BOARD OF PHYSICIAN QUALITY ASSURANCE NEWSLETTER
Volume 5, Number 3
NEW LAWS GO INTO EFFECT OCTOBER 1, 1997
Several new laws will take effect this fall which apply to physicians and allied health providers. Perhaps most licensees will be affected by changes to the Medical Records Act. Among the amendments is a clarification of the definition of the medical record to include documentation of examination of a patient regardless of who requests the examination or who pays for it. This clarifies that independent medical examinations, often done at the request of an attorney to evaluate an assertion of persistent injury or disability, are part of the patients medical records and should be made available to the patient upon request. This change in the statute resolves a long-standing controversy regarding whether these examinations are considered part of the attorneys work product or part of the patients medical record, with the General Assembly weighing in for the latter. Similarly, insurance examinations should be made available to the examinee upon request.
The Medical Records Act was further amended to specify that requested medical records should be provided within 21 working days of receipt of request. This is consistent with previous BPQA policy which has held that four-weeks was a "timely" response to a patient request for records production. Further, the law now specifies explicitly that disclosure of the medical record may not be delayed or denied due to an outstanding bill for prior services.
Physicians are required to provide for the maintenance of medical records upon the discontinuance of their practice. This provision was necessitated by numerous complaints patients have made that they cannot locate their medical records upon their physicians retirement or relocation. The BPQA Disciplined one physician last year who left medical records behind when he moved to another state. Subsequently, when the lease on his building expired, the landlord dumped the abandoned records into the alley behind the suite where they lay exposed to the elements and eyes of anyone who cared to read them.
The disciplinary authority of BPQA has been further clarified through the addition of several grounds to the Medical Practice Act under which BPQA can take action against a licensee. These include:
* Intimidating or influencing a witness for the purpose of causing a person to change or withhold testimony.
* Preventing or delaying another person from making information available to BPQA.
* Intentionally misrepresenting credentials when rendering an expert opinion.
* Failing to keep adequate records.
ADDITIONAL NEW LEGISLATION
The following legislation was signed into law by the Governor and is slated to take effect on October 1, 1997. This legislation will have an impact on physicians and allied health professionals regulated by the Board of Physician Quality Assurance
SB 636 "Child Support Enforcement Procedures" requires the BPQA to suspend or deny a license of a licensee, upon notice from the Child Support Administration that an individual is in arrears by more than 120 days when the Child Support Administration has been the assignor of debt.
HB 1110 "Physician Assistants Termination of Employment Reporting Requirements" requires an employer of a physician assistant to notify the BPQA of any termination of a physician assistant if the cause for termination was related to quality of care.
HB 1323 "Health Occupations Physician Assistants Medication Orders" authorizes physician assistants working in hospitals, public health facilities under the auspices of the Department of Health and Mental Hygiene, correctional facilities, and detention centers to write medication orders under an approved job description and in accordance with facility protocols. The bill also changes the educational requirements for all applicants who have graduated after October 1, 2003 to a bachelors degree or its equivalent.
If you are interested in obtaining more information about the above legislative initiatives, please call Marie Savage at 410-764-4782.
REGISTRATION AND REREGISTRATION OF UNLICENSED MEDICAL PRACTITIONERS - Code Of Maryland Regulations (COMAR) 10.32.07
In Maryland, all medical school graduates who are working in a postgraduate program in any health care entity must be registered and on record with BPQA. The Code of Maryland Regulation 10.32.07 allows a medical school graduate to practice medicine without a license only in an accredited training program and only under a written training program contract with the providing institution in Maryland. The Chief of Service of the institution providing the accredited training program is responsible for the registration and reregistration of unlicensed medical practitioners with the Board within thirty (30) days of the effective date of the training program contract between the institution and the unlicensed medical practitioner. Failure to register the unlicensed medical practitioners by the applicable deadline date may result in a violation of Md. Code Ann., Health Occ. §14404(a)(3) and (18) (1996).
To obtain a copy of the regulations and/or a copy of the application for registration/reregistration of an unlicensed medial practitioner, please call the Board at 410-764-4777. Any other questions regarding unlicensed medical practitioners should be directed to Ellen Douglas Smith at 410-764-2477.
WHEN MULTIPLE DOCTORS FAIL, WHOS TO BLAME?
