Forum of the North Carolina Medical Board

              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