Volume 7, Number 3
FROM ATTORNEY
GENERAL CURRAN TO MARYLAND PHYSICIANS
NEW LAWS GOVERNING THE
PRACTICE OF MEDICINE
PHYSICIAN ASSISTANTS'
PRESCRIPTIVE AUTHORITY
GENERAL ASSEMBLY RETURNS
6% OF FEES TO BPQA
MEDICINE LICENSE REQUIREMENTS
PHYSICIAN PROFILES DISCLOSURE
TO THE PUBLIC
EXEMPTION FROM LICENSURE FEES
COMPUTER BASED USMLE STEP 3
NEW PHYSICIAN ORIENTATION INFORMATION
ORIENTATION SCHEDULE
THE DOCTOR AS PRODUCT SALESPERSON
BOARD ORDERS April - June 1999
ADMINISTRATIVE FINES
QUERY TO THE BOARD:
WHAT ABOUT FINDER'S FEES?
GOVERNOR APPOINTS
SIDNEY SEIDMAN, M.D. AS BPQA CHAIR
DRUG DIVERSION PROGRAM - CATEGORY I CME CREDITS
OFFERED
Dear Doctor:
You may have heard that the Maryland Legislature recently enacted a new law on assisted suicide. I want to make certain that all physicians in Maryland have accurate information about what this bill does and does not do, and I am grateful to the Board for providing me with this forum.
The new law, known as Senate Bill 319 and effective on October 1, 1999, makes assisting a suicide a felony, punishable by fine and imprisonment. This is not really a change in the law. Assisting a suicide, just like criminal homicide, has been a crime for centuries. The new law simply makes the nature of the crime, and the penalties for committing it, very clear. The new law only prohibits certain actions done "with the purpose of assisting another person to commit or to attempt to commit suicide." An individual may not, with this purpose:
(1) Knowingly cause, by coercion, duress, or deception, another person to commit suicide or attempt to commit suicide;
(2) Knowingly provide the physical means by which a person commits or attempts to commit suicide with knowledge of the person's intent to use the physical means to commit suicide; or
(3) Knowingly participate in a physical act by which another person commits or attempts to commit suicide.
The new law does not affect aggressive efforts at pain control or decisions to withhold or withdraw life-sustaining treatment. In fact, the new law has language to protect physicians, other health care professionals, and lay care givers.
First, the new law contains a specific intent requirement; the only prohibited actions are those done "with the purpose of assisting another person to commit or to attempt to commit suicide." The prescribing or administering of pain -relief medication for the purpose of relieving pain, rather than to assist a suicide, is outside the criminal prohibition.
In addition, the new law explicitly codifies what is often called the principle of "double effect": Providing someone with medically appropriate pain relief in order to relieve pain, rather than to cause death or assist a suicide, cannot give rise to criminal liability even if the patient dies after taking the medication. Although for some patients an increased risk of death might be considered a foreseeable side effect of the medication, relief of pain, not death, is the therapeutic goal. The new law contains language to reassure both health care professionals and family care givers that proper pain management practices are outside the law's scope.
Finally, the new law makes it clear that a physician or other licensed health care professional who withholds or withdraws a medically administered life-sustaining procedure in compliance with the Health Care Decisions Act does not violate the prohibition on assisted suicide. This provision reinforces current law: Under the Health Care Decisions Act, "The withholding or withdrawal of life-sustaining procedures in accordance with the provisions of [the Act] shall not, for any purpose, constitute a suicide."
In short, physicians who assess and document pain in dying patients and who follow good clinical practice in titrating dosage will not be affected by the new law, even if the patient's pain can only be controlled by substantial amounts of opioids and the patient subsequently dies. The public policy of this State favors excellent palliative care and supports those physicians and other health care professionals who provide it.
Very truly yours,
J. Joseph Curran, Jr.
Attorney General
On June 1, 1999 HB 674 became effective which replaces Job Descriptions with Delegation Agreements. Delegation Agreements expand the authority of physicians to delegate medical acts to physician assistants. This law authorizes a physician to delegate to a physician assistant the authority to prescribe and administer controlled dangerous substances, prescription medication, and medical devices in any setting after the physician assistant meets certain requirements.
This law repeals the requirement that the State Comptroller distribute into the General Fund of the State 6% of certain fees collected by the BPQA from licensure fees. This means that the BPQA will now keep the 6% of fees that were previously distributed to the General Fund.
