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Primum Non Nocere N C M E D I C A L B O A R D In This Issue of the FORUM President’s Message: Are You Having a Bad Day? ........................1 From the Executive Director: License Registration .....................................1 From Dr Elizabeth P. Kanof: A Personal Thank You................................2 Notice: Annual Registration Fee to Rise ........3 The Reality of Child Abuse Homicides ..........4 Save Time, Register on Line ..........................5 Training Staff and Seeing Patients: Stories from the Moldova Hospice Project ..........................................6 DUR Recommendation: Aggressively Treating Dyslipidemia ............8 President’s Message Walter J. Pories, MD Primum Non Nocere NORTH CAROLINA MEDICAL BOARD April 15, 1859 Item Page Item Page Are You Having a Bad Day? Charles Granville Rob, MD, one of our licensees, was a true hero, well worth remembering in these difficult times. After he completed his surgical residency in 1941 at the St Thomas Hospital during the London Blitz, he was assigned as a surgical specialist to the First Parachute Brigade. Only a few months later, he was dropped into the desert, 90 miles east of Tunis, behind the German lines. Fighting was fierce and casualties were heavy. Even though he sustained fractures of the tibia and patella during the drop, he rapidly con-verted a French garrison school into a 20 bed hospital and carried out 150 operations on the first day of the battle. He cared for all: the British soldiers first, then the civil-ians, and finally, with equal care, the German prisoners. When the blood bank was exhausted, he gave a unit of his own blood. Only when the work was done did he final-ly dress his own wounds. For these contri-butions under fire, he received the British Military Cross, the United Kingdom’s sec-ond highest medal for valor. He had a glorious career. He was one of the founders of vascular surgery, performed the first carotid endarterectomy, and offered the first descrip-tions of the tho-racic outlet syn-drome and meral-gia paresthetica. He also taught legions of grateful surgeons as a chair-man at St. Thomas and the University of Rochester, as an inspiring professor at East Carolina and, finally, at the Uniformed Services University for the Health Sciences (USUHS), our country’s License Registration In the last number of this publication, we offered a guest article by Dr Alison C. VanFrank in this space. In that article, she explained the travails of her most recent encounter with license registration. You see, she failed to register her license in 2000 as required by law and suffered some rather significant consequences. One consequence was that, at the request of the Board, she agreed to write an explanation of what had happened for the benefit of other licensees. The Board’s intentions were good. It did not view this as some sort of humiliation; rather, it wanted to be helpful to its licensees by showing sequelae that can accrue from this process if one is not careful. Many of these problems are unanticipated, particular-ly if one views medical license registration as simply bureaucratic and ministerial. The burden to register annually is placed by law on the licensee. We are not isolated in this respect; in 49 other states, medical board licensees have an affirmative responsibility to keep their licenses current. This serves sev-eral purposes, not the least of which is the providing of information to the Board that is critical for the public trust conferred by medical licensure. In my opinion, Dr VanFrank’s article was thoughtful and very well written. It pointed out the problem she encountered and made the point the Board envisioned. However, it did generate several strong letters of concern in response (see the “Letters to the Editor” in this number of the Forum). Physicians, attempting to practice medicine as best they can, often feel that they are up to their necks in bureaucracy. The message conveyed in Dr VanFrank’s article was received by some as reflecting an uncaring bureaucracy adding to continued on page 3 continued on page 2 NCMB Elects Officers....................................9 Review: Death Be Not Proud: The Meaning of Wit ..10 Letters to the Editor: More on End-of-Life Care; Dr VanFrank’s Dilemma ............................12 Avoid Treating Family Members! .................13 Position Statements of the NCMB ...............14 Board Actions: 8/2001-10/2001 .................22 Board Calendar ............................................27 Change of Address Form..............................28 Annual Registration on Line ........................28 No. 4 2001 forumMoldova Hospice Project - page 6 Position Statements of the NCMB - page 14 From the Executive Director Andrew W. Watry Charles Granville Rob, MD The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum, including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are affiliated. Official statements, policies, positions, or reports of the Board are clearly identified. We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form depending on available space. A letter should include the writer’s full name, address, and telephone number. North Carolina Medical Board Raleigh, NC forum N C M E D I C A L B O A R D Vol. VI, No. 4, 2001 Primum NonNocere NORTH CAROLINA MEDICAL BOARD April15, 1859 Primum Non Nocere 2 NCMB Forum Walter J. Pories, MD President Greenville Term expires October 31, 2003 John T. Dees, MD Vice President Bald Head Island Term expires October 31, 2003 Paul Saperstein Secretary-Treasurer Greensboro Term expires October 31, 2001 George C. Barrett, MD Charlotte Term expires October 31, 2002 E.K. Fretwell, Jr, PhD Charlotte Term expires October 31, 2002 Charles L. Garrett, Jr, MD Jacksonville Term expires October 31, 2002 Stephen M. Herring, MD Fayetteville Term expires October 31, 2004 Robin N. Hunter-Buskey, PA-C Gastonia Term expires October 31, 2003 Elizabeth P. Kanof, MD Raleigh Term expires October 31, 2002 Robert C. Moffatt, MD Asheville Term expires October 31, 2004 Michael E. Norins, MD Greensboro Term expires October 31, 2004 Aloysius P. Walsh Greensboro Term expires October 31, 2003 Andrew W. Watry Executive Director Helen Diane Meelheim Assistant Executive Director Bryant D. Paris, Jr Executive Director Emeritus Publisher NC Medical Board Editor Dale G Breaden Assistant Editor Shannon L. Kingston Address 1201 Front Street Raleigh, NC 27609 Telephone (919) 326-1100 (800) 253-9653 Fax (919) 326-1130 Web Site: www.ncmedboard.org E-Mail: info@ncmedboard.org Are You Having a Bad Day? continued from page 1 military medical school. There are, of course, many “Rob Stories,” of which two are especially timely. I recall one about his uncle that he told us during a graduation address at ECU. Uncle Mitchell was a morbidly obese family physician who provided excellent care in northern England during the war under unusually harsh condi-tions. However, when he was summoned one day to deliver a baby in a rural trailer, it rapidly became apparent that he could not fit through the narrow door, even when he stripped down to his skivvies. It must have been quite a sight. Eventually, the problem was solved by erecting a makeshift tent out-side the trailer where the baby was success-fully delivered. During a visit to the village about 40 years later, Rob asked the family how they survived the war. “Oh, we made it”, they said, “we got along,” but instead of dwelling on the hardships, they spent most of the time still laughing about the time Uncle Mitchell couldn’t get into the trailer. By this point in his story, Rob had the stu-dents laughing too, and then he offered them the moral, which is good advice for all of us: “Be careful what you do as a physician, folks will remember it for a long time.” My other favorite story occurred when I was his resident at the University of Rochester. Similar to many other centers, we had developed a culture of surgical divas, surgeons whose every operation was a tantrum with screamed obscenities and flung instruments. After all, that’s how surgeons were expected to behave. Rob felt different-ly. To him, caring for patients was the great-est privilege and surgery was not only easy, it was fun. If you didn’t enjoy doing it, you shouldn’t be in the OR. After he heard sev-eral complaints from the staff, he told Connie, the OR supervisor, also from England, to give him a call at the next inci-dent. He did not have to wait long. On the next day, one of our most notorious bullies was having the mother of all tantrums dur-ing a thyroidectomy, throwing clamps and insults in all directions. While there is never, in my opinion, a reason to lose your temper during surgery, such misbehavior is especial-ly difficult to understand during a thyroidec-tomy, an operation that is a delight to per-form. The procedure is rarely emergent, the anatomy is stunningly beautiful, and the techniques are not very challenging. But back to the story. Rob suddenly appeared in the OR, fully scrubbed, and asked, “Are you having a bad day?” As he donned the gown, he quietly told the bewildered surgeon that he would finish the case for him; after all, if he was that upset, he must be in trouble and needed help. When the surgeon refused to leave, Rob told him that he must if he want-ed to keep his privileges. When he did, the operation was finished quickly and qui-etly. It was the last time I ever observed a tantrum in the operating rooms at Rochester. I am not at all sure that Rob’s decision would stand today in our restrictive legal environment, but his principle is still sound. The physician who causes peptic ulcers in his staff as he treats such a lesion in his patient is not a great humanitarian. Charles Rob died at age 84. We will miss him. However, his principles will long sur-vive. They bear reemphasis in these difficult times. • Patients come first. • Folks have long memories. • Serve with grace and be thoughtful of your colleagues. From Dr Elizabeth P. Kanof: A Personal Thank You Over the past year or so, I have had the great pleasure and honor of visiting over 30 medical societies, hospitals, and other groups across the state to dis-cuss the role and work of the North Carolina Medical Board and to answer questions about the Board. During most of that time, I was also serving as president of the Board. Today, as immediate past president of the Board, I want to extend my deepest apprecia-tion to those many people, physicians and non-physicians, who invited me to meet with them and who welcomed me so warmly. Though other Board mem-bers, Board staff, and I will continue to respond to requests for presentations from all interested organizations, pro-fessional and public, I want to take this opportunity to offer my thanks to those groups that have given me their time and attention over the past year. Elizabeth P. Kanof, MD Immediate Past President, NCMB No. 4 2001 3 License Registration continued from page 1 a physician’s bureaucratic headaches. There are those who, perhaps without intending to do so, make a case that tends to devalue the significance and meaning of the medical license. Quite frankly, I think that the privilege of practicing medicine is one of the highest that can be conferred by any state, that the medical license is a positive reflection of the importance our society places on medical practice. In fact, our fore-fathers thought requiring a license to prac-tice medicine was so essential to the public good that North Carolina was one of the first states to do so. Our medical licensing statute was created in 1859. Today, there are very few places in the civ-ilized world where one can practice medicine without a license. I was once visited by the health minister of a breakaway Soviet repub-lic. As this country was joining the interna-tional community, one of its first tasks was to set up a medical licensing system to pro-tect its citizens from unqualified practition-ers. So in my mind, if one trivializes the medical license and the supporting registra-tion process, one is trivializing the impor-tance of the practice of medicine itself. I am not aware of a single court in this land that has found there is an inherent right to prac-tice medicine. Many plaintiffs have unsuc-cessfully argued there is such a right. We care about the process and we are ded-icated to making the registration system eas-ier for all licensees. We were one of the early states to adopt electronic registration and we have one of the highest participation rates in the country — over 70%. What used to take weeks now takes minutes, with next-day written confirmation via e-mail. This process required a substantial investment of time and money to make work. We send reminders about registration to the last address furnished to us by each licensee, and we publish reminders to each licensee quar-terly via the Forum. All of this is intended to help avoid the significant consequences suf-fered by Dr VanFrank. We do care signifi-cantly about serving the public and all licensees. One thing we have planned to help both licensees and their patients is to expand our range of disciplinary options. The benefits of an expanded range of disciplinary options to patients are perhaps obvious, the benefits to licensees not so obvious. As of today, the disciplinary options available to the Board by statute (see NCGS 90-14 at our Web site) are “. . . deny, annul, suspend, or revoke a license. . . .” This list needs to be updated to include probation, withholding disposition, levying a fine, requiring community service, issuing private or public reprimand, and other lesser sanctions. These would provide a range of appropriate actions available for marginal violations or special circumstances. So, in a peculiar way, increasing our range of disciplinary options helps both the public and those subject to Board action. We will likely work on this in the legislature. As to consequences for failure to keep a license current, my point can be made by analogy. Let’s consider deer hunting in a neighboring state. If you drive a brand new truck into the woods, shoot a deer without a hunting license, and get caught, the brand new truck becomes the property of the state, along with your hunting rifle. That is the penalty before the court decides what to do with you. These items are confiscated because they were used in the commission of a crime. You can’t go into court with the defense that the state failed to notify you of the requirement to get a hunting license. In that instance, the state sends you no reminders. If you intend to go into the woods and hunt, it is your responsibility to find out what the law is, where to get a hunt-ing license, and how to obtain one. It is fur-ther your sole responsibility to keep that license current. If you don’t keep it current, you will suffer the consequences. In my estimation, the medical license is many times more important than that hunt-ing license. It has to do with people render-ing medical care to the most precious of a state’s assets: its citizens. That gets to the core of why the Board asked Dr VanFrank to write her article: to be helpful to her colleagues. There are sequelae to non-registration that are quite significant. Medical malpractice carriers may drop cov-erage. Third-party insurers, who check our system, sometimes daily, to see who is cur-rently registered, may also drop someone from coverage. In some instances, they may only check at intervals of six months. If they happen to check at the wrong interval, the licensee may get a recoupment notice for five whole months of services rendered. These consequences are quite dramatic, as pointed out by Dr VanFrank. Even when the Board decides to retroactively reinstate a license, there are still potentially many trees to stand back up in the forest. The licensee may even decide to hire a lawyer to help sort through all of this, which will probably result in sev-eral thousand more dollars of expense. These consequences are far more significant than our $20.00 late fee. The criticisms we have received for the VanFrank article have been taken seriously. We respect the concerns expressed. However, with 31,000 licensees, I don’t think the average licensee would want or expect us to use his or her registration money to pay for the extra staff necessary to track down or search out people who fail to take care of their registration burden. There would be significant overhead in that. It is better to publish regular reminders in the Forum, to provide a mechanism to make the process much easier, as we have done with our electronic registration, to mail individual notices, and to put detailed information on our Web site, all which we have done. The Board cares about this process to the extent that it was one of the first to invest in ser-vices to make the process easier, like elec-tronic registration. Licensees uniformly advise us that our electronic registration process is superior to any other they have used. We are, therefore, grateful to Dr VanFrank for her commentary. We are also grateful for the letters we have received that were gener-ated by her article. It all draws attention to the importance of the licensee keeping up with the registration process. So although we have generated some criticism, at the end of the day we hope some good has come of it. One of our critics writes: “By appear-ances, a Brobdingnagian punishment was meted out for a Lilliputian offense.” I dis-agree. The medical license and the respect in which it should be held by every licensee is anything but Lilliputian, and much of what he sees as punishment is really sequelae. I hope this helps, and as always we genuinely appreciate your comments about these and other issues. NOTICE: Annual Registration Fee to Rise Beginning with March 2002 Birthdays During its 2001 session, the North Carolina General Assembly approved legislation raising the annual registration fee for the medical license from its cur-rent level of $100 to $125. The new fee is still below the average of medical license registration fees nationwide. The $125 annual fee becomes effective beginning with the registration of licensees with birthdays in March 2002, and will be reflected in registration notices. Most licensees now register on line by way of the “Electronic Registra-tion” section of the Board’s Web site (www.ncmedboard.org), and the new $125 fee will be clearly noted on the site for birthdays in March 2002 and following. 4 NCMB Forum continued on page 5 The Reality of Child Abuse Homicides Marcia E. Herman-Giddens, PA, DrPH Senior Fellow, North Carolina Child Advocacy Institute Former Medical Director, North Carolina Child Fatality Prevention Team A child is killed every two to three weeks in North Carolina by a caregiver, usually a biological parent, sometimes a stepparent, sometimes a boyfriend or girlfriend of the parent, occasionally other relatives or babysitters. These children’s deaths are not easy deaths. Too often they have been abused before the lethal event, and, in some cases, tortured for months or years. Sometimes the killings are silent and with-out outward sign of force, usually they are far more violent than anyone would want to believe. Autopsy photographs in these cases are all too often full of bruises, cuts, and blood. Our society’s violence towards children belies the impression we give of caring about children, our concern for children’s safety, our desire for good schools, and the adver-tisements of smiling babies and doting par-ents. Statistics tell of another reality. Homicide is now the third leading cause of death for children ages one to five in the United States. Almost all of these homicides are due to abuse. Behind this number are the tragic, awful stories of the murdered children. These stories are described to offer a depth and perspective to the reality of child abuse. Each case history represents a brief summary of extensive work done by not only the medical examiner, but often many other professionals. Names have been changed to protect the fact that in some cases some of the information is from confi-dential files. All are North Carolina cases from the last 15 years. Legal outcome data in some cases were impossible to get because information is not kept in central files by the name of the victim. Disparities in legal out-come are clear from these cases. Always, there is a lot of missing information. And always, there is a tragedy that should never have happened. Two-year-old Susan Susan was placed on an adult toilet by her mother’s live-in boyfriend. He then alleged-ly struck the child in the chest causing injuries from which she later died. Susan’s siblings had been removed from the home before her birth. Susan had been seen at age one for vaginal bleeding. Her mother had changed her story about the bleeding twice. There had been three reports of child neglect (one substantiated) and one for sexual abuse (unsubstantiated) on Susan. Her mother had brought an assault charge against her boyfriend, but it had been dismissed. The boyfriend was a convicted sex offender with a history of substance abuse. Legal outcome: Susan’s mother’s boyfriend was charged with murder but found not guilty in a jury trial. One-month-old Rebecca Rebecca died from blunt force that frac-tured her skull and several bones. The rescue squad had arrived at her house to see blood on the mother’s shirt and to find the child dead. The rescue squad said that the moth-er seemed inebriated at the time of the inci-dent. An older boy also living in the home was found to be abused. He was removed from the home and sent to live with his grandparents. Legal outcome: Rebecca’s mother was con-victed of first-degree murder. Information about her sentence was not available. Ten-month-old Daria Daria was sleeping in the same bed as her father. The father later gave the story that he saw Daria falling off of the bed and pulled her back on the bed by her arm. At that time, he noted that she was limp and unre-sponsive. He called Emergency Medical Services but when they arrived they found the baby dead. At first it was considered to be a SIDS death, but the ER doctor felt there was some question. The autopsy found that Daria died from abdominal trau-ma. Her father reportedly said it was his fault because he was too rough with her. Legal outcome: The case against Daria’s father was closed due to insufficient evi-dence. The investigators concluded, “No evidence of prior abuse or trauma. Injuries innocently obtained.” Eight-year-old Sara Sara’s father took her into a wooded area and shot her in the neck. It took several days to locate the child’s body. Prior to the incident, he had sent Sara’s mother a mur-der/ suicide note. Sara’s parents had recently separated and the child was living with her father. The mother had wanted to have Sara on weekends when she received the note. There had been some concerns about sexual abuse on the part of the father. No evidence was found by the autopsy to confirm or deny sexual abuse. Legal outcome: Sara’s father pled guilty to a murder charge, and was sentenced to life in prison. Nineteen-month-old Lily Lily had been forcibly immersed in a tub of scalding water one morning by her moth-er’s boyfriend. The child’s injuries were noted by a policeman who saw her with her mother and her boyfriend at a parking lot at a ‘remote’ restaurant later that day. Lily was wearing a diaper and the burns were evident. The couple said they were on the way to get help. Lily was taken to the hospital for treat-ment of burns over 47 percent of her body. Other injuries noted included a cigarette burn on her mid upper back, and bruises on her arm, face and cheeks, and labia. Her burns were consistent with intentionally holding the child in hot water. Lily died due to complications from the burns. Legal outcome: Lily’s mother’s boyfriend was charged with murder and pled not guilty. The jury determined he was not guilty. Newborn Dahlia Dahlia’s mother had concealed her preg-nancy by saying she had a tumor. Her estranged husband and his mother were vis-iting when she excused herself to go to the bathroom for her “tumor” problem. She came out about 11/2 hours later. A full-term fetus was later found in the trash can behind the house. The mother admitted herself to Dorothea Dix a few days later. Legal outcome: Dahlia’s mother was charged with concealing a birth and first-degree murder. She pled guilty to conceal-ing the birth and received a six-year sus-pended sentence with supervised probation and mental health involvement. The following is the third article to appear in the Forum by Dr Herman-Giddens on the subject of child abuse homicide. The first, A New Book - A Helpful Tool: Not Invisible, Not in Vain - Child Maltreatment Fatalities: Guidelines for Response, appeared in Forum #1, 2001. The second, Child Abuse Homicides in North Carolina: Characteristics Physicians Should Understand, appeared in Forum #2, 2001. The stories below bring a painful dimension of reality to the tragedy of child abuse homicide in this state. No. 4 2001 5 Child Abuse Homicides continued from page 4 Three-year-old Jimmy Jimmy’s mother’s boyfriend was babysit-ting for Jimmy. The boyfriend ‘disciplined’ the child by administering blows on the head with a hairbrush, which subsequently killed the child. The medical examiner’s file had clear pictures of the patterned injuries that matched the hairbrush. Legal outcome: Jimmy’s mother’s boyfriend was charged with second-degree murder. The jury convicted him of a misde-meanor and gave him a two-year jail sen-tence. Two-year-old Bruce Bruce was found dead in the early morn-ing in his home. He had been ill for a week following a visit to his biological father’s house. Bruce’s mother said that he was hav-ing trouble walking and was vomiting inter-mittently. She had taken him to the emer-gency room the day before his death, but no specific therapy was given. An appointment with a doctor was made for a later time, but he died before this could occur. The autop-sy found that he died from blunt trauma to the head and had evidence (rectal bleeding and enlargement ) of child sexual abuse. Legal outcome: Bruce’s father was charged with first-degree murder and first-degree sexual offense. The outcome of the trial was not available. Four-month-old Lynn The mother of Lynn was having problems with Lynn’s father. She went to the police department to get an officer to remove the father, age 19, from the residence. When she returned, the father met her at the door and stated that Lynn had just quit breathing. The mother took Lynn to the police depart-ment, but by the time an emergency medical worker saw the baby she was unresponsive. The father’s account was that he was drunk and went to bed, leaving the baby strapped in her chair. The next door neighbor had come over and put the baby in bed with him. The father stated that the baby started crying and he reached over and put a pacifi-er in her mouth and, then, a few minutes later she started ‘losing her breath.’ The autopsy found that the child died as a result of multiple traumatic insults, including 24 new and healing rib fractures, bruises to the back of the head, eye, lips, chest, and a left skull fracture. Legal outcome: The child’s father was charged with first-degree murder. The first trial was a mistrial. In the second, he was convicted of second-degree murder, and given a life sentence. Eight-month-old Billy Billy lived with his mother and maternal grandparents. The sequence of events regarding his death was not clear and varied with the interviewer. Neither of the grand-parents was at home at the time of the lethal incident. Billy’s mother called EMS four hours after the child’s death. Billy was found in his crib, naked, with his head lying between cushions. His death was consid-ered to be due to SIDS until the mother confessed to the SIDS counselor that she smothered Billy. Billy’s parents were not married and his father only saw him occa-sionally. There was some evidence that the mother may have been intoxicated at the time of the incident. Billy did not have evi-dence of abuse on his body. Legal outcome: Billy’s mother was charged with first-degree murder. She pled guilty of second-degree murder and received a 40 year prison sentence. _____________________ Sources National Vital Statistics Reports, Vol. 48, No. 11, July 24, 2000 (1998 data, most recent year for final data). Source of case information: NC Medical Examiner files, law enforcement and Department of Social Services reports, and The North Carolina Child Homicide Study, Office of the Chief Medical Examiner, Chapel Hill, NC, 1998. Save Time, Register on Line Nick Hun, NCMB Licensing Staff It is no secret that members of the medical community are extremely busy. Doctors, especially those new to the profession, can regularly work 80 hours per week. Throw in the additional demands placed by family, friends, and everyday life, and the result can be a community of tired practitioners. The mere fact that you are reading this publica-tion is a credit to your time management skills. The North Carolina Medical Board wants to make your annual license registration as quick and painless as possible. In an effort to save you time and increase the accuracy of your medical license information, we have established on-line registration renewal. With a few simple clicks of the mouse, we will eliminate the hassle of pens, paper cuts, and the U.S. Postal Service. On-line regis-tration is simple. All you need are a • computer with Internet access, • certificate ID number (found on last year’s certificate and renewal notices sent by the Board), • Social Security number, and • birth date. Secure on-line payment can be made using a Visa® or MasterCard®. It’s that sim-ple! Renew your registration up to two months prior to expiration by going to our Web site (www.ncmedboard.org) and clicking on the link for electronic registration. Just a few quick keystrokes, pushes of the “enter” button, and mouse clicks, and you are done. Need another reason to forgo paper and peck at the PC? The chances of your infor-mation being correct increase ten-fold when your registration is completed on line. When you register using the paper method, numerous things can happen that can delay or corrupt the processing of your applica-tion, including slow mail service and our staff or computer misinterpreting illegible handwriting. On-line registration also saves the time you would have spent filling out the paper forms, and that is just the beginning. It takes one or two days to process on-line reg-istration. Compare that to the three weeks (from the time you mail it to us) that it takes to process the paper registration. Won’t it be nice when the DEA calls for proof of your license and you can provide it instantly? Some of you may not consider yourselves computer savvy. We understand that and are trying to help make your on-line registration as painless as possible. If you have trouble, e-mail us at registration@ncmedboard.org. We will send you a response within two business days. Save time, increase the odds that your reg-istration information will be correct, and maybe learn a little about the Internet by registering on line. E-Mail: info@ncmedboard.org Web Site: www.ncmedboard.org North Carolina Medical Board 6 NCMB Forum continued on page 7 Training Staff and Seeing Patients: Stories from the Moldova Hospice Project Laurie Saxton, Director of Communications Carolinas Center for Hospice and End of Life Care Last spring, Pat Ashworth was drawn back to Moldova. Ashworth, a certified hos-pice palliative nurse at Hospice and Palliative Care of Greensboro, is a consultant to the project to open the first hospice in this Eastern European country. She had first joined Judi Lund Person, president and CEO of The Carolinas Center for Hospice and End of Life Care, on a trip to Moldova in the fall of 2000. On her return visit, sponsored by The Carolinas Center, she joined the staff of the planned hospice for two weeks of training in Romania. Home visits in Moldova followed, to put the team’s new knowledge into practice. This is the story of her journey. Ashworth shared her experiences in a workshop she presented with Person at The Carolinas Center’s annual conference in October. The workshop offered the oppor-tunity to discuss the hospice movement in Eastern Europe, the Moldova experience, and cultural similarities and differences regarding death and dying. Moldova: the Country and the Challenge About 4.5 million people live in this hilly agricultural country with rich traditions of family ties, culture, art and music. The liter-acy rate is near 100 percent. About the size of Connecticut, Moldova lies between Romania and Ukraine. After a long history of foreign domination, Moldova achieved independence from the Soviet Union in 1991. Since then, Moldovans have strug-gled to rebuild and replace their system of social and medical care. (Life expectancy there has actually declined during the last 10 years.) NATO’s Partnership for Peace paired each former Soviet state with a partner in the United States. Moldova is North Carolina’s partner. Many private and public organiza-tions are working to support the partner-ship, foster democracy in Moldova, and pro-vide assistance to the government and pri-vate economy. The Moldova Hospice Project is a collab-oration of The Carolinas Center, other med-ical and hospice professionals, the North Carolina National Guard, and North Carolina Rotary Clubs in an endeavor to make a real difference in the lives of dying Moldovan patients and their families. These people and organizations are working to achieve the dream of developing the coun-try’s first hospice in the village of Zubresti. The service area of the new hospice includes 51,000 people who live in 11 towns ranging in size from 1,400 to 22,000 inhab-itants. Approximately 100 people within the service area die each month. The leading causes of death include cardiovascular dis-ease, liver disease including cirrhosis and cancer, and other cancers. Efforts to improve the area’s health must overcome several challenges. The local water supply is contaminated with pesticides and human waste. Leukemia in children has been linked to the impure water. Pain med-ication is scarce, affecting both hospice care and more general medical care. Morphine is available only in very small doses; the amount of a four-hour dose in the U.S. must last all day in Moldova. Four key elements were identified early in the hospice development plan and are now being addressed: training for hospice staff; governmental and regulatory issues (import laws, medication, standards of care); the proposed hospice facility itself; and the funding required to tackle the first three ele-ments. Training the Hospice Medical Staff Fourteen physicians and nurses from Moldova participated in a very intensive two-week training program, covering all the standards of hospice care, operations, and protocols applicable to Eastern Europe. Ashworth praised her colleagues’ dedication and enthusiasm under difficult circum-stances. “The Brasov Study Center [in Romania] had never conducted training in back-to-back weeks. They agreed to try it to make it easier for the Moldova staff to attend — and it was intense!” Hospice care is a completely new field in Moldova. Education in pain management and palliative care, so fundamental to hos-pice, was essential for the medical team. They absorbed it eagerly, mastering the pain management ladder, knowledge of round-the- clock dosing, and other aspects of hos-pice care. After the training, Ashworth and the hos-pice team returned to Moldova for home vis-its in the service area of the new hospice. The two-way education continued with dis-cussions of the care appropriate for the kinds of illnesses and patients seen in the area. “We can learn from them, too,” Ashworth said. “Moldovans have a very family-cen-tered idea of care for the dying.” But there is a severe shortage of caregivers in a country where over 600,000 people leave every year in search of work. Imagine delivering home care — on foot — for an entire day. Within the villages, this is a way of life for physicians and nurses. In and around Straseni, the largest town in the area, visits were made in the “company car”— a WWII-era jeep. After a day of nav-igating the terrain by jeep, Ashworth was glad to travel on foot again. The most mem-orable features of this remarkable environ-ment were the patients and their families. Here are just three of their stories. Given to the Neighbors In Straseni, the team paid a visit to the home of a 37-year-old woman with advanced breast cancer. The patient was not there; instead, a small boy came out to meet them. Where was his mother? The boy’s aunt had come and taken his mother to the aunt’s home to die. His father had left home years before, an older sibling was away working — and this eight-year-old had been given to the neighbors. As his mother was dying, this boy was given to the neighbors. No. 4 2001 7 Stories from Moldova continued from page 6 A Physician Needs Healing Drs Andre and Maria Grozav run the clin-ic in the village of Recea. Maria accompa-nied Ashworth and Dr Eleonora Suruceanu on their travels. One day as they stopped for lunch at Andre and Maria’s home, Maria confided in broken English, “My husband is not well.” Dr Andre Grozav was undergoing chemotherapy for pancreatic cancer. The Grozavs are the only physicians in their vil-lage. So, though pale and thin, he was still making his rounds. Maria too continued to provide care, to her patients and to Andre, working through her fear that she may soon be the only doctor in Recea. Confined to One Room for Five Years On her home visits, Ashworth saw more than one case of untreated fractures resulting in disability. One patient had been confined to bed for eight years, and to only one room for five. Untreated fractures, including her right hip, left her unable to walk. The woman’s situation, so rare to American eyes, was not unusual. The woman’s daughter cares for her at night when she returns from work. During the day, a neighbor looks in on her. Family members often must go to another village to find work. When this happens, it is not uncommon for neighbors to provide care. Patients even administer their own med-ications — including IV — because there is no one else to do it. Ashworth was humbled by the experience. “We have so much in the U.S. So many of us take for granted that our fractures and our heart disease will be treated.” Prosparae Zubresti — the New Hospice Facility The Moldovan government has donated a former hospital building to be used as the hospice inpatient facility. Major renovations are needed to get the building into working condition and to provide even the basics of comfort and care: running water, indoor plumbing, electricity, heat. Changes will have to take place as well in the practices of the patients and their fami-lies. In Moldova, patients generally take their own linens, food, and even medicines with them when they enter a hospital. How will they respond to a hospice facility where all these things are provided for them? And there might be some adjustments in the American expectations of a hospice inpa-tient facility. In Moldova, 98% of patients die at home. How should a hospice be sen-sitive to the customs and wishes of the patients? The inpatient facility might address short-term pain management and symptom control needs, then release patients to return to their homes. Support and Funding for the New Hospice After 25 years of providing hospice care in North Carolina, it is time for us to share our knowledge with people in other countries, as we ourselves learned in the 1970s from Dame Cicely Saunders and her hospice expe-rience in Great Britain. The commitment to hospice care in Moldova is not a short-term association, but a lasting relationship Drs Eleonora Suruceanu, Andre & Maria Grozav. Untreated fractures left her confined to one room for five years. The hospice building sunroom will be renovated to accommodate baths and a common area. between our countries and our hospice care providers that is based on mutual under-standing. The training of the Moldova hospice staff last spring marked one step in this relation-ship. The contributions of many individuals in the Carolinas made this training possible, paying for the travel by van to Romania and for the two-week intensive course. The Carolinas Center for Hospice and End of Life Care is seeking funding through grants and individual contributions to realize the goal of opening the inpatient facility next year and continuing to serve patients like the ones Ashworth saw. The Carolinas Center is awaiting word on a grant that will allow renovation of the 20- bed former hospital to create the hospice inpatient facility. The needed renovations could begin as early as next spring, and not a day too soon for those who await the sup-port and care the hospice will provide. More than dollars are needed. Volunteers are vital as well, to travel to Moldova to assist the fledgling hospice. Individual contributors can have an enor-mous impact on the lives of Moldovan fam-ilies. Contributions are needed for both start-up and operating costs. For example, $320 will heat the hospice facility for one year and $500 will build the wheelchair ramps needed. Salaries and other operating expenses are comparably modest: the annual salaries for a doctor and a nurse are $1,800 and $840 respectively. For information on how you can help, contact The Carolinas Center at 1.800.662.8859 or www.carolinasendoflife-care. org. If you would like to hear more of the first-hand account of a journey to Moldova, or to volunteer, call Judi Lund Person at The Carolinas Center or Pat Ashworth at Hospice and Palliative Care of Greensboro (336.621.2500). 8 NCMB Forum text continued on page 11 Last quarter, the North Carolina Medicaid Drug Utilization Review (DUR) Board, consisting of practicing physicians and clinical pharmacists, conducted a review of prescription claims for patients who had been diagnosed with diabetes and were not receiving a “statin” drug. Surprisingly, over 24,000 patients met this criterion; 1,000 of these were further reviewed. We do not mean to imply that all patients with diabetes automatically require statin therapy. However, analyzing the aggregate data has at least raised the possibility that we are not treating dyslipidemia as aggressively as we should. Persons with diabetes who have had a myocardial infarction have an unusually high death rate.1 The American Diabetes Association recommends annual lipid pro-files for adult patients with diabetes. However, according to data compiled by Medical Review of North Carolina, only about 60% of Medicare patients with dia-betes received this test within two years in the Carolinas.2 A complete discussion of the new National Cholesterol Education Program (NCEP) ATP III high cholesterol guidelines is beyond the scope of this article, but can be found in JAMA1 and other medical litera-ture. The Executive Summary of these new guidelines may be downloaded from the fol-lowing National Institutes of Health (NIH) Web site: http://www.nhlbi.nih.gov/guidelines /cholesterol/atp_iii.htm. Therapeutic lifestyle changes (TLC) such as diet, weight reduction, and increased physical activity remain an integral part of cholesterol treatment. Key changes include more aggressive LDL lowering to less than 100 mg/dL in all patients with diabetes, a higher level (40 mg/dL) at which HDL becomes a risk factor, a new set of TLC, tar-geting the “metabolic syndrome,” and increased attention to high triglycerides.3 Please refer to peer-reviewed, evidence-based medicine (EBM) guidelines for detailed recommendations on managing your patients who suffer from diabetes or dyslipidemia. The American College of Endocrinology (ACE) and American Association of Clinical Endocrinologists (AACE) practice guidelines for the diagnosis and treatment of dyslipidemia and preven-tion of atherogenesis may be found at http://www.aace.com/clin/guidelines. In addi-tion, diabetes management guidelines from the ACE Consensus Conference on Guidelines for Glycemic Control may be From NCDHHS Division of Medical Assistance, Medical Policy, Pharmacy Program DUR Recommendation: Aggressively Treating Dyslipidemia in Diabetics Sharman Leinwand, MPH, RPh, Manager, NC Medicaid Pharmacy Program and Mark D. Krueger, RPh, BCNP Table 1: Statin Effects On Lipids After 8 Weeks of Treatment With LDL from 192 to 244 mg/dL4 (% change from baseline with the following daily doses) Key: TC: total cholesterol; LDL: low-density lipoprotein; HDL: high-density lipoprotein; TG: triglycerides Table 2: Lipid-Lowering Properties of Statins in Placebo-Controlled Trials5 (mean % change from baseline with the following daily doses) Key: TC: total cholesterol; LDL: low-density lipoprotein; HDL: high-density lipoprotein; TG: triglycerides Table 3: Antihyperlipidemic Drugs and Their Effects1 Table 4: EBM Outcome Data and Dose of the Statins4 Primary prevention: AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study: WOSCOPS = West of Scotland Coronary Prevention Study Secondary prevention: 4S = Scandinavian Simvastatin Survival Study; CARE = Cholesterol and Recurrent Events Trial; LIPID = Long-Term Intervention With Pravastatin in Ischemic Disease Effectiveness Tables No. 4 2001 9 In October, Andrew W. Watry, executive director of the North Carolina Medical Board, announced the Board’s election of its officers for the coming year: Walter J. Pories, MD, of Greenville, as president; John T. Dees, MD, of Bald Head Island, as vice pres-ident; and Paul Saperstein, of Greensboro, as secretary-treasurer. They took office on November 1, 2001 and will serve until October 31, 2002. Walter J. Pories, MD, President Walter J. Pories, MD, of Greenville, took office as the Board’s new president on November 1, replac-ing Dr Elizabeth P. Kanof, of Raleigh, in that post. A native of Germany, Dr Pories is professor of surgery and bio-chemistry at the East Carolina University School of Medicine. He is also a clinical professor of surgery at the Uniformed Services University of Health Sciences. He received his BA at Wesleyan University, Middletown, Connecticut, and his MD with honors from the University of Rochester School of Medicine and Dentistry. His postgraduate study included an internship at Strong Memorial Hospital of the University of Rochester; a part-time fellowship at the Centre du Cancer of the Universite de Nancy, France; a graduate research fellow-ship in biochemistry at the University of Rochester; and a residency in general and thoracic surgery at Strong Memorial Hospital. He is certified by the American Board of Surgery and the American Board of Thoracic Surgery. He was first appointed to the North Carolina Medical Board by Governor James B. Hunt, Jr, in 1997, and has served as the Board’s secretary-treasurer and vice president. Frequently honored for his work as a sur-geon and teacher, Dr Pories is a past gover-nor of the American College of Surgeons and has served as president of the North Carolina Chapter of the American College of Surgeons, the North Carolina Surgical Association, the Eastern Carolina Health Organization, Hospice of Greenville, and the Association of Program Directors in Surgery. Active on a large number of pro-fessional boards and committees, he is also the author/coauthor of 47 book chapters, 7 books, and over 250 medical articles dealing primarily with the metabolism of trace ele-ments, diabetes, and surgical education. He has also been involved in the making of four educational films. In 2001, he was awarded the O. Max Gardner Award by the University of North Carolina Board of Governors, the highest faculty honor it can bestow. Dr Pories is a retired colonel of the U.S. Army Reserves. He has published over 50 cartoons and is a talented artist. John T. Dees, MD, Vice President John T. Dees, MD, of Bald Head Island (formerly of Cary), became the Board’s vice president on November 1, replac-ing Dr Walter Pories in that position. A family physician, he practiced for many years in his native Burgaw, a rural area of the state. He received his under-graduate education at the University of North Carolina, Chapel Hill, and his MD from Duke University School of Medicine. He did his internship at Durham’s Watts Hospital and his residency at Duke Hospital. He is a charter diplomate of the American Board of Family Physicians. Besides his private practice, Dr Dees has served, among other things, as Pender County Health Director, chief of staff of Pender Memorial Hospital, and medical director of the Huntington Health Care Center. He has rendered distinguished ser-vice to a wide variety of professional organi-zations, including the North Carolina Academy of Family Physicians, the North Carolina Medical Society, the American Academy of Family Physicians, the Southern Medical Association, the Wake and New Hanover-Pender County Medical Societies, and the American Medical Association. He served as president of the North Carolina Medial Society in 1991-92 and was a mem-ber of the Society’s Executive Council and NCMB Elects Officers: Walter J. Pories, MD, President; John T. Dees, MD, Vice President; Paul Saperstein, Secretary-Treasurer an alternate delegate to the American Medical Association’s House of Delegates. He has also been an active participant in civic affairs in Burgaw and Pender County and at the state level. Dr Dees was first named to the Board by Governor James B. Hunt, Jr, in 1997. While on the Board, Dr Dees has served, among other committees, on the Complaints Committee, the Physicians Health Program Committee, the Investigative Committee, the Clinical Pharmacist Practitioner Joint Subcommittee, and the Executive Committee. In 2000, he was elected secre-tary- treasurer of the Board. Dr Dees says his philosophy is that “ser-vice to humanity is the best work of life.” Paul Saperstein, Secretary-Treasurer On November 1, Mr Paul Saperstein, of Greensboro, took office as secretary-treasur-er of the North Carolina Medical Board, suc-ceeding Dr Dees. First appointed to the Board by Governor James B. Hunt, Jr, in 1993, he was elected secretary-treasurer of the Board in 1995 and 1996 and vice president in 1997. In 1998, he became the first public mem-ber of the Board to be elected its presi-dent. He has been a member of a number of Board commit-tees, including the Investigative, Complaints, Physician Assistant, and Telemedicine Committees, and has chaired the Operations and Executive Committees. A graduate of North Carolina State University, he is president and chief execu-tive officer of Concept Plastics, Inc, includ-ing its Craft-Tex and Ladybug divisions, in High Point. He founded Concept Plastics, Inc, which is one of the nation’s largest man-ufacturers of custom-molded polyester, in 1970. In the 1980s, he was also president and chief executive officer of Case Casard Furniture Manufacturing Corporation. Over the years, he has been active in a wide variety of community organizations and groups. Dr Pories Dr Dees Mr Saperstein 10 NCMB Forum continued on page 11 Death Be Not Proud: The Meaning of Wit Jeffrey A. Peake, NCMB Licensing Staff Vivian Bearing has advanced metastatic ovarian cancer. She has just endured eight grueling treatment cycles, one cycle a month, each combining chemotherapy and experimental drug administrations. It has taken enormous courage and toughness to get through each treatment, and in fact no one else has ever made it through all eight at full dosage. Always attracted to difficult challenges, Vivian recognizes that her latest accomplishment makes her a celebrity around the hospital, one who will soon be written about in a medical journal article. But there is nothing comforting in this fact, and, ever closer to death, she is not inclined to illusions. “The article will not be about me,” she says, “It will be about my ovaries. It will be about my peritoneal cavity, which despite their best intentions, is crawling with cancer. What we have come to think of as me is, in fact, just the specimen jar, just the dust jacket, just the white piece of paper that bears the little black marks.” There is a central tension in modern life we all periodically encounter, perhaps never more so than when we are in a hospital set-ting. It is the struggle to maintain human dignity amidst the forces of technology, spe-cialization, and bureaucracy. This tension drives Margaret Edson’s wonderful, though devastating, play Wit, a dramatization of a woman’s battle against cancer, which won the Pulitzer Prize in 1999. Edson’s play has been lovingly adapted into an Emmy-win-ning HBO movie (now available on VHS and DVD), directed by Mike Nichols and starring the unrivaled Emma Thompson, whose performance is a tour de force. _______________________________ Wit Margaret Edson Dramatists Play Service, New York, 1999 68 pages, $5.95 (ISBN #0-8222-1704-X) .................. Wit Screenplay by Mike Nichols and Emma Thompson Directed by Mike Nichols; HBO Films, Avenue Pictures HBO Home Video, DVD, 2000 99 minutes, $19.95 _________________________________ The entire drama unfolds at the fictional University Hospital Comprehensive Cancer Center, though there are flashback scenes throughout. Edson, an elementary school teacher now living in Georgia, previously worked in the cancer and AIDS unit of a research hospital, and that experience was the impetus for writing the play. We can sur-mise from Wit that her impressions of the hospital were largely unflattering, even ghastly at times. In a recent television inter-view, she said she wanted to write a story about grace, and could best do so through use of a graceless setting. The narrator and lead character of both the play and film is Vivian Bearing, an English professor with expertise in the poet-ry of John Donne, the seventeenth-century Englishman best known for his highly com-plex works that have been dubbed “meta-physical” poetry. In particular, she is a schol-ar of Donne’s Holy Sonnets, 19 intense reli-gious meditations. The play’s title derives from Vivian’s connection with Donne, for in the seventeenth century the term wit did not merely suggest arousing amusement, but referred to a high level of mental activity, characterized in Donne’s poetry through finding similarities in seemingly dissimilar images or elements, and in exploring para-doxes, contradictions, and irony. The point of this wit, as Vivian’s mentor, Professor Ashford, reminds her in a flashback scene, is to illuminate truth. Edson’s play follows suit, using wit to great dramatic purpose. For example, connections are made in Wit between poems and tumors, English profes-sors and research fellows, the rich language of poetry and the clinical language of sci-ence. The result is a complex and layered work, one that contemplates the lessons of mortality and the sad consequences of for-getting our primary responsibilities for each other. Vivian is an extremely intelligent woman, at the top of her field, proud of her work and quite willing to show off her verbal dexteri-ty. She is impressive, or in her own words, she is “a force.” Early in the play, she greets us with an engaging sarcasm, remaining as objective about and as distant from her dire situation as she can, though as the play pro-gresses she becomes more insular and per-haps more her true self. In the midst of telling her story, Vivian is constantly being wheeled from room to room, poked and prodded by staff members who don’t know her name, and put at the mercy of tubes and machines. Her physicians, Dr Kelekian and his chief clinical fellow, Dr Posner, have woe-ful bedside manners, which generally consist of empty exhortations, such as “keep push-ing the fluids.” Once she is even thought-lessly left alone in a room, lying prone and exposed on an exam table. The indignities seem to increase as Vivian’s condition wors-ens. Competitive research fellows speak over her during grand rounds, discussing her symptoms and side effects as if she were not even present. While on individual rounds, a masked Dr Posner enters her isolation unit, such a harrowing and lonely place, and mur-murs “I really have not got time for this. . . .” _____________________ . . . my physicians by their love are grown Cosmographers, and I their map, who lie Flat on this bed. ..................................... I observe the physician with the same diligence as he the disease. John Donne, Devotions VI _____________________ The play, though, is not simply a philippic against cold and faceless hospitals. As Vivian reviews her life, we see that she, too, is guilty of living ungraciously. Flashback scenes reveal she has had little to no affection for her students, often “refused them the touch of human kindness,” and was mainly interested in impressing them. Apparently her colleagues do not like her, and she imag-ines many “would be relieved” at her death. Though her entire history is not revealed, we learn that she has lived largely in isolation and has no husband or children, no close family members, no close friends. The impression is that she has almost invited such a life. Perhaps most importantly, we see Vivian’s sterile attitude towards her life’s work for the past 20 years. Of all the formal arts, poetry is best able to capture the totality of experi-ence. In our greatest poems, the proper wedding of words and images creates what has been called a “miracle of harmony,” through which we glimpse truths that can-not be represented any other way. Donne’s poetry achieves this harmony through com-plex images and arguments. In his Holy Sonnets, these complexities lead to a moving exploration of sin, suffering, death, and, ulti-mately, divine reconciliation. Vivian, how-ever, is drawn to Donne only because he is complex, saying that his “wit provides an invaluable exercise for sharpening the mental REVIEW No. 4 2001 11 faculties.” Thus, the best reason she can give for her studies is that they bring an intellec-tual challenge, “a way to see how good you really are.” Such reasoning ignores, of course, the most important dimension of poetry, the human dimension. In the same way, Vivian’s physicians seem to have for-gotten that their research isn’t done for the sake of research, but for the sake of people. We remember those haunting words, “just the specimen jar, just the dust jacket, just the white piece of paper that bears the little black marks.” Yet, out of the darkness comes light. In her most desperate moments, when the pain of cancer and loneliness grow unbearable, Vivian becomes most fully human. In two scenes of great emo-tional depth, she shares her vulnerabilities at last, and accepts the warmth that is finally offered her. First, with the help of her nurse (the one standout hospital employee), Vivian is able to make a crucial decision about her end-of-life care, illustrating that she is now able to be gracious with herself. Then, in a moment of touching symmetry, she is visited by her former mentor, Professor Ashford, now an old woman who no longer offers admoni-tions, but tenderness and love. These scenes in the film version of Wit affected me like few I have ever seen, and in them one rec-ognizes that redemption had occurred for Vivian through her suffering. At the play’s tumultuous end, there is also hope. Dr Posner, the most callous of the clinical fel-lows, has been redeemed through a shocking epiphany, and one suspects the way he views his patients has been altered forever. _____________________________________ Death be not proud, though some have called thee Mighty and dreadful, for thou art not so, For those whom thou think’st thou dost over-throw, Die not, poor death, nor yet canst thou kill me. .................. Thou art slave to fate, chance, kings, and des-perate men. .................. One short sleep past, we wake eternally, And death shall be no more; death, thou shalt die. John Donne, Holy Sonnets X ____________________________________ We are so privileged to live in an age of medical breakthroughs, to benefit from the hard work of researchers, the expertise of specialists, and the wonders of modern med-ical facilities. But what do we profit by it if we lose our souls? In reading, and watching, Wit, I was remind-ed of the author C.S. Lewis, who more than 50 years ago warned us that the pursuit of biological and medical con-quests can, if we are not careful, obscure our very humanity. “If man chooses to treat himself as raw material, raw material he will be,” he wrote, adding, “Man’s final conquest has proved to be the abolition of Man.” Wit, both as a play and a film, stands against our dehumanizing tendencies, and urges us to do better. Few patients are quite like Vivian, which is probably a good thing, and few physicians are like Drs Kelekian and Posner, which is certainly a good thing. But all involved in the health care equation, laypersons and professionals, will find a bit of themselves in each of these char-acters; and that shock of recognition, that expression of wit, that troubling similarity in the dissimilar, cannot help but benefit every-one who reads or sees this remarkably mov-ing piece. Be one of those if you can. Death Be Not Proud continued from page 10 found at http://www.aace.com/pub/press/releas-es/ diabetesconsensuswhitepaper.php. Since this DUR was generated from aggregate claims data, we did not have access to lipid profiles and other detailed medical information. For your patients with diabetes, we recommend obtaining an annu-al lipid panel and using the new NCEP guidelines to guide therapy. Please remem-ber to exercise caution when considering drug therapy for children. Keep in mind that most antihyperlipidemic therapies are contraindicated in pregnancy. We have included above several useful tables summarizing reported effectiveness of cholesterol lowering agents. Tables 14 and 25 provide various estimates of lipid lowering effectiveness of the statin drugs. Table 31 compares the effectiveness of the cholesterol lowering agents by class. Table 44 contains important data on EBM outcomes. Although Lipitor® (atorvastatin) is the cur-rent market leader with over $5 billion in annual sales and has data to support lipid lowering effectiveness, it currently has no supporting outcomes data (morbidity/mor-tality). 