CMA vs. "Licensed Health Professionals"

The California Medical Association (CMA) is concerned that the California Department of Public Health (CDPH) has proposed regulations that would expand the power of non-physicians to perform certain medical procedures. The changes include:

Allowing psychologists to perform medical, as opposed to psychological, examinations (Section 70577);

Allowing "licensed health practitioners" to order restraint of patients (Sections 70577, 71545, 72319,72461, 73409, 79315);

Implying that "licensed health practitioners" may assume overall responsibility of a psychiatric unit (Section 70577);

Substituting "licensed health practitioner" for "physician" as the health professional who has primary responsibility for coordinating care (Section70707);

Allowing admission, transfer, and discharge decisions to be made by "licensed health practitioners" (Sections 70717,70749, 70751, 70753, 71517, 71553, 72515,73517); and
Proposing changes that affect the self governance of medical staffs (Sections 70703, 70706, 71503).

I generally believe that, so long as the patients have obtained full disclosure and have properly consented to non-physicians overseeing their treatments, then doctors should not object. Granted, when it comes to certain medical matters, physicians are more extensively trained than nurses, PAs, and certainly psychologists, and are likely to make fewer mistakes or misdiagnoses (Similarly, most doctors would be fired on Day 1 for incompetence, if they tried to take over a nursing job). However, requiring a physician to coordinate care for every patient comes with other unique costs, which I'll expound upon in a future post.

The power to order "restraint" of a patient or to oversee psychiatric a psychiatric unit is more controversial. In such cases, the patients are either unable or unauthorized to make informed decisions about their care. Even physicians are potentially treating many patients without their consent, a phenomenon that should be tread with caution. Do we really want to expand the number of people with the power to control the movements of a dissenting patient?

Obviously, in an acutely dangerous situation, everyone from the lab tech and billing officer should be allowed to restrain a patient, until the situation is considered secure. But once we've insured every one's safety, we should do all we can to maximize patient autonomy. (I should note that, as much as I respect Thomas Szasz's views on medical paternalism toward psychiatric patients, I support restricting the movements of someone whom I suspect could soon harm someone. Many nurses have been attacked and severely injured in psych units, and preventing such incidents trumps personal liberty).

The CMA is a physicians' lobbying group, so their views on the issue matches the circumstances that would reduce physician competition. Their list of "talking points" include:

Ignores Physician Responsibility for Medical Care

As the most extensively trained health care professionals, physicians are the most qualified to coordinate medical care. The proposed amendments offer that a psychologist may perform medical examinations, not just psychological examinations. This extends activities to psychologists beyond the scope of their professional licensure.

Jeopardizes Patient Safety

By authorizing "licensed health practitioners" to make medical decisions such as ordering restraints and making transfer and discharge decisions, the Department of Public Health is failing to protect public safety and ignoring a number of federal and state laws. Physicians are trained to consider the array of physiological factors that may affect a patient's condition and the regulations should reinforce that authority rather than undermine it. Although CDPH does not regulate health practitioners, it does have a stake in assuring quality standards of care in licensed health facilities as a matter of public health.

Leads to Confusion in Medical Decision Making

The regulations remove specific references to physicians in various situations. The regulations allow a "licensed health care practitioner acting within the scope of his or her professional licensure" to oversee admission decisions and the coordination of patient care. This amendment is overly broad and offers no clarity as to which practitioners are actually responsible for these functions in health facilities. Leaving individual facilities to interpret these regulations and the scope of practice of the various health care providers operating in hospitals may lead to varying standards of care across the state that are also inconsistent with statutory restrictions.

Undercuts the Independence of Medical Staff Committees

The organized medical staff is responsible for the quality of medical care in inpatient facilities. California law has upheld this authority as a part of the prohibition on the corporate practice of medicine. Self-governance and independence in medical quality decision making are foundational to patient safety. The amendments to the regulations propose that the organized medical staff is "subject to the bylaws, rules and regulations of the hospital.

If anybody ends up reading this, what do you think? Do any of the CMA's arguments have merit?

My First Drug Addicted Patient

This post is about a (likely dual-diagnosis) patient whom I visited last year. As usual, many details have been changed.

When I first saw Ms. Smith, she was sleeping quietly in her dark area behind the curtain, her two legs in casts raised on a tuft of pillows. When I called her name, she awoke and, with a sweet Southern drawl, agreed to talk to me.

