97
DAVID LEE JOYCE, M.D., License #D45028, Specialty: OB/GYN (Annapolis, MD) Suspension for two (2) years subject to terms and conditions; in the event of reinstatement, probation for three (3) years subject to terms and conditions. The Board concluded that the physician was guilty of unprofessional conduct in the practice of obstetrics and gynecology. Among other things, the Board found that the physician had a intense intimate relationship with a patient. Effective 12/17/97
THE BOARD'S DISCIPLINARY ACTIONS ARE A MATTER OF PUBLIC RECORD.
A COMPLETE COPY OF ANY FINAL ORDER MAY BE OBTAINED BY CALLING 410-764-2475. THERE IS A SMALL FEE TO COVER THE COST OF COPYING THE DOCUMENT.MARCH 98 NEWSLETTER
The BPQA Web-Site at www.docboard.org lists all licensees and states whether or not there has been a disciplinary action.
DENISE MCKAIN, P.A., Certificate #: C01671, Specialty: Physician Assistant (Lanham-Seabrook, MD) Administrative fine of $500 for practicing with a lapsed certification. Effective 10/3/97
STEPHEN D. BROWN, M.D., License #: D38300, Specialty: Orthopedic Surgery (Glen Burnie, MD) Administrative fine of $500; terms and conditions with regard to incomplete CME requirements. Effective 10/22/97
MICHAEL D. DARDEN, M.D. , License #: D29247, Specialty: Pediatrics; Allergy Immunology (Hyattsville, MD) Administrative fine of $500; terms and conditions with regard to incomplete CME requirements. Effective 11/19/97MARCH 98 NEWSLETTER
PHYSICIAN ADDRESSES ON LINE
During the past few months, the Board of Physician Quality Assurance has made changes in the information available to the general public as they surf the internet. On December 17, 1997, several decisions were made by the Board which will provide the public with physician information through the internet and at the same time assure the physician fair treatment regarding the information available to the public.
Realizing that an address of record can be problematical for physicians who choose to use a home address rather than a hospital address for mailing purposes, the Board has developed a new bifurcated address system. Beginning immediately with all initial licensees and continuing through all subsequent renewal periods, physicians will be asked to provide the Board with two addresses. The first will be the address of record which will be available to the public and the other, a non-public address. The other will be the mailing address or location where the physician will receive mail. This second address will be non-public. Currently, on BPQA's web-page, only the physician's City and State address information is displayed. All street address information has been eliminated for the time being.
On page 5 of this newsletter a change of address form is provided. If any physician or allied health care professional regulated by the Board would like to have a mailing address changed or have a public address of record revised, we encourage the use of this form. Please return the signed form in order to have address information updated. The address is: Board of Physician Quality Assurance, 4201 Patterson Avenue, Baltimore, Maryland 21215-0095.
All renewal packets as well as initial medical application packets will include this two level address system.
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
BOARD OF PHYSICIAN QUALITY ASSURANCE
4201 PATTERSON AVE. P.O. BOX # 2571 BALTIMORE, MD 21215-0095
Phone (410) 764-4777 TDD FOR DISABLED
Fax (410) 358-2252 MD Relay Service
1-800-735-2258 MARCH 98 NEWSLETTER
CHANGE OF ADDRESS FORM
Mail to BPQA, Information Systems Division
4201 Patterson Avenue, Baltimore
License #: _____________________________________________________
Address 1 _____________________________________________________
Address 2 _____________________________________________________
City _______________________ State ___________________________
Zipcode _____________________ Foreign Country ___________________
Non-public Address (Confidential):
Address 1 _____________________________________________________
Address 2 _____________________________________________________
City ________________________ State ____________________________
Zipcode _____________________ Foreign Country ____________________
Please Note: Original signature is required.MARCH 98 NEWSLETTER
PHYSICIAN RESPONSIBILITIES IN CARING FOR
ELDERLY AND CHRONICALLY ILL PATIENTS Steven Levenson, M.D., President, Maryland Medical Director Association
Expectations for physician performance in long-term care and subacute care settings include providing necessary medical coverage and supervision, including adequate, responsive covering physicians; visiting patients in a timely fashion, determined by their overall condition and their care plan; providing necessary documentation and signatures; and completing outstanding medical records within the required time frame.