4 There are at least eight long-term, large-scale outcome studies now underway that will provide additional crucial EBM data10. Of the statin drugs, pravastatin (Pravachol®) is the only one with supporting EBM data for both primary and secondary prevention. In summary, for patients with diabetes, check a lipid panel annually to identify those who may benefit from more aggressive lipid lowering therapy. Follow the new and more aggressive NCEP guidelines. Please consid-er EBM and medication costs when choos-ing drug therapy. _____________________ References 1. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-97. 2. Henley N. National Cholesterol Educational Program Designates Diabetes as a Coronary Heart Disease Risk Equivalent. Quality Partners 2001; 6(4):1, 9. 3. Anonymous. NCEP issues major new cholesterol guidelines. National Institutes of Health news release 2001; 15 May. Available at: http:// www.nih.gov/news/pr/may2001/nhlbi-15.htm. Accessed 12 September 2001. 4. Jellinger PS. AACE Lipid Guidelines. Endocr Pract 2000; 6(2):162-213. 5. Antihyperlipidemic Agents. Drug Facts and Com-parisons. St. Louis, 2000, p. 537. 6. Lipitor Product Information, Warner-Lambert Co., Morris Plains, NJ 07950, 1999. 7. Lescol Product Information, Novartis Pharmaceu-ticals Corporation, East Hanover, New Jersey 07936, 2001. 8. Pravachol Product Information, Bristol-Myers Squibb Co., Princeton, NJ 08543, 2001. 9. Zocor Product Information, Merck & Co., Inc., Whitehouse Station, NJ 08889, 2001. 10. Wierzbicki AS. Synthetic Statins: More Data on Newer Lipid-Lowering Agents. Curr Med Res Opin 2001; 17(1):74-77. .......................................... Questions and comments may be directed to Sharman Leinwand by telephone (919.857-4034) or by e-mail (Sharman.Leinwand@ncmail.net.) DUR Recommendation: continued from page 8 12 NCMB Forum More on End-of-Life Care To the Editor: I just finished reading [Dr Pories’] article in regard to euthanasia [,Killing a Panda,] in the NCMB Forum [#2, 2001]. I feel compelled to write and to challenge [his] association between being a good physician and being the patient’s “suc-cor of last resort.” We should all pride ourselves on being caring physicians. We must love medicine but love our patients more. We need to spend time with them, to help them, to comfort them, and to protect them. On all of the above, I certainly agree with [Dr Pories]. There comes a time, however, when lov-ing is letting go. “Sores, bad smells, and incontinence” do not bother me as a physi-cian. However, they certainly bother the patient. Life with quality is wonderful. Life without quality can be a true burden. I lost my mother one year ago. I loved her dearly. She was in poor health even before her “gut” was “in knots.” It was my initial objective to make certain that we relieved her obstruction as soon as possible. However, my mother has always been smarter than I. Without hesitation, she refused the surgery. When I challenged her and told her that I was not ready to lose her, she challenged me for being so selfish and non-understanding. She pointed out that I wanted life for her for my own sake. As a physician, and as a son, I was unwilling to let her go. However, in her wisdom, she saw that life was always limited and that death was sometimes a greater gift than a painful, unhappy life. Please do not get me wrong. I am not in favor of positive euthanasia. However, the election that my family eventually reached of relieving my mother’s pain and not putting her through further surgery, nursing home care, and possible years of suffering, was not one that I regret. We must be willing to always place our patient’s overall welfare above our own per-sonal desires to heal and prolong life. A good physician is one who helps his or her patient have quality in life and who sits by their side and holds their hand as they die. Your article implied that death is wrong. Death is real, and will be real for each of us. Let us hope that we, as physicians, can make the passage of our patients smoother, not only in life, but also in death. Curtis W. Schupbach, MD Charlotte, NC Response: I appreciate Dr Schupbach’s thoughtful com-ments. His poignant description of his mother’s passing proves, indeed, that he is a “caring physician.” I’ve thought a lot about death and how to ease its burden. I founded and directed two hospices, one in Cleveland and another in Greenville, so that our patients would have a place where death is accepted and even welcomed. I did not mean to imply that death is wrong. It may be unexpected or untimely or overdue, but it is never wrong. As Dr Schupbach reminds us, we will all die. My mother’s end was also awful. She was lively and fun even until her 93rd birthday. She reminded me again and again that I would never let her linger, that I would allow her to have the “gift of a kind death” when her time came. “Promise me,” she said, and promise I did. Unfortunately, when she had a major stroke, someone carried out a full resuscitation that left her hanging on a ventilator for several terrible months, unable to communicate. When she was finally extubated, she spent the next eight weeks crying, “help, help, help,” in the empty canyons of the nursing home. She could not communicate, and, frankly, I could not look into her eyes without feeling guilty. It is inter-esting that on the last day of her life she changed her mindless cry to, “God, please help me,” and within an hour, passed away. Yes, Dr Schupbach, I’m right there with you in recognizing that there is a time to let go. I have no argument with your thesis. I only dis-agree with those who would take a life, who would rather dispose of the person than help, who find caring inconvenient. Thank you for sharing your thoughts so well. Walter J. Pories, MD, FACS President, NCMB Dr VanFrank’s Dilemma To the Editor: I read today with a mixture of sympathy, shock, and anger Dr VanFrank’s moving account of the repercussions of inad-vertently failing to renew her license [Forum #3, 2001]. I have never met nor heard of Dr VanFrank, but if, as I assume because the document was published, her story is true, this seems fairly clear evidence of a bureau-cracy out of control. Not that I would coun-tenance sloth or irresponsibility, but it does not seem like any reasonable effort was expended to effectively contact Dr VanFrank. Mailing was attempted, and when that failed, it was attempted again and again. We all know how easy it is to forget to notify all the different sources when our address changes. Why the mail was not effectively forwarded, I cannot answer. Why the Board could not contact her at her known and apparently regular place of work seems worthy of exploration. It does not seem like much if any customer-friendly effort was expended. More significantly, it seems tragic that a simple failure to make connection by mail should result in so much wasted effort, money, time, and suffering. When the lapse in licensure was discovered, it would seem some simple informal investigation would have revealed this to be an honest mistake, with appropriate and simple steps taken to clear the record without any pejorative residue. By appearances, a Brobdingnagian punishment was meted out for a Lilliputian offense. With rare exceptions, bureaucracies con-tribute little if anything to effective delivery of care to patients. We all struggle mightily every day with the ever-increasing volumes of paperwork, diverting useful effort to use-less purposes. The North Carolina Medical Board really should have little difficulty doing their job effectively while still being compassionate. If anything, they probably owe Dr VanFrank an apology! Karol T. Wolicki, MD Greensboro, NC To the Editor: I read every issue of the Forum. It is always informative, usually interesting, and occasionally worrisome. An article by Dr Alison VanFrank in the Forum, No. 3, 2001, fits the latter category. The error of failing to register her NC license and to send the $100 annual fee in a timely manner appears to me to carry an extremely heavy consequence. Dr VanFrank had not been found to be incompetent, fraudulent, or unprofessional, which are the important measures of us as physicians. Rather, she moved her office and thereby failed to receive the annual renewal notice for registering her NC medical license. This administrative oversight led to an extreme impact on her medical practice as well as dis-proportionate financial and mental costs to her. I personally think the Medical Board could take a greater degree of responsibility in reaching physicians who are delinquent in renewal of their medical licenses. Physicians, of course, have the primary responsibility to keep their licenses current. But in my 28 years of practice, I have seen a noticeable increase in the number of month-continued on page 13 LETTERS TO THE EDITOR No. 4 2001 13 ly renewals to local hospital staffs, profes-sional organizations, state and national med-ical societies, and the subsequent required renewals, refilings, and certified responses. Could the Medical Board staff not make one telephone call reminder to physicians who fail to renew by their birthday? Give them a two week period to update and renew, with an appropriate late-filing fee (hopefully less than Dr VanFrank’s $12,000 [attorney’s fee]) to cover the additional administrative costs? If this additional reminder did not work, then let the sky fall on the poor soul. C. Allan Eure, MD Raleigh, NC Comment: The above are two of five letters received at the Board expressing concern about the Board’s action in this matter. We appreciate all five let-ters and each writers’ viewpoint. While we regret space does not allow all the letters to be published in the Forum, the two printed here well reflect the opinions of all the writers. For a response, please see the comments of the Board’s executive director in his column beginning on the first page of this number of the Forum. Letters to the Editor continued from page 12 Most physicians enter the medical profes-sion because it provides them with the train-ing and opportunity to help people in need. It seems natural, therefore, that physicians might be tempted to take a professional role in providing medical care to those persons dearest and closest to them: their own fam-ilies. Indeed, studies suggest many physi-cians regularly provide medical care for their family members. The instinct to take a pro-fessional role in providing medical care to a loved one, however, should be weighed against the overwhelming evidence from professional organizations, academic litera-ture, and regulatory bodies that uniformly declares the treatment of family members to be professionally unwise and ethically prob-lematic. The North Carolina Medical Board (Board) issues Position Statements on pro-fessional and practice issues to provide guid-ance for physicians. While the Board’s Position Statements are not legally binding, they provide clearly articulated and useful advice and reflect the Board’s general view of what constitutes acceptable professional behavior. The Board’s statement, Self-Treatment and Treatment of Family Members and Others with Whom Significant Emotional Relationships Exist, clearly states that: . . . except for minor illnesses and emergen-cies, physicians should not treat, medically or surgically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. The Board strongly believes that such treat-ment and prescribing is inappropriate and may result in less than optimal care being provided. The admonition against treating close family members is longstanding and nearly ubiquitous. It is contained in the AMA’s first Code of Ethics, adopted in 1847. The current AMA Council on Ethical and Judicial Affairs (Opinion 8.19) and the American College of Physicians’ Ethics Manual echo the Board’s warning against physicians treating family members. Ethical and professional objections to a physician treating his or her family members are based on the danger that the physician’s personal feelings for his or her patient/fami-ly member will undermine rather than enhance the care the family member receives. Personal feelings and fears might compromise a physician’s professional objec-tivity and judgment, leading him or her to either over-or under-estimate the seriousness of the patient’s condition. For example, fearing the worst, the physi-cian may over-diagnose a condition, subject-ing the patient/family member to a series of unnecessary tests, treatments, fears, and risks. Conversely, the physician, reluctant to face the possibility of a seriously ill family member, may dismiss prematurely a viable but more serious diagnosis. These tenden-cies may be aggravated in that the potential informality associated with treating family members sometimes leads to less scrupulous adherence to traditional protocols of history-taking, physical and diagnostic workup, and record keeping. Moreover, family members are frequently examined outside the tradi-tional office setting, without the appropriate support and proper equipment and resources. Personal connections may also complicate the way in which the patient/family mem-bers and physician interact. Physicians with familial connections to their patients might be less likely to ask potentially sensitive, but clinically relevant, questions or to perform intimate, but necessary, examinations. Similarly, patient/family members may be less likely to disclose personal facts. Frequently, the very advantage of speaking to an unrelated physician is that information will be kept from family members. The per-sonal distance may enhance disclosure. On one hand, some patients, especially children, may be less likely to refuse and question treatment recommended by a family mem-ber who is a physician. On the other hand, older family members may doubt the insight and wisdom of a younger, albeit profession-ally trained, physician/family member, and, as a result, be less compliant. Treating physicians must sometimes play the role of mediator, negotiating between and among family members to help them understand and resolve difficult clinical and emotional questions. Here, too, familial connections can be a handicap rather than a benefit. Familiarity and interlocking loyal-ties can confound the already challenging issues of confidentiality, decision making capacity, informed consent, and the host of issues surrounding end-of-life care. While the Board’s Position Statement clearly discourages physicians from treating their family members, providing such care may be appropriate in some limited circum-stances. In emergencies, minor illnesses, and A Word with You Avoid Treating Family Members! Edward E. Hollowell, JD Kenneth A. De Ville, JD in isolated settings in which no other appro-priate medical care is available, physicians may legitimately treat a family member. In those cases in which a physician must pro-vide emergency care for a family member, the patient’s/family member’s care should be transferred to another physician as soon as it is practical. The Board reminds physicians who treat family members for emergency or minor illness that they “must prepare and keep a proper written record of that treat-ment, including but not limited to prescrip-tions written for controlled substances and the medical indications for them.” Abiding by the long-standing warning against providing medical care to family members does not mean abandoning loved ones in their time of need. Instead, physi-cians can best help family members by refer-ring them to qualified and appropriate health care professionals. _____________________ Revised from an article by the same authors in the Medical Law Alert, a newsletter published by Hollowell, Peacock & Meyer, PA, Attorneys and Counselors at Law, Raleigh, NC. 14 NCMB Forum continued on page 15 Position Statements of the North Carolina Medical Board Table of Contents What Are the Position Statements of the Board and To Whom Do They Apply......................................................14 The Physician-Patient Relationship .............................................14 Medical Record Documentation .................................................15 Access to Physician Records........................................................15 Retention of Medical Records.....................................................15 Departures from or Closings of Medical Practices.......................16 The Retired Physician ...............................................................16 Advance Directives and Patient Autonomy..................................16 Availability of Physicians to Their Patients After Hours ..............17 Guidelines for Avoiding Misunderstandings During Physical Examinations ............................................................17 Sexual Exploitation of Patients....................................................17 Contact With Patients Before Prescribing....................................17 Writing of Prescriptions ..............................................................17 Self- Treatment and Treatment of Family Members and Others With Whom Significant Emotional Relationships Exist ..........18 The Use of Anorectics in Treatment of Obesity ..........................18 Prescribing Legend or Controlled Substances for Other Than Valid Medical or Therapeutic Purposes, with Particular Reference to Substances or Preparations with Anabolic Properties.........................................................18 Management of Chronic Non-Malignant Pain ............................18 End-of-Life Responsibilities and Palliative Care ..........................19 (Medical, Nursing, Pharmacy Boards: Joint Statement on Pain Management in End-of-Life Care...............................19 Office-Based Surgery ..................................................................20 Laser Surgery..............................................................................20 Care of Surgical Patients* ...........................................................20 HIV/HBV Infected Health Care Workers ...................................21 Professional Obligation to Report Incompetence, Impairment, and Unethical Conduct ......................................21 Advertising and Publicity*..........................................................21 Sale of Goods From Physician Offices ........................................21 Fee Splitting ...............................................................................21 Unethical Agreements in Complaint Settlements ........................21 [The principles of professionalism and performance expressed in the posi-tion statements of the North Carolina Medical Board apply to all persons licensed and/or approved by the Board to render medical care at any level. The words “physician” and “doctor” as used in the position statements of the North Carolina Medical Board refer to persons who are MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina.] Disclaimer The North Carolina Medical Board makes the information in this publica-tion available as a public service. We attempt to update this printed material as often as possible and to ensure its accuracy. However, because the Board’s position statements may be revised at any time and because errors can occur, the information presented here should not be considered an official or com-plete record. Under no circumstances shall the Board, its members, officers, agents, or employees be liable for any actions taken or omissions made in reliance on information in this publication or for any consequences of such reliance. A more current version of the Board’s position statements will be found on the Board’s Web site: www.ncmedboard.org, which is usually updated shortly after revisions are made. In no case, however, should this publication or the material found on the Board’s Web site substitute for the official records of the Board. What Are The Position Statements of the Board and to Whom Do They Apply? The North Carolina Medical Board’s Position Statements are interpretive statements that attempt to define or explain the meaning of laws or rules that govern the practice of physicians,* physician assistants, and nurse practition-ers in North Carolina, usually those relating to discipline. They also set forth criteria or guidelines used by the Board’s staff in investigations and in the pros-ecution or settlement of cases. When considering the Board’s Position Statements, the following four points should be kept in mind. 1. In its Position Statements, the Board attempts to articulate some of the standards it believes applicable to the medical profession and to the other health care professions it regulates. However, a Position Statement should not be seen as the promulgation of a new standard as of the date of issuance or amendment. Some Position Statements are reminders of traditional, even mil-lennia old, professional standards, or show how the Board might apply such standards today. 2. The Position Statements are not intended to be comprehensive or to set out exhaustively every standard that might apply in every circumstance. Therefore, the absence of a Position Statement or a Position Statement’s silence on cer-tain matters should not be construed as the lack of an enforceable standard. 3. The existence of a Position Statement should not necessarily be taken as an indication of the Board’s enforcement priorities. 4. A lack of disciplinary actions to enforce a particular standard mentioned in a Position Statement should not be taken as an abandonment of the principles set forth therein. The Board will continue to decide each case before it on all the facts and cir-cumstances presented in the hearing, whether or not the issues have been the subject of a Position Statement. The Board intends that the Position Statements will reflect its philosophy on certain subjects and give licensees some guidance for avoiding Board scrutiny. The principles of professionalism and performance expressed in the Position Statements apply to all persons licensed and/or approved by the Board to render medical care at any level. *The words “physician” and “doctor” as used in the Position Statements refer to persons who are MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina. [Adopted November 1999] THE PHYSICIAN-PATIENT RELATIONSHIP The North Carolina Medical Board recognizes the movement toward restructuring the delivery of health care and the significant needs that motivate that movement. The resulting changes are providing a wider range and vari-ety of health care delivery options to the public. Notwithstanding these devel-opments in health care delivery, the duty of the physician remains the same: to provide competent, compassionate, and economically prudent care to all his or her patients. Whatever the health care setting, the Board holds that the physi-cian’s fundamental relationship is always with the patient, just as the Board’s relationship is always with the individual physician. Having assumed care of a patient, the physician may not neglect that patient nor fail for any reason to prescribe the full care that patient requires in accord with the standards of acceptable medical practice. Further, it is the Board’s position that it is uneth-ical for a physician to allow financial incentives or contractual ties of any kind to adversely affect his or her medical judgment or patient care. Therefore, it is the position of the North Carolina Medical Board that any act by a physi-cian that violates or may violate the trust a patient places in the physician places the relationship between physician and patient at risk. This is true whether such an act is entirely self-determined or the result of the physician’s contractual association with a health care entity. The Board believes the inter-ests and health of the people of North Carolina are best served when the physi-cian- patient relationship remains inviolate. The physician who puts the physi-cian- patient relationship at risk also puts his or her relationship with the Board in jeopardy. Elements of the Physician-Patient Relationship The North Carolina Medical Board licenses physicians as a part of regulat-ing the practice of medicine in this state. Receiving a license to practice med- No. 4 2001 15 Position Statement continued from page 14 continued on page 16 icine grants the physician privileges and imposes great responsibilities. The people of North Carolina expect a licensed physician to be competent and worthy of their trust. As patients, they come to the physician in a vulnerable condition, believing the physician has knowledge and skill that will be used for their benefit. Patient trust is fundamental to the relationship thus established. It requires that there be adequate communication between the physician and the patient; there be no conflict of interest between the patient and the physician or third parties; intimate details of the patient’s life shared with the physician be held in confidence; the physician maintain professional knowledge and skills; there be respect for the patient’s autonomy; the physician be compassionate; the physician be an advocate for needed medical care, even at the expense of the physician’s personal interests; and the physician provide neither more nor less than the medical problem requires. The Board believes the interests and health of the people of North Carolina are best served when the physician-patient relationship, founded on patient trust, is considered sacred, and when the elements crucial to that relationship and to that trust — communication, patient primacy, confidentiality, compe-tence, patient autonomy, compassion, selflessness, appropriate care — are fore-most in the hearts, minds, and actions of the physicians licensed by the Board. This same fundamental physician-patient relationship also applies to mid-level health care providers such as physician assistants and nurse practitioners in all practice settings. Termination of the Physician-Patient Relationship The Board recognizes the physician’s right to choose patients and to termi-nate the professional relationship with them when he or she believes it is best to do so. That being understood, the Board maintains that termination of the physician-patient relationship must be done in compliance with the physician’s obligation to support continuity of care for the patient. The decision to ter-minate the relationship must be made by the physician personally. Further, ter-mination must be accompanied by appropriate written notice given by the physician to the patient, the relatives, or the legally responsible parties suffi-ciently far in advance (at least 30 days) to allow other medical care to be secured. Should the physician be a member of a group, the notice of termi-nation must state clearly whether the termination involves only the individual physician or includes other members of the group. In the latter case, those members of the group joining in the termination must be designated. (Adopted July 1995) (Amended July 1998, January 2000) MEDICAL RECORD DOCUMENTATION ❐ The North Carolina Medical Board takes the position that physicians and physician extenders should maintain accurate patient care records of histo-ry, physical findings, assessments of findings, and the plan for treatment. The Board recommends the Problem Oriented Medical Record method known as SOAP (developed by Lawrence Weed). ❐ SOAP charting is a schematic recording of facts and information. The S refers to “subjective information” (patient history and testimony about feel-ings). The O refers to objective material and measurable data (height, weight, respiration rate, temperature, and all examination findings). The A is the assessment of the subjective and objective material that can be the diagnosis but is always the total impression formed by the care provided after review of all materials gathered. And finally, the P is the treatment plan presented in sufficient detail to allow another care provider to follow the plan to completion. The plan should include a follow-up schedule. ❐ Such a chronological document records pertinent facts about an individual’s health and wellness; enables the treating care provider to plan and evaluate treatments or interventions; enhances communication between professionals, assuring the patient optimum continuity of care; assists both patient and physician to communicate to third party partici-pants; allows the physician to develop an ongoing quality assurance program; provides a legal document to verify the delivery of care; and is available as a source of clinical data for research and education. ❐ Certain items should appear in the medical record as a matter of course: the purpose of the patient encounter; the assessment of patient condition; the services delivered — in full detail; the rationale for the requirement of any support services; the results of therapies or treatments; the plan for continued care; whether or not informed consent was obtained; and, finally, that the delivered services were appropriate for the condition of the patient. ❐ The record should be legible. When the care giver will not write legibly, notes should be dictated, transcribed, reviewed, and signed within reason-able time. Signature, date, and time should also be legible. All therapies should be documented as to indications, method of delivery, and response of the patient. Special instructions given to other care givers or the patient should be documented: Who received the instructions and did they appear to understand them? ❐ All drug therapies should be named, with dosage instructions and indica-tion of refill limits. All medications a patient receives from all sources should be inventoried and listed to include the method by which the patient understands they are to be taken. Any refill prescription by phone should be recorded in full detail. ❐ The physician needs and the patient deserves clear and complete documen-tation. (Adopted May 1994) (Amended May 1996) ACCESS TO PHYSICIAN RECORDS A physician’s policies and practices relating to medical records should be designed to benefit the health and welfare of patients, whether current or past, and should facilitate the transfer of clear and reliable information about a patient’s care when such a transfer is requested by the patient or anyone autho-rized by law to act on the patient’s behalf. It is the position of the North Carolina Medical Board that notes made by a physician in the course of diagnosing and treating patients are primarily for the physician’s use and are therefore the property of that physician. Moreover, the resulting record is a confidential document and should only be released with proper written consent of the patient. Each physician has a duty on the request of a patient to release a copy or a summary of the record in a timely manner to the patient or anyone the patient designates. If a summary is pro-vided, it should include all the information and data necessary to allow conti-nuity of care by another physician. The physician may charge a reasonable fee for the preparation and/or the photocopying of the materials. To assist in avoiding misunderstandings, and for a reasonable fee, the physician should be willing to review the materials with the patient at the patient’s request. Materials should not be held because an account is overdue or a bill is owed. Should it be the physician’s policy not to include in either the copied or the summarized record those materials that were provided by other physicians regarding the patient’s former or current care, he or she should advise the patient of that fact and of ways those materials might be obtained. Should it be the physician’s policy to complete insurance or other forms for established patients, it is the position of the Board that the physician should complete those forms in a timely manner. If a form is simple, the physician should perform this task for no fee. If a form is complex, the physician may charge a reasonable fee. To prevent misunderstandings, the physician’s policies about providing copies or summaries of patient records and about completing forms should be made available in writing to patients when the physician-patient relationship begins. (Adopted November 1993) (Amended May 1996, September 1997) RETENTION OF MEDICAL RECORDS The North Carolina Medical Board supports and adopts the following lan-guage of Section 7.05 of the American Medical Association’s current Code of Medical Ethics regarding the retention of medical records by physicians. 