Immediately, pandemonium struck. Ms. Smith desperately needed to urinate, and demanded her bedpan right away. I rushed to put on gloves, and handed her the bedpan that was under her bed. However, the bedpan had apparently not been washed after the last time it was used, and Ms. Smith screamed that she did not want it on her clean bed. I nervously washed it with soap and water at the sink, and, in the nick of time, tossed it to Ms. Smith. This was the first of many narrowly averted crises.

During the bedpan incident, I noticed Ms. Smith’s extensive injuries. She had what must have been over 100 stitches lined up along her spine. She moved her individually bundled legs with great difficulty, and was constantly clutched what she called her “busted” rib. She also had cuts and old scars on her chin and scalp, which she later explained matter-of-factly with “my ex-boyfriend was kind of bad.” When I proceeded to ask Ms. Smith about the source of her injuries, a second crisis commenced. Ms. Smith suddenly felt extremely hot, and demanded that the air conditioner be raised. Other patients in the room felt cold, however, so I looked to the nurse to make a verdict. Eventually, a compromise was reached.

Throughout the interview, these interruptions continued. Ms. Smith was clearly in terrible pain, and constantly buzzed for the nurse to administer more pain medication. When the nurse continuously refused, Ms. Smith pleaded and sobbed that the last doses did not go through when she hit the button on the drug delivery machine (I do not believe that Ms. Smith was intentionally misleading- she thought that the machine would beep when the drugs were delivered, until the nurse explained that that is not necessarily the case). Ms. Smith called her nurse so often that eventually she was summarily ignored. This proved to be problematic when Ms. Smith had legitimate concerns.

Ms. Smith had interesting things to say about her 34 years of life, but had trouble staying on point, and every few minutes of conversation were halted by her feelings of pain, or her need to readjust in her bed. While I learned a little about the source of her wounds- apparently it was caused by a (stolen) motor vehicle accident, with her intoxicated boyfriend as the driver - after a while, I realized that I had not broken much ground in my questions, and decided that I would just allow Ms. Smith to talk freely.

Ms. Smith’s chart noted that she had attended college, and her language was relatively sophisticated. However, after about 15 minutes, after I asked her to list all of the injuries she had sustained, Ms. Smith responded, “I’m not usually this religious crazy, but these last few days- by the way, all this is off the record, they can’t publish this-I have learned some things. All of life is based on opposites. Yin.Yang. Keeps the world spinning. Right.Wrong. Good. Bad. You see I could have gone to any university on scholarship, but I went to Southern State University. I wrote a paper about dogs and their origins. My grandfather used to say, “You can lead a horse to water, but you cannot make him drink- but you can put salt in his oats! Get it?” After 10 minutes of rambling, Ms. Smith would become composed and thoughtful, telling me about her childhood.

When I visited again the next day, Ms. Smith seemed to be experiencing some drug withdrawal symptoms, as she was nervously shaking and saying she was cold in the very warm room. After a while, I decided to speak to Ms. Smith principally about her drug use.

This conversation taught me a lot about the power dynamics between drugs, drug users, mental illness, and the physicians who would like for their patients to quit. I once had a certain utopian vision of a prototypical conversation about drugs between a doctor and a patient. The doctor would inquire about how the patient feels about her addiction, and how the substances have changed his life for the worse. The patient would admit that the drugs have hurt him socially, personally, mentally, physically. The patient may never actually quit- he would perhaps rebound after some bouts of trying. But I thought that at least one point was pretty much standard: that the patient would recognize that the drugs were hurting him.

This is why talking to Ms. Smith about this topic was so difficult. Ms. Smith wanted to get back to the drugs when she was out of the hospital. This was not simply because she craved them or because she had poor self-control. Ms. Smith actually believed that the drugs made her life better. When I asked her to reflect upon how the daily use of crack cocaine and ecstasy have changed her life, I thought that maybe she’d find a link between the drugs and her current homelessness, her string of abusive boyfriends, her contraction of Hepatitis B. But Ms. Smith didn’t respond that way. She believed that she never had such good friends as the people she’d met on Skid Row, friends who would tell her where all the good dealers were. She had never been so happy nor had experienced so much fun in her life before she started doing drugs. This really made me ponder- how can you help someone to “get off” drugs if she doesn’t even recognize the harm that the drugs are doing to her? The first step of addiction therapy has to be, at an absolute minimum, a admission and dislike of the addiction. So I just decided to sit and listen, all the while getting schooled on doctors’ limitations to help people.