The case: When Dr. A., a family practitioner, hears bilateral carotid bruits in his 60 year old patient, Mr. John Doe, he refers Mr. Doe to Dr. B., a vascular surgeon. Dr. B. confirms that Mr. Doe needs an angiogram and arranges pre-admission testing. The testing on Mr. Doe includes a chest X-ray which shows a mass compatible with a neoplasm. Dr. C., the radiologist, notifies Dr. B. of the abnormal chest X-ray finding by fax the same day. Mr. Doe is scheduled to discuss his test results and proposed surgery a few days hence. On the morning of his appointment with Dr. B., Mr. Doe is shoveling snow and suffers an acute myocardial infarction. Dr. D. , Mr. Does cardiologist, admits him to the hospital. He reviews a portable chest X-ray done in the emergency room and is satisfied that his patient is not in congestive heart failure. Dr. E., the hospital radiologist, reads Mr. Does film and again notes the 2.5 x 1.5 c.m. density in the right apex. In the body of his report, Dr. E. states that this apical density could represent a parenchymal neoplasm.
Mr. Doe is then seen by Dr. F., a second vascular surgeon, who recommends coronary angioplasty. The abnormal chest X-ray is noted and a CT of the chest is recommended to be done later. Dr. F. dictates a report containing this suggestion and a copy of the consultation is sent to Dr. A. Subsequently, Mr. Doe is transferred to another hospital for emergency cardiac catherization. In the transfer summary, dictated by the resident, Dr. G., there is no mention made of the abnormal chest findings or recommended evaluation. When, post angioplasty, Mr. Doe continues to have chest pains, Dr. H., yet another vascular surgeon, is consulted at the second hospital because Dr. F. does not have privileges there. Dr. H. suggests delaying carotid endarterectomy surgery due to the patients recent myocardial infarction. Upon discharge, Mr. Doe is instructed to see his primary care physician, Dr. A., the cardiologist, Dr. D., and the new vascular surgeon, Dr. H.
A few months later, Mr. Doe starts the whole process over again. He goes to the hospital for preadmission physical and chest X-ray prior to his scheduled neck surgery. The preoperative evaluation is done by a nurse practitioner, Ms. !. The radiologist, Dr. J., again notes the chest X-ray abnormality but the medical record contains no other comment about this finding. Subsequently, anesthesiologist Dr. K. recommends a 6-week delay in surgery due to the recent MI and Dr. D. sends Mr. Doe home.
Six weeks later, Mr. Doe starts the whole process over again, with a preoperative physical and chest X-ray. Dr. H. notes the abnormal chest X-ray finding in the patients chart, operates on Mr. Does neck, and schedules him for two postoperative visits. Mr. Doe follows up with Dr. H. as an out-patient two and ten weeks later.
Over the ensuing six months, Mr. Doe is seen by a number of his physicians, none of whom have communicated to him the his chest X-ray findings require further evaluation. When Dr. A. subsequently sees Mr. Doe for a respiratory infection, bronchospy is scheduled. A poorly differentiated small cell carcinoma with multiple bony metastases is diagnosed. Mr. Doe files a malpractice action against the physicians involved in his care.
Enter the BPQA: Unfortunately, cases like Mr. Does come to the Board with some frequency. In this case, a focused peer review was requested from Med-Chi and each physicians contribution to the delay in diagnosing Mr. Doe was evaluated.
This case is illustrative of the difficulties physicians face in communicating important findings when multiple physicians are involved, unexpected events occur, and no one has appraised the patient that there is an unresolved issue that must be addressed.
How could the delay in diagnosis of Mr. Does cancer have been averted?
The following are some suggestions which might have helped Mr. Doe:
1) When there is an abnormal finding, include the patient in the dialogue.
2) Dont bury important information in the body of a letter or report.
3) Develop a system that insures that all reports are reviewed by the physician before they are filed in the chart.
4) Assume the worst: the fax wont go through, the mail wont arrive,the report will be filed without being read, and act accordingly. When a significant and unexpected finding is uncovered, CALL the primary care physician to be absolutely sure that he/she know of your concern, in addition to faxing or mailing your report or consultation.
5) Red flag important problems in the chart, especially if there is going to be a delay in evaluation of the problem and theres a chance you might forget. Use colored markers to highlight the problem.
6) When the patient fails to come for a follow-up visit, review their record. Call patients to reschedule if there are significant unresolved issues.