7.05: Retention of Medical Records Physicians have an obligation to retain patient records which may reason-ably be of value to a patient. The following guidelines are offered to assist 16 NCMB Forum continued on page 17 physicians in meeting their ethical and legal obligations: (1) Medical considerations are the primary basis for deciding how long to retain medical records. For example, operative notes and chemotherapy records should always be part of the patient’s chart. In deciding whether to keep certain parts of the record, an appropriate criterion is whether a physician would want the information if he or she were seeing the patient for the first time. (2) If a particular record no longer needs to be kept for medical reasons, the physician should check state laws to see if there is a requirement that records be kept for a minimum length of time. Most states will not have such a pro-vision. If they do, it will be part of the statutory code or state licensing board. (3) In all cases, medical records should be kept for at least as long as the length of time of the statute of limitations for medical malpractice claims. The statute of limitations may be three or more years, depending on the state law. State medical associations and insurance carriers are the best resources for this infor-mation. (4) Whatever the statute of limitations, a physician should measure time from the last professional contact with the patient. (5) If a patient is a minor, the statute of limitations for medical malpractice claims may not apply until the patient reaches the age of majority. (6) Immunization records always must be kept. (7) The records of any patient covered by Medicare or Medicaid must be kept at least five years. (8) In order to preserve confidentiality when discarding old records, all docu-ments should be destroyed. (9) Before discarding old records, patients should be given an opportunity to claim the records or have them sent to another physician, if it is feasible to give them the opportunity. ............................ Please Note: a. North Carolina has no statute relating specifically to the retention of medical records. b. Several North Carolina statutes relate to time limitations for the filing of mal-practice actions. Legal advice should be sought regarding such limitations. (Adopted May 1998) DEPARTURES FROM OR CLOSINGS OF MEDICAL PRACTICES Departures from (when one or more physicians leave and others remain) or closings of medical practices are trying times. They can be busy, emotional, and stressful for all concerned: practitioners, staff, patients, and other parties that may be involved. If mishandled, they can significantly disrupt continuity of care. It is the position of the North Carolina Medical Board that during such times practitioners and other parties that may be involved in such processes must consider how their actions affect patients. In particular, prac-titioners and other parties that may be involved have the following obliga-tions. Permit Patient Choice It is the patient’s decision from whom to receive care. Therefore, it is the responsibility of all practitioners and other parties that may be involved to ensure that: patients are notified of changes in the practice, which is often done by newspaper advertisement and by letters to patients currently under care; patients are told how to access their medical records; patients are told how to reach any practitioner(s) remaining in practice; and patients clearly understand that the choice of a health care provider is the patients’. Provide Continuity of Care Practitioners continue to have obligations toward patients during and after the departure from or closing of a medical practice. Except in case of the death or other incapacity of the practitioner, practitioners may not abandon a patient or abruptly withdraw from the care of a patient. Therefore, patients should be given reasonable advance notice to allow their securing other care. Good continuity of care includes preserving, keeping confiden-tial, and providing appropriate access to medical records.* Also, good con-tinuity of care may often include making appropriate referrals. The practi-tioner( s) and other parties that may be involved should ensure the require-ments for continuity of care are effectively addressed. No practitioner, group of practitioners, or other parties that may be involved should interfere with the fulfillment of these obligations, nor should practitioners put themselves in a position where they cannot be assured these obligations can be met. *The Board’s position statement on the Retention of Medical Records applies, even when practices close permanently due to the retirement or death of the practitioner. (Adopted January 2000) THE RETIRED PHYSICIAN ❐ The retirement of a physician is defined by the North Carolina Medical Board as the total and complete cessation of the practice of medicine and/or surgery by the physician in any form or setting. According to the Board’s def-inition, the retired physician is not required to maintain a currently registered license and SHALL NOT: provide patient services; order tests or therapies; prescribe, dispense, or administer drugs; perform any other medical and/or surgical acts; or receive income from the provision of medical and/or surgical services per-formed following retirement. ❐ The North Carolina Medical Board is aware that a number of physicians consider themselves “retired,” but still hold a currently registered medical license (full, volunteer, or limited) and provide professional medical and/or surgical services to patients on a regular or occasional basis. Such physicians customarily serve the needs of previous patients, friends, nursing home resi-dents, free clinics, emergency rooms, community health programs, etc. The Board commends those physicians for their willingness to continue service fol-lowing “retirement,” but it recognizes such service is not the “complete cessa-tion of the practice of medicine” and therefore must be joined with an undi-minished awareness of professional responsibility. That responsibility means that such physicians SHOULD: practice within their areas of professional competence; prepare and keep medical records in accord with good professional practice; and meet the Board’s continuing medical education requirement. ❐ The Board also reminds “retired” physicians with currently registered licens-es that all federal and state laws and rules relating to the practice of medicine and/or surgery apply to them, that the position statements of the Board are as relevant to them as to physicians in full and regular practice, and that they con-tinue to be subject to the risks of liability for any medical and/or surgical acts they perform. (Adopted January 1997) (Amended January 2001) ADVANCE DIRECTIVES AND PATIENT AUTONOMY Advances in medical technology have given physicians the ability to prolong the mechanics of life almost indefinitely. Because of this, physicians must be aware that North Carolina law specifically recognizes the individual’s right to a peaceful and natural death. NC Gen Stat §90-320 (a) (1993) reads: The General Assembly recognizes as a matter of public policy that an individual’s rights include the right to a peaceful and natural death and that a patient or his representative has the fundamental right to control the decisions relating to the rendering of his own medical care, including the decision to have extraordinary means withheld or withdrawn in instances of a terminal condition. They must also be aware that North Carolina law empowers any adult indi-vidual with understanding and capacity to make a Health Care Power of Attorney [NC Gen Stat §32A-17 (1995)] and stipulates that, when a patient lacks understanding or capacity to make or communicate health care decisions, the instructions of a duly appointed health care agent are to be taken as those of the patient unless evidence to the contrary is available [NC Gen Stat §32A- 24(b)(1995). ❐ It is the position of the North Carolina Medical Board that it is in the best interest of the patient and of the physician-patient relationship to encourage patients to complete documents that express their wishes for the kind of care they desire at the end of their lives. Physicians should encourage their patients to appoint a health care agent to act with the Health Care Power of Attorney Position Statement continued from page 15 No. 4 2001 17 continued on page 18 and to provide documentation of the appointment to the responsible physi-cian( s). Further, physicians should provide full information to their patients in order to enable those patients to make informed and intelligent decisions prior to a terminal illness. ❐ It is also the position of the Board that physicians are ethically obligated to follow the wishes of the terminally ill or incurable patient as expressed by and properly documented in a declaration of a desire for a natural death. ❐ It is also the position of the Board that when the wishes of a patient are con-trary to what a physician believes in good conscience to be appropriate care, the physician may withdraw from the case once continuity of care is assured. ❐ It is also the position of the Board that withdrawal of life prolonging tech-nologies is in no manner to be construed as permitting diminution of nursing care, relief of pain, or any other care that may provide comfort for the patient. (Adopted July 1993) (Amended May 1996) AVAILABILITY OF PHYSICIANS TO THEIR PATIENTS AFTER HOURS ❐ It is the position of the North Carolina Medical Board that once a physi-cian- patient relationship is created, it is the duty of the physician to provide care whenever it is needed or to assure that proper physician backup is avail-able to take care of the patient during or outside normal office hours. If the physician is not generally available outside normal office hours and does not have an arrangement whereby another physician is available at such times, this fact must be clearly communicated to the patient, verbally and in writing, along with written instructions for securing care at such times. ❐ If the condition of the patient is such that the need for care at a time the physician cannot be available is anticipated, the physician should consider transfer of care to another physician who can be available when needed. (Adopted July 1993) (Amended May 1996, January 2001) GUIDELINES FOR AVOIDING MISUNDERSTANDINGS DURING PHYSICAL EXAMINATIONS It is the position of the North Carolina Medical Board that proper care and sensitivity are needed during physical examinations to avoid misunderstand-ings that could lead to charges of sexual misconduct against physicians. In order to prevent such misunderstandings, the Board offers the following guidelines. 1. Sensitivity to patient dignity should be considered by the physician when undertaking a physical examination. The patient should be assured of adequate auditory and visual privacy and should never be asked to dis-robe in the presence of the physician. Examining rooms should be safe, clean, and well maintained, and should be equipped with appropriate fur-niture for examination and treatment. Gowns, sheets and/or other appropriate apparel should be made available to protect patient dignity and decrease embarrassment to the patient while a thorough and profes-sional examination is conducted. 2. Whatever the sex of the patient, a third party acceptable to the patient should be readily available at all times during a physical examination, and it is strongly advised that a third party acceptable to the patient be pre-sent when the physician performs an examination of the breast(s), geni-talia, or rectum. When appropriate or when requested by the patient, the physician should have a third party acceptable to the patient present throughout the examination or at any given point during the examina-tion. 3. The physician should individualize the approach to physical examinations so that each patient’s apprehension, fear, and embarrassment are dimin-ished as much as possible. An explanation of the necessity of a complete physical examination, the components of that examination, and the pur-pose of disrobing may be necessary in order to minimize the patient’s possible misunderstanding. 4. The physician and staff should exercise the same degree of professional-ism and care when performing diagnostic procedures (eg, electro-cardio-grams, electromyograms, endoscopic procedures, and radiological stud-ies, etc), as well as during surgical procedures and postsurgical follow-up examinations when the patient is in varying stages of consciousness. 5. The physician should be on the alert for suggestive or flirtatious behav-ior or mannerisms on the part of the patient and should not permit a compromising situation to develop. (Adopted May 1991) (Amended May 1993, May 1996, January 2001, February 2001) SEXUAL EXPLOITATION OF PATIENTS ❐ It is the position of the North Carolina Medical Board that entering into a sexual relationship with a patient, consensual or otherwise, is unprofessional conduct and is grounds for the suspension or revocation of a physician’s license. Such conduct is not tolerated. As a guide in defining sexual exploita-tion of a patient by a licensee, the Board will use the language of the North Carolina General Statutes, Chapter 90, Article 1F (Psychotherapy Patient/Client Sexual Exploitation Act), §90-21.41. ❐ As with other disciplinary actions taken by the Board, Board action against a medical licensee for sexual exploitation of a patient or patients is published by the Board, the nature of the offense being clearly specified. It is also released to the news media, to state and federal government, and to medical and professional organizations. ❐ This position also applies to mid-level health care providers such as physi-cian assistants, nurse practitioners, and EMTs authorized to perform medical acts by the Board. (Adopted May 1991) (Amended April 1996, January 2001) CONTACT WITH PATIENTS BEFORE PRESCRIBING It is the position of the North Carolina Medical Board that prescribing drugs to an individual the prescriber has not personally examined is inappro-priate except as noted in the paragraph below. Before prescribing a drug, a physician should make an informed medical judgment based on the circum-stances of the situation and on his or her training and experience. Ordinarily, this will require that the physician personally perform an appropriate history and physical examination, make a diagnosis, and formulate a therapeutic plan, a part of which might be a prescription. This process must be documented appropriately. Prescribing for a patient whom the physician has not personally examined may be suitable under certain circumstances. These may include admission orders for a newly hospitalized patient, prescribing for a patient of another physician for whom the prescriber is taking call, or continuing medication on a short-term basis for a new patient prior to the patient’s first appointment. Established patients may not require a new history and physical examination for each new prescription, depending on good medical practice. It is the position of the Board that prescribing drugs to individuals the physician has never met based solely on answers to a set of questions, as is common in Internet or toll-free telephone prescribing, is inappropriate and unprofessional. [Adopted November 1999] [Amended February 2001] WRITING OF PRESCRIPTIONS ❐ It is the position of the North Carolina Medical Board that prescriptions for controlled substances or mind-altering chemicals should be written in ink or indelible pencil or typewritten and should be manually signed by the practi-tioner at the time of issuance. Quantities should be indicated in both numbers AND words, eg, 30 (thirty). Such prescriptions must not be written on pre-signed prescription blanks. ❐ Each prescription for a DEA controlled substance (2, 2N, 3, 3N, 4, and 5) should be written on a separate prescription blank. Multiple medications may appear on a single prescription blank only when none are DEA-controlled. ❐ No prescriptions, including those for controlled substances or mind-alter-ing chemicals, should be issued for a patient in the absence of a documented physician-patient relationship. Position Statement continued from page 16 Position Statement continued from page 17 ❐ No prescription for controlled substances or mind-altering chemicals should be issued by a practitioner for his or her personal use. ❐ The practice of pre-signing prescriptions is unacceptable to the Board. (Adopted May 1991, September 1992) (Amended May 1996) SELF-TREATMENT AND TREATMENT OF FAMILY MEMBERS AND OTHERS WITH WHOM SIGNIFICANT EMOTIONAL RELATIONSHIPS EXIST* ❐ It is the position of the North Carolina Medical Board that, except for minor illnesses and emergencies, physicians should not treat, medically or sur-gically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. The Board strongly believes that such treatment and prescribing practices are inappropriate and may result in less than optimal care being provided. A variety of factors, including personal feelings and attitudes that will inevitably color judgment, will compromise the objectivity of the physician and make the delivery of sound medical care problematic in such situations, while real patient autono-my and informed consent may be sacrificed. ❐ When a minor illness or emergency requires self-treatment or treatment of a family member or other person with whom the physician has a significant emotional relationship, the physician must prepare and keep a proper written record of that treatment, including but not limited to prescriptions written for controlled substances and the medical indications for them. Record keeping is too frequently neglected when physicians manage such cases. ❐ The Board expects physicians to delegate the medical and surgical care of themselves, their families, and those with whom they have significant emo-tional relationships to one or more of their colleagues in order to ensure appro-priate and objective care is provided and to avoid misunderstandings related to their prescribing practices. *This position statement was formerly titled, “Treatment of and Prescribing for Family Members.” (Adopted May 1991) (Amended May 1996; May 2000) THE USE OF ANORECTICS IN TREATMENT OF OBESITY ❐ It is the position of the North Carolina Medical Board that under particu-lar circumstances certain anorectic agents may have an adjunctive use in the treatment of obesity. Good medical practice requires that such use be guided by a written protocol that is based on published medical data and that patient compliance and progress will be documented. ❐ It remains the policy of the Board that there is no place for the use of amphetamines or methamphetamines in the treatment of obesity. (Adopted October 1987) (Amended March 1996) PRESCRIBING LEGEND OR CONTROLLED SUBSTANCES FOR OTHER THAN VALIDATED MEDICAL OR THERAPEUTIC PURPOSES, WITH PARTICULAR REFERENCE TO SUBSTANCES OR PREPARATIONS WITH ANABOLIC PROPERTIES General It is the position of the North Carolina Medical Board that prescribing any controlled or legend substance for other than a validated medical or therapeu-tic purpose is unprofessional conduct. The physician shall complete and maintain a medical record that establish-es the diagnosis, the basis for that diagnosis, the purpose and expected response to therapeutic medications, and the plan for the use of medications in treatment of the diagnosis. The Board is not opposed to the use of innovative, creative therapeutics; however, treatments not having a scientifically validated basis for use should be studied under investigational protocols so as to assist in the establishment of evidence-based, scientific validity for such treatments. Substances/Preparations with Anabolic Properties The use of anabolic steroids, testosterone and its analogs, human growth hormone, human chorionic gonadotrophin, other preparations with anabolic properties, or autotransfusion in any form, to enhance athletic performance or muscle development for cosmetic, nontherapeutic reasons, in the absence of an established disease or deficiency state, is not a medically valid use of these med-ications. The use of these medications under these conditions will subject the person licensed by the Board to investigation and potential sanctions. The Board recognizes that most anabolic steroid abuse occurs outside the medical system. It wishes to emphasize the physician’s role as educator in pro-viding information to individual patients and the community, and specifically to high school and college athletes, as to the dangers inherent in the use of these medications. (Adopted May 1998) (Amended July 1998, January 2001) MANAGEMENT OF CHRONIC NON-MALIGNANT PAIN It has become increasingly apparent to physicians and their patients that the use of effective pain management has not kept pace with other advances in medical practice. There are several factors that have contributed to this. These include a history of relatively low priority given pain management in our health care system, the incomplete integration of current knowledge in med-ical education and clinical practice, a sparsity of practitioners specifically trained in pain management, and the fear of legal consequences when con-trolled substances are used — fear shared by physician and patient. There are three general categories of pain. Acute Pain is associated with surgery, trauma and acute illness. It has received its share of attention by physicians, its treatment by various means is widely accepted by patients, and it has been addressed in guidelines issued by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services. Cancer Pain has been receiving greater attention and more enlightened treat-ment by physicians and patients, particularly since development of the hospice movement. It has also been addressed in AHCPR guidelines. Chronic Non-Malignant Pain is often difficult to diagnose, often intractable, and often undertreated. It is the management of chronic non-malignant pain on which the North Carolina Medical Board wishes to focus attention in this position statement. ❐ The North Carolina Medical Board recognizes that many strategies exist for treating chronic non-malignant pain. Because such pain may have many caus-es and perpetuating factors, treatment will vary from behavioral and rehabili-tation approaches to the use of a number of medications, including opioids. Specialty groups in the field point out that most chronic non-malignant pain is best managed in a coordinated way, using a number of strategies in concert. Inadequate management of such pain is not uncommon, however, despite the availability of safe and effective treatments. The Board is aware that some physicians avoid prescribing controlled sub-stances such as opioids in treating chronic non-malignant pain. While it does not suggest those physicians abandon their reservations or professional judg-ment about using opioids in such situations, neither does the Board wish to be an obstacle to proper and effective management of chronic pain by physicians. It should be understood that the Board recognizes opioids can be an appro-priate treatment for chronic pain. ❐ It is the position of the North Carolina Medical Board that effective man-agement of chronic pain should include: thorough documentation of all aspects of the patient’s assessment and care; a thorough history and physical examination, including a drug and pain history; appropriate studies; a working diagnosis and treatment plan; a rationale for the treatment selected; education of the patient; clear understanding by the patient and physician of methods and goals of treatment; a specific follow-up protocol, which must be adhered to; regular assessment of treatment efficacy; consultation with specialists in pain medicine, when warranted; and continued on page 19 18 NCMB Forum Position Statement continued from page 18 use of a multidisciplinary approach, when indicated. ❐ The Board expects physicians using controlled substances in the manage-ment of chronic pain to be familiar with conditions such as: physical dependence; respiratory depression and other side effects; tolerance; addiction; and pseudo addiction. There is an abundance of literature available on these topics and on the effec-tive management of pain. The physician’s knowledge should be regularly updated in these areas. ❐ No physician need fear reprisals from the Board for appropriately prescrib-ing, as described above, even large amounts of controlled substances indefi-nitely for chronic non-malignant pain. ❐ Nothing in this statement should be construed as advocating the imprudent use of controlled substances. (Adopted September 1996) END-OF-LIFE RESPONSIBILITIES AND PALLIATIVE CARE Assuring Patients Death is part of life. When appropriate processes have determined that the use of life-sustaining or invasive interventions will only prolong the dying process, it is incumbent on physicians to accept death “not as a failure, but the natural culmination of our lives.”* It is the position of the North Carolina Medical Board that patients and their families should be assured of competent, comprehensive palliative care at the end of their lives. Physicians should be knowledgeable regarding effective and compassionate pain relief, and patients and their families should be assured such relief will be provided. Palliative Care There is no one definition of palliative care, but the Board accepts that found in the Oxford Textbook of Palliative Medicine: “The study and man-agement of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is the quality of life.” This is not intended to exclude remissions and requires that the management of patients be comprehensive, embracing the efforts of medical clinicians and of those who provide psychosocial services, spiritual support, and hospice care. A physician who provides palliative care, encompassing the full range of comfort care, should assess his or her patient’s physical, psychological, and spiritual conditions. Because of the overwhelming concern of patients about pain relief, special attention should be given the effective assessment of pain. It is particularly important that the physician frankly but sensitively discuss with the patient and the family their concerns and choices at the end of life. As part of this discussion, the physician should make clear that, in some cases, there are inherent risks associated with effective pain relief in such situations. Opioid Use The Board will assume opioid use in such patients is appropriate if the responsible physician is familiar with and abides by acceptable medical guide-lines regarding such use, is knowledgeable about effective and compassionate pain relief, and maintains an appropriate medical record that details a pain management plan. (See the Board’s position statement on the Management of Chronic Non-Malignant Pain for an outline of what the Board expects of physicians in the management of pain.) Because the Board is aware of the inherent risks associated with effective pain relief in such situations, it will not interpret their occurrence as subject to discipline by the Board. Selected Guides To assist physicians in meeting these responsibilities, the Board recom-mends Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed (1996), Cancer Pain Relief and Palliative Care (1990), Cancer Pain Relief and Palliative Care in Children (1999), and Symptom Relief in Terminal Illness (1998), (World Health Organization, Geneva); Management of Cancer Pain (1994), (Agency for Health Care Policy and Research, Rockville, MD); Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 4th Edition (1999)(American Pain Society, Glenview, IL); Hospice Care: A Physician’s Guide (1998) ( Hospice for the Carolinas, Raleigh); and the Oxford Textbook of Palliative Medicine (1993) (Ox
Object Description
Description
Title | Forum of the North Carolina Medical Board |
Date | 2001 |