This law prohibits licensure based on individual state examinations taken after 1985, when the national examination of physicians and osteopaths became available. This law aligns the statutory requirements of the BPQA with those of most other states. Any applicant whose state board exam was before 1985 will not be affected by this legislation.
The BPQA is required to create an individual profile on each licensed physician that includes:
*Final disciplinary actions taken by the BPQA or other
state Board as provided to the National Practitioner Data
Bank.
*Medical school attended and the date of graduation.
*Internship or residency training.
*Certification by the American Board of Medical
Specialties and the American Osteopathic Association.
*Hospital privileges.
*Primary practice setting.
*Participation in Maryland Medical
Assistance Program.
This law also requires the BPQA to provide Internet links to the American Medical Association and Maryland licensed Health Maintenance Organizations. The BPQA will provide physicians with the initial profile, as required by law, and permit physicians to correct any inaccuracies. Physicians may request to receive a copy of their initial profile electronically.
HB662 provides that a volunteer license shall expire every two years, instead of every year. There are approximately 44 volunteer physicians in Maryland at this time. The licensure fee is waived for those physicians who restrict their activities to uncompensated charitable care.
For information on legislative issues, contact Marie Savage, BPQA Legislative Liaison, at (410) 764-4782.
On May 11-12, 1999, the final paper and pencil USMLE Step 3 was administered. The Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners have implemented computer based testing for USMLE Step 3. The computer based test (CBT) will allow year round scheduling instead of just two administrations per year. The CBT will be administered at Sylvan Technology Centers in both the U.S. and Canada.
To register and determine eligibility requirements for the USMLE Step 3 CBT, please contact the FSMB at (817) 571-2949; usmle@fsmb.org; or Examination Services, FSMB, 400 Fuller Wiser Road, Suite 300, Euless, TX 76039-3855.
On April 5, 1999, new regulations went into effect requiring physicians who are applying for the first renewal of a Maryland Medical License to attend the Board of Physician Quality Assurance New Physician Orientation Program. This means that any physician who is renewing his/her medical license for the first time must attend this orientation program prior to this first license renewal. The BPQA may defer this requirement for license renewal for physicians who are not practicing medicine in Maryland. These deferments will be handled on an individual basis. Please contact Rod Clark, Education and Training Director, at 410-764-2492, or 1-800 492-6836, ext. 2492.
All programs will begin at 6:00 p.m. and will end by 9:00 p.m., unless otherwise noted. Select your first and second preference from the schedule below and register for your selected session by mailing the request to the BPQA office; faxing your request to 410-358-2252; or e-mailing the request to kmelville@dhmh.state.md.us.
Sept. 16, 1999 MedChi Offices 1211 Cathedral Street Baltimore, MD
Sept. 18, 1999 BPQA Office 4201 Patterson Ave, Baltimore, MD (10:00 a.m. - 1:00 p.m.)
Sept. 21, 1999 Sacred Heart Hospital, Cumberland, MD
Sept. 23, 1999 Shady Grove Adventist Hospital, Rockville, MD
Sept. 27, 1999 Civista Hospital, LaPlata, MD
Sept. 28, 1999 MedChi 1211 Cathedral St., Baltimore, MD
Sept. 30, 1999 Doctors Community Hospital, Lanham, MD
Oct. 4, 1999 Washington Co. Hospital Hagerstown, MD
Oct. 9, 1999 BPQA Office 4201 Patterson Ave. Baltimore, MD (10:00 a.m. - 1:00 p.m.)
Oct. 13, 1999 MedChi Offices 1211 Cathedral Street Baltimore, MD
Oct. 20, 1999 Montgomery County Medical Society 15855 Crabbs Branch Way, Rockville, MD
Nov. 15, 1999 Peninsula General Hospital, Salisbury, MD (5:00 - 8:00 p.m.)
Nov. 18, 1999 Montgomery County Medical Society 15855 Crabbs Branch Way, Rockville, MD
Dec. 6, 1999 Civista Hospital LaPlata. MD
Dec 9, 1999 MedChi Offices 1211 Cathedral St., Baltimore, MD
Jan. 12, 2000 Cumberland Memorial Hospital Cumberland, MD
Jan. 13, 2000 MedChi Offices 1211 Cathedral St. Baltimore, MD
Jan. 20, 2000 Montgomery County Medical Society 15855 Crabbs Branch Way, Rockville, MD
Feb. 10, 2000 MedChi Offices1211 Cathedral St., Baltimore, MD
Feb. 19, 2000 BPQA Office 4201 Patterson Ave. Baltimore, MD (10:00 a.m. to 1:00 p.m.)