7) When multiple physicians are involved, communicate with the other doctors on the case regularly.
8) Take the necessary time to be thorough. Review the patients records and follow-through. Remember, patients are putting their lives in your hands.
EPILOGUE: After careful review and investigation of Mr. Does medical care provided by each physician, BPQA did not issue charges of sub-standard care against any of the doctors. Advisory letters were issued incorporating the above recommendations.
QUERY TO THE BOARD
A PHYSICIAN ASKS:
"I provide service as an anesthesiologist for a patient undergoing nasal surgery as an outpatient. The interaction is purely professional. One week later I receive a card thanking me for my care and inviting me to visit her in a nearby city. There is no ongoing professional relationship with this patient. Would it be unprofessional or unwise to pursue this invitation? One colleague taking a class dealing with legal aspects of medicine noted the law professor believed it extremely imprudent for a physician to get involved, no matter how benign it might appear at the outset."
AND THE BOARD RESPONDS:
As long as the physician holds no "undue influence" derived from the prior doctor-patient relationship, there is no prohibition against physicians striking up a personal relationship with a former patient. "Undue influence" generally derives from a long-term professional relationship or pertains when the physician has provided counseling on personal issues in the patient's life as part of the professional interchange. Specifically, psychiatrists, who have provided therapy, are considered to have an enduring "undue influence" that persists long after the doctor-patient relationship has presumably "ended". The American Pyschiatric Association is on record stating that it is never appropriate for a psychiatrist to have a romantic relationship with a current or former patient. But, in the situation described, it is hard to imagine that the anesthesiologist would be taking advantage of the doctor-patient relationship in accepting the invitation to continue the acquaintance. If, however, the patient requires subsequent anesthesiology services, the doctor should certainly decline to treat the patient and refer her to a colleague.
BOARD ORDERS April - June 1997
DANIEL F. KRANK, M.D., License #D07172, Specialty: Psychiatry (Silver Spring, MD) Reprimand; suspension for one year effective thirty days from the date of order; six months from the suspension of the license the physician may petition for a stay provided he completes a condition precedent; if suspension is stayed, one year probation with terms and conditions. The Board concluded that the physician was guilty of immoral or unprofessional conduct, failed to meet standards of care, and failed to cooperate with a lawful investigation conducted by the Board. The case arose from complaints to the Board that the physician engaged in a personal relationship with a former patient for whom he had provided extensive psychotherapy. Effective 4/9/97
ELODIA A. MANASAN, M.D., License #D19597, Specialty: Anesthesiology (Burke, VA) Inactive License. The physician retired from active medical practice and decided to go inactive in lieu of further investigation of a health claim and a hospital adverse action. Effective 4/9/97
PETER TANNA, M.D., License #D24861, Specialty: General Practice (Silver Spring, MD) Reinstatement of license; three (3) years probation with terms and conditions. The physician completed the Board approved billing and coding course as required as a precondition to reinstatement. Effective 4/9/97
SAMUEL WISE CHANG, M.D., License #D14746, Specialty: Family Practice (Potomac, MD) Revocation. The physician was found guilty in the Circuit Court for the City of Alexandria of fifteen (15) counts of Distribution of Stimulants and seven (7) counts of Unlawful Dispensing of a Controlled Substance, and after an appeal the convictions were affirmed by the Court of Appeals of Virginia. The physician is, therefore, subject to State statute which requires revocation of a license. Effective 4/23/97
CHRISTOPHER J. MAYS, M.D., License #D39793, Specialty: Internal Medicine (Gaithersburg, MD) Reinstatement of license; probation for two (2) years subject to terms and conditions. Effective 4/23/97
STEPHEN C. PAPASTEPHANOU, M.D., License #D09245, Specialty: General Surgery; Colon & Rectal Surgery (Baltimore, MD) Reprimand; terms and conditions. The physician failed to meet standards of care in his practice of general surgery with respect to a patient. Effective 4/23/97
