_ISSUES and ANSWERS

Vol 11 No 2
May 2000

Graham Crackers and Apricot Pits

by Gerald C. Zumwalt, M.D
Board Secretary

Case Medical School in Cleveland, Ohio offers a one-hour medical school course entitled "Graham Crackers and Apricot Pits." One surmises that this is a history of medical quackery since the fruit reference undoubtedly refers to laetrile. It is a bit of a stretch to realize that the whole wheat cracker was supposedly a product of Sylvester Graham (1794-1851) and intended as a guaranteed pathway to good health and clean bowels.

Gazing backward with sophisticated retroscope vision allows us the comforting feeling of mental superiority over such naiveté. But creeping in around our smugness is a still, small voice asking the question, "How will the next medical generation view our beliefs and actions?"

What will be the opinion of dicta pushed and practiced recently? Over the course of only a few years we have been told to avoid shrimp like the plague only to be advised the following year that the cholesterol in shrimp is protective. Fat is an ugly word with noxious odors and repellant visualizations but olive oil rolls off the tongue with silky smoothness and lubricates the system to near eternal life. Alcohol raises the blood pressure and cooks the brain but red wine transforms us into long lived Charles Boyers. We are instructed to eat nothing but complex carbohydrates to avoid obesity, atherosclerosis, diabetes, and baldness but Atkins followers eschew any starch or sugar and push proteins and fat. Health food advocates _ including apparently well-educated MD's _ encapsulate and recommend every weed known to mankind.

How will the future look at a profession that expends millions treating premature neonates, some of whom weigh less than the fetuses we abort? And, a profession that extends life far beyond any capacity for knowing or caring? How will all-knowing posterity appraise our current craze for transplanting any organ harvested from any patient? Our developing and using multiple new antibiotics and thereby stimulating the appearance of resistant pathologic organisms?

Will our efforts to preserve all the inhabitants of the earth turn out to be gallant and productive, or be viewed as a failure to allow the survival of the fittest and production of a weakened population?

Simmelweiss and Holmes were widely regarded as compulsive old maid cranks in their time. Brinkley was rewarded with vast wealth and political acclaim for his goat gland planting (although not among the society of Billys). Some of our sneer energy expenditure might better be utilized for millennium introspection.

But perhaps it is more mentally soothing to cruise along with all current thought rather than buck the tide and risk ridicule by insisting that thought, processes, and procedures be examined in rational studied method.

Health food advocates - including apparently well-educated MD's- encapsulate and recommend every weed known to mankind.

Good Doctor, Bad Doctor

by Gerald C. Zumwalt, M.D.
Board Secretary

In Volume 86, #2 issue of the Federation Bulletin, there is an article from the New York Board of Professional Conduct in which various members of that Board express opinion on "What Makes a Good Doctor Turn Bad."

There are the obvious examples of greed, ego and sickness (physical, mental, and degenerative). Some cited a failure to maintain competency through education. And one pointed out that the bad doctor might have been bad from the beginning.

This entire article is available for perusal at our office.

Several recent cases heard at our Board raise serious questions about the selection and education of students and residents in medical schools. One resident who had engaged in a sexual relationship with a patient stated he knew it was wrong but had never been told it was unethical or illegal. He further said that although he knew it was against the law to write prescriptions for CDS using another doctor's name, signature and DEA number, no one had told him such actions were felonies. One applicant had been granted a residency slot who had an outstanding arrest warrant in another state and a past history of multiple lawsuits involving arson and embezzlement. A recent case involved a resident who had been accepted into medical school and then residency despite previously being convicted of illegal controlled substance use.

The point is that given these foundations, what other result is possible? Violation of professional behavior is inevitable.

Universities spend much time and effort evaluating MCAT scores and grade averages then scrimp on discovering criminal records and behavior. It is more important to teach medical ethics and law than to define the piston stroke of Jennet.

I would suggest that the Oklahoma Medical Practice Act and the AMA Code of Medical Ethics should be as required as Gray's Anatomy and that courses on these text should be taught in all four years of medical school as requirements, not electives. Residents should be held to and judged by standards of moral conduct, not by how helpful they are to faculty.

It isn't just that as the twig is bent so it will grow but that there are some twigs that should be left out to dry, not planted.

The votes are in and…..

"The Eyes have it!"

What:

Permanent Cosmetics are legal in Oklahoma effective April 28, 2000 when Governor Keating signed House Bill 1872 into law. The legal term for the process of applying any color pigmentation by needle or electronic means to areas of the face or other part of the body as a result of cosmetic surgery or trauma is called Medical Micropigmentation. Artistic tattooing is specifically excluded from this definition and is still illegal in Oklahoma.

Who:

1. A Registered Nurse (RN) licensed in Oklahoma can provide medical micropigmentation under supervision of an Oklahoma licensed Medical Doctor (MD), Doctor of Osteopathy (DO) or a Doctor of Dental Surgery (DDS).