The Maryland Medical Directors Association (MMDA), the State Chapter of the 6,000-member American Medical Directors Association (AMDA), represents medical directors and attending physicians across the long-term continuum in Maryland, including nursing facilities and subacute settings. A primary objective is to improve the medical care rendered to frail elderly and other chronically disabled individuals served in these settings. Physicians should be aware of the substantial regulatory accountability of these settings, and the concerns within the industry about obtaining physician cooperation.
The MMDA has identified some simple steps by which physicians can help provide better care and at the same time help protect themselves and the facilities from potential legal liability. These are also consistent with recent policy position statements from the AMA regarding physician responsibility across the spectrum of care.
For various reasons, providing care to those of any age with chronic illness and disabilities is a great challenge for physicians. Some physicians do an outstanding job despite these challenges and various other obstacles.
However, overall physician participation in the long-term and subacute care continuum has traditionally been uneven and often highly problematic. Physicians should recognize that we are in a new era, requiring accountability and appropriate performance across the continuum, not just in selected settings.
Therefore, physicians should identify the special knowledge and skills required to provide effective long-term and subacute care, and consider whether they are sufficiently committed to do it well. These generally well founded principles focus especially on detection of treatable problems that will make a difference in quality of life, on secondary and tertiary prevention, and on circumstances where aggressive medical interventions may not be indicated. They are readily understandable and not too numerous, and are increasingly reflected in clinical standards and practice guidelines. A physician who does not agree with these care standards or does not wish to abide by them or to follow relevant regulations and laws, should consider transferring his or her patients to another physician.
In addition to acute illness, comorbidities and functional dependency are highly relevant to the outcomes and the cost of care in various settings. Certain syndromes (collections of signs and symptoms), which often have readily discoverable, treatable cause, afflict those of any age with multiple chronic conditions or disabilities. Medication complications, interactions, and side effects are well-known causes of often preventable illness and hospitalization. Problems left unaddressed in one setting simply add to the burden and cost of care inherited by another setting. A physician should cooperate with others to assess and manage these problems such as undernutrition, incontinence, and confusion. For instance, delirium (acute confusional state) is a proven risk factor for further morbidity and mortality in every setting. A physician who is only involved with one aspect of a person's care does not have to manage all aspects of care, but must at least ensure that these other non-acute medical problems are addressed, and that current treatments are not themselves causing other preventable problems. Physicians also should inform patients or substitute decision makers of all appropriate alternatives for such decision making, consistent with applicable laws and regulations. Laws, judicial decisions, and medical standards all support the rights of individuals to choose to withhold or withdraw treatment, depending on their values or wishes. While some individuals cannot make a decision and so defer to their physician, most individuals or substitute decision makers want to, and can, make decisions when given correct information and proper guidance.
A physician who does not agree with the potential right to withhold or withdraw treatment or who does not intend to abide by the federal Patient Self-Determination Act or Maryland's Health Care Decision Act should inform his or her patients of such, and should offer to transfer those patients to another physician. The physician should not simply impose a treatment, or imply that it is ethically wrong to withhold or withdraw treatment under appropriate circumstances.
Finally, physicians should be aware of organizations and other opportunities for receiving support and information about their roles and responsibilities within the broad non-acute care spectrum. For further information about the Maryland Medical Directors Association, please call 410-685-0687 or write to P.O. Box 451, Riderwood, MD 21139-0451.
1. Ouslander, J.G., Osterweil, D., Morley, J. 1997. Medical Care in the Nursing Home (2nd ed.). New York: McGraw-Hill.
2. Levenson, S.A. Subacute and Transitional Care Handbook. (St. Louis: Beverly-Cracom), 1996.
3. Levenson, S.A. (ed). Medical Direction in Long-Term Care: A guidebook for the Future. (Durham, N.C.: Carolina Academic Press), 1993. MARCH 98 NEWSLETTER
THE DETERMINATION OF MEDICAL NECESSITY
It is the opinion of the Board of Physician Quality Assurance (the "Board"), that the act of determining medical necessity or appropriateness is the practice of medicine and must be made by a Maryland licensed physician. As in all physician-patient interactions, these medical decisions must be documented in an adequate medical record which includes the rationale for the medical decision.
Making determinations of medical necessity or appropriateness of care requires independent medical judgment that should be reserved for physicians. Furthermore, the individual who makes the decision must be responsible for ensuring that the decision made is within the boundaries of the community standard.