STACEY R. SHERRY, M.D., License #D48140, Specialty: Anesthesiology (Baltimore, MD) Surrender of Certificate. The physician based the decision on her present inability to work competently due to illness and to avoid further investigation and possible issuance of charges for violation of a disposition agreement. Effective 4/25/97
PAUL A. LANGE, M.D., License #D14520, Specialty: Psychiatry (Washington, DC) Summary Suspension based on Reciprocal Summary Suspension. The physician at the show cause hearing in Maryland admitted to sexual conduct with a recent former patient, and displayed a lack of understanding of boundary violations and the proper relationship between a psychiatrist and a patient. Effective 4/25/97
JOHN J. SHIGO, M.D. License #D08107, Specialty: Family Practice (Gaithersburg, MD) Suspension for three (3) years; suspension stayed; probation for three (3) years subject to terms and conditions. The Board found the physician guilty of unprofessional conduct, filing a false report in the practice of medicine, and submitting a false statement to collect fees. Effective 5/21/97
ESTHER C. ESTWICK, M.D., License #D18134, Specialty: Psychiatry (Silver Spring, MD) Reprimand with terms and conditions. The physician failed to meet appropriate standards of care and prescribed drugs for illegitimate medical purposes, that is, overprescribed or inappropriately prescribed CDS. Effective 5/28/97
DENIS FRANKS, M.D., License #D17419, Specialty: Plastic Surgery (Baltimore, MD) Summary Suspension. The Board has reason to believe that the physician has violated the probationary conditions of the November 21, 1994 Consent Order and that he has engaged in a consistent, longstanding pattern of disruptive behavior toward patients and inappropriate professional conduct while acting in his capacity as a physician licensee, and has probable cause to believe that the physician has failed to meet appropriate standards of care. Effective 5/28/97
GIDEON M. KIOKO, M.D., License #D08283, Specialty: OB/GYN (Washington, DC) Reinstatement; probation for three (3) years subject to terms and conditions in regard to his practice of obstetrics. Effective 5/28/97
EDWIN LOUIS KAHAN, M.D., License #D06296, Specialty: General; Family Practice (Edgewood, MD) Surrender of license. The decision to surrender was prompted by the physicians age, his plans for retirement, and an investigation which found that the physician failed to perform physical examinations, failed to order appropriate laboratory studies, was deficient in medical record keeping and inappropriately prescribed CDS drugs to drug seeking patients. Effective 5/28/97
JOHN JEEJOON LOH, D.O., License #H25593, Specialty: General Practice (Baltimore, MD) Reprimand; $5,000. fine; terms and conditions. The physician practiced medicine with unlicensed and uncertified personnel. Effective 5/28/97
JOSEPH J. MARTINEZOHARA, M.D., License #D24049, Specialty: Internal Medicine; General Practice (Brownsville, TX) Revocation. The physician pled guilty to being in Possession of a Controlled Dangerous Substance, Diazepam, by Fraud, and, therefore, the Board concluded that the physician was subject to statute which requires revocation of a license. Effective 5/28/97
REGINALD W. STALLING, M.D., License #D22887, Specialty: General Practice (Baltimore, MD) Reprimand; terms and conditions. The physician failed to cooperate with a lawful investigation conducted by the Board and failed to comply with Maryland drug dispensing requirements. Effective 5/28/97
MICHAEL Q. STEARNS, M.D., License #D33966, Specialty: Neurology (Vienna, VA) Suspension. The physician pled guilty to Assault and Battery in Violation of the Uniform Code of Military Justice and, therefore, the Board concluded that the physician was subject to state statute that requires suspension of his license. Effective 5/28/97
SOL WITRIOL, M.D., License #D29137, Specialty: Internal Medicine (Pasadena, MD) Reprimand; terms and conditions; fine of $500. The physician failed to respond to the Boards lawfully issued subpoena for records. Effective 5/28/97
KATHERINE M. PUGH, P.A., Certificate #C01617, (Rockville, MD) Administrative fine of $500. The physician assistant practiced without a certification issued by the Board. Effective 5/29/97
BRADFORD A. ROSS, M.D., License #D26689, Specialty: Emergency Medicine (Frederick, MD) Modification of effective date of the March 2, 1995 order. The length of the probation is extended to May 12, 2002. Effective 6/17/97
