from American Medical News
Oregon's efforts to eliminate end of life suffering are once again in the spotlight, following the state medical board's decision to discipline a physician for undertreating his patients' pain.
Medical board leader said it is the first time a state board has taken such an action. But they added that it is just the latest and most dramatic effort by a disciplinary body to shed the image of state boards as obstacles to the effective treatment if chronic pain through the overly cautious policing of opioid prescribing.
Paul A Bilder, MD, a Roseburg, Ore., pulmonologist, engaged in "unprofessional or dishonorable conduct" and "gross negligence or repeated negligence," according to a stipulated order released by the Oregon Board of Medical Examiners. Among the six patient complaints detailed in the Sept. 1 document are cases in which Dr. Bilder failed to prescribe adequate pain medication or patients, including some who were dying, and removed a catheter from terminally ill patients over the objections of the patient and his family.
"This is egregious undertreatment of suffering," said Susan Tolle, MD an internist and director of the Center for Ethics in Health Care at the Oregon Health Sciences University.
Dr. Bilder who did not lose his license, declined to comment. Over the next year he has agreed to enroll in a peer evaluation and education program run by the Oregon Medical Assn., complete a course on physician-patient communication and continue to receive psychiatric care.
Though most boards have a history of aggressively pursuing overprescribers of morphine and other controlled substances, this action is consistent with the Oregon board's intent to aggressively investigate underprescribing. Officials have explained this stance in the board's newsletter and in presenting to doctors.
"They've gone to quite a bit of effort to educate physicians, but this, more than any other technique, lets the physicians know that their serious," said Peter Rasmussen, MD, a medical oncologist in Salem, Ore.
As in all cases when a state board investigates a complaint and finds a pattern of poor medical care, it needs to take some type of remedial action.
"Any doctor who is practicing this type of medicine can expect to get in trouble if it comes to the attention of the board," said James R. Winn, MD, executive vice president of the Federation of State Medical Boards.
"Whether they failed to provide appropriate antibiotic therapy to treat a severe infection, if they fall below the standard of care, then they are subject to being disciplined."
The medical board's action against Dr. Bilder was a "pretty clear-cut case," said Kathleen Haley, the board's executive director.
But some critics of the board said the decision to pursue undertreatment of pain isn't that simple.
"Why is the board getting involved with this?" asked Leigh Dolin, MD, a general internist in Portland and former OMA president. "It's politically correct, and I think they want to curry some favor with the public."
That viewpoint has been intensified by the publicity of Dr. Bilder's case.
"Board actions are not generally widely publicized by the lay press," Dr. Winn admitted. "What is unusual about this case is there are groups that are advocating that doctors be disciplined when they fail to provide appropriate pain relief."
Those groups include the Compassion in Dying Federation, which last year sent a letter to the FSMB and each state medical board asking them to encourage proper treatment of end-of -life pain. "Right now so much of the undertreatment, doctors say, is because they feel as though they will be scrutinized for adequate therapy by their licensing boards," said executive director Barbara Coombs Lee. "Whether that is an accurate perception or not, it needs to be remedied."
Compassion in Dying has tried to bring instance of undertreatment to the attention of state boards, which typically get few complaints from patients or families about such issues.
In contrast to the precedent set in Oregon, the medical board in California recently chose not to take action against a physician even though his treatment of a dying patient was a "clear violation" of the pain management guidelines it had distributed several years earlier, Lee said.
Though the Oregon board has gotten physicians' attention, disciplinary action isn't an ideal solution.
"We wouldn't like to think that the only way doctors are going to improve pan management is to be afraid of this kind of disciplinary action," said Kathleen Foley, MD, an attending neurologist at Memorial Sloan-Kettering Cancer Center in New York and director of Project on Death in America.
Added Dr. Rasmussen: "any time you have to look over your shoulder to see if what you're going to do with this patient is going to meet some other body's approval, it has potential for interfering with good patient care."
In addition, it has left some doctors questioning how the board defines the appropriate standard of treatment.
"They've flip-flopped," said Frank Baumeister, MD, a Portugal gastroenterologist and former OMA president. "Nobody knows where they stand."
Still other states are expected to follow suit. "This is going t be an evolving trend," said B. Elliot Cole, MD, administrator of the American Academy of Pain Management's National Pain Databank and Pain Program Accreditation. "It's not going to be the last such case."
Some patients said it's a long overdue step. "Up to now the line has been drawn only on one side of the battle, and that forces everyone to go very far to the right," said Mary Nissenson, who heads the Triumph over Pain Foundation in Chicago.
Last year, the FSMB released model guidelines aimed at increasing patient access to pain relief. More than 443 of the 69 state medical boards have adopted them or put similar guidelines in place, Dr. Winn said.
These changes, both at the state and National level, Come at a time when there's increasing recognition that treating pain needs to be considered part of standard medical care.
"Doing good pain management is something everybody's capable of doing." Dr. Cole said. "It's not just for a few dedicated specialists."
How little care is too little?
Among the Oregon state medical board's allegation involving a pulmonologists undertreatment of pain were cases in which the doctor:
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