ISSUES AND ANSWERS

Board of Medical Licensure and Supervision
Volume 8, No. 4
June 1997

Never Wear Open-Toed Shoes In A Barnyard

by Gerald C. Zumwalt, M.D.
Board Secretary/Medical Advisor

There are certain facts that are so apparent and so eternal that there would seem to be no need to repeat them. It, therefore, comes as a surprise when learned groups convene and publish such information.

The relation of managed care organizations to doctors and patients is such a subject. Discussions are voiced and published on the dilemmas of economics, rationing, traditional medical ethics versus managed care ethics, personal and financial accountability, selection and deselection of physicians, responsibility of organizational credentialing to the managed care groups and to the public, possible unprofessional physician conduct required by managed care groups, and who eventually makes the decisions on patient care.

It is obvious from reviewing legislation proposed and/or created in various states, that any address of abuse by HMO's or other managed care organizations must be done through the Insurance Commission since these organizations primarily are selling a product or are fully intend to profit. Decisions on medical care and procedures become not right/wrong but cost/benefit. Individual outcomes become less important than group outcomes since the employers purchase coverage without input from the employees.

All state boards are wrestling with who does and who should have decision making authority over the determination of medical necessity and/or appropriateness of treatments. Several states require such decision makers to have medical licenses and to be licensed in the patient's state. The possession of a local license would not insure a more rational or advantageous decision but would be a necessity for any state board to take disciplinary action based on treatment decisions.

In the end, it comes back to one of those first mentioned verities, each individual doctor or other medical professional is responsible for good patient care regardless of financial arrangement. The physician must be an advocate for what is in the patient's best interest. This always has been so and must remain so now and in the future.

Results of Board Meeting

May 16, 17, 1997

The Board met in a regularly scheduled meeting to consider applications, discipline, adoption of rules, and other matters.

Ten licenses were granted after personal appearance with one license being issued under an agreement to affiliate with the Physician Recovery Program. One license was issued with probating terms to include evaluation for sexual misconduct (exhibitionism) and continue in recommended treatment. One special purpose license was issued for remote area practice with the provision that the doctor must return to the Board in one year with evidence of having passed required licensing exams. One special purpose applicant was denied based on no domestic post graduate training. One special purpose licensee sought to expand scope of practice which was denied.

Disciplinary hearings resulted in three revocations. Two resulted from chemical abuse relapse while the licensees were on probation. One resulted from prescribing opiates without establishing a doctor/patient relationship.

One Voluntary Submittal to Jurisdiction was adopted with probationary terms regarding personal use of alcohol and included affiliation and participation in a twelve-step program and abstention from further use. One case involved a bipolar condition and mandated agreed practice hours and conditions, and continued medical therapy.

One reprimand was issued for establishment of sexual relationships with mothers of pediatric patients.

SUPERVISION OF ADVANCED REGISTERED NURSE PRACTITIONERS

The following are new rules adopted by the Board in their May meeting. They are subject to approval by the Governor and the Legislature.

SUPERVISION OF ADVANCED PRACTICE NURSE WITH PRESCRIPTIVE AUTHORITY

435:10-13-1. Purpose

The purpose of this Subchapter is to set forth the requirements for allopathic physicians to supervise the advanced practice nurse with prescriptive authority pursuant to 59 O.S., §567.1 et seq.

435:10-13-2. Eligibility to supervise advanced practice nurse with prescriptive authority

(a) To be eligible to serve as supervising physician for the advanced practice nurse with prescriptive authority, an allopathic physician shall meet the following criteria:

(1) Have possession of a full and unrestricted Oklahoma medical license with Drug Enforcement Agency (DEA) and Oklahoma Bureau of Narcotics (OBN) permits for any drug on the formulary as defined in the Oklahoma Nursing Practice Act.

(2) The physician shall be in an active clinical practice in which no less than twenty (20) hours per week shall involve direct patient contact.

(3) The supervising physician shall be trained and fully qualified in the field of the advanced practice nurse's specialty.

(4) No physician shall supervise more than two (2) full time equivalent advanced practice nurses regarding their prescriptive authority at any one time. For purposes of this section, each "full time equivalent" advanced practice nurse position equals forty (40) hours per week collectively worked by the part-time advanced practice nurses being supervised by the physician. Notwithstanding the provisions for the supervision of two (2) full time equivalent advanced practice nurses above, no physician shall supervise more than a total of four (4) advanced practice nurses. The Board may make an exception to any limit set herein upon request by the physician.