Physicians not required to attend may earn 3-hours Category I Continuing Medical Education Credits toward licensure renewal.
Is it in patients' best interest when physicians offer to sell merchandise in their offices? Increasingly, physicians are offering both medical and non-medical products and they are using their offices as their salesrooms. These products range from vitamins and dietary supplements to beauty aids and even home cleaning supplies. Are patients being exploited? Do they feel pressured to buy these products so that they will please their doctor? Is the way to remain on good terms to buy liberally from the in-office store? What is the doctor's motivation? Is it to help patients obtain hard to find treatments related to the patients' medical problems? Or is it to supplement falling incomes that are being squeezed down by managed care? The ethics of this practice are being hotly debated by numerous physician organizations.
The practice of selling medicated salves and specially compounded dermatologic treatments has been practiced by physicians for decades. Orthopaedists often supply crutches or braces they have recommended, thus saving the injured patient a trip to a medical supply store when their mobility has been compromised. Historically, the sale of such products have been incidental to the reason the patient consulted their physician and are generally provided to make it more convenient for the patient. Unless the doctor is charging the patient significantly more than the patient would be charged should they purchase the item elsewhere, few people would raise an eyebrow or question whether the doctor's motivation was related to profit rather than to patient convenience. Such product sales are incidental to physicians' major source of income which is derived from utilizing their medical expertise in the care of patients.
Some patients who are exposed to physician enterpreneurism may not verbalize their discontent, but their trust and admiration for their physician may be affected. Their next decision may include transfer to another doctor without any mention of the role that the merchandise promotion had on their decision. But many patients may just feel obligated to make the recommended purchases to avoid offending their physician and to keep on good terms with them. They may feel that their purchasing the merchandise is necessary to preserve access to their doctor. Or worse, they may feel trapped by their insurance plan and be unable to easily transfer to another physician. When that happens, their discomfort over one aspect of the doctor's practice may adversely influence their attitude about the quality of the medical care that they are being provided as well.
At present, there is little agreement about the propriety of physicians selling products, medically related or otherwise, when patients come for medical care. But there is widespread agreement that offering products for sale in one's medical office has significant potential to abuse the doctor-patient relationship for financial gain. BPQA urges physicians to be aware of their significant influence over patient behavior which derives from the doctor-patient relationship. That influence should always be used to benefit the patient. As members of a profession, we owe it to our patients and to our fellow physicians to have our patients' best interest foremost in any recommendations we make to them.
Mary H. Fang, M.D. License D23448, Specialty: Internal Medicine (Rockville, MD) Revocation. The physician was found guilty of Mail Fraud and Selling Samples and her time to appeal this conviction has passed. The Board found the physician guilty of a crime of moral turpitude and is thereby subject to state law which mandates revocation of a license. Date of Action: April 7, 1999.
Theodore A. Bowles, D.O. License H35804, Specialty: Osteopathic Medicine (Macon, GA) Suspension. The physician was sanctioned by the Texas Board for substance abuse issues. Date of Action: April 14, 1999.
James S. Kehler, M.D. License D08616, Specialty: Psychiatry; Child Psychiatry (Annapolis, MD) Suspension for six (6) months, effective May 1, 1999; $20,000 fine; terms and conditions; if suspension is stayed, probation for three years subject to further terms and conditions. The Board concluded that the physician was guilty of unprofessional conduct and failed to meet standards of care in his practice of psychiatry in regard to a patient with whom the physician engaged in a social and sexual relationship. Date of Action: April 14, 1999.
Norman F. Henthorn, Jr., P.A. License C01919, Specialty: Physician Assistant (Baltimore, MD) Reprimand; probation for three (3) years subject to terms and conditions. The physician assistant engaged in acts which constituted practice as a physician assistant without required certification, failed to advise the Board that a hospital terminated his employment, and failed to advise the Board of a criminal charge (uttering a false document, a forged check) and the probation before judgement. Date of Action: April 28, 1999.