Description | No. 4, (2001) |
Digital Characteristics-A | 642 KB; 28 p. |
Digital Format | application/pdf |
Full Text | Primum Non Nocere N C M E D I C A L B O A R D In This Issue of the FORUM President’s Message: Are You Having a Bad Day? ........................1 From the Executive Director: License Registration .....................................1 From Dr Elizabeth P. Kanof: A Personal Thank You................................2 Notice: Annual Registration Fee to Rise ........3 The Reality of Child Abuse Homicides ..........4 Save Time, Register on Line ..........................5 Training Staff and Seeing Patients: Stories from the Moldova Hospice Project ..........................................6 DUR Recommendation: Aggressively Treating Dyslipidemia ............8 President’s Message Walter J. Pories, MD Primum Non Nocere NORTH CAROLINA MEDICAL BOARD April 15, 1859 Item Page Item Page Are You Having a Bad Day? Charles Granville Rob, MD, one of our licensees, was a true hero, well worth remembering in these difficult times. After he completed his surgical residency in 1941 at the St Thomas Hospital during the London Blitz, he was assigned as a surgical specialist to the First Parachute Brigade. Only a few months later, he was dropped into the desert, 90 miles east of Tunis, behind the German lines. Fighting was fierce and casualties were heavy. Even though he sustained fractures of the tibia and patella during the drop, he rapidly con-verted a French garrison school into a 20 bed hospital and carried out 150 operations on the first day of the battle. He cared for all: the British soldiers first, then the civil-ians, and finally, with equal care, the German prisoners. When the blood bank was exhausted, he gave a unit of his own blood. Only when the work was done did he final-ly dress his own wounds. For these contri-butions under fire, he received the British Military Cross, the United Kingdom’s sec-ond highest medal for valor. He had a glorious career. He was one of the founders of vascular surgery, performed the first carotid endarterectomy, and offered the first descrip-tions of the tho-racic outlet syn-drome and meral-gia paresthetica. He also taught legions of grateful surgeons as a chair-man at St. Thomas and the University of Rochester, as an inspiring professor at East Carolina and, finally, at the Uniformed Services University for the Health Sciences (USUHS), our country’s License Registration In the last number of this publication, we offered a guest article by Dr Alison C. VanFrank in this space. In that article, she explained the travails of her most recent encounter with license registration. You see, she failed to register her license in 2000 as required by law and suffered some rather significant consequences. One consequence was that, at the request of the Board, she agreed to write an explanation of what had happened for the benefit of other licensees. The Board’s intentions were good. It did not view this as some sort of humiliation; rather, it wanted to be helpful to its licensees by showing sequelae that can accrue from this process if one is not careful. Many of these problems are unanticipated, particular-ly if one views medical license registration as simply bureaucratic and ministerial. The burden to register annually is placed by law on the licensee. We are not isolated in this respect; in 49 other states, medical board licensees have an affirmative responsibility to keep their licenses current. This serves sev-eral purposes, not the least of which is the providing of information to the Board that is critical for the public trust conferred by medical licensure. In my opinion, Dr VanFrank’s article was thoughtful and very well written. It pointed out the problem she encountered and made the point the Board envisioned. However, it did generate several strong letters of concern in response (see the “Letters to the Editor” in this number of the Forum). Physicians, attempting to practice medicine as best they can, often feel that they are up to their necks in bureaucracy. The message conveyed in Dr VanFrank’s article was received by some as reflecting an uncaring bureaucracy adding to continued on page 3 continued on page 2 NCMB Elects Officers....................................9 Review: Death Be Not Proud: The Meaning of Wit ..10 Letters to the Editor: More on End-of-Life Care; Dr VanFrank’s Dilemma ............................12 Avoid Treating Family Members! .................13 Position Statements of the NCMB ...............14 Board Actions: 8/2001-10/2001 .................22 Board Calendar ............................................27 Change of Address Form..............................28 Annual Registration on Line ........................28 No. 4 2001 forumMoldova Hospice Project - page 6 Position Statements of the NCMB - page 14 From the Executive Director Andrew W. Watry Charles Granville Rob, MD The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum, including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are affiliated. Official statements, policies, positions, or reports of the Board are clearly identified. We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form depending on available space. A letter should include the writer’s full name, address, and telephone number. North Carolina Medical Board Raleigh, NC forum N C M E D I C A L B O A R D Vol. VI, No. 4, 2001 Primum NonNocere NORTH CAROLINA MEDICAL BOARD April15, 1859 Primum Non Nocere 2 NCMB Forum Walter J. Pories, MD President Greenville Term expires October 31, 2003 John T. Dees, MD Vice President Bald Head Island Term expires October 31, 2003 Paul Saperstein Secretary-Treasurer Greensboro Term expires October 31, 2001 George C. Barrett, MD Charlotte Term expires October 31, 2002 E.K. Fretwell, Jr, PhD Charlotte Term expires October 31, 2002 Charles L. Garrett, Jr, MD Jacksonville Term expires October 31, 2002 Stephen M. Herring, MD Fayetteville Term expires October 31, 2004 Robin N. Hunter-Buskey, PA-C Gastonia Term expires October 31, 2003 Elizabeth P. Kanof, MD Raleigh Term expires October 31, 2002 Robert C. Moffatt, MD Asheville Term expires October 31, 2004 Michael E. Norins, MD Greensboro Term expires October 31, 2004 Aloysius P. Walsh Greensboro Term expires October 31, 2003 Andrew W. Watry Executive Director Helen Diane Meelheim Assistant Executive Director Bryant D. Paris, Jr Executive Director Emeritus Publisher NC Medical Board Editor Dale G Breaden Assistant Editor Shannon L. Kingston Address 1201 Front Street Raleigh, NC 27609 Telephone (919) 326-1100 (800) 253-9653 Fax (919) 326-1130 Web Site: www.ncmedboard.org E-Mail: info@ncmedboard.org Are You Having a Bad Day? continued from page 1 military medical school. There are, of course, many “Rob Stories,” of which two are especially timely. I recall one about his uncle that he told us during a graduation address at ECU. Uncle Mitchell was a morbidly obese family physician who provided excellent care in northern England during the war under unusually harsh condi-tions. However, when he was summoned one day to deliver a baby in a rural trailer, it rapidly became apparent that he could not fit through the narrow door, even when he stripped down to his skivvies. It must have been quite a sight. Eventually, the problem was solved by erecting a makeshift tent out-side the trailer where the baby was success-fully delivered. During a visit to the village about 40 years later, Rob asked the family how they survived the war. “Oh, we made it”, they said, “we got along,” but instead of dwelling on the hardships, they spent most of the time still laughing about the time Uncle Mitchell couldn’t get into the trailer. By this point in his story, Rob had the stu-dents laughing too, and then he offered them the moral, which is good advice for all of us: “Be careful what you do as a physician, folks will remember it for a long time.” My other favorite story occurred when I was his resident at the University of Rochester. Similar to many other centers, we had developed a culture of surgical divas, surgeons whose every operation was a tantrum with screamed obscenities and flung instruments. After all, that’s how surgeons were expected to behave. Rob felt different-ly. To him, caring for patients was the great-est privilege and surgery was not only easy, it was fun. If you didn’t enjoy doing it, you shouldn’t be in the OR. After he heard sev-eral complaints from the staff, he told Connie, the OR supervisor, also from England, to give him a call at the next inci-dent. He did not have to wait long. On the next day, one of our most notorious bullies was having the mother of all tantrums dur-ing a thyroidectomy, throwing clamps and insults in all directions. While there is never, in my opinion, a reason to lose your temper during surgery, such misbehavior is especial-ly difficult to understand during a thyroidec-tomy, an operation that is a delight to per-form. The procedure is rarely emergent, the anatomy is stunningly beautiful, and the techniques are not very challenging. But back to the story. Rob suddenly appeared in the OR, fully scrubbed, and asked, “Are you having a bad day?” As he donned the gown, he quietly told the bewildered surgeon that he would finish the case for him; after all, if he was that upset, he must be in trouble and needed help. When the surgeon refused to leave, Rob told him that he must if he want-ed to keep his privileges. When he did, the operation was finished quickly and qui-etly. It was the last time I ever observed a tantrum in the operating rooms at Rochester. I am not at all sure that Rob’s decision would stand today in our restrictive legal environment, but his principle is still sound. The physician who causes peptic ulcers in his staff as he treats such a lesion in his patient is not a great humanitarian. Charles Rob died at age 84. We will miss him. However, his principles will long sur-vive. They bear reemphasis in these difficult times. • Patients come first. • Folks have long memories. • Serve with grace and be thoughtful of your colleagues. From Dr Elizabeth P. Kanof: A Personal Thank You Over the past year or so, I have had the great pleasure and honor of visiting over 30 medical societies, hospitals, and other groups across the state to dis-cuss the role and work of the North Carolina Medical Board and to answer questions about the Board. During most of that time, I was also serving as president of the Board. Today, as immediate past president of the Board, I want to extend my deepest apprecia-tion to those many people, physicians and non-physicians, who invited me to meet with them and who welcomed me so warmly. Though other Board mem-bers, Board staff, and I will continue to respond to requests for presentations from all interested organizations, pro-fessional and public, I want to take this opportunity to offer my thanks to those groups that have given me their time and attention over the past year. Elizabeth P. Kanof, MD Immediate Past President, NCMB No. 4 2001 3 License Registration continued from page 1 a physician’s bureaucratic headaches. There are those who, perhaps without intending to do so, make a case that tends to devalue the significance and meaning of the medical license. Quite frankly, I think that the privilege of practicing medicine is one of the highest that can be conferred by any state, that the medical license is a positive reflection of the importance our society places on medical practice. In fact, our fore-fathers thought requiring a license to prac-tice medicine was so essential to the public good that North Carolina was one of the first states to do so. Our medical licensing statute was created in 1859. Today, there are very few places in the civ-ilized world where one can practice medicine without a license. I was once visited by the health minister of a breakaway Soviet repub-lic. As this country was joining the interna-tional community, one of its first tasks was to set up a medical licensing system to pro-tect its citizens from unqualified practition-ers. So in my mind, if one trivializes the medical license and the supporting registra-tion process, one is trivializing the impor-tance of the practice of medicine itself. I am not aware of a single court in this land that has found there is an inherent right to prac-tice medicine. Many plaintiffs have unsuc-cessfully argued there is such a right. We care about the process and we are ded-icated to making the registration system eas-ier for all licensees. We were one of the early states to adopt electronic registration and we have one of the highest participation rates in the country — over 70%. What used to take weeks now takes minutes, with next-day written confirmation via e-mail. This process required a substantial investment of time and money to make work. We send reminders about registration to the last address furnished to us by each licensee, and we publish reminders to each licensee quar-terly via the Forum. All of this is intended to help avoid the significant consequences suf-fered by Dr VanFrank. We do care signifi-cantly about serving the public and all licensees. One thing we have planned to help both licensees and their patients is to expand our range of disciplinary options. The benefits of an expanded range of disciplinary options to patients are perhaps obvious, the benefits to licensees not so obvious. As of today, the disciplinary options available to the Board by statute (see NCGS 90-14 at our Web site) are “. . . deny, annul, suspend, or revoke a license. . . .” This list needs to be updated to include probation, withholding disposition, levying a fine, requiring community service, issuing private or public reprimand, and other lesser sanctions. These would provide a range of appropriate actions available for marginal violations or special circumstances. So, in a peculiar way, increasing our range of disciplinary options helps both the public and those subject to Board action. We will likely work on this in the legislature. As to consequences for failure to keep a license current, my point can be made by analogy. Let’s consider deer hunting in a neighboring state. If you drive a brand new truck into the woods, shoot a deer without a hunting license, and get caught, the brand new truck becomes the property of the state, along with your hunting rifle. That is the penalty before the court decides what to do with you. These items are confiscated because they were used in the commission of a crime. You can’t go into court with the defense that the state failed to notify you of the requirement to get a hunting license. In that instance, the state sends you no reminders. If you intend to go into the woods and hunt, it is your responsibility to find out what the law is, where to get a hunt-ing license, and how to obtain one. It is fur-ther your sole responsibility to keep that license current. If you don’t keep it current, you will suffer the consequences. In my estimation, the medical license is many times more important than that hunt-ing license. It has to do with people render-ing medical care to the most precious of a state’s assets: its citizens. That gets to the core of why the Board asked Dr VanFrank to write her article: to be helpful to her colleagues. There are sequelae to non-registration that are quite significant. Medical malpractice carriers may drop cov-erage. Third-party insurers, who check our system, sometimes daily, to see who is cur-rently registered, may also drop someone from coverage. In some instances, they may only check at intervals of six months. If they happen to check at the wrong interval, the licensee may get a recoupment notice for five whole months of services rendered. These consequences are quite dramatic, as pointed out by Dr VanFrank. Even when the Board decides to retroactively reinstate a license, there are still potentially many trees to stand back up in the forest. The licensee may even decide to hire a lawyer to help sort through all of this, which will probably result in sev-eral thousand more dollars of expense. These consequences are far more significant than our $20.00 late fee. The criticisms we have received for the VanFrank article have been taken seriously. We respect the concerns expressed. However, with 31,000 licensees, I don’t think the average licensee would want or expect us to use his or her registration money to pay for the extra staff necessary to track down or search out people who fail to take care of their registration burden. There would be significant overhead in that. It is better to publish regular reminders in the Forum, to provide a mechanism to make the process much easier, as we have done with our electronic registration, to mail individual notices, and to put detailed information on our Web site, all which we have done. The Board cares about this process to the extent that it was one of the first to invest in ser-vices to make the process easier, like elec-tronic registration. Licensees uniformly advise us that our electronic registration process is superior to any other they have used. We are, therefore, grateful to Dr VanFrank for her commentary. We are also grateful for the letters we have received that were gener-ated by her article. It all draws attention to the importance of the licensee keeping up with the registration process. So although we have generated some criticism, at the end of the day we hope some good has come of it. One of our critics writes: “By appear-ances, a Brobdingnagian punishment was meted out for a Lilliputian offense.” I dis-agree. The medical license and the respect in which it should be held by every licensee is anything but Lilliputian, and much of what he sees as punishment is really sequelae. I hope this helps, and as always we genuinely appreciate your comments about these and other issues. NOTICE: Annual Registration Fee to Rise Beginning with March 2002 Birthdays During its 2001 session, the North Carolina General Assembly approved legislation raising the annual registration fee for the medical license from its cur-rent level of $100 to $125. The new fee is still below the average of medical license registration fees nationwide. The $125 annual fee becomes effective beginning with the registration of licensees with birthdays in March 2002, and will be reflected in registration notices. Most licensees now register on line by way of the “Electronic Registra-tion” section of the Board’s Web site (www.ncmedboard.org), and the new $125 fee will be clearly noted on the site for birthdays in March 2002 and following. 4 NCMB Forum continued on page 5 The Reality of Child Abuse Homicides Marcia E. Herman-Giddens, PA, DrPH Senior Fellow, North Carolina Child Advocacy Institute Former Medical Director, North Carolina Child Fatality Prevention Team A child is killed every two to three weeks in North Carolina by a caregiver, usually a biological parent, sometimes a stepparent, sometimes a boyfriend or girlfriend of the parent, occasionally other relatives or babysitters. These children’s deaths are not easy deaths. Too often they have been abused before the lethal event, and, in some cases, tortured for months or years. Sometimes the killings are silent and with-out outward sign of force, usually they are far more violent than anyone would want to believe. Autopsy photographs in these cases are all too often full of bruises, cuts, and blood. Our society’s violence towards children belies the impression we give of caring about children, our concern for children’s safety, our desire for good schools, and the adver-tisements of smiling babies and doting par-ents. Statistics tell of another reality. Homicide is now the third leading cause of death for children ages one to five in the United States. Almost all of these homicides are due to abuse. Behind this number are the tragic, awful stories of the murdered children. These stories are described to offer a depth and perspective to the reality of child abuse. Each case history represents a brief summary of extensive work done by not only the medical examiner, but often many other professionals. Names have been changed to protect the fact that in some cases some of the information is from confi-dential files. All are North Carolina cases from the last 15 years. Legal outcome data in some cases were impossible to get because information is not kept in central files by the name of the victim. Disparities in legal out-come are clear from these cases. Always, there is a lot of missing information. And always, there is a tragedy that should never have happened. Two-year-old Susan Susan was placed on an adult toilet by her mother’s live-in boyfriend. He then alleged-ly struck the child in the chest causing injuries from which she later died. Susan’s siblings had been removed from the home before her birth. Susan had been seen at age one for vaginal bleeding. Her mother had changed her story about the bleeding twice. There had been three reports of child neglect (one substantiated) and one for sexual abuse (unsubstantiated) on Susan. Her mother had brought an assault charge against her boyfriend, but it had been dismissed. The boyfriend was a convicted sex offender with a history of substance abuse. Legal outcome: Susan’s mother’s boyfriend was charged with murder but found not guilty in a jury trial. One-month-old Rebecca Rebecca died from blunt force that frac-tured her skull and several bones. The rescue squad had arrived at her house to see blood on the mother’s shirt and to find the child dead. The rescue squad said that the moth-er seemed inebriated at the time of the inci-dent. An older boy also living in the home was found to be abused. He was removed from the home and sent to live with his grandparents. Legal outcome: Rebecca’s mother was con-victed of first-degree murder. Information about her sentence was not available. Ten-month-old Daria Daria was sleeping in the same bed as her father. The father later gave the story that he saw Daria falling off of the bed and pulled her back on the bed by her arm. At that time, he noted that she was limp and unre-sponsive. He called Emergency Medical Services but when they arrived they found the baby dead. At first it was considered to be a SIDS death, but the ER doctor felt there was some question. The autopsy found that Daria died from abdominal trau-ma. Her father reportedly said it was his fault because he was too rough with her. Legal outcome: The case against Daria’s father was closed due to insufficient evi-dence. The investigators concluded, “No evidence of prior abuse or trauma. Injuries innocently obtained.” Eight-year-old Sara Sara’s father took her into a wooded area and shot her in the neck. It took several days to locate the child’s body. Prior to the incident, he had sent Sara’s mother a mur-der/ suicide note. Sara’s parents had recently separated and the child was living with her father. The mother had wanted to have Sara on weekends when she received the note. There had been some concerns about sexual abuse on the part of the father. No evidence was found by the autopsy to confirm or deny sexual abuse. Legal outcome: Sara’s father pled guilty to a murder charge, and was sentenced to life in prison. Nineteen-month-old Lily Lily had been forcibly immersed in a tub of scalding water one morning by her moth-er’s boyfriend. The child’s injuries were noted by a policeman who saw her with her mother and her boyfriend at a parking lot at a ‘remote’ restaurant later that day. Lily was wearing a diaper and the burns were evident. The couple said they were on the way to get help. Lily was taken to the hospital for treat-ment of burns over 47 percent of her body. Other injuries noted included a cigarette burn on her mid upper back, and bruises on her arm, face and cheeks, and labia. Her burns were consistent with intentionally holding the child in hot water. Lily died due to complications from the burns. Legal outcome: Lily’s mother’s boyfriend was charged with murder and pled not guilty. The jury determined he was not guilty. Newborn Dahlia Dahlia’s mother had concealed her preg-nancy by saying she had a tumor. Her estranged husband and his mother were vis-iting when she excused herself to go to the bathroom for her “tumor” problem. She came out about 11/2 hours later. A full-term fetus was later found in the trash can behind the house. The mother admitted herself to Dorothea Dix a few days later. Legal outcome: Dahlia’s mother was charged with concealing a birth and first-degree murder. She pled guilty to conceal-ing the birth and received a six-year sus-pended sentence with supervised probation and mental health involvement. The following is the third article to appear in the Forum by Dr Herman-Giddens on the subject of child abuse homicide. The first, A New Book - A Helpful Tool: Not Invisible, Not in Vain - Child Maltreatment Fatalities: Guidelines for Response, appeared in Forum #1, 2001. The second, Child Abuse Homicides in North Carolina: Characteristics Physicians Should Understand, appeared in Forum #2, 2001. The stories below bring a painful dimension of reality to the tragedy of child abuse homicide in this state. No. 4 2001 5 Child Abuse Homicides continued from page 4 Three-year-old Jimmy Jimmy’s mother’s boyfriend was babysit-ting for Jimmy. The boyfriend ‘disciplined’ the child by administering blows on the head with a hairbrush, which subsequently killed the child. The medical examiner’s file had clear pictures of the patterned injuries that matched the hairbrush. Legal outcome: Jimmy’s mother’s boyfriend was charged with second-degree murder. The jury convicted him of a misde-meanor and gave him a two-year jail sen-tence. Two-year-old Bruce Bruce was found dead in the early morn-ing in his home. He had been ill for a week following a visit to his biological father’s house. Bruce’s mother said that he was hav-ing trouble walking and was vomiting inter-mittently. She had taken him to the emer-gency room the day before his death, but no specific therapy was given. An appointment with a doctor was made for a later time, but he died before this could occur. The autop-sy found that he died from blunt trauma to the head and had evidence (rectal bleeding and enlargement ) of child sexual abuse. Legal outcome: Bruce’s father was charged with first-degree murder and first-degree sexual offense. The outcome of the trial was not available. Four-month-old Lynn The mother of Lynn was having problems with Lynn’s father. She went to the police department to get an officer to remove the father, age 19, from the residence. When she returned, the father met her at the door and stated that Lynn had just quit breathing. The mother took Lynn to the police depart-ment, but by the time an emergency medical worker saw the baby she was unresponsive. The father’s account was that he was drunk and went to bed, leaving the baby strapped in her chair. The next door neighbor had come over and put the baby in bed with him. The father stated that the baby started crying and he reached over and put a pacifi-er in her mouth and, then, a few minutes later she started ‘losing her breath.’ The autopsy found that the child died as a result of multiple traumatic insults, including 24 new and healing rib fractures, bruises to the back of the head, eye, lips, chest, and a left skull fracture. Legal outcome: The child’s father was charged with first-degree murder. The first trial was a mistrial. In the second, he was convicted of second-degree murder, and given a life sentence. Eight-month-old Billy Billy lived with his mother and maternal grandparents. The sequence of events regarding his death was not clear and varied with the interviewer. Neither of the grand-parents was at home at the time of the lethal incident. Billy’s mother called EMS four hours after the child’s death. Billy was found in his crib, naked, with his head lying between cushions. His death was consid-ered to be due to SIDS until the mother confessed to the SIDS counselor that she smothered Billy. Billy’s parents were not married and his father only saw him occa-sionally. There was some evidence that the mother may have been intoxicated at the time of the incident. Billy did not have evi-dence of abuse on his body. Legal outcome: Billy’s mother was charged with first-degree murder. She pled guilty of second-degree murder and received a 40 year prison sentence. _____________________ Sources National Vital Statistics Reports, Vol. 48, No. 11, July 24, 2000 (1998 data, most recent year for final data). Source of case information: NC Medical Examiner files, law enforcement and Department of Social Services reports, and The North Carolina Child Homicide Study, Office of the Chief Medical Examiner, Chapel Hill, NC, 1998. Save Time, Register on Line Nick Hun, NCMB Licensing Staff It is no secret that members of the medical community are extremely busy. Doctors, especially those new to the profession, can regularly work 80 hours per week. Throw in the additional demands placed by family, friends, and everyday life, and the result can be a community of tired practitioners. The mere fact that you are reading this publica-tion is a credit to your time management skills. The North Carolina Medical Board wants to make your annual license registration as quick and painless as possible. In an effort to save you time and increase the accuracy of your medical license information, we have established on-line registration renewal. With a few simple clicks of the mouse, we will eliminate the hassle of pens, paper cuts, and the U.S. Postal Service. On-line regis-tration is simple. All you need are a • computer with Internet access, • certificate ID number (found on last year’s certificate and renewal notices sent by the Board), • Social Security number, and • birth date. Secure on-line payment can be made using a Visa® or MasterCard®. It’s that sim-ple! Renew your registration up to two months prior to expiration by going to our Web site (www.ncmedboard.org) and clicking on the link for electronic registration. Just a few quick keystrokes, pushes of the “enter” button, and mouse clicks, and you are done. Need another reason to forgo paper and peck at the PC? The chances of your infor-mation being correct increase ten-fold when your registration is completed on line. When you register using the paper method, numerous things can happen that can delay or corrupt the processing of your applica-tion, including slow mail service and our staff or computer misinterpreting illegible handwriting. On-line registration also saves the time you would have spent filling out the paper forms, and that is just the beginning. It takes one or two days to process on-line reg-istration. Compare that to the three weeks (from the time you mail it to us) that it takes to process the paper registration. Won’t it be nice when the DEA calls for proof of your license and you can provide it instantly? Some of you may not consider yourselves computer savvy. We understand that and are trying to help make your on-line registration as painless as possible. If you have trouble, e-mail us at registration@ncmedboard.org. We will send you a response within two business days. Save time, increase the odds that your reg-istration information will be correct, and maybe learn a little about the Internet by registering on line. E-Mail: info@ncmedboard.org Web Site: www.ncmedboard.org North Carolina Medical Board 6 NCMB Forum continued on page 7 Training Staff and Seeing Patients: Stories from the Moldova Hospice Project Laurie Saxton, Director of Communications Carolinas Center for Hospice and End of Life Care Last spring, Pat Ashworth was drawn back to Moldova. Ashworth, a certified hos-pice palliative nurse at Hospice and Palliative Care of Greensboro, is a consultant to the project to open the first hospice in this Eastern European country. She had first joined Judi Lund Person, president and CEO of The Carolinas Center for Hospice and End of Life Care, on a trip to Moldova in the fall of 2000. On her return visit, sponsored by The Carolinas Center, she joined the staff of the planned hospice for two weeks of training in Romania. Home visits in Moldova followed, to put the team’s new knowledge into practice. This is the story of her journey. Ashworth shared her experiences in a workshop she presented with Person at The Carolinas Center’s annual conference in October. The workshop offered the oppor-tunity to discuss the hospice movement in Eastern Europe, the Moldova experience, and cultural similarities and differences regarding death and dying. Moldova: the Country and the Challenge About 4.5 million people live in this hilly agricultural country with rich traditions of family ties, culture, art and music. The liter-acy rate is near 100 percent. About the size of Connecticut, Moldova lies between Romania and Ukraine. After a long history of foreign domination, Moldova achieved independence from the Soviet Union in 1991. Since then, Moldovans have strug-gled to rebuild and replace their system of social and medical care. (Life expectancy there has actually declined during the last 10 years.) NATO’s Partnership for Peace paired each former Soviet state with a partner in the United States. Moldova is North Carolina’s partner. Many private and public organiza-tions are working to support the partner-ship, foster democracy in Moldova, and pro-vide assistance to the government and pri-vate economy. The Moldova Hospice Project is a collab-oration of The Carolinas Center, other med-ical and hospice professionals, the North Carolina National Guard, and North Carolina Rotary Clubs in an endeavor to make a real difference in the lives of dying Moldovan patients and their families. These people and organizations are working to achieve the dream of developing the coun-try’s first hospice in the village of Zubresti. The service area of the new hospice includes 51,000 people who live in 11 towns ranging in size from 1,400 to 22,000 inhab-itants. Approximately 100 people within the service area die each month. The leading causes of death include cardiovascular dis-ease, liver disease including cirrhosis and cancer, and other cancers. Efforts to improve the area’s health must overcome several challenges. The local water supply is contaminated with pesticides and human waste. Leukemia in children has been linked to the impure water. Pain med-ication is scarce, affecting both hospice care and more general medical care. Morphine is available only in very small doses; the amount of a four-hour dose in the U.S. must last all day in Moldova. Four key elements were identified early in the hospice development plan and are now being addressed: training for hospice staff; governmental and regulatory issues (import laws, medication, standards of care); the proposed hospice facility itself; and the funding required to tackle the first three ele-ments. Training the Hospice Medical Staff Fourteen physicians and nurses from Moldova participated in a very intensive two-week training program, covering all the standards of hospice care, operations, and protocols applicable to Eastern Europe. Ashworth praised her colleagues’ dedication and enthusiasm under difficult circum-stances. “The Brasov Study Center [in Romania] had never conducted training in back-to-back weeks. They agreed to try it to make it easier for the Moldova staff to attend — and it was intense!” Hospice care is a completely new field in Moldova. Education in pain management and palliative care, so fundamental to hos-pice, was essential for the medical team. They absorbed it eagerly, mastering the pain management ladder, knowledge of round-the- clock dosing, and other aspects of hos-pice care. After the training, Ashworth and the hos-pice team returned to Moldova for home vis-its in the service area of the new hospice. The two-way education continued with dis-cussions of the care appropriate for the kinds of illnesses and patients seen in the area. “We can learn from them, too,” Ashworth said. “Moldovans have a very family-cen-tered idea of care for the dying.” But there is a severe shortage of caregivers in a country where over 600,000 people leave every year in search of work. Imagine delivering home care — on foot — for an entire day. Within the villages, this is a way of life for physicians and nurses. In and around Straseni, the largest town in the area, visits were made in the “company car”— a WWII-era jeep. After a day of nav-igating the terrain by jeep, Ashworth was glad to travel on foot again. The most mem-orable features of this remarkable environ-ment were the patients and their families. Here are just three of their stories. Given to the Neighbors In Straseni, the team paid a visit to the home of a 37-year-old woman with advanced breast cancer. The patient was not there; instead, a small boy came out to meet them. Where was his mother? The boy’s aunt had come and taken his mother to the aunt’s home to die. His father had left home years before, an older sibling was away working — and this eight-year-old had been given to the neighbors. As his mother was dying, this boy was given to the neighbors. No. 4 2001 7 Stories from Moldova continued from page 6 A Physician Needs Healing Drs Andre and Maria Grozav run the clin-ic in the village of Recea. Maria accompa-nied Ashworth and Dr Eleonora Suruceanu on their travels. One day as they stopped for lunch at Andre and Maria’s home, Maria confided in broken English, “My husband is not well.” Dr Andre Grozav was undergoing chemotherapy for pancreatic cancer. The Grozavs are the only physicians in their vil-lage. So, though pale and thin, he was still making his rounds. Maria too continued to provide care, to her patients and to Andre, working through her fear that she may soon be the only doctor in Recea. Confined to One Room for Five Years On her home visits, Ashworth saw more than one case of untreated fractures resulting in disability. One patient had been confined to bed for eight years, and to only one room for five. Untreated fractures, including her right hip, left her unable to walk. The woman’s situation, so rare to American eyes, was not unusual. The woman’s daughter cares for her at night when she returns from work. During the day, a neighbor looks in on her. Family members often must go to another village to find work. When this happens, it is not uncommon for neighbors to provide care. Patients even administer their own med-ications — including IV — because there is no one else to do it. Ashworth was humbled by the experience. “We have so much in the U.S. So many of us take for granted that our fractures and our heart disease will be treated.” Prosparae Zubresti — the New Hospice Facility The Moldovan government has donated a former hospital building to be used as the hospice inpatient facility. Major renovations are needed to get the building into working condition and to provide even the basics of comfort and care: running water, indoor plumbing, electricity, heat. Changes will have to take place as well in the practices of the patients and their fami-lies. In Moldova, patients generally take their own linens, food, and even medicines with them when they enter a hospital. How will they respond to a hospice facility where all these things are provided for them? And there might be some adjustments in the American expectations of a hospice inpa-tient facility. In Moldova, 98% of patients die at home. How should a hospice be sen-sitive to the customs and wishes of the patients? The inpatient facility might address short-term pain management and symptom control needs, then release patients to return to their homes. Support and Funding for the New Hospice After 25 years of providing hospice care in North Carolina, it is time for us to share our knowledge with people in other countries, as we ourselves learned in the 1970s from Dame Cicely Saunders and her hospice expe-rience in Great Britain. The commitment to hospice care in Moldova is not a short-term association, but a lasting relationship Drs Eleonora Suruceanu, Andre & Maria Grozav. Untreated fractures left her confined to one room for five years. The hospice building sunroom will be renovated to accommodate baths and a common area. between our countries and our hospice care providers that is based on mutual under-standing. The training of the Moldova hospice staff last spring marked one step in this relation-ship. The contributions of many individuals in the Carolinas made this training possible, paying for the travel by van to Romania and for the two-week intensive course. The Carolinas Center for Hospice and End of Life Care is seeking funding through grants and individual contributions to realize the goal of opening the inpatient facility next year and continuing to serve patients like the ones Ashworth saw. The Carolinas Center is awaiting word on a grant that will allow renovation of the 20- bed former hospital to create the hospice inpatient facility. The needed renovations could begin as early as next spring, and not a day too soon for those who await the sup-port and care the hospice will provide. More than dollars are needed. Volunteers are vital as well, to travel to Moldova to assist the fledgling hospice. Individual contributors can have an enor-mous impact on the lives of Moldovan fam-ilies. Contributions are needed for both start-up and operating costs. For example, $320 will heat the hospice facility for one year and $500 will build the wheelchair ramps needed. Salaries and other operating expenses are comparably modest: the annual salaries for a doctor and a nurse are $1,800 and $840 respectively. For information on how you can help, contact The Carolinas Center at 1.800.662.8859 or www.carolinasendoflife-care. org. If you would like to hear more of the first-hand account of a journey to Moldova, or to volunteer, call Judi Lund Person at The Carolinas Center or Pat Ashworth at Hospice and Palliative Care of Greensboro (336.621.2500). 8 NCMB Forum text continued on page 11 Last quarter, the North Carolina Medicaid Drug Utilization Review (DUR) Board, consisting of practicing physicians and clinical pharmacists, conducted a review of prescription claims for patients who had been diagnosed with diabetes and were not receiving a “statin” drug. Surprisingly, over 24,000 patients met this criterion; 1,000 of these were further reviewed. We do not mean to imply that all patients with diabetes automatically require statin therapy. However, analyzing the aggregate data has at least raised the possibility that we are not treating dyslipidemia as aggressively as we should. Persons with diabetes who have had a myocardial infarction have an unusually high death rate.1 The American Diabetes Association recommends annual lipid pro-files for adult patients with diabetes. However, according to data compiled by Medical Review of North Carolina, only about 60% of Medicare patients with dia-betes received this test within two years in the Carolinas.2 A complete discussion of the new National Cholesterol Education Program (NCEP) ATP III high cholesterol guidelines is beyond the scope of this article, but can be found in JAMA1 and other medical litera-ture. The Executive Summary of these new guidelines may be downloaded from the fol-lowing National Institutes of Health (NIH) Web site: http://www.nhlbi.nih.gov/guidelines /cholesterol/atp_iii.htm. Therapeutic lifestyle changes (TLC) such as diet, weight reduction, and increased physical activity remain an integral part of cholesterol treatment. Key changes include more aggressive LDL lowering to less than 100 mg/dL in all patients with diabetes, a higher level (40 mg/dL) at which HDL becomes a risk factor, a new set of TLC, tar-geting the “metabolic syndrome,” and increased attention to high triglycerides.3 Please refer to peer-reviewed, evidence-based medicine (EBM) guidelines for detailed recommendations on managing your patients who suffer from diabetes or dyslipidemia. The American College of Endocrinology (ACE) and American Association of Clinical Endocrinologists (AACE) practice guidelines for the diagnosis and treatment of dyslipidemia and preven-tion of atherogenesis may be found at http://www.aace.com/clin/guidelines. In addi-tion, diabetes management guidelines from the ACE Consensus Conference on Guidelines for Glycemic Control may be From NCDHHS Division of Medical Assistance, Medical Policy, Pharmacy Program DUR Recommendation: Aggressively Treating Dyslipidemia in Diabetics Sharman Leinwand, MPH, RPh, Manager, NC Medicaid Pharmacy Program and Mark D. Krueger, RPh, BCNP Table 1: Statin Effects On Lipids After 8 Weeks of Treatment With LDL from 192 to 244 mg/dL4 (% change from baseline with the following daily doses) Key: TC: total cholesterol; LDL: low-density lipoprotein; HDL: high-density lipoprotein; TG: triglycerides Table 2: Lipid-Lowering Properties of Statins in Placebo-Controlled Trials5 (mean % change from baseline with the following daily doses) Key: TC: total cholesterol; LDL: low-density lipoprotein; HDL: high-density lipoprotein; TG: triglycerides Table 3: Antihyperlipidemic Drugs and Their Effects1 Table 4: EBM Outcome Data and Dose of the Statins4 Primary prevention: AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study: WOSCOPS = West of Scotland Coronary Prevention Study Secondary prevention: 4S = Scandinavian Simvastatin Survival Study; CARE = Cholesterol and Recurrent Events Trial; LIPID = Long-Term Intervention With Pravastatin in Ischemic Disease Effectiveness Tables No. 4 2001 9 In October, Andrew W. Watry, executive director of the North Carolina Medical Board, announced the Board’s election of its officers for the coming year: Walter J. Pories, MD, of Greenville, as president; John T. Dees, MD, of Bald Head Island, as vice pres-ident; and Paul Saperstein, of Greensboro, as secretary-treasurer. They took office on November 1, 2001 and will serve until October 31, 2002. Walter J. Pories, MD, President Walter J. Pories, MD, of Greenville, took office as the Board’s new president on November 1, replac-ing Dr Elizabeth P. Kanof, of Raleigh, in that post. A native of Germany, Dr Pories is professor of surgery and bio-chemistry at the East Carolina University School of Medicine. He is also a clinical professor of surgery at the Uniformed Services University of Health Sciences. He received his BA at Wesleyan University, Middletown, Connecticut, and his MD with honors from the University of Rochester School of Medicine and Dentistry. His postgraduate study included an internship at Strong Memorial Hospital of the University of Rochester; a part-time fellowship at the Centre du Cancer of the Universite de Nancy, France; a graduate research fellow-ship in biochemistry at the University of Rochester; and a residency in general and thoracic surgery at Strong Memorial Hospital. He is certified by the American Board of Surgery and the American Board of Thoracic Surgery. He was first appointed to the North Carolina Medical Board by Governor James B. Hunt, Jr, in 1997, and has served as the Board’s secretary-treasurer and vice president. Frequently honored for his work as a sur-geon and teacher, Dr Pories is a past gover-nor of the American College of Surgeons and has served as president of the North Carolina Chapter of the American College of Surgeons, the North Carolina Surgical Association, the Eastern Carolina Health Organization, Hospice of Greenville, and the Association of Program Directors in Surgery. Active on a large number of pro-fessional boards and committees, he is also the author/coauthor of 47 book chapters, 7 books, and over 250 medical articles dealing primarily with the metabolism of trace ele-ments, diabetes, and surgical education. He has also been involved in the making of four educational films. In 2001, he was awarded the O. Max Gardner Award by the University of North Carolina Board of Governors, the highest faculty honor it can bestow. Dr Pories is a retired colonel of the U.S. Army Reserves. He has published over 50 cartoons and is a talented artist. John T. Dees, MD, Vice President John T. Dees, MD, of Bald Head Island (formerly of Cary), became the Board’s vice president on November 1, replac-ing Dr Walter Pories in that position. A family physician, he practiced for many years in his native Burgaw, a rural area of the state. He received his under-graduate education at the University of North Carolina, Chapel Hill, and his MD from Duke University School of Medicine. He did his internship at Durham’s Watts Hospital and his residency at Duke Hospital. He is a charter diplomate of the American Board of Family Physicians. Besides his private practice, Dr Dees has served, among other things, as Pender County Health Director, chief of staff of Pender Memorial Hospital, and medical director of the Huntington Health Care Center. He has rendered distinguished ser-vice to a wide variety of professional organi-zations, including the North Carolina Academy of Family Physicians, the North Carolina Medical Society, the American Academy of Family Physicians, the Southern Medical Association, the Wake and New Hanover-Pender County Medical Societies, and the American Medical Association. He served as president of the North Carolina Medial Society in 1991-92 and was a mem-ber of the Society’s Executive Council and NCMB Elects Officers: Walter J. Pories, MD, President; John T. Dees, MD, Vice President; Paul Saperstein, Secretary-Treasurer an alternate delegate to the American Medical Association’s House of Delegates. He has also been an active participant in civic affairs in Burgaw and Pender County and at the state level. Dr Dees was first named to the Board by Governor James B. Hunt, Jr, in 1997. While on the Board, Dr Dees has served, among other committees, on the Complaints Committee, the Physicians Health Program Committee, the Investigative Committee, the Clinical Pharmacist Practitioner Joint Subcommittee, and the Executive Committee. In 2000, he was elected secre-tary- treasurer of the Board. Dr Dees says his philosophy is that “ser-vice to humanity is the best work of life.” Paul Saperstein, Secretary-Treasurer On November 1, Mr Paul Saperstein, of Greensboro, took office as secretary-treasur-er of the North Carolina Medical Board, suc-ceeding Dr Dees. First appointed to the Board by Governor James B. Hunt, Jr, in 1993, he was elected secretary-treasurer of the Board in 1995 and 1996 and vice president in 1997. In 1998, he became the first public mem-ber of the Board to be elected its presi-dent. He has been a member of a number of Board commit-tees, including the Investigative, Complaints, Physician Assistant, and Telemedicine Committees, and has chaired the Operations and Executive Committees. A graduate of North Carolina State University, he is president and chief execu-tive officer of Concept Plastics, Inc, includ-ing its Craft-Tex and Ladybug divisions, in High Point. He founded Concept Plastics, Inc, which is one of the nation’s largest man-ufacturers of custom-molded polyester, in 1970. In the 1980s, he was also president and chief executive officer of Case Casard Furniture Manufacturing Corporation. Over the years, he has been active in a wide variety of community organizations and groups. Dr Pories Dr Dees Mr Saperstein 10 NCMB Forum continued on page 11 Death Be Not Proud: The Meaning of Wit Jeffrey A. Peake, NCMB Licensing Staff Vivian Bearing has advanced metastatic ovarian cancer. She has just endured eight grueling treatment cycles, one cycle a month, each combining chemotherapy and experimental drug administrations. It has taken enormous courage and toughness to get through each treatment, and in fact no one else has ever made it through all eight at full dosage. Always attracted to difficult challenges, Vivian recognizes that her latest accomplishment makes her a celebrity around the hospital, one who will soon be written about in a medical journal article. But there is nothing comforting in this fact, and, ever closer to death, she is not inclined to illusions. “The article will not be about me,” she says, “It will be about my ovaries. It will be about my peritoneal cavity, which despite their best intentions, is crawling with cancer. What we have come to think of as me is, in fact, just the specimen jar, just the dust jacket, just the white piece of paper that bears the little black marks.” There is a central tension in modern life we all periodically encounter, perhaps never more so than when we are in a hospital set-ting. It is the struggle to maintain human dignity amidst the forces of technology, spe-cialization, and bureaucracy. This tension drives Margaret Edson’s wonderful, though devastating, play Wit, a dramatization of a woman’s battle against cancer, which won the Pulitzer Prize in 1999. Edson’s play has been lovingly adapted into an Emmy-win-ning HBO movie (now available on VHS and DVD), directed by Mike Nichols and starring the unrivaled Emma Thompson, whose performance is a tour de force. _______________________________ Wit Margaret Edson Dramatists Play Service, New York, 1999 68 pages, $5.95 (ISBN #0-8222-1704-X) .................. Wit Screenplay by Mike Nichols and Emma Thompson Directed by Mike Nichols; HBO Films, Avenue Pictures HBO Home Video, DVD, 2000 99 minutes, $19.95 _________________________________ The entire drama unfolds at the fictional University Hospital Comprehensive Cancer Center, though there are flashback scenes throughout. Edson, an elementary school teacher now living in Georgia, previously worked in the cancer and AIDS unit of a research hospital, and that experience was the impetus for writing the play. We can sur-mise from Wit that her impressions of the hospital were largely unflattering, even ghastly at times. In a recent television inter-view, she said she wanted to write a story about grace, and could best do so through use of a graceless setting. The narrator and lead character of both the play and film is Vivian Bearing, an English professor with expertise in the poet-ry of John Donne, the seventeenth-century Englishman best known for his highly com-plex works that have been dubbed “meta-physical” poetry. In particular, she is a schol-ar of Donne’s Holy Sonnets, 19 intense reli-gious meditations. The play’s title derives from Vivian’s connection with Donne, for in the seventeenth century the term wit did not merely suggest arousing amusement, but referred to a high level of mental activity, characterized in Donne’s poetry through finding similarities in seemingly dissimilar images or elements, and in exploring para-doxes, contradictions, and irony. The point of this wit, as Vivian’s mentor, Professor Ashford, reminds her in a flashback scene, is to illuminate truth. Edson’s play follows suit, using wit to great dramatic purpose. For example, connections are made in Wit between poems and tumors, English profes-sors and research fellows, the rich language of poetry and the clinical language of sci-ence. The result is a complex and layered work, one that contemplates the lessons of mortality and the sad consequences of for-getting our primary responsibilities for each other. Vivian is an extremely intelligent woman, at the top of her field, proud of her work and quite willing to show off her verbal dexteri-ty. She is impressive, or in her own words, she is “a force.” Early in the play, she greets us with an engaging sarcasm, remaining as objective about and as distant from her dire situation as she can, though as the play pro-gresses she becomes more insular and per-haps more her true self. In the midst of telling her story, Vivian is constantly being wheeled from room to room, poked and prodded by staff members who don’t know her name, and put at the mercy of tubes and machines. Her physicians, Dr Kelekian and his chief clinical fellow, Dr Posner, have woe-ful bedside manners, which generally consist of empty exhortations, such as “keep push-ing the fluids.” Once she is even thought-lessly left alone in a room, lying prone and exposed on an exam table. The indignities seem to increase as Vivian’s condition wors-ens. Competitive research fellows speak over her during grand rounds, discussing her symptoms and side effects as if she were not even present. While on individual rounds, a masked Dr Posner enters her isolation unit, such a harrowing and lonely place, and mur-murs “I really have not got time for this. . . .” _____________________ . . . my physicians by their love are grown Cosmographers, and I their map, who lie Flat on this bed. ..................................... I observe the physician with the same diligence as he the disease. John Donne, Devotions VI _____________________ The play, though, is not simply a philippic against cold and faceless hospitals. As Vivian reviews her life, we see that she, too, is guilty of living ungraciously. Flashback scenes reveal she has had little to no affection for her students, often “refused them the touch of human kindness,” and was mainly interested in impressing them. Apparently her colleagues do not like her, and she imag-ines many “would be relieved” at her death. Though her entire history is not revealed, we learn that she has lived largely in isolation and has no husband or children, no close family members, no close friends. The impression is that she has almost invited such a life. Perhaps most importantly, we see Vivian’s sterile attitude towards her life’s work for the past 20 years. Of all the formal arts, poetry is best able to capture the totality of experi-ence. In our greatest poems, the proper wedding of words and images creates what has been called a “miracle of harmony,” through which we glimpse truths that can-not be represented any other way. Donne’s poetry achieves this harmony through com-plex images and arguments. In his Holy Sonnets, these complexities lead to a moving exploration of sin, suffering, death, and, ulti-mately, divine reconciliation. Vivian, how-ever, is drawn to Donne only because he is complex, saying that his “wit provides an invaluable exercise for sharpening the mental REVIEW No. 4 2001 11 faculties.” Thus, the best reason she can give for her studies is that they bring an intellec-tual challenge, “a way to see how good you really are.” Such reasoning ignores, of course, the most important dimension of poetry, the human dimension. In the same way, Vivian’s physicians seem to have for-gotten that their research isn’t done for the sake of research, but for the sake of people. We remember those haunting words, “just the specimen jar, just the dust jacket, just the white piece of paper that bears the little black marks.” Yet, out of the darkness comes light. In her most desperate moments, when the pain of cancer and loneliness grow unbearable, Vivian becomes most fully human. In two scenes of great emo-tional depth, she shares her vulnerabilities at last, and accepts the warmth that is finally offered her. First, with the help of her nurse (the one standout hospital employee), Vivian is able to make a crucial decision about her end-of-life care, illustrating that she is now able to be gracious with herself. Then, in a moment of touching symmetry, she is visited by her former mentor, Professor Ashford, now an old woman who no longer offers admoni-tions, but tenderness and love. These scenes in the film version of Wit affected me like few I have ever seen, and in them one rec-ognizes that redemption had occurred for Vivian through her suffering. At the play’s tumultuous end, there is also hope. Dr Posner, the most callous of the clinical fel-lows, has been redeemed through a shocking epiphany, and one suspects the way he views his patients has been altered forever. _____________________________________ Death be not proud, though some have called thee Mighty and dreadful, for thou art not so, For those whom thou think’st thou dost over-throw, Die not, poor death, nor yet canst thou kill me. .................. Thou art slave to fate, chance, kings, and des-perate men. .................. One short sleep past, we wake eternally, And death shall be no more; death, thou shalt die. John Donne, Holy Sonnets X ____________________________________ We are so privileged to live in an age of medical breakthroughs, to benefit from the hard work of researchers, the expertise of specialists, and the wonders of modern med-ical facilities. But what do we profit by it if we lose our souls? In reading, and watching, Wit, I was remind-ed of the author C.S. Lewis, who more than 50 years ago warned us that the pursuit of biological and medical con-quests can, if we are not careful, obscure our very humanity. “If man chooses to treat himself as raw material, raw material he will be,” he wrote, adding, “Man’s final conquest has proved to be the abolition of Man.” Wit, both as a play and a film, stands against our dehumanizing tendencies, and urges us to do better. Few patients are quite like Vivian, which is probably a good thing, and few physicians are like Drs Kelekian and Posner, which is certainly a good thing. But all involved in the health care equation, laypersons and professionals, will find a bit of themselves in each of these char-acters; and that shock of recognition, that expression of wit, that troubling similarity in the dissimilar, cannot help but benefit every-one who reads or sees this remarkably mov-ing piece. Be one of those if you can. Death Be Not Proud continued from page 10 found at http://www.aace.com/pub/press/releas-es/ diabetesconsensuswhitepaper.php. Since this DUR was generated from aggregate claims data, we did not have access to lipid profiles and other detailed medical information. For your patients with diabetes, we recommend obtaining an annu-al lipid panel and using the new NCEP guidelines to guide therapy. Please remem-ber to exercise caution when considering drug therapy for children. Keep in mind that most antihyperlipidemic therapies are contraindicated in pregnancy. We have included above several useful tables summarizing reported effectiveness of cholesterol lowering agents. Tables 14 and 25 provide various estimates of lipid lowering effectiveness of the statin drugs. Table 31 compares the effectiveness of the cholesterol lowering agents by class. Table 44 contains important data on EBM outcomes. Although Lipitor® (atorvastatin) is the cur-rent market leader with over $5 billion in annual sales and has data to support lipid lowering effectiveness, it currently has no supporting outcomes data (morbidity/mor-tality). 