PRENDIS O. BENNETT, M.D., License #D20116, Specialty: Pediatrics (Baltimore, MD) Inactive License and Tolling of Probation of Consent Order of March 27, 1997. The physician does not wish to actively practice medicine at this time. Effective 6/17/97
BARRY RAY BYRAM, M.D., License #D50059, Specialty: Diagnostic Radiology (Costa Mesa, CA) Probation for five (5) years, concurrent with his probation in Louisiana. The Louisiana Board sanctioned the physician placing him on five (5) years probation subject to terms and conditions, because the Louisiana Board had probable cause to charge the physician with abuse of drugs which are capable of causing the inability to practice medicine with reasonable skill and safety. Effective 6/11/97
JEFFREY I. GOLTZ, M.D., License #D16463, Specialty: General Surgery (Oxon Hill, MD) Revocation. The physician entered a guilty plea to one count of felony involving tax evasion in the United States District Court for the District of Columbia and, therefore, the Board concluded that the physician was subject to State statute which requires revocation of the license. Effective 6/11/97
ROBERT S. CALTRIDER, PAC, License #C00418, (Glen Burnie, MD) Revocation. The physician assistant violated his consent order of December 20, 1995; the Board was notified that the health provider was forging prescriptions for himself in the name of a licensed physician. Effective 6/20/97
LISE A. GOLDBERG, M.D., License #D29617, Specialty: Surgery (Silver Spring, MD) Inactive license; the physician shall not apply for reinstatement of an active license for three (3) years. The Board has sufficient evidence to conclude that the physicians care and treatment of five (5) patients failed to meet the standard of care in her practice of vascular surgery. Effective 6/25/97
COLEMAN R. JACKSON, RCP, Certification #L01007, (Baltimore, MD) Certification as a respiratory therapist is reinstated; four (4) years probation subject to terms and conditions with respect to addressing prior substance abuse. Effective 6/25/97
ELIZABETH O. ADEBOYEGAPANOX, M.D., License #D37809, Specialty: Orthopedic Surgery (Silver Spring, MD) Reprimand; probation for two (2) years subject to terms and conditions. The physician failed to meet appropriate standards of care in that she performed surgery on the wrong knee and was guilty of unprofessional conduct in the practice of medicine in that she failed to obtain informed consent prior to performing surgery on the left knee, that is, the wrong knee. Effective 6/25/97
GUY B. STEINBERG, M.D., License #D26192, Specialty: Family Practice; Internal Medicine (Laurel, MD) Sixty (60) day suspension; suspension stayed; probation for three (3) years subject to terms and conditions. The physician failed to meet standards of care in his prescribing practices. Effective 6/25/97.
KENNETH L. HALL, PAC, License #C00556, (Baltimore, MD) Reprimand; terms and conditions. The health provider failed to obtain the required hours of continuing education credits. Effective 6/25/97
VERNON HARRIS, JR., MRT., Certification #R03643, (Baltimore, MD) Surrender of certification which was prompted by an investigation of the Board into the technician testing positive for cocaine. Effective 6/25/97
EDDIE S. SAW, M.D., License #D17113, Specialty: Urology (Elkton, MD) Suspension for ninety (90) days; fine of $2,500; probation for three (3) years subject to terms and conditions. The physician was guilty of unprofessional conduct in the practice of medicine by engaging in inappropriate conduct with three patients. Effective 6/25/97
TERMINATION OF PROBATION
IVAN W. LAURICH, M.D. License #D16245, Specialty: None (Baltimore, MD) Termination of probation and the order of April 27, 1994. Effective 4/11/97
LUCIANO BELIZAN, M.D., License #D23752, Specialty: OB/GYN (Rockville, MD) Termination of the order of February 22, 1995. Effective 4/23/97
JOHN G. MYERS, MRT, Certification #R03237, (Westchester, PA) Termination of probation and the order of December 20, 1994. Effective 5/14/97
KRISHAN KUMAR SINGAL, M.D., License #D36900, Specialty: Internal Medicine; Cardiovascular Diseases (Glen Burnie, MD) Termination of probation and the Consent Order of May 25, 1994. Effective 6/17/97
DANUTA T HACISKI, M.D., License #D18879, Specialty: None (Glen Burnie MD) Termination of probation and the Consent Order of May 2, 1992. Effective 5/14/97
ILUMINADA HERNANDEZ, M.D., License #D18885, Specialty: Pediatrics (Baltimore, MD) Termination of probation and the Consent Order of May 30, 1995. Effective 6/17/97
NAJI J. HAROUN, M.D., License #C19133, Specialty: Internal Medicine (Baltimore, MD) Termination of probation and the order of November 10, 1994. Effective 6/25/97