State Member Board Briefs

IMPROVING COMMUNICATION MAY AVOID SOME COMPLAINTS TO THE BOARD

“Can my doctor fire me for asking too many questions?”

“I want to file a complaint against my doctor; his office manager treats me like dirt and won't let me talk to the doctor.”

“My son's doctor told him to be quiet and learn to behave like a human being! I want his license pulled!”

This is a very small sampling of the types of calls the board office receives every day. In an average week, we receive at least 50 complaints, 90 percent of which could have been avoided with a little more patience, professionalism or awareness of the patient's educational or physical limitations.

By far, the most common complaint is rudeness on the part of the physician and/or the physician's staff. Often this is not the result of any real discourtesy to the patient but a perception on the part of the patient of being rushed, talked down to, intimidated, bullied or misunderstood. Sometimes the patient or family member does not have adequate skills to cope with these feelings, and as a result they may become angry or hostile. When this happens, they often incur the frustration and anger of the physician or staff members in the office. It is up to the physician and staff to recognize and defuse this kind of situation before it becomes a problem. There are many learning opportunities available for physicians and their employees to gain experience and communication skills that can be useful in daily practice and called upon in the case of a problem patient.

The second most frequent type of call is more avoidable (and thus less explainable) than complaints of rudeness. In this case, the complaints come from pharmacists who experience difficulty making direct contact with a physician, or someone in authority, when there is a question about a prescription. The pharmacist may have a question about the dosage strength or drug interactions, or may have important information about the patient receiving medications from other physicians. At times, the pharmacist is simply trying to ensure that the prescription is not a forgery or an attempt at forgery. In these cases, the pharmacist must be able to contact the physician in a timely manner. Most often the problem arises when a member of the physician's staff fails, or refuses, to notify the physician of the pharmacist's needs. The impact this problem has on patient care is serious and should not be minimized. Make certain that you have an acceptable procedure in place to comply with these needs and deal with such problems.

We have seen many cases where there was not such a procedure and a staff member has authorized controlled substance prescriptions, or phoned in controlled substance prescriptions, without the physician's approval. Unfortunately, some of the most trusted members of an office staff have obtained controlled substances for personal use, or for their family members, by phoning in prescriptions without the physician's knowledge, authority or approval. When this occurs, the physician should report the incidents to a local law enforcement agency or an area Drug Task Force. Such activity constitutes a Class C felony offense in Alabama and may be punishable by imprisonment and/or significant fines.

Less often, but still too frequently, we receive complaints that a physician's office repeatedly failed to call a patient back about medications, health questions, test results, etc. Evidence suggests that these are often the same medical offices that pharmacists have experienced communication problems with. Again, the need here is to develop appropriate lines of communication and procedures for taking and returning messages. It is an important part of your practice and may go a long way in helping to avoid complaints being made to our agency.

Complaints about medical records copying and transfer are very common. These issues range from patients having difficulty locating a previous provider to obtain records, to difficulties having copies of medical information transferred to a new provider. In some instances, medical offices have refused to transfer medical information or have failed to do so in a timely manner. This can interfere in the continuity of care, which could become a viable medical complaint. When a physician leaves a practice, patients should be notified in writing about the departure, as well as the procedure for transfer of their medical information. Also, the Medical Licensure Commission must be notified of any change of address within 15 days. If you receive a request to transfer records to another physician, it is customary to waive copying charges. Requests should be honored in a timely manner. If a patient requests a copy of his or her medical record, you may charge a reasonable fee and request payment in advance, but you may not withhold medical information because of an unpaid bill for medical services. This is another area where staff persons may be short circuiting communication between patient, staff and physician. You should be aware of the procedures in your office concerning medical records transfer/copying, and whether the procedure is operating efficiently.

Another area of confusion for patients is when medical services have to be discontinued. As previously mentioned, upon a physician leaving a practice, patients should be notified in advance and when possible, in writing. If the practice is closing, the patients should be provided with as much advance notice as possible in order for them to secure another practitioner and have medical information transferred. It is when patients receive no notification, or cannot contact the physician to request medical information, that they call the medical board to complain. This can give the appearance of patient abandonment. Sometimes a patient will have to be “fired” for one reason or another – suspected drug diversion, non-compliance, unpaid bills, etc. You can discharge a patient for any reason, but you cannot do so without adequate written notice and provisional coverage while the patient is finding another physician. The provisional coverage does involve providing adequate parting medications. You cannot refuse to treat a non-discharged patient due to unpaid bills.

Our agency's staff often attempts to resolve these issues by providing the individual with pertinent information or by contacting the physician for more information. The physician's timely and full cooperation with board staff in providing the requested information is important. If we can satisfy the complainant at this stage, a formal complaint and a visit from a board investigator might be avoided.

NOTICE TO CHIROPRACTORS: “PHYSICIAN” TERM

The Kansas State Board of Healing Arts has issued an official policy statement, based upon the District Court's interpretation of statutes, mandating that chiropractors shall no longer advertise or represent themselves to the public as “chiropractic physicians.”

An order was issued on Aug. 15, 2008, by the board to rescind the Dec. 13, 1991, resolution that permitted chiropractors to be referred to as “chiropractic physicians.” This is in accordance with the District Court's ruling in 91-CV-388. In accordance with this determination, the Kansas State Board of Healing Arts reminds all chiropractors to please discontinue all references to and advertisements with the term “chiropractic physicians.”

