BOARD OF PHYSICIAN QUALITY ASSURANCE NEWSLETTER
VOLUME 8, NUMBER 1
By Israel H. Weiner, M.D., BPQA Medical Consultant
The treatment of pain has become a major issue in American medicine over the past several years. It has become almost universally accepted that American physicians treat pain inadequately, especially at the end of life. The Maryland Board of Physician Quality Assurance has published several advisory articles in previous issues of the BPQA Newsletter, and has produced a video, "A Sense of Balance", to address physicians' reluctance to use opiates to relieve chronic pain. The Board has made these efforts because physicians may fear censure and discipline against their medical licenses if they aggressively utilize opiate medications to relieve pain.
Pain management specialists estimate the risk of addiction at less than 5% when narcotics are employed in the treatment of chronic pain. Nevertheless, the possibility of addiction and the reality of drug dependence and habituation are major factors deserving consideration in the decision to commit a patient to long-term treatment with narcotics. Physicians considering the use of opiate medication for chronic pain may find the following categorization of chronic pain patients into three broad groups useful.
I. Chronic pain due to malignant disease. Patients in this category are the least problematic in the decision to commit to chronic opiate therapy. Good medical practice requires physicians to relieve pain and suffering to the maximum degree possible, especially when due to incurable malignancy. A physician is not likely to be criticized for aggressive use of long-term narcotics, and the question of possible addiction is irrelevant. On the contrary, state medical boards may well view timidity in the use of pain relieving medication to constitute substandard care, and a valid cause for disciplinary action. Patients with known malignancy, even in the absence of as yet demonstrable metastasis as a cause for significant pain, can reasonably be considered candidates for narcotics.
II. Chronic pain due to established diagnosis of non-malignant disease. Patients in this category can be reasonably considered for long-term narcotic therapy, if the specific diagnosed disease can be reasonably expected to be a cause for significant chronic pain. Such disease entities as advanced arthritis, spinal arachnoiditis, and sickle cell disease may well fall into this group. It is usually prudent for the treating doctor to have demonstrated inadequacy of pain relief with non-narcotic analgesics, and to have employed specialty consultations to be sure that further specific therapy is not available. It is desirable that physicians discuss the possibility of habituation or addiction with these patients, and consider even obtaining a formal signed consent before committing to long-term narcotic therapy.
III. Chronic pain without demonstrated pathology. Diagnoses such as fibromyalgia, failed back syndrome, chronic pelvic pain, or chronic headache are conditions without clear anatomic causes. These patients are difficult for physicians to manage. Some of these patients may have other occult disease, not yet diagnosed. Some may have pain of psychological origin, or pain aggravated by psychological factors. Patients who present with ever changing symptoms, shifting their pain complaint from one anatomic area to another, may not be suitable candidates for opiate treatment and will not benefit from superimposing drug dependence on their pre-existing psychological problems. Prudent physicians will consider specialty consultation, psychiatric evaluation, and pain specialist evaluation to assist in treating this difficult group of patients. If the decision is made to use chronic opiate therapy, documented informed consent is also desirable.
Whenever a physician embarks upon a long term therapy with narcotics, there are basic factors to be considered and documented to enable a reviewing physician to understand the rationale of therapy. Peer reviewers are reassured by evidence of serious, thoughtful consideration of all the factors leading to a decision to commit to chronic opiate prescription. The physician should be familiar with the common ploys of drug-seeking patients such as claims of "lost" prescriptions, stolen purses, accidental flushing of pills, etc. And when patients repeatedly run through their medications early, the possibility that the patient is demonstrating "pseudo-addiction" due to unrelieved pain must also be considered. Adequate monitoring of therapy, while avoiding patient exploitation by requiring excessively frequent office visits or expensive offices charges, requires physicians to develop a delicate sense of balance when dealing with patients in chronic pain. Physicians need to be certain that their medical records accurately reflect the considerations they have employed to give these challenging patients the best care possible.
Dr. Cheryl Winchell and Dr. Sidney Seidman will complete their terms of Board service this year. Each has served two full terms and is ineligible for reappointment. They will serve until Governor Parris Glendening appoints two physicians to replace them this summer.
The procedure for identifying new members for BPQA is established by statute. MedChi is charged with conducting an election and transmitting the results to the Governor who then makes his selections. MedChi established the nominating procedures in 1999. In order to be on the ballot, a Maryland licensed physician must be placed in nomination by a physician organization of at least 25 members. Alternatively, a physician may also be nominated by petition by obtaining the signatures of 25 Maryland licensed physicians who support the candidacy.
