Some Clarity, Some Fog: AG Opines on Physician-Optometrist Relationship

An opinion by the Texas attorney general will keep the Texas Optometry Board (TOB) from exerting influence over the practice of medicine - to a certain point.

Diversity in Professionalism Framings Across U.S. Medical Boards

Lapses in professionalism are a common cause of disciplinary action against physicians by U.S. medical boards. However, the exact definition of "professionalism" is unclear, making it likely that a physician will not train or practice under the same framing of professionalism and so may fail to develop certain skills. The goal of this study was to identify and compare the professionalism framings of medical boards. The medical board web pages for all 50 states, the District of Columbia, and four territories were examined in June 2017 for use of the word "professionalism" or "professional" in their application, rules, or laws, which was then coded as a best fit to one of six core framings of professionalism. Of the 55 states and territories, integrity was the most common professionalism framing (40.0%), followed by excellence (23.6%), behavior (12.7%), mixed (9.1%), unclear (9.1%), and absent (5.5%). Although integrity was the most common framing, diversity exists among medical boards, which could lead to board misunderstandings of incidents labeled as professionalism violations and ineffective remediation of offenses. In order to best communicate the nature of the offense and thus best facilitate remediation, the incident should be called by its true name rather than the all-encompassing term "professionalism."

One eye of the future, one eye on the past

Purpose The purpose of this paper is to assess if the GOC considers relevant factors at all stages of its deliberations into misconduct, as required by the determinations in the cases of Cohen, Zygmunt, and Azzam, and to assess whether those circumstances described in the Hearings Guidance and Indicative Sanctions as warranting removal of an optician from the relevant registers lead to that outcome. Design/methodology/approach The consideration of specific factors in determining impairment of fitness to practise was compared with their subsequent consideration when determining the severity of sanction. Additionally, cases that highlighted aggravating circumstances deemed as serious enough to warrant removal were monitored. Pearson's χ² test was used to detect any variation from the expected distribution of data. Findings In total, 42 cases met the inclusion criteria. Each of the four factors considered was more likely to be heard when determining sanction having first been factored in to the consideration of impairment. Where risk of harm was identified as an aspect of an optician's misconduct, the sanctions of suspension or removal were no more likely to be imposed. Where dishonesty was involved, they were more likely to result in suspension or removal. Originality/value The GOC do, in general, factor the rulings of High Court appeal cases into their deliberations on the impairment of fitness to practice and, where dishonesty is involved, consider their own guidance in determining which sanction to apply. The authors were unable to show that placing the safety of patients at risk was more likely to result in removal from the register.

Why Become Pharmacy Compounding Accreditation Board Accredited?

The Pharmacy Compounding Accreditation Board's goal is to assist pharmacies to obtain formal recognition of their status as a high-quality and fully compliant provider of pharmaceuticals and patient services. This article provides a brief outline of the application process, the survey preparation, points of information about the actual survey, and suggestions on how to remain in compliance with Pharmacy Compounding Accreditation Board's standards.

Office-based surgery: embracing patient safety strategies

Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.

State medical board members' attitudes about the legality of chronic prescribing to patients with noncancer pain: the influence of knowledge and beliefs about pain management, addiction, and opioid prescribing

CONTEXT

In the United States, physicians' practice is regulated at the state level, with medical board members distinguishing legitimate medical practice from unprofessional conduct. For this process to be effective, regulators should have knowledge and beliefs that conform to current standards of practice and medical understanding. Past research has demonstrated that some board members continue to view the prolonged prescribing of opioid analgesics to treat noncancer pain as being unlawful or unacceptable medical practice, especially when the patient with pain has a history of substance abuse.

OBJECTIVES

This study was designed to determine whether relevant clinical or policy issues can adequately explain regulators' attitudes about the legality of opioid prescribing for patients with noncancer pain.

METHODS

A total of 277 questionnaires were obtained from a national sample of medical board members. Using binomial logistic regression procedures, the predictive significance of 12 factors related to four variable domains was explored: 1) beliefs about opioid addiction and diversion, 2) beliefs and knowledge about federal and state policy, 3) clinical beliefs about opioid prescribing, and 4) demographic characteristics.

RESULTS

Separate logistic regression models were computed to determine the extent that knowledge and beliefs contribute to attitudes about the legality of chronic opioid therapy for noncancer pain and for noncancer pain with a history of substance abuse. Three variables demonstrated statistical significance in both regression models: 1) characterizing addiction in terms of physiological phenomena, 2) believing regulatory policy is useful to improve pain relief, and 3) incorrectly believing that federal law limits the amount of Schedule II medication that can be prescribed at one time. When considering the legality of prescribing opioids for patients with noncancer pain, the following additional factors had a notable influence: viewing addiction as common when treating pain with opioids (P=0.030), considering it very important for a board to have a regulatory policy about pain treatment (P=0.038), doubting the legitimacy of more than one opioid prescription for a single patient (P<0.0001), and being younger (P=0.038). Alternatively, for patients with noncancer pain and a history of abuse, only one other factor was significant: reporting the adequacy of their training in pain management as "poor" (P=0.012).