(b) Proper physician supervision of the advanced practice nurse with prescriptive authority is essential. The supervising physician should regularly and routinely review the prescriptive practices and patterns of the advanced practice nurse with prescriptive authority. Supervision implies that there is appropriate referral, consultation, and collaboration between the advanced practice nurse and the supervising physician.

The More Things Change...

by Gerald C. Zumwalt, M.D.

Recently I saw a package of OTC anti-inflammatory ointment containing hydrocortisone and aloe—a mixture of scientific and folk medicine. Increasingly we are seeing this same type mixture in both academic and practice medical circles. Both lay and medical journals recount the beliefs and practices of Andrew Weil, M.D. and other "alternative" medical practitioners. The NIH has an office of Alternative Medicine which currently is funded with 12 million dollars annually (take comfort in that as you file your income tax). Established and reputable medical centers such as Harvard, Stanford, Southern Cal, and obviously University of Arizona have ongoing studies on the efficacy of these practices.

A session at the recent Federation of State Medical Boards annual meeting was devoted to "Scientific Scrutiny and Alternative Practices." Dr. Weil did use one remarkable phrase when he referred to a "placebo controlled trial of homeopathic medicines" without explaining how you can come up with a placebo to a substance which has no detectable active ingredients.

Obviously much of the current romance between consumers and "alternative, unorthodox, natural" medicines can be explained by the universal desire for a quick, easy fix. Why bother with the costly, time-consuming process of scientific trials when a person can be healed by pulling a few weeds from the nearest vacant lot or thinking good thoughts (it worked for Professor Henry Hill in the "Music Man")? Folk medicine takes all of us back to the attractive past when front doors weren't locked and children could walk streets without danger.

No one wants to be in the crowd that condemns new ideas just because they are new. Few want to impede any procedure that truly grants relief to any type of suffering. All of us of a certain age, however, have memories of fads that have come and gone with no permanent imprint other than the word quackery.

Laws and regulations of necessity are going to be made by individuals who are naive in scientific thought and evidentiary evaluation. It is up to members of the medical family, as a group and singly, to offer advice and support to those who will formulate policy and expend precious public funds. This should be done in a positive mode as we recall Alexander Pope's advice not to be the first to take up the new nor the last to lay down the old.

RESULTS OF LAST MONTH'S CASE

The case was a doctor who was reported to be writing large doses of opiates and benzodiazepines. The doctor was charged with prescribing controlled dangerous drugs in excess of good medical practice and without medical need.

The Board found the allegation of excessive and improper prescribing of controlled and dangerous drugs to be substantiated by a preponderance of evidence. (All cases in this series occurred prior to the Supreme Court ruling which mandated the use of clear and convincing evidence.) The doctor was placed on a five-year probation with a prohibition on prescribing Schedule II and III drugs, a requirement that Schedule IV and V drugs be written on serially numbered, duplicate prescriptions, and to keep substantial and adequate medical records. Other standard terms included were to notify other professionals of the Board's action and payment of the cost of investigation, prosecution, and probation.

Board Elects New President

Deborah Huff, M.D. was elected President of the Board at the May 1997 meeting for a one-year term beginning July 1. Dr. Huff was appointed to the Board in January 1995 by Governor David Walters.

Dr. Huff graduated from the University of Oklahoma College of Medicine in 1984 and completed an obstetrics/gynecology residency at the Health Sciences Center. She is in a group practice at Baptist Medical Center in Oklahoma City.

She is married to Dr. John Huff and has four children. They live in Oklahoma City.

Have you moved or had a change of address?

State Medical Board rule 435:10-7-7 requires all medical doctors licensed in the State of Oklahoma to submit a street address upon relocation of address (if used as mailing address) and/or your practice address.

The duty is the responsibility of each individual physician. The Board and its staff are not, nor can they be, responsible for such updating. Failure to report a change of address has resulted in or exacerbated detrimental action regarding several physicians. Please avert such matters and resolve any address change report at your first opportunity.
Information on Board meetings and on licensees may be accessed on the Internet at www.osbmls.state.ok.us
RENEWAL REMINDER

If your medical license was issued in July, renewal of your license is due by July 1. If your license was issued in August, renewal is due by August 1.

Remember, when completing the renewal application, the questions at the bottom of the front page pertain only to the time "since the last renewal or initial licensure (whichever is most recent.)"