Board service is not compensated and involves considerable time commitment. Most Board members are assigned to two committees of the Board in addition to the monthly meeting of the full Board. Preparation for Board meetings requires 5 to 10 hours of reading. Additionally, Board members are often asked to review malpractice claims and to attend, in rotation, the Weekly Review Panel which screens all new complaints. Candidates should be aware that they will need to dedicate at least 25 hours a month to Board activities. There were only seven nominees submitted in 1999 for Board vacancies.
To be included in the election process, nominations should be submitted to MedChi, The Maryland Sate Medical Society, 1211 Cathedral Street, Baltimore, MD 21201 before March 29, 2000. The nominees will be listed in the next issue of BPQA Newsletter and a ballot will be provided. All Maryland licensed physicians are authorized to cast a ballot. Only original Newsletter ballots (no faxes or copies) will be accepted. The physician must both sign the ballot and include his/her license number in order for it to be considered a valid ballot.
Veluppillai Nagulendran, M.D., License #D24910, Specialty: Psychiatry. (Cumberland, MD). Second modification to Order of Reinstatement. The frequency of supervision meetings can be reduced from bi-weekly to quarterly. Date of Action: October 19, 1999.
Paul V. Beals, M.D., License #D25922, Specialty: Family Practice. (Laurel, MD). Modification of Consent Order of November 10 1993. The physician will not do FSH Testing in his own office laboratory and other terms and conditions with regard to FSH Testing. Date of Action: October 20, 1999.
Michael Koger, Sr., M.D., License #D28250, Specialty: None. (Atlanta, GA). Suspension. The physician was sanctioned in Georgia for failing to provide the Georgia Board with evaluation results as ordered by the Georgia Board. The Georgia Board ordered the evaluation of the physician because of the suspension of hospital privileges after the hospital's investigation regarding "undue familiarity" with female patients. Date of Action: October 27, 1999.
Barbara N. Van Horn, M.D., License #D28796, Specialty: Family Practice. (Washington, DC). Final Order dated November 18, 1998, is vacated and reversed. Date of Action: November 8, 1999.
Earl N. McLeod, M.D., License #D25792, Specialty: OB/GYN. (Rockville, MD). Suspension for 3 months; immediately stayed; probation for 3 years subject to terms and conditions. The physician failed to meet standards of care with regard to a patient receiving outpatient surgical care, that is, with respect to postoperative monitoring, treatment, and resuscitation of a patient. Date of Action: November 17, 1999.
Jeffrey H. Schimandle, M.D., License #D44215, Specialty: Orthopaedic Surgery. (Oklahoma City, OK). Prohibition against the practice of medicine in Maryland. The Agreement is pending resolution of Oklahoma charges in regard to the physician's personal substance abuse. Date of Action: November 17, 1999.
Reginald Stalling, M.D., License #D22887, Specialty: Family Practice. (Baltimore, MD) Suspension. The physician has failed to pay fine imposed by the Board's Order of 5/5/99. Date of Action: November 17, 1999.
Bannister Raines, Jr., M.D., License #: D17735, Specialty: Internal Medicine. (Baltimore, MD) Reinstatement; probation for 5 years from effective date of Reinstatement Order; probation subject to terms and conditions. The physician met requirements for reinstatement and will be subject to five years probation and compliance with his disposition agreement with the physician rehabilitation program in Maryland. Date of Action: November 24, 1999.
Laurence T. Allen, M.D., License #D24293, Specialty: Psychiatry. (Washington, DC). Surrender Order. The physician failed to meet the condition of the Consent Order of August 25, 1999, as to his completion of a medical record keeping course. Date of Action: December 10, 1999.
Leon R. Levitsky, M.D., License #D09187, Specialty: Family Practice. (Lanham, MD). Revocation of 7/30/97 is effective March 5, 1999. The physician appealed the Board's Order of Revocation of 7/30/97. The February 5, 1998 order of Prince George's County Circuit Court was vacated by the Court of Appeals on January 13, 1999; the Motion for reconsideration was denied by the Court of Appeal on March 5, 1999. Date of Action: March 5, 1999.
Melvin J. Duckett, M.D., License #D32401, Specialty: Urology. (Sparks, MD). Suspension for six (6) months; suspension stayed in 90 days if the physician pays in full the $7,500. fine. The physician failed to pay the fine imposed by the April 22, 1998 Board Final Opinion and Order. Date of Action: December 15, 1999.
James M. Grimes, P.A., License #C01204, Specialty: Physician Assistant. (Baltimore, MD). Summary Suspension. The Board concluded that investigative facts indicated that the health provider was addicted to or habitually used narcotics or CDS and provided professional services while using narcotics or CDS. Date of Action: December 15, 1999.