4 There are at least eight long-term, large-scale outcome studies now underway that will provide additional crucial EBM data10. Of the statin drugs, pravastatin (Pravachol®) is the only one with supporting EBM data for both primary and secondary prevention. In summary, for patients with diabetes, check a lipid panel annually to identify those who may benefit from more aggressive lipid lowering therapy. Follow the new and more aggressive NCEP guidelines. Please consid-er EBM and medication costs when choos-ing drug therapy. _____________________ References 1. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-97. 2. Henley N. National Cholesterol Educational Program Designates Diabetes as a Coronary Heart Disease Risk Equivalent. Quality Partners 2001; 6(4):1, 9. 3. Anonymous. NCEP issues major new cholesterol guidelines. National Institutes of Health news release 2001; 15 May. Available at: http:// www.nih.gov/news/pr/may2001/nhlbi-15.htm. Accessed 12 September 2001. 4. Jellinger PS. AACE Lipid Guidelines. Endocr Pract 2000; 6(2):162-213. 5. Antihyperlipidemic Agents. Drug Facts and Com-parisons. St. Louis, 2000, p. 537. 6. Lipitor Product Information, Warner-Lambert Co., Morris Plains, NJ 07950, 1999. 7. Lescol Product Information, Novartis Pharmaceu-ticals Corporation, East Hanover, New Jersey 07936, 2001. 8. Pravachol Product Information, Bristol-Myers Squibb Co., Princeton, NJ 08543, 2001. 9. Zocor Product Information, Merck & Co., Inc., Whitehouse Station, NJ 08889, 2001. 10. Wierzbicki AS. Synthetic Statins: More Data on Newer Lipid-Lowering Agents. Curr Med Res Opin 2001; 17(1):74-77. .......................................... Questions and comments may be directed to Sharman Leinwand by telephone (919.857-4034) or by e-mail (Sharman.Leinwand@ncmail.net.) DUR Recommendation: continued from page 8 12 NCMB Forum More on End-of-Life Care To the Editor: I just finished reading [Dr Pories’] article in regard to euthanasia [,Killing a Panda,] in the NCMB Forum [#2, 2001]. I feel compelled to write and to challenge [his] association between being a good physician and being the patient’s “suc-cor of last resort.” We should all pride ourselves on being caring physicians. We must love medicine but love our patients more. We need to spend time with them, to help them, to comfort them, and to protect them. On all of the above, I certainly agree with [Dr Pories]. There comes a time, however, when lov-ing is letting go. “Sores, bad smells, and incontinence” do not bother me as a physi-cian. However, they certainly bother the patient. Life with quality is wonderful. Life without quality can be a true burden. I lost my mother one year ago. I loved her dearly. She was in poor health even before her “gut” was “in knots.” It was my initial objective to make certain that we relieved her obstruction as soon as possible. However, my mother has always been smarter than I. Without hesitation, she refused the surgery. When I challenged her and told her that I was not ready to lose her, she challenged me for being so selfish and non-understanding. She pointed out that I wanted life for her for my own sake. As a physician, and as a son, I was unwilling to let her go. However, in her wisdom, she saw that life was always limited and that death was sometimes a greater gift than a painful, unhappy life. Please do not get me wrong. I am not in favor of positive euthanasia. However, the election that my family eventually reached of relieving my mother’s pain and not putting her through further surgery, nursing home care, and possible years of suffering, was not one that I regret. We must be willing to always place our patient’s overall welfare above our own per-sonal desires to heal and prolong life. A good physician is one who helps his or her patient have quality in life and who sits by their side and holds their hand as they die. Your article implied that death is wrong. Death is real, and will be real for each of us. Let us hope that we, as physicians, can make the passage of our patients smoother, not only in life, but also in death. Curtis W. Schupbach, MD Charlotte, NC Response: I appreciate Dr Schupbach’s thoughtful com-ments. His poignant description of his mother’s passing proves, indeed, that he is a “caring physician.” I’ve thought a lot about death and how to ease its burden. I founded and directed two hospices, one in Cleveland and another in Greenville, so that our patients would have a place where death is accepted and even welcomed. I did not mean to imply that death is wrong. It may be unexpected or untimely or overdue, but it is never wrong. As Dr Schupbach reminds us, we will all die. My mother’s end was also awful. She was lively and fun even until her 93rd birthday. She reminded me again and again that I would never let her linger, that I would allow her to have the “gift of a kind death” when her time came. “Promise me,” she said, and promise I did. Unfortunately, when she had a major stroke, someone carried out a full resuscitation that left her hanging on a ventilator for several terrible months, unable to communicate. When she was finally extubated, she spent the next eight weeks crying, “help, help, help,” in the empty canyons of the nursing home. She could not communicate, and, frankly, I could not look into her eyes without feeling guilty. It is inter-esting that on the last day of her life she changed her mindless cry to, “God, please help me,” and within an hour, passed away. Yes, Dr Schupbach, I’m right there with you in recognizing that there is a time to let go. I have no argument with your thesis. I only dis-agree with those who would take a life, who would rather dispose of the person than help, who find caring inconvenient. Thank you for sharing your thoughts so well. Walter J. Pories, MD, FACS President, NCMB Dr VanFrank’s Dilemma To the Editor: I read today with a mixture of sympathy, shock, and anger Dr VanFrank’s moving account of the repercussions of inad-vertently failing to renew her license [Forum #3, 2001]. I have never met nor heard of Dr VanFrank, but if, as I assume because the document was published, her story is true, this seems fairly clear evidence of a bureau-cracy out of control. Not that I would coun-tenance sloth or irresponsibility, but it does not seem like any reasonable effort was expended to effectively contact Dr VanFrank. Mailing was attempted, and when that failed, it was attempted again and again. We all know how easy it is to forget to notify all the different sources when our address changes. Why the mail was not effectively forwarded, I cannot answer. Why the Board could not contact her at her known and apparently regular place of work seems worthy of exploration. It does not seem like much if any customer-friendly effort was expended. More significantly, it seems tragic that a simple failure to make connection by mail should result in so much wasted effort, money, time, and suffering. When the lapse in licensure was discovered, it would seem some simple informal investigation would have revealed this to be an honest mistake, with appropriate and simple steps taken to clear the record without any pejorative residue. By appearances, a Brobdingnagian punishment was meted out for a Lilliputian offense. With rare exceptions, bureaucracies con-tribute little if anything to effective delivery of care to patients. We all struggle mightily every day with the ever-increasing volumes of paperwork, diverting useful effort to use-less purposes. The North Carolina Medical Board really should have little difficulty doing their job effectively while still being compassionate. If anything, they probably owe Dr VanFrank an apology! Karol T. Wolicki, MD Greensboro, NC To the Editor: I read every issue of the Forum. It is always informative, usually interesting, and occasionally worrisome. An article by Dr Alison VanFrank in the Forum, No. 3, 2001, fits the latter category. The error of failing to register her NC license and to send the $100 annual fee in a timely manner appears to me to carry an extremely heavy consequence. Dr VanFrank had not been found to be incompetent, fraudulent, or unprofessional, which are the important measures of us as physicians. Rather, she moved her office and thereby failed to receive the annual renewal notice for registering her NC medical license. This administrative oversight led to an extreme impact on her medical practice as well as dis-proportionate financial and mental costs to her. I personally think the Medical Board could take a greater degree of responsibility in reaching physicians who are delinquent in renewal of their medical licenses. Physicians, of course, have the primary responsibility to keep their licenses current. But in my 28 years of practice, I have seen a noticeable increase in the number of month-continued on page 13 LETTERS TO THE EDITOR No. 4 2001 13 ly renewals to local hospital staffs, profes-sional organizations, state and national med-ical societies, and the subsequent required renewals, refilings, and certified responses. Could the Medical Board staff not make one telephone call reminder to physicians who fail to renew by their birthday? Give them a two week period to update and renew, with an appropriate late-filing fee (hopefully less than Dr VanFrank’s $12,000 [attorney’s fee]) to cover the additional administrative costs? If this additional reminder did not work, then let the sky fall on the poor soul. C. Allan Eure, MD Raleigh, NC Comment: The above are two of five letters received at the Board expressing concern about the Board’s action in this matter. We appreciate all five let-ters and each writers’ viewpoint. While we regret space does not allow all the letters to be published in the Forum, the two printed here well reflect the opinions of all the writers. For a response, please see the comments of the Board’s executive director in his column beginning on the first page of this number of the Forum. Letters to the Editor continued from page 12 Most physicians enter the medical profes-sion because it provides them with the train-ing and opportunity to help people in need. It seems natural, therefore, that physicians might be tempted to take a professional role in providing medical care to those persons dearest and closest to them: their own fam-ilies. Indeed, studies suggest many physi-cians regularly provide medical care for their family members. The instinct to take a pro-fessional role in providing medical care to a loved one, however, should be weighed against the overwhelming evidence from professional organizations, academic litera-ture, and regulatory bodies that uniformly declares the treatment of family members to be professionally unwise and ethically prob-lematic. The North Carolina Medical Board (Board) issues Position Statements on pro-fessional and practice issues to provide guid-ance for physicians. While the Board’s Position Statements are not legally binding, they provide clearly articulated and useful advice and reflect the Board’s general view of what constitutes acceptable professional behavior. The Board’s statement, Self-Treatment and Treatment of Family Members and Others with Whom Significant Emotional Relationships Exist, clearly states that: . . . except for minor illnesses and emergen-cies, physicians should not treat, medically or surgically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. The Board strongly believes that such treat-ment and prescribing is inappropriate and may result in less than optimal care being provided. The admonition against treating close family members is longstanding and nearly ubiquitous. It is contained in the AMA’s first Code of Ethics, adopted in 1847. The current AMA Council on Ethical and Judicial Affairs (Opinion 8.19) and the American College of Physicians’ Ethics Manual echo the Board’s warning against physicians treating family members. Ethical and professional objections to a physician treating his or her family members are based on the danger that the physician’s personal feelings for his or her patient/fami-ly member will undermine rather than enhance the care the family member receives. Personal feelings and fears might compromise a physician’s professional objec-tivity and judgment, leading him or her to either over-or under-estimate the seriousness of the patient’s condition. For example, fearing the worst, the physi-cian may over-diagnose a condition, subject-ing the patient/family member to a series of unnecessary tests, treatments, fears, and risks. Conversely, the physician, reluctant to face the possibility of a seriously ill family member, may dismiss prematurely a viable but more serious diagnosis. These tenden-cies may be aggravated in that the potential informality associated with treating family members sometimes leads to less scrupulous adherence to traditional protocols of history-taking, physical and diagnostic workup, and record keeping. Moreover, family members are frequently examined outside the tradi-tional office setting, without the appropriate support and proper equipment and resources. Personal connections may also complicate the way in which the patient/family mem-bers and physician interact. Physicians with familial connections to their patients might be less likely to ask potentially sensitive, but clinically relevant, questions or to perform intimate, but necessary, examinations. Similarly, patient/family members may be less likely to disclose personal facts. Frequently, the very advantage of speaking to an unrelated physician is that information will be kept from family members. The per-sonal distance may enhance disclosure. On one hand, some patients, especially children, may be less likely to refuse and question treatment recommended by a family mem-ber who is a physician. On the other hand, older family members may doubt the insight and wisdom of a younger, albeit profession-ally trained, physician/family member, and, as a result, be less compliant. Treating physicians must sometimes play the role of mediator, negotiating between and among family members to help them understand and resolve difficult clinical and emotional questions. Here, too, familial connections can be a handicap rather than a benefit. Familiarity and interlocking loyal-ties can confound the already challenging issues of confidentiality, decision making capacity, informed consent, and the host of issues surrounding end-of-life care. While the Board’s Position Statement clearly discourages physicians from treating their family members, providing such care may be appropriate in some limited circum-stances. In emergencies, minor illnesses, and A Word with You Avoid Treating Family Members! Edward E. Hollowell, JD Kenneth A. De Ville, JD in isolated settings in which no other appro-priate medical care is available, physicians may legitimately treat a family member. In those cases in which a physician must pro-vide emergency care for a family member, the patient’s/family member’s care should be transferred to another physician as soon as it is practical. The Board reminds physicians who treat family members for emergency or minor illness that they “must prepare and keep a proper written record of that treat-ment, including but not limited to prescrip-tions written for controlled substances and the medical indications for them.” Abiding by the long-standing warning against providing medical care to family members does not mean abandoning loved ones in their time of need. Instead, physi-cians can best help family members by refer-ring them to qualified and appropriate health care professionals. _____________________ Revised from an article by the same authors in the Medical Law Alert, a newsletter published by Hollowell, Peacock & Meyer, PA, Attorneys and Counselors at Law, Raleigh, NC. 14 NCMB Forum continued on page 15 Position Statements of the North Carolina Medical Board Table of Contents What Are the Position Statements of the Board and To Whom Do They Apply......................................................14 The Physician-Patient Relationship .............................................14 Medical Record Documentation .................................................15 Access to Physician Records........................................................15 Retention of Medical Records.....................................................15 Departures from or Closings of Medical Practices.......................16 The Retired Physician ...............................................................16 Advance Directives and Patient Autonomy..................................16 Availability of Physicians to Their Patients After Hours ..............17 Guidelines for Avoiding Misunderstandings During Physical Examinations ............................................................17 Sexual Exploitation of Patients....................................................17 Contact With Patients Before Prescribing....................................17 Writing of Prescriptions ..............................................................17 Self- Treatment and Treatment of Family Members and Others With Whom Significant Emotional Relationships Exist ..........18 The Use of Anorectics in Treatment of Obesity ..........................18 Prescribing Legend or Controlled Substances for Other Than Valid Medical or Therapeutic Purposes, with Particular Reference to Substances or Preparations with Anabolic Properties.........................................................18 Management of Chronic Non-Malignant Pain ............................18 End-of-Life Responsibilities and Palliative Care ..........................19 (Medical, Nursing, Pharmacy Boards: Joint Statement on Pain Management in End-of-Life Care...............................19 Office-Based Surgery ..................................................................20 Laser Surgery..............................................................................20 Care of Surgical Patients* ...........................................................20 HIV/HBV Infected Health Care Workers ...................................21 Professional Obligation to Report Incompetence, Impairment, and Unethical Conduct ......................................21 Advertising and Publicity*..........................................................21 Sale of Goods From Physician Offices ........................................21 Fee Splitting ...............................................................................21 Unethical Agreements in Complaint Settlements ........................21 [The principles of professionalism and performance expressed in the posi-tion statements of the North Carolina Medical Board apply to all persons licensed and/or approved by the Board to render medical care at any level. The words “physician” and “doctor” as used in the position statements of the North Carolina Medical Board refer to persons who are MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina.] Disclaimer The North Carolina Medical Board makes the information in this publica-tion available as a public service. We attempt to update this printed material as often as possible and to ensure its accuracy. However, because the Board’s position statements may be revised at any time and because errors can occur, the information presented here should not be considered an official or com-plete record. Under no circumstances shall the Board, its members, officers, agents, or employees be liable for any actions taken or omissions made in reliance on information in this publication or for any consequences of such reliance. A more current version of the Board’s position statements will be found on the Board’s Web site: www.ncmedboard.org, which is usually updated shortly after revisions are made. In no case, however, should this publication or the material found on the Board’s Web site substitute for the official records of the Board. What Are The Position Statements of the Board and to Whom Do They Apply? The North Carolina Medical Board’s Position Statements are interpretive statements that attempt to define or explain the meaning of laws or rules that govern the practice of physicians,* physician assistants, and nurse practition-ers in North Carolina, usually those relating to discipline. They also set forth criteria or guidelines used by the Board’s staff in investigations and in the pros-ecution or settlement of cases. When considering the Board’s Position Statements, the following four points should be kept in mind. 1. In its Position Statements, the Board attempts to articulate some of the standards it believes applicable to the medical profession and to the other health care professions it regulates. However, a Position Statement should not be seen as the promulgation of a new standard as of the date of issuance or amendment. Some Position Statements are reminders of traditional, even mil-lennia old, professional standards, or show how the Board might apply such standards today. 2. The Position Statements are not intended to be comprehensive or to set out exhaustively every standard that might apply in every circumstance. Therefore, the absence of a Position Statement or a Position Statement’s silence on cer-tain matters should not be construed as the lack of an enforceable standard. 3. The existence of a Position Statement should not necessarily be taken as an indication of the Board’s enforcement priorities. 4. A lack of disciplinary actions to enforce a particular standard mentioned in a Position Statement should not be taken as an abandonment of the principles set forth therein. The Board will continue to decide each case before it on all the facts and cir-cumstances presented in the hearing, whether or not the issues have been the subject of a Position Statement. The Board intends that the Position Statements will reflect its philosophy on certain subjects and give licensees some guidance for avoiding Board scrutiny. The principles of professionalism and performance expressed in the Position Statements apply to all persons licensed and/or approved by the Board to render medical care at any level. *The words “physician” and “doctor” as used in the Position Statements refer to persons who are MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina. [Adopted November 1999] THE PHYSICIAN-PATIENT RELATIONSHIP The North Carolina Medical Board recognizes the movement toward restructuring the delivery of health care and the significant needs that motivate that movement. The resulting changes are providing a wider range and vari-ety of health care delivery options to the public. Notwithstanding these devel-opments in health care delivery, the duty of the physician remains the same: to provide competent, compassionate, and economically prudent care to all his or her patients. Whatever the health care setting, the Board holds that the physi-cian’s fundamental relationship is always with the patient, just as the Board’s relationship is always with the individual physician. Having assumed care of a patient, the physician may not neglect that patient nor fail for any reason to prescribe the full care that patient requires in accord with the standards of acceptable medical practice. Further, it is the Board’s position that it is uneth-ical for a physician to allow financial incentives or contractual ties of any kind to adversely affect his or her medical judgment or patient care. Therefore, it is the position of the North Carolina Medical Board that any act by a physi-cian that violates or may violate the trust a patient places in the physician places the relationship between physician and patient at risk. This is true whether such an act is entirely self-determined or the result of the physician’s contractual association with a health care entity. The Board believes the inter-ests and health of the people of North Carolina are best served when the physi-cian- patient relationship remains inviolate. The physician who puts the physi-cian- patient relationship at risk also puts his or her relationship with the Board in jeopardy. Elements of the Physician-Patient Relationship The North Carolina Medical Board licenses physicians as a part of regulat-ing the practice of medicine in this state. Receiving a license to practice med- No. 4 2001 15 Position Statement continued from page 14 continued on page 16 icine grants the physician privileges and imposes great responsibilities. The people of North Carolina expect a licensed physician to be competent and worthy of their trust. As patients, they come to the physician in a vulnerable condition, believing the physician has knowledge and skill that will be used for their benefit. Patient trust is fundamental to the relationship thus established. It requires that there be adequate communication between the physician and the patient; there be no conflict of interest between the patient and the physician or third parties; intimate details of the patient’s life shared with the physician be held in confidence; the physician maintain professional knowledge and skills; there be respect for the patient’s autonomy; the physician be compassionate; the physician be an advocate for needed medical care, even at the expense of the physician’s personal interests; and the physician provide neither more nor less than the medical problem requires. The Board believes the interests and health of the people of North Carolina are best served when the physician-patient relationship, founded on patient trust, is considered sacred, and when the elements crucial to that relationship and to that trust — communication, patient primacy, confidentiality, compe-tence, patient autonomy, compassion, selflessness, appropriate care — are fore-most in the hearts, minds, and actions of the physicians licensed by the Board. This same fundamental physician-patient relationship also applies to mid-level health care providers such as physician assistants and nurse practitioners in all practice settings. Termination of the Physician-Patient Relationship The Board recognizes the physician’s right to choose patients and to termi-nate the professional relationship with them when he or she believes it is best to do so. That being understood, the Board maintains that termination of the physician-patient relationship must be done in compliance with the physician’s obligation to support continuity of care for the patient. The decision to ter-minate the relationship must be made by the physician personally. Further, ter-mination must be accompanied by appropriate written notice given by the physician to the patient, the relatives, or the legally responsible parties suffi-ciently far in advance (at least 30 days) to allow other medical care to be secured. Should the physician be a member of a group, the notice of termi-nation must state clearly whether the termination involves only the individual physician or includes other members of the group. In the latter case, those members of the group joining in the termination must be designated. (Adopted July 1995) (Amended July 1998, January 2000) MEDICAL RECORD DOCUMENTATION ❐ The North Carolina Medical Board takes the position that physicians and physician extenders should maintain accurate patient care records of histo-ry, physical findings, assessments of findings, and the plan for treatment. The Board recommends the Problem Oriented Medical Record method known as SOAP (developed by Lawrence Weed). ❐ SOAP charting is a schematic recording of facts and information. The S refers to “subjective information” (patient history and testimony about feel-ings). The O refers to objective material and measurable data (height, weight, respiration rate, temperature, and all examination findings). The A is the assessment of the subjective and objective material that can be the diagnosis but is always the total impression formed by the care provided after review of all materials gathered. And finally, the P is the treatment plan presented in sufficient detail to allow another care provider to follow the plan to completion. The plan should include a follow-up schedule. ❐ Such a chronological document records pertinent facts about an individual’s health and wellness; enables the treating care provider to plan and evaluate treatments or interventions; enhances communication between professionals, assuring the patient optimum continuity of care; assists both patient and physician to communicate to third party partici-pants; allows the physician to develop an ongoing quality assurance program; provides a legal document to verify the delivery of care; and is available as a source of clinical data for research and education. ❐ Certain items should appear in the medical record as a matter of course: the purpose of the patient encounter; the assessment of patient condition; the services delivered — in full detail; the rationale for the requirement of any support services; the results of therapies or treatments; the plan for continued care; whether or not informed consent was obtained; and, finally, that the delivered services were appropriate for the condition of the patient. ❐ The record should be legible. When the care giver will not write legibly, notes should be dictated, transcribed, reviewed, and signed within reason-able time. Signature, date, and time should also be legible. All therapies should be documented as to indications, method of delivery, and response of the patient. Special instructions given to other care givers or the patient should be documented: Who received the instructions and did they appear to understand them? ❐ All drug therapies should be named, with dosage instructions and indica-tion of refill limits. All medications a patient receives from all sources should be inventoried and listed to include the method by which the patient understands they are to be taken. Any refill prescription by phone should be recorded in full detail. ❐ The physician needs and the patient deserves clear and complete documen-tation. (Adopted May 1994) (Amended May 1996) ACCESS TO PHYSICIAN RECORDS A physician’s policies and practices relating to medical records should be designed to benefit the health and welfare of patients, whether current or past, and should facilitate the transfer of clear and reliable information about a patient’s care when such a transfer is requested by the patient or anyone autho-rized by law to act on the patient’s behalf. It is the position of the North Carolina Medical Board that notes made by a physician in the course of diagnosing and treating patients are primarily for the physician’s use and are therefore the property of that physician. Moreover, the resulting record is a confidential document and should only be released with proper written consent of the patient. Each physician has a duty on the request of a patient to release a copy or a summary of the record in a timely manner to the patient or anyone the patient designates. If a summary is pro-vided, it should include all the information and data necessary to allow conti-nuity of care by another physician. The physician may charge a reasonable fee for the preparation and/or the photocopying of the materials. To assist in avoiding misunderstandings, and for a reasonable fee, the physician should be willing to review the materials with the patient at the patient’s request. Materials should not be held because an account is overdue or a bill is owed. Should it be the physician’s policy not to include in either the copied or the summarized record those materials that were provided by other physicians regarding the patient’s former or current care, he or she should advise the patient of that fact and of ways those materials might be obtained. Should it be the physician’s policy to complete insurance or other forms for established patients, it is the position of the Board that the physician should complete those forms in a timely manner. If a form is simple, the physician should perform this task for no fee. If a form is complex, the physician may charge a reasonable fee. To prevent misunderstandings, the physician’s policies about providing copies or summaries of patient records and about completing forms should be made available in writing to patients when the physician-patient relationship begins. (Adopted November 1993) (Amended May 1996, September 1997) RETENTION OF MEDICAL RECORDS The North Carolina Medical Board supports and adopts the following lan-guage of Section 7.05 of the American Medical Association’s current Code of Medical Ethics regarding the retention of medical records by physicians. 