2. A licensed or unlicensed technician under the direct supervision of a MD, DO or DDS and who is certified by an approved program by the Oklahoma Department of Vocational and Technical Education may also provide medical micropigmentation. Those technicians seeking certification and currently working under the direct supervision of a doctor have 12 months from the implementation of the program by the Vo-Tech to successfully complete the program.

Caution:

1. In certain circumstances, medical micropigmentation may require the administration of sedating agents (anesthetics) by an Oklahoma licensed RN, MD, DO, or DDS.

2. This law is not intended to sanction or circumvent the unlawful practice of artistic tattooing.

3. Violation of any provision of this law is a misdemeanor with a punishment of up to 90 days in jail and a $1,000 fine.

This law was the product of several legislators: Representatives Lindley, Paulk, Coleman and Sullivan and Senator Weedn working together with the medical, nursing, osteopathic and dental professions. Their goal was to protect the public by ensuring that qualified individuals practice medical micropigmentation in a safe and supervised environment. If you are involved in this practice, it is imperative that you obtain a copy of this law to make sure you are familiar with its requirements.

Further Hot Info on Licenses

The 1999-2000 Exchange containing current medical licensing requirements has been received in our office. There do not appear to be any revolutionary changes in policies and requirements from the various states.

All states require postgraduate training after graduation. For domestic graduates, 42 states require one year, ten states require two years and one state (Nevada) requires three. For international graduates, 13 states require one year, 12 states require two years and 24 states require three.

Information required to obtain an initial license varies markedly. New York queries only to the National Practitioner Data Bank while most other states query the AMA, Federation of State Medical Board Data Bank, educational databases and other agencies.

Oklahoma is one of only seven states that requires a jurisprudence exam on original application.

Cost of a first time application runs from a high of $1108+ in Florida to a low of $20 in Pennsylvania. Late fees for reregistration are the thorns on the rose of licensure. Most states impose the fee for any time past the stated expiration, although seven charge no late fee. Arizona charges $350, North Dakota $450 if late by thirty days, and Nevada $600. Oklahoma's late fee of $125 is about the medium.

Board Meeting March 9, 10, 2000

Results of the regularly scheduled Board meeting in the field of licensing included issuance of one full license after personal appearance. One applicant was issued a license with agreement to continue anger management counseling. One application was tabled until the SPEX exam was successfully completed. One application was tabled pending evaluation at a recognized center for sexual addiction and misconduct. One application was denied due to multiple failures on licensing exams.

Licensing results for allied professionals included approving one PA but giving him a reprimand for practicing prior to issuance of his license. Another PA license was approved but the application to practice that included administering general anesthesia was denied.

Three licenses were issued with agreement for continued treatment for alcohol and/or drug abuse. One license was denied due to long-term practice without a license. One license was suspended for thirty days due to misrepresentation to the public as a licensed therapist rather than a therapy assistant.

Disciplinary hearings on M.D.s resulted in one surrender of license due to violation of probation terms involving chemical abuse. Two licenses were suspended for sixty days based on charges of chemical abuse followed by a five-year probation for one and an indefinite term of probation for the other. One doctor was suspended for at least six months and required to undergo a multifaceted evaluation after soliciting nude photographs of patients.

Online Prescribing

North Carolina and Texas medical boards have recently addressed Internet prescribing by adopting policy statements. North Carolina's position is that prescribing drugs based solely on answers to a set of questions without meeting the patient is inappropriate and unprofessional. The full statement may be obtained at www.docboard.org/nc.

Texas likewise notes that an online or telephonic evaluation by questionnaire is inadequate and lists criteria to establish a proper relationship. The web site for this policy is www.tsbme.state.tx.us.

Although the Oklahoma Board has not adopted a policy, present law and rules adequately address the subject. Unprofessional conduct is defined in Title 59 §509 and includes "13. Prescribing or administering a drug or treatment without sufficient examination and the establishment of a valid physician-patient relationship."

Further, in OAC Title 435:10-7-4, it states as unprofessional "41. Failure to provide a proper setting . . . for medical acts . . . . Adequate medical records to support treatment or prescribed medications must be produced and maintained."

The Board has consistently maintained that convenience and cost must not take precedence over patient safety.

Office Based Anesthesia

The American Society of Anesthesiology (ASA) has recently issued a comprehensive set of medical guidelines for the delivery and monitoring of anesthesia in office-based settings, according to the March 2000 issue of Anesthesiology News.

Although this Board has not adopted these specific guidelines, as well as not specifically adopting other treatment guidelines, the issuance and wide spread acceptance of any such rules does indicate that these procedures are now the medical profession's standard of care. As such, failure to follow these recommendations could be interpreted as unprofessional conduct as defined in the Oklahoma Administrative Code, Title 435:10-7-4(41) "Failure to provide a proper setting and assistive personnel for medical act, including but not limited to examination, surgery or other treatment. Adequate medical records to support treatment or prescribed medications must be produced and maintained."

It would be prudent for any doctor or clinic using office-based anesthesia to obtain and follow the ASA guidelines.