Richard W. Holland, M.D. License D48276, Specialty: Family Practice (Silver Spring, MD) Suspension; terms and conditions. The physician was sanctioned in Virginia for personal substance abuse. Date of Action: April 28, 1999.
Jeffrey M. Levitt, M.D. License D29875, Specialty: OB/GYN (Kensington, MD) Summary Suspension. The Board concluded that the health, safety, and welfare imperatively require emergency action based on investigatory facts which show that the physician wrote prescriptions for patients for CDS (Stadol) and would use part or all for himself; the physician engaged in sexual relationships with patients to whom he was concurrently providing medical care; the physician requested a number of physicians to write him prescriptions for CDS (Stadol); the physician practiced acupuncture without a Maryland registration and abandoned a patient whom he was treating by acupuncture. Date of Action: April 28, 1999.
Yasar Aksoy, M.D. License D19223, Specialty: General Practice; Anesthesiology (Beckley, WV) Revocation. The physician was disciplined in Virginia for an act that would be grounds for disciplinary action in Maryland and pled guilty to a crime of moral turpitude, one count of mail fraud which was directly related to the practice of medicine, that is, billing to Blue Cross/Blue Shield of West Virginia. Date of Action: May 26, 1999.
Stacey Sherry, M.D. License D48140, Specialty: Radiology (New York, NY) Surrender of license. The decision was prompted by a report from the Committee for Physician Health from the State of New York and subsequent investigation by the Board of Physician Assurance. Date of Action: May 5, 1999.
Reginald W. Stalling, M.D. License D22887, Specialty: General Surgery (Baltimore, MD) Suspension; stayed on condition of completion of terms of probation of the Consent Order of May 28, 1997. Date of Action: May 5, 1999.
Luanne Ruona, M.D. License D14211, Specialty: Psychiatry (Alexandria, VA) Surrender of License. The physician's surrender was prompted by an inability to work due to illness. Date of Action: May 19, 1999.
Alan S. Greenberg, M.D. License D04728, Specialty: Neurology; Psychiatry (Pasadena, MD) Suspension for a minimum of six (6) months; suspension may be stayed on completion of conditions; when the license is reinstated, probation of four (4) years subject to terms and conditions. The Board concluded that the physician is guilty of failing to meet standards of care, prescribing drugs for illegitimate medical purposes, and failing to keep adequate medical records. Date of Action: May 12, 1999.
Ursula D. Poydras, M.D. License D42448, Specialty: Pediatrics (Bowie, MD) Reprimand. The physician failed to meet standards of care with regard to a patient in a hospital emergency room. Date of Action: May 26, 1999.
Sol Witriol, M.D. License D29137, Specialty: None (Pasadena, MD) Suspension; stayed subject to terms and conditions; probation for three (3) years subject to terms and conditions. The physician failed to meet standards of care, failed to provide for continuity of care for his patients by terminating the physician patient relationship without notice to patient and provision for retrieval of records, failure to provide accurate information on his renewal application, and failure to give notice to the Board of a change of address as required by statute. Date of Action: May 26, 1999.
Carlos A. Almeida, D.O. License H41126, Specialty: Osteopathics (Timonium, MD) Physician's practice is subject to conditions. Pending final action by the Board, the physician must submit to the Board monthly monitoring reports in his practice of anesthesiology and provide documentation of all CMEs completed two years preceding the date of the Consent Order. Date of Action: May 26, 1999.
Carlos A. Almeida, D.O. License H41126, Specialty: Osteopathics (Timonium, MD) Suspension for one (1) year immediately stayed; probation for three (3) years subject to terms and conditions. The physician failed to meet standards of care in his practice of anesthesiology with regard to four (4) patients. Date of Action: June 23, 1999.
Morris A. Wilkinson, M.D. License D20279, Specialty: None (Frederick, MD) Application for reinstatement of licensure denied. The applicant has not met his burden of showing that he possesses the good moral character to be relicensed. The physician did not prove his rehabilitation in regard to acts for which the Board found him guilty of unprofessional conduct in the practice of medicine and for which he was found guilty of two counts of a fourth degree sexual offense in violation of Maryland statute. Date of Action: June 9, 1999.