An individual who makes a determination of medical necessity or appropriateness or any medical evaluation of care which affects the diagnosis or treatment of a patient in Maryland, and who does not possess a Maryland medical license may be acting in contradiction to the Maryland Medical Practice Act and may be subject to penalties. MARCH 98 NEWSLETTER
On December 29, 1997 amendments to Regulation .12 Advertising under COMAR 10.32.01 became final. The changes allow physicians to advertise in more specialty areas and clarify what constitutes prohibited advertising. Prohibited advertising includes advertisements that contain statements that cannot be verified by the Board for truthfulness, and statements advertising discounted or free services when an additional charge for services will likely incur within 72 hours. The new regulations recognize the specialties identified by the Board before 1996 when the specialty identification program ended.
For a copy of this Regulation, please contact Carol Johnson at 410-764-4780. A complete copy of the Medical Practice Act including Regulations will be available at a cost of $10 per copy this spring.MARCH 98 NEWSLETTER
ANNOUNCEMENT TO ALL LICENSED PHYSICIANS
Pursuant to § 14-202 of the Health Occupations Article of the Annotated Code of Maryland, the Medical and Chirurgical Faculty (the "Faculty") is hereby advising all licensed physicians in Maryland that, as of July 1, 1997, there will be two vacancies on the Board of Physicians Quality Assurance that are to be filled by the Governor from a list submitted by the Faculty. Appointees from this list are required to be practicing licensed physicians It is not a requirement for BPQA membership that the physician be a member of the Faculty.
The BPQA is the state agency with the authority to license physicians and other health care providers such as physician assistants, cardiac rescue technicians, EMT-Paramedics, medical radiation technologists, nuclear medical technologists, respiratory care practitioners, and psychiatrist assistants to practice medicine in Maryland, and to discipline licensees who violate the Maryland Medical Practice Act.
All practicing licensed physicians with an interest in serving as a member of the Board of Physician Quality Assurance are encouraged to apply and should do so by submitting their names to the following address:
The Medical and Chirurgical Faculty of Maryland
1211 Cathedral Street
Baltimore, MD 21201
The submission should include certification that the interested party is a practicing licensed physician.
In May, a ballot listing the names of all qualified applicants will be mailed to each licensed physician as part of the BPQA News, the quarterly newsletter of the BPQA . Candidates will be invited to submit a CV and a brief (less than 125 words) statement. The mailing will include directions for balloting.
Further information may be obtained from the Faculty offices at the above address.MARCH 98 NEWSLETTER
NEW WAYS TO EARN CME CREDIT
Effective October 7, 1996, new regulations became effective which provide two new ways to earn Category I CME credit. A physician may earn up to a maximum of 10 credit hours for a 2-year period of service performed under the auspices of a peer review, focused professional education or physician rehabilitation committee.
Effective October 20, 1997, the Board also recognizes a service performed as a preceptor to medical students in LCME accredited medical schools and to postgraduate trainees in accredited training programs as a source of Category I CME credit. A physician may earn up to a maximum of 10 credit hours per 2-year period for providing these services.
For more detailed information regarding these new ways to earn and document these CME's, please contact the Board at 410-764-4777 or 1-800-492-6836 or via e-mail to BPQA@erols.com and request a copy of the current CME requirements.MARCH 98 NEWSLETTER
PHYSICIAN LICENSURE RENEWAL TIME
Physicians whose last names begin with the letters A-L must renew their medical licenses before September 30, 1998. The renewal applications are mailed in late June to the last address the physician supplied to the Board. Please notify the Board if you have not received your renewal application by the middle of July. Earning 50 Category I CME's is a requirement for renewal. If you are unsure of what constitutes Category I CME's, contact the Board and request a copy of the CME regulations. Please also pay close attention to when your CME's should have been earned and how long you should keep the documentation.
Physicians whose renewal applications are not postmarked by September 30, 1998 are no longer licensed to practice in Maryland. In the two month period following expiration of licensure, the Board will accept the renewal form with the renewal application fees and a $50 late fee. Until their licenses are renewed, physicians who file late applications are not authorized to practice medicine. Any physician who does not renew the license by the end of the two month period will have to reinstate the license.
There will not be an increase in the licensure fee for this renewal.MARCH 98 NEWSLETTER