7.05: Retention of Medical Records Physicians have an obligation to retain patient records which may reason-ably be of value to a patient. The following guidelines are offered to assist 16 NCMB Forum continued on page 17 physicians in meeting their ethical and legal obligations: (1) Medical considerations are the primary basis for deciding how long to retain medical records. For example, operative notes and chemotherapy records should always be part of the patient’s chart. In deciding whether to keep certain parts of the record, an appropriate criterion is whether a physician would want the information if he or she were seeing the patient for the first time. (2) If a particular record no longer needs to be kept for medical reasons, the physician should check state laws to see if there is a requirement that records be kept for a minimum length of time. Most states will not have such a pro-vision. If they do, it will be part of the statutory code or state licensing board. (3) In all cases, medical records should be kept for at least as long as the length of time of the statute of limitations for medical malpractice claims. The statute of limitations may be three or more years, depending on the state law. State medical associations and insurance carriers are the best resources for this infor-mation. (4) Whatever the statute of limitations, a physician should measure time from the last professional contact with the patient. (5) If a patient is a minor, the statute of limitations for medical malpractice claims may not apply until the patient reaches the age of majority. (6) Immunization records always must be kept. (7) The records of any patient covered by Medicare or Medicaid must be kept at least five years. (8) In order to preserve confidentiality when discarding old records, all docu-ments should be destroyed. (9) Before discarding old records, patients should be given an opportunity to claim the records or have them sent to another physician, if it is feasible to give them the opportunity. ............................ Please Note: a. North Carolina has no statute relating specifically to the retention of medical records. b. Several North Carolina statutes relate to time limitations for the filing of mal-practice actions. Legal advice should be sought regarding such limitations. (Adopted May 1998) DEPARTURES FROM OR CLOSINGS OF MEDICAL PRACTICES Departures from (when one or more physicians leave and others remain) or closings of medical practices are trying times. They can be busy, emotional, and stressful for all concerned: practitioners, staff, patients, and other parties that may be involved. If mishandled, they can significantly disrupt continuity of care. It is the position of the North Carolina Medical Board that during such times practitioners and other parties that may be involved in such processes must consider how their actions affect patients. In particular, prac-titioners and other parties that may be involved have the following obliga-tions. Permit Patient Choice It is the patient’s decision from whom to receive care. Therefore, it is the responsibility of all practitioners and other parties that may be involved to ensure that: patients are notified of changes in the practice, which is often done by newspaper advertisement and by letters to patients currently under care; patients are told how to access their medical records; patients are told how to reach any practitioner(s) remaining in practice; and patients clearly understand that the choice of a health care provider is the patients’. Provide Continuity of Care Practitioners continue to have obligations toward patients during and after the departure from or closing of a medical practice. Except in case of the death or other incapacity of the practitioner, practitioners may not abandon a patient or abruptly withdraw from the care of a patient. Therefore, patients should be given reasonable advance notice to allow their securing other care. Good continuity of care includes preserving, keeping confiden-tial, and providing appropriate access to medical records.* Also, good con-tinuity of care may often include making appropriate referrals. The practi-tioner( s) and other parties that may be involved should ensure the require-ments for continuity of care are effectively addressed. No practitioner, group of practitioners, or other parties that may be involved should interfere with the fulfillment of these obligations, nor should practitioners put themselves in a position where they cannot be assured these obligations can be met. *The Board’s position statement on the Retention of Medical Records applies, even when practices close permanently due to the retirement or death of the practitioner. (Adopted January 2000) THE RETIRED PHYSICIAN ❐ The retirement of a physician is defined by the North Carolina Medical Board as the total and complete cessation of the practice of medicine and/or surgery by the physician in any form or setting. According to the Board’s def-inition, the retired physician is not required to maintain a currently registered license and SHALL NOT: provide patient services; order tests or therapies; prescribe, dispense, or administer drugs; perform any other medical and/or surgical acts; or receive income from the provision of medical and/or surgical services per-formed following retirement. ❐ The North Carolina Medical Board is aware that a number of physicians consider themselves “retired,” but still hold a currently registered medical license (full, volunteer, or limited) and provide professional medical and/or surgical services to patients on a regular or occasional basis. Such physicians customarily serve the needs of previous patients, friends, nursing home resi-dents, free clinics, emergency rooms, community health programs, etc. The Board commends those physicians for their willingness to continue service fol-lowing “retirement,” but it recognizes such service is not the “complete cessa-tion of the practice of medicine” and therefore must be joined with an undi-minished awareness of professional responsibility. That responsibility means that such physicians SHOULD: practice within their areas of professional competence; prepare and keep medical records in accord with good professional practice; and meet the Board’s continuing medical education requirement. ❐ The Board also reminds “retired” physicians with currently registered licens-es that all federal and state laws and rules relating to the practice of medicine and/or surgery apply to them, that the position statements of the Board are as relevant to them as to physicians in full and regular practice, and that they con-tinue to be subject to the risks of liability for any medical and/or surgical acts they perform. (Adopted January 1997) (Amended January 2001) ADVANCE DIRECTIVES AND PATIENT AUTONOMY Advances in medical technology have given physicians the ability to prolong the mechanics of life almost indefinitely. Because of this, physicians must be aware that North Carolina law specifically recognizes the individual’s right to a peaceful and natural death. NC Gen Stat §90-320 (a) (1993) reads: The General Assembly recognizes as a matter of public policy that an individual’s rights include the right to a peaceful and natural death and that a patient or his representative has the fundamental right to control the decisions relating to the rendering of his own medical care, including the decision to have extraordinary means withheld or withdrawn in instances of a terminal condition. They must also be aware that North Carolina law empowers any adult indi-vidual with understanding and capacity to make a Health Care Power of Attorney [NC Gen Stat §32A-17 (1995)] and stipulates that, when a patient lacks understanding or capacity to make or communicate health care decisions, the instructions of a duly appointed health care agent are to be taken as those of the patient unless evidence to the contrary is available [NC Gen Stat §32A- 24(b)(1995). ❐ It is the position of the North Carolina Medical Board that it is in the best interest of the patient and of the physician-patient relationship to encourage patients to complete documents that express their wishes for the kind of care they desire at the end of their lives. Physicians should encourage their patients to appoint a health care agent to act with the Health Care Power of Attorney Position Statement continued from page 15 No. 4 2001 17 continued on page 18 and to provide documentation of the appointment to the responsible physi-cian( s). Further, physicians should provide full information to their patients in order to enable those patients to make informed and intelligent decisions prior to a terminal illness. ❐ It is also the position of the Board that physicians are ethically obligated to follow the wishes of the terminally ill or incurable patient as expressed by and properly documented in a declaration of a desire for a natural death. ❐ It is also the position of the Board that when the wishes of a patient are con-trary to what a physician believes in good conscience to be appropriate care, the physician may withdraw from the case once continuity of care is assured. ❐ It is also the position of the Board that withdrawal of life prolonging tech-nologies is in no manner to be construed as permitting diminution of nursing care, relief of pain, or any other care that may provide comfort for the patient. (Adopted July 1993) (Amended May 1996) AVAILABILITY OF PHYSICIANS TO THEIR PATIENTS AFTER HOURS ❐ It is the position of the North Carolina Medical Board that once a physi-cian- patient relationship is created, it is the duty of the physician to provide care whenever it is needed or to assure that proper physician backup is avail-able to take care of the patient during or outside normal office hours. If the physician is not generally available outside normal office hours and does not have an arrangement whereby another physician is available at such times, this fact must be clearly communicated to the patient, verbally and in writing, along with written instructions for securing care at such times. ❐ If the condition of the patient is such that the need for care at a time the physician cannot be available is anticipated, the physician should consider transfer of care to another physician who can be available when needed. (Adopted July 1993) (Amended May 1996, January 2001) GUIDELINES FOR AVOIDING MISUNDERSTANDINGS DURING PHYSICAL EXAMINATIONS It is the position of the North Carolina Medical Board that proper care and sensitivity are needed during physical examinations to avoid misunderstand-ings that could lead to charges of sexual misconduct against physicians. In order to prevent such misunderstandings, the Board offers the following guidelines. 1. Sensitivity to patient dignity should be considered by the physician when undertaking a physical examination. The patient should be assured of adequate auditory and visual privacy and should never be asked to dis-robe in the presence of the physician. Examining rooms should be safe, clean, and well maintained, and should be equipped with appropriate fur-niture for examination and treatment. Gowns, sheets and/or other appropriate apparel should be made available to protect patient dignity and decrease embarrassment to the patient while a thorough and profes-sional examination is conducted. 2. Whatever the sex of the patient, a third party acceptable to the patient should be readily available at all times during a physical examination, and it is strongly advised that a third party acceptable to the patient be pre-sent when the physician performs an examination of the breast(s), geni-talia, or rectum. When appropriate or when requested by the patient, the physician should have a third party acceptable to the patient present throughout the examination or at any given point during the examina-tion. 3. The physician should individualize the approach to physical examinations so that each patient’s apprehension, fear, and embarrassment are dimin-ished as much as possible. An explanation of the necessity of a complete physical examination, the components of that examination, and the pur-pose of disrobing may be necessary in order to minimize the patient’s possible misunderstanding. 4. The physician and staff should exercise the same degree of professional-ism and care when performing diagnostic procedures (eg, electro-cardio-grams, electromyograms, endoscopic procedures, and radiological stud-ies, etc), as well as during surgical procedures and postsurgical follow-up examinations when the patient is in varying stages of consciousness. 5. The physician should be on the alert for suggestive or flirtatious behav-ior or mannerisms on the part of the patient and should not permit a compromising situation to develop. (Adopted May 1991) (Amended May 1993, May 1996, January 2001, February 2001) SEXUAL EXPLOITATION OF PATIENTS ❐ It is the position of the North Carolina Medical Board that entering into a sexual relationship with a patient, consensual or otherwise, is unprofessional conduct and is grounds for the suspension or revocation of a physician’s license. Such conduct is not tolerated. As a guide in defining sexual exploita-tion of a patient by a licensee, the Board will use the language of the North Carolina General Statutes, Chapter 90, Article 1F (Psychotherapy Patient/Client Sexual Exploitation Act), §90-21.41. ❐ As with other disciplinary actions taken by the Board, Board action against a medical licensee for sexual exploitation of a patient or patients is published by the Board, the nature of the offense being clearly specified. It is also released to the news media, to state and federal government, and to medical and professional organizations. ❐ This position also applies to mid-level health care providers such as physi-cian assistants, nurse practitioners, and EMTs authorized to perform medical acts by the Board. (Adopted May 1991) (Amended April 1996, January 2001) CONTACT WITH PATIENTS BEFORE PRESCRIBING It is the position of the North Carolina Medical Board that prescribing drugs to an individual the prescriber has not personally examined is inappro-priate except as noted in the paragraph below. Before prescribing a drug, a physician should make an informed medical judgment based on the circum-stances of the situation and on his or her training and experience. Ordinarily, this will require that the physician personally perform an appropriate history and physical examination, make a diagnosis, and formulate a therapeutic plan, a part of which might be a prescription. This process must be documented appropriately. Prescribing for a patient whom the physician has not personally examined may be suitable under certain circumstances. These may include admission orders for a newly hospitalized patient, prescribing for a patient of another physician for whom the prescriber is taking call, or continuing medication on a short-term basis for a new patient prior to the patient’s first appointment. Established patients may not require a new history and physical examination for each new prescription, depending on good medical practice. It is the position of the Board that prescribing drugs to individuals the physician has never met based solely on answers to a set of questions, as is common in Internet or toll-free telephone prescribing, is inappropriate and unprofessional. [Adopted November 1999] [Amended February 2001] WRITING OF PRESCRIPTIONS ❐ It is the position of the North Carolina Medical Board that prescriptions for controlled substances or mind-altering chemicals should be written in ink or indelible pencil or typewritten and should be manually signed by the practi-tioner at the time of issuance. Quantities should be indicated in both numbers AND words, eg, 30 (thirty). Such prescriptions must not be written on pre-signed prescription blanks. ❐ Each prescription for a DEA controlled substance (2, 2N, 3, 3N, 4, and 5) should be written on a separate prescription blank. Multiple medications may appear on a single prescription blank only when none are DEA-controlled. ❐ No prescriptions, including those for controlled substances or mind-alter-ing chemicals, should be issued for a patient in the absence of a documented physician-patient relationship. Position Statement continued from page 16 Position Statement continued from page 17 ❐ No prescription for controlled substances or mind-altering chemicals should be issued by a practitioner for his or her personal use. ❐ The practice of pre-signing prescriptions is unacceptable to the Board. (Adopted May 1991, September 1992) (Amended May 1996) SELF-TREATMENT AND TREATMENT OF FAMILY MEMBERS AND OTHERS WITH WHOM SIGNIFICANT EMOTIONAL RELATIONSHIPS EXIST* ❐ It is the position of the North Carolina Medical Board that, except for minor illnesses and emergencies, physicians should not treat, medically or sur-gically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. The Board strongly believes that such treatment and prescribing practices are inappropriate and may result in less than optimal care being provided. A variety of factors, including personal feelings and attitudes that will inevitably color judgment, will compromise the objectivity of the physician and make the delivery of sound medical care problematic in such situations, while real patient autono-my and informed consent may be sacrificed. ❐ When a minor illness or emergency requires self-treatment or treatment of a family member or other person with whom the physician has a significant emotional relationship, the physician must prepare and keep a proper written record of that treatment, including but not limited to prescriptions written for controlled substances and the medical indications for them. Record keeping is too frequently neglected when physicians manage such cases. ❐ The Board expects physicians to delegate the medical and surgical care of themselves, their families, and those with whom they have significant emo-tional relationships to one or more of their colleagues in order to ensure appro-priate and objective care is provided and to avoid misunderstandings related to their prescribing practices. *This position statement was formerly titled, “Treatment of and Prescribing for Family Members.” (Adopted May 1991) (Amended May 1996; May 2000) THE USE OF ANORECTICS IN TREATMENT OF OBESITY ❐ It is the position of the North Carolina Medical Board that under particu-lar circumstances certain anorectic agents may have an adjunctive use in the treatment of obesity. Good medical practice requires that such use be guided by a written protocol that is based on published medical data and that patient compliance and progress will be documented. ❐ It remains the policy of the Board that there is no place for the use of amphetamines or methamphetamines in the treatment of obesity. (Adopted October 1987) (Amended March 1996) PRESCRIBING LEGEND OR CONTROLLED SUBSTANCES FOR OTHER THAN VALIDATED MEDICAL OR THERAPEUTIC PURPOSES, WITH PARTICULAR REFERENCE TO SUBSTANCES OR PREPARATIONS WITH ANABOLIC PROPERTIES General It is the position of the North Carolina Medical Board that prescribing any controlled or legend substance for other than a validated medical or therapeu-tic purpose is unprofessional conduct. The physician shall complete and maintain a medical record that establish-es the diagnosis, the basis for that diagnosis, the purpose and expected response to therapeutic medications, and the plan for the use of medications in treatment of the diagnosis. The Board is not opposed to the use of innovative, creative therapeutics; however, treatments not having a scientifically validated basis for use should be studied under investigational protocols so as to assist in the establishment of evidence-based, scientific validity for such treatments. Substances/Preparations with Anabolic Properties The use of anabolic steroids, testosterone and its analogs, human growth hormone, human chorionic gonadotrophin, other preparations with anabolic properties, or autotransfusion in any form, to enhance athletic performance or muscle development for cosmetic, nontherapeutic reasons, in the absence of an established disease or deficiency state, is not a medically valid use of these med-ications. The use of these medications under these conditions will subject the person licensed by the Board to investigation and potential sanctions. The Board recognizes that most anabolic steroid abuse occurs outside the medical system. It wishes to emphasize the physician’s role as educator in pro-viding information to individual patients and the community, and specifically to high school and college athletes, as to the dangers inherent in the use of these medications. (Adopted May 1998) (Amended July 1998, January 2001) MANAGEMENT OF CHRONIC NON-MALIGNANT PAIN It has become increasingly apparent to physicians and their patients that the use of effective pain management has not kept pace with other advances in medical practice. There are several factors that have contributed to this. These include a history of relatively low priority given pain management in our health care system, the incomplete integration of current knowledge in med-ical education and clinical practice, a sparsity of practitioners specifically trained in pain management, and the fear of legal consequences when con-trolled substances are used — fear shared by physician and patient. There are three general categories of pain. Acute Pain is associated with surgery, trauma and acute illness. It has received its share of attention by physicians, its treatment by various means is widely accepted by patients, and it has been addressed in guidelines issued by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services. Cancer Pain has been receiving greater attention and more enlightened treat-ment by physicians and patients, particularly since development of the hospice movement. It has also been addressed in AHCPR guidelines. Chronic Non-Malignant Pain is often difficult to diagnose, often intractable, and often undertreated. It is the management of chronic non-malignant pain on which the North Carolina Medical Board wishes to focus attention in this position statement. ❐ The North Carolina Medical Board recognizes that many strategies exist for treating chronic non-malignant pain. Because such pain may have many caus-es and perpetuating factors, treatment will vary from behavioral and rehabili-tation approaches to the use of a number of medications, including opioids. Specialty groups in the field point out that most chronic non-malignant pain is best managed in a coordinated way, using a number of strategies in concert. Inadequate management of such pain is not uncommon, however, despite the availability of safe and effective treatments. The Board is aware that some physicians avoid prescribing controlled sub-stances such as opioids in treating chronic non-malignant pain. While it does not suggest those physicians abandon their reservations or professional judg-ment about using opioids in such situations, neither does the Board wish to be an obstacle to proper and effective management of chronic pain by physicians. It should be understood that the Board recognizes opioids can be an appro-priate treatment for chronic pain. ❐ It is the position of the North Carolina Medical Board that effective man-agement of chronic pain should include: thorough documentation of all aspects of the patient’s assessment and care; a thorough history and physical examination, including a drug and pain history; appropriate studies; a working diagnosis and treatment plan; a rationale for the treatment selected; education of the patient; clear understanding by the patient and physician of methods and goals of treatment; a specific follow-up protocol, which must be adhered to; regular assessment of treatment efficacy; consultation with specialists in pain medicine, when warranted; and continued on page 19 18 NCMB Forum Position Statement continued from page 18 use of a multidisciplinary approach, when indicated. ❐ The Board expects physicians using controlled substances in the manage-ment of chronic pain to be familiar with conditions such as: physical dependence; respiratory depression and other side effects; tolerance; addiction; and pseudo addiction. There is an abundance of literature available on these topics and on the effec-tive management of pain. The physician’s knowledge should be regularly updated in these areas. ❐ No physician need fear reprisals from the Board for appropriately prescrib-ing, as described above, even large amounts of controlled substances indefi-nitely for chronic non-malignant pain. ❐ Nothing in this statement should be construed as advocating the imprudent use of controlled substances. (Adopted September 1996) END-OF-LIFE RESPONSIBILITIES AND PALLIATIVE CARE Assuring Patients Death is part of life. When appropriate processes have determined that the use of life-sustaining or invasive interventions will only prolong the dying process, it is incumbent on physicians to accept death “not as a failure, but the natural culmination of our lives.”* It is the position of the North Carolina Medical Board that patients and their families should be assured of competent, comprehensive palliative care at the end of their lives. Physicians should be knowledgeable regarding effective and compassionate pain relief, and patients and their families should be assured such relief will be provided. Palliative Care There is no one definition of palliative care, but the Board accepts that found in the Oxford Textbook of Palliative Medicine: “The study and man-agement of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is the quality of life.” This is not intended to exclude remissions and requires that the management of patients be comprehensive, embracing the efforts of medical clinicians and of those who provide psychosocial services, spiritual support, and hospice care. A physician who provides palliative care, encompassing the full range of comfort care, should assess his or her patient’s physical, psychological, and spiritual conditions. Because of the overwhelming concern of patients about pain relief, special attention should be given the effective assessment of pain. It is particularly important that the physician frankly but sensitively discuss with the patient and the family their concerns and choices at the end of life. As part of this discussion, the physician should make clear that, in some cases, there are inherent risks associated with effective pain relief in such situations. Opioid Use The Board will assume opioid use in such patients is appropriate if the responsible physician is familiar with and abides by acceptable medical guide-lines regarding such use, is knowledgeable about effective and compassionate pain relief, and maintains an appropriate medical record that details a pain management plan. (See the Board’s position statement on the Management of Chronic Non-Malignant Pain for an outline of what the Board expects of physicians in the management of pain.) Because the Board is aware of the inherent risks associated with effective pain relief in such situations, it will not interpret their occurrence as subject to discipline by the Board. Selected Guides To assist physicians in meeting these responsibilities, the Board recom-mends Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed (1996), Cancer Pain Relief and Palliative Care (1990), Cancer Pain Relief and Palliative Care in Children (1999), and Symptom Relief in Terminal Illness (1998), (World Health Organization, Geneva); Management of Cancer Pain (1994), (Agency for Health Care Policy and Research, Rockville, MD); Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 4th Edition (1999)(American Pain Society, Glenview, IL); Hospice Care: A Physician’s Guide (1998) ( Hospice for the Carolinas, Raleigh); and the Oxford Textbook of Palliative Medicine (1993) (Ox |
OCLC number | 34607701 |