CONCLUSION

Study results showed that the parsimonious regression models used in this study reasonably explained such attitudes. Suggestions were offered for achieving more comprehensive insight about the factors that can shape regulators' attitudes about prescribing legality.

Four decades of complaints to a State Medical Board about graduates from one medical school: implications for change in self-regulation processes

In the context of the impending national registration of health practitioners in Australia including doctors, this column describes the types and patterns of complaints to a State Medical Board across an extended period, about graduates from one medical school. De-identified data concerning complaints about medical practitioners who had graduated from the University of Queensland, made to the Medical Board of Queensland between 1968 and 2006, were analysed. The main outcome measures were category of complaint, total complaint rate per doctor-year, frequency of complaints per practitioner and outcomes of complaints. There were 12 categories of complaints, encompassing different aspects of clinical management, impairment and unethical conduct. Outcomes included "no further action", a hierarchy of recommendations and conditions on registration, suspension, deregistration, health assessment, or referral to alternative bodies. Complaints predominantly related to clinical standards, and this also applied to those who attracted multiple complaints. Most cases were managed without resort to sanctions of any kind. Sanctions may be underutilised, particularly in cases of apparent recalcitrance. Improved tracking and appropriate reeducation and disciplinary measures will assist in better protecting the public under the new national registration arrangements.

Commentary: impaired physicians and the new politics of accountability

Several recent articles, including the one by Schroeder and colleagues in this issue, document violations of the Americans with Disabilities Act (ADA) by state medical boards that ask applicants for initial licensure and relicensure whether they have any history of mental illness. The authors of these articles argue that the boards' violation of the ADA is a disincentive for applicants to seek treatment, especially for depression. This commentary discusses the behavior of the boards, and efforts to address it, in the larger context of what organizations that educate, examine, license, certify, credential, and represent physicians are doing to improve the accountability of members of the profession and, as a result, the quality of their services.

Can state medical boards adequately respond to reports that physicians are inappropriately prescribing opioids?

In this issue, Reidenberg and Willis share results of a 2-year study of cases in which physicians were criminally prosecuted for their prescribing of opioids "outside the bounds of proper medical practice."(1) They found that in only two of 32 such cases had a state medical board reviewed the case before indictment. In many of the cases, the authors argue that the prosecutors overreached and that these kinds of cases could be better handled by referral to state medical boards.

Prosecution of physicians for prescribing opioids to patients

Many patients in pain receive inadequate doses of opioids. Fear of government action against prescribing doctors is one cause of this inadequate treatment. The purpose of the study was to assess criminal prosecutions by reviewing press reports of indictments or trials of doctors for opioid offenses during 2 years. Forty-seven cases were reported involving 53 doctors. Fifteen cases were for offenses unrelated to medical practice. In 32 cases, the charge was based on determining the prescriptions for opioids were outside the bounds of proper medical practice. Only two of these cases were evaluated by a state medical board before indictment. Five doctors were indicted for murder related to drug overdose deaths. None were found guilty of murder. Prosecutorial excesses and hyperbole were common. The state medical board's review of appropriateness of prescribing opioids when a doctor-patient relationship is presumed to exist could decrease inappropriate criminal indictments and reduce this component of fear of prescribing adequate opioid therapy for patients in pain.

Der Unterricht im Fach „Psychosomatische Medizin und Psychotherapie” an den Hochschulen der Bundesrepublik Deutschland nach Änderung der Approbationsordnung für Ärzte

BACKGROUND

The new licensing regulations for physicians introduced in 2002 place core competencies in the field of Psychosomatic Medicine and Psychotherapy at the centre of medical training and have been considered to constitute a favourable opportunity for psychosocial faculties. To date, no data have been published concerning the consequences of these new regulations.

METHODS

All 34 chairs of Psychosomatic Medicine and Psychotherapy currently held by professors were surveyed by means of a written questionnaire at the beginning of the year 2006, regarding the present teaching situation and changes occurring through the introduction of the new regulations, as well as particular problem areas and respective solutions and suggestions.

RESULTS

The rate of return for the questionnaires was 100 %. The consequences of the new regulations were rated predominantly positively. From a content point of view, classes continue to be more heavily weighted in cognitive areas and less so in areas of clinical practice; demands for an emphasis on affective learning objectives hence appear to have not been adequately met thus far. The newly established course formats (cross-sectional areas, obligatory optional courses, tutorials) also appear to have been employed to a rather limited degree. In addition to a lack of resources, the co-ordination with other specialist areas as well as the adequate assessment of teaching content poses a particular problem.