Leonard C. Kinland, M.D. License D22037, Specialty: Family Practice (Brunswick, MD) Suspension for 12 months effective twenty days from the date of the order; stayed after 6 months from imposition if terms and conditions are met; after completion of active suspension probation for 3 years subject to terms and conditions. The physician engaged in a sexual relationship with a patient. The Board found the physician guilty of immoral or unprofessional conduct; failing to met standards of care and misprescribing drugs with respect to this patient. Date of Action: June 2, 1999.
Alan R. Weinstock, M.D. License D09748, Specialty: Family Practice (Silver Spring, MD) Reprimand. Probation for two (2) years subject to terms and conditions. The Respondent failed to meet standards of care with regard to ten (10) patients. Date of Action: June 16, 1999.
Darlene Campbell, CRTT Certification L00317, Specialty: Respiratory Care Technician (Baltimore, MD) Summary Suspension. The health provider was found guilty of violations of the medical practice act, that is guilty of unprofessional conduct and is addicted to or habitually abuses any narcotic or controlled dangerous substance. Date of Action: June 23, 1999.
Paul J. Edgar, M.D. License D01939, Specialty: Internal Medicine (Towson MD) Reprimand; terms and conditions. The physician failed to meet standards of care in his practice of internal medicine with respect to five patients. Date of Action: June 30, 1999.
James Michael D'Angelo, M.D. License D08068, Specialty: Internal Medicine (Chevy Chase, MD) Administrative fine of $1,000. The physician practiced medicine with a lapsed license. Date of Action: May 19, 1999.
Youngsik Moon, M.D. License D09178, Specialty: General Surgery (Hollywood, MD) Reprimand; fine of $10,000; subject to terms and conditions for one year. The physician practiced medicine with an unauthorized person who performed physical therapy. Date of Action: June 2, 1999.
A physician received a solicitation to refer patients to a research center for treatment of non-Hodgkin's lymphoma. He queries the BPQA, "Is it appropriate for me to accept the $200 'finders fee' offered if one of my patients is subsequently enrolled in the research study?"
NO! The Maryland Medical Practice Act is clear on this issue. Ground #15 states that a licensee may be sanctioned if the Board finds he/she "Pays or agrees to pay any sum to any person for bringing or referring a patient or accepts or agrees to accept any sum from any person for bringing or referring a patient."
Additionally, the BPQA ascribes to the AMA Code of Medical Ethics which states: "Fee Splitting. Payment by or to any physician solely for the referral of a patient is fee splitting and is unethical. A physician may not accept payment of any kind, in any form, from any source, such as a pharmaceutical company or pharmacist, an optical company, or the manufacturer of medical appliances of devices, for prescribing or referring a patient to said source. In each case, the payment violates the requirement to deal honestly with patients and colleagues. The patient relies upon the advice of the physician on matters of referral. All referrals and prescriptions must be based on the skill and quality of the physician to whom the patient has been referred or the quality and efficacy of the drug or product prescribed. Offering or accepting payment for referring patients to research studies (finder's fees) is also unethical." (Opinion issued prior to April, 1977.)
Therefore, a physician who engages in fee splitting would be guilty of unprofessional conduct (Ground #3 of the Medical Practice Act) as well as Ground #15 which specifically precludes accepting a fee for referrals.
Governor Parris N. Glendening has appointed Dr. Sidney Seidman to the Chairmanship of the Maryland Board of Physician Quality Assurance. Dr Seidman is currently in his eighth and final year of service to the Board. Dr. Seidman has served as Board Vice-Chairman, Chairman of the Executive Committee, and Chairman of the Practice of Medicine Committee. He maintains an active pediatric practice in Baltimore.
After his appointment, Dr. Seidman said, "I am looking forward to serving as Board chairman. Although my tenure will be short, there are many challenges and opportunities the Board must face as we continue in our role of ensuring quality medical care from physicians and health care providers licensed to practice in our state. The work of the Board is so important to both physicians and the citizens of Maryland."
On Monday, October 11, 1999 from 6:00 p.m. until 10:30 p.m. the Case Western Reserve University School of Medicine and the National Association of Drug Diversion Investigators will sponsor a continuing education program, Avoiding the Pitfalls, Prescription Drugs of Abuse and the Health Professional, at the Holiday Inn-Select, Timonium, MD. The registration fee is $35.00 Physicians and physician assistants may claim the hours spent in the education activity for a maximum of 4.0 Category I hours. For further information, contact Heather McLaughlin at (410) 764-4783.