The board has the authority to take disciplinary action if violations are found. The board will be reviewing these matters on a case-by-case basis and will be utilizing the newly adopted disciplinary guidelines if a complaint is received in this area. The Board may utilize cautionary statements and decisions as well as other disciplinary action if anyone is found to be out of compliance with this mandate.

Reprinted from volume 1 issue 1 of the State Board of Kansas Healing Arts News, published by the Kansas State Board of Healing Arts.

BOARD ADOPTS OPINION ADDRESSING COLLABORATIVE AGREEMENTS WITH ARNPS

The board, at its September 2008 meeting, adopted an opinion regarding the standards of acceptable and prevailing medical practice for physicians involved in collaborative agreements with ARNPs. The Kentucky Medical Association, on behalf of its members, asked the board to issue this opinion in order to provide guidance to any physician who intends to enter or does enter into a collaborative agreement with an ARNP.

The board issued this opinion pursuant to KRS 311.602, to assist licensees in determining what actions would constitute unacceptable conduct under the provisions of KRS 311.595. The board decided to publish this opinion because it addresses issues of significant public and medical interest.

This opinion is not a statute or administrative regulation, and does not have the force of law. A copy of this opinion by may be viewed or downloaded by visiting the board's web-site, www.kbml.ky.gov.

TRAMADOL LISTED AS SCHEDULE IV CONTROLLED SUBSTANCE IN KENTUCKY

In response to significant concerns raised by health care professionals, the Kentucky Cabinet For Health and Family Services, Office of the Inspector General, Division of Audits and Investigations, Drug Enforcement and Professional Practices Branch submitted a request to the Kentucky Legislature to modify regulation 902 KAR 55:030 to add Tramadol to the list of Schedule IV controlled substance products in Kentucky.

The regulation change was adopted and became effective on Dec. 5, 2008. At that time any prescriber without a valid DEA license cannot write or issue a prescription for Tramadol. In addition, any remaining refills on a Tramadol prescription issued by a prescriber without a valid DEA license may not be dispensed.

It is important for all physician assistants to be aware that as of Dec. 5, 2008, they are not able to write prescriptions for Tramadol or Tramadol containing products.

Following are additional actions that should be taken by controlled substance dispensers, distributors and wholesalers, along with the appropriate statutory references.

Controlled substance dispensers must adhere to KRS 218A.200 (7)(b):

“A substance which is added to any schedule of controlled substances and which was not previously listed in any schedule shall be initially inventoried within thirty (30) days of the effective date of the statute or administrative regulation which adds the substance to the provisions of this chapter. Thereafter, the substance shall be included in the inventory required by paragraph (a) of this subsection.”

Controlled substance dispensers must report all dispensing of Tramadol to the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system (KRS 218A.202 (3). Questions regarding this regulation change, please contact the Drug Enforcement and Professional Practices Branch at (502) 564-7985.

NEW LAWS

329:26 Confidential Communications. Effective Sept. 5, 2008

The confidential relations and communications between a physician or surgeon licensed under provisions of this chapter and the patient of such physician or surgeon are placed on the same basis as those provided by law between attorney and client, and, except as otherwise provided by law, no such physician or surgeon shall be required to disclose such privileged communications. Confidential relations and communications between a patient and any person working under the supervision of a physician or surgeon that are customary and necessary for diagnosis and treatment are privileged to the same extent as though those relations or communications were with such supervising physician or surgeon. This section shall not apply to investigations and hearings conducted by the board of medicine under RSA 329, any other statutorily created health occupational licensing or certifying board conducting licensing, certifying or disciplinary proceedings or hearings conducted pursuant to RSA 135-C:27-54 or RSA 464-A. This section shall also not apply to the release of blood or urine samples and the results of laboratory tests for drugs or blood alcohol content taken from a person for purposes of diagnosis and treatment in connection with the incident giving rise to the investigation for driving a motor vehicle while such person was under the influence of intoxicating liquors or controlled drugs. The use and disclosure of such information shall be limited to the official criminal proceedings. (New sections of this law are in bold print)

329:1-c Physician-Patient Relationship Effective Jan. 1, 2009

“Physician-patient relationship” means a medical connection between a licensed physician and a patient that includes an in-person exam, a history, a diagnosis, a treatment plan appropriate for the licensee's medical specialty, and documentation of all prescription drugs including name and dosage.

Exceptions: Writing admission orders for a newly hospitalized patient: for a patient of another licensee for whom the prescriber is taking call: for a patient examined by a physician assistant, nurse practitioner, or other licensed practitioner: or for medication on a short-term basis for a new patient prior to the patient's first appointment or where providing limits treatment to a family member in accordance what the AMA Code of medical Ethics.

Providers will need to have a full evaluation of the patient including a face to face meeting for prescriptions, with exceptions noted above.

329:16-g Continuing Medical Education Requirement Effective August 25, 2008

As a condition of renewal of license, the Board shall require each licensee to show proof at least at every biennial license renewal that the licensee has completed 100 hours of approved continuing medical education program within the preceding 2 years.

Renewal of license is now every two years and CME, instead of requiring 150 hours every three years, is now 100 hours every other year.

Reprinted from the January 2009 issue of Newsletter, published by the New Hampshire State Board of Medicine.