DISCUSSION

The field of Psychosomatic Medicine and Psychotherapy constitutes an important engine for the didactic and content-related advancement of the medical curriculum in Germany. Nevertheless, the opportunities which the new licensing regulations for physicians offer to psychosocial faculties have not yet been entirely made use of. Surveyed individuals consider nationwide agreement concerning learning objectives, an exchange of experiences regarding the efficient and creative use of available resources and the development of suitable assessment methodologies, to be tasks to be urgently undertaken.

Human rights and health law

Important statutory and common law developments are changing the landscape of health law in Australia. Human rights considerations are formally included amongst the factors to be applied in the interpretation of statutory provisions and evaluating the lawfulness of actions on the part of government instrumentalities. The Human Rights Act 2004 (ACT) and the Charter of Human Rights and Responsibilities Act 2006 (Vic) create limited bills of rights at State/Territory level in two Australian jurisdictions. Although neither is entrenched, they have the potential to make it more difficult for government to promulgate laws that are inconsistent with human rights, as defined. They will have important repercussions for the evolution of health law in these jurisdictions. The decision of Royal Women's Hospital v Medical Practitioners Board (Vic) [2006] VSCA 85 by the Victorian Court of Appeal has also provided a legitimation for parties to incorporate human rights perspectives in submissions about the interpretation of statutory provisions where health rights are in conflict.

Access to confidential medical records by courts and tribunals: the inapplicability of the doctrine of public interest immunity

A number of Australian courts' decisions have afforded protection to public records. Statutory protection has also been given to counselling records in some jurisdictions in the context of the provision of services to victims of sexual assault. In the aftermath of the extension of public interest immunity in the particular circumstances of Clifford v Victorian Institute of Forensic Mental Health [1999] VSC 359, the argument was raised that a further extension should be made to protect personal health records against attempts at regulatory investigation of allegations of unprofessional conduct. In Royal Women's Hospital v Medical Practitioners Board (Vic) [2006] VSCA 85 the Victorian Court of Appeal unanimously declined to make such an extension. This appears to be indicative of a shift by Australian courts toward compelling disclosure of medical records in the interests of fairness save in very exceptional circumstances.

Views of physicians, disciplinary board members and practicing lawyers on the new statutory disciplinary system for health care in The Netherlands

The introduction of the Individual Health Care Professions Act (IHCP Act) at the end of 1997 brought a change in various aspects of the disciplinary proceedings. The opinions of those directly involved give an overview of the way in which the disciplinary proceedings functions under the IHCP Act in daily practice, and thus an indication of the contribution made by the disciplinary system to fostering and monitoring high standards of professional practice. Questionnaires were sent to 1300 physicians: 400 general practitioners, 350 internists, 250 gynaecologists and 300 psychiatrists (response 69%, 65%, 60% and 60%, respectively), all 388 disciplinary board members (response 89%) and 43 practicing lawyers (response 65%). Almost all of the disciplinary board members and the practicing lawyers, compared to less than one-third of the physicians, were of the opinion that in their judgement of the complaints the disciplinary boards complied adequately with the concept of good professional practice. A large majority of the disciplinary board members and the practicing lawyers regretted that a complaint could not be declared justified without a sanction being imposed. Most of them were of the opinion that there would be an increase in the number of justified complaints if this possibility were incorporated in the Act. According to the majority of the disciplinary board members and practicing lawyers, the change in the composition of the disciplinary boards had not strengthened the position of the complainant. Most of the respondents were of the opinion that the inclusion of a health professional instead of a legally qualified member was necessary in order to promote consistency in the verdicts concerning professional practice, and thought that a member from the same specialism should always be involved in the judgement of a complaint. A further contribution to the fostering and monitoring of high standards of professional practice could be made by increasing the number of health professional members, adapting the composition of the disciplinary boards to suit the specialism of the accused professional, and introducing the possibility to justify a complaint without imposing a sanction.

The role of the Malaysian Medical Council in medical education

The Malaysian Medical Council (MMC) operates under the Medical Act of 1971, which defines its core functions related to (a) the registration and practice of medical practitioners (b) the period of compulsory service (c) provisions to be enacted for purposes of (a) and (b). In the early years the MMC used the list of recognised colleges or Universities that appeared in the list of degrees recognised by the General Medical Council of United Kingdom (GMC). Over the years the MMC has undertaken the role of granting recognition to other medical schools in the country and overseas, and added the name of these schools to the existing register of recognised medical degrees in the second schedule of the Act. For the purpose of recognition of medical schools the MMC endorsed a guideline on standards and procedures on accreditation developed in 1996, which was later realigned with international and regional guidelines, in 2000 and 2001. It is recommended that the MMC establishes an active functional 'Education Committee' and that the role of MMC in medical education should be clearly and explicitly stated in the Act. An amendment to the Act would require the MMC to be responsible not only for undergraduate medical education but medical education in its entire phase.