Leonard C. Kinland, M.D., License #D22037, Specialty: Family Practice. (Brunswick, MD). Stay of Suspension imposed by June 2, 1999; probation for 3 years subject to terms and conditions. Date of Action: December 15, 1999.
Felix K. Prakasam, M.D., License #D20231, Specialty: Anesthesiology. (Loma Linda, CA). Suspension until March 13, 2001, or until the Respondent has complied with all the terms and conditions of the Medical Board of California. The Medical Board of California sanctioned the physician for allowing a physician assistant to prescribe or dispense drugs without authorization and for failure to establish guidelines and procedures for appropriate care and referral of patient. Date of Action: December 15, 1999.
Alejandro Serrano, P.A., License #No License, Specialty: Physician Assistant. (Virginia Beach, VA). Application for certification denied. The applicant was found guilty by a court-martial of the Navy for self prescribing and prescribing for his spouse CDS without authorization, lying to the Navy about his medical health, that is, his mental health, and assault on his spouse, and, in a separate incident, on his stepdaughter. Date of Action: December 15, 1999.
Robert C. Daddario, M.D., License #D01110, Specialty: Internal Medicine. (Bethesda, MD). Fine of $1,000; terms and conditions. The physician failed to obtain the required CME credits for his last renewal of license. Date of Action: December 30, 1999.
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.
The BPQA Web-Site at www.docboard.org lists all licensees and whether or not there has been a disciplinary action.
In the past, medical boards only responded to written requests for disciplinary information on their licensees. With the advent of the internet, however, most boards are maintaining web sites and making at least some of their disciplinary information easily accessible to the public. Currently forty-one states name disciplined doctors on their sites.
Information about disciplinary actions varies greatly. According to a study conducted by Public Citizen's Health Research Group and released on February 2, 2000, board sites are often difficult to access and supply inadequate information for consumers. Only one state, Maryland, received an "A" rating on a grading scale of web content. Maryland earned the high rating because it posts the name of the disciplined doctor, the offense committed, the disciplinary action taken, a summary narrative of the misconduct, and the full text of the board order. All other state medical board sites lacked at lease one of these categories of information.
In 1999, the Maryland General Assembly mandated that the BPQA web site information be further expanded to include information about physician privileges at hospitals and other health care entities, participation in the Maryland Medical Assistance Program, and provide Internet links to the AMA and HMOs. The Board is currently implementing the legislative mandate to include this information on the profile of every licensed Maryland physician.
All Maryland licensees are encouraged to log into the BPQA web site at www.docboard.org to check their own listing. The Board has worked hard to achieve accuracy, but realizes that each licensee is the most critical proof reader! In addition to disciplinary information, the web site also contains excerpts from the BPQA Newsletter, recent Board advisories, and general information about the Board.
Physicians often ask about the Board's policy on addresses, and why a physician is asked to identify a public and non-public address. In 1998, in response to the growing concern about physician's home address posted on the Internet, and to carry out provisions of HB 958, the Board developed a bifurcated address system. Beginning in 1998 with all initial licensees and continuing through all subsequent renewal periods, physicians are asked to provide the Board with two addresses. The first is the address which will be available to the public. This information can be obtained either by accessing BPQA's web site on the Internet or by contacting BPQA directly by phone or by mail to request the address of a particular physician or a group of physicians. The other, a non-public address, is the address BPQA uses to communicate with the physician concerning license renewal, newsletters, and other correspondence to the physician.
A physician can obtain a copy of the "Change Of Address" by downloading it from the web site www.docboard.org. If any physician or allied health care professional regulated by the Board wishes to have a mailing address changed or have a public address of record revised, BPQA encourages the use of the form on page 5 of this Newsletter. Additional forms may be ordered by contacting the Board at 410-764-4777 or 1-800 492-6836.
BPQA will only accept original signed forms from physicians who wish to change or update their address information. Please send the completed and signed Change of Address forms to:
Board of Physician Quality Assurance
4201 Patterson Avenue
Baltimore, Maryland 21215
Based on the evaluation of the Communicator Awards panel of judges, the Board of Physician Quality Assurance received the Award of Distinction for the videotape, A Sense Of Balance. The Communicator Awards organization recognizes outstanding training and educational tapes. Several thousand training films and videotapes from federal, state, and local government agencies and large and small corporations were submitted for for the 1999 recognition from throughout the world. BPQA is proud to receive this prestigious award.
The Board's video, A Sense of Balance, is a videotape presentation on drugs, chronic pain, and related subjects including appropriate prescribing of controlled drugs, over prescribing, the addicted physician and identifying the drug seeking patient. This video presents the position of the Maryland Medical Board as well as that of the Federation of State Medical Boards on prescribing to patients with pain.