Another sloppy action from the WA medical board

Ultimately the Washington Medical Quality Assurance Commission (MQAC) acted appropriately in this case, but by gilding the lily lost some much needed credibility. Furthermore, some of the criticisms leave questions unanswered. In this case MQAC reviewed "approximately nine" cases treated by a psychiatrist practicing in a Seattle suburb but does not explain what prompted the review. The allegations mostly involve inappropriate prescribing, mostly of controlled substances:

  • Unjustified prescription of drugs of abuse to patients with a history of addiction.
  • Prescription of controlled substances in excessive doses.
  • "Allowing" patients to adjust their doses.
  • Failure to document informed consent.
  • "Allowing" patients to start taking a drug when they are ready.
  • Failure to provide guidance with regard to dangerous interactions with prescribed monoamine oxidase inhibitor drugs.
  • Failure to adequately address thyroid status in prescribing lithium.
  • Combining multiple sedating drugs.
  • Failure to address repeated falls in a patient prescribed benzodiazepines.
  • Failure to coordinate with another physician prescribing a controlled substance.
  • Failure to assess psychosis and cognitive impairment.
  • Failure to "respond in a timely manner to an e-mail from Patient D complaining of suicidal thoughts."
  • Continued prescription of drugs of abuse to a patient who needed addiction treatment.
  • Prescription of methylphenidate to a patient with symptomatic aortic stenosis.
  • Prescribing stimulants and benzodiazepines to a patient whose behaviors strongly suggested the possibility of abuse or diversion and "using marijuana while in treatment."

MQAC further alleges repetition of the words, "alert, responsive, well-oriented, and euthymic" among multiple progress notes of single patients and from patient to patient.

Improper Allegations

Every such statement of allegations should state the source of the complaint.

I am able to count precisely seven (7) cases A through G. If the medical board must approximate a single digit count the board cannot be competent to judge a physician's practice. Simply including this gratuitous word (approximately) should raises doubts in the minds of the citizens of Washington of MQAC's judgement.

The following trade names of drugs appear in the statement: "Ritalin," "Klonopin," "Ambien," "Seroquel," "OxyContin," "Depakote," "Concerta," and "Aricept." Use of trade names for drugs in a public document is inappropriate, unless, for example, the respondent physician actuall specified these drugs when prescribing them. The authors, by using trade names instead of generic names, suggest promotion of a particular product, raising ethical questions about the relationship of MQAC to the pharmaceutical industry.

MQAC fails to acknowledge the reality that patients decide when and whether to take a drug, even how much to take. Can MQAC be so naive as to think that patients precisely follow a physician's directions? I call this make believe medicine. It promotes a paternalistic approach that dis-empowers the patient while ignoring reality at great risk to the patient. Would MQAC have physicians observe the patient taking each dose?

MQAC fails to acknowledge that responsibility for coordination of treatment between professionals rests equally with both. Can we assume that the Commission investigates any other physicians referenced in this regard?

Would MQAC fault a physician for failing to "respond in a timely manner" to a complaint of thoughts of suicide contained in an ordinary postal letter? When can the patient take responsibility for using an appropriate medium for communicating with a physician? Casting psychiatrists in the role of suicide police already provides a strong incentive to avoid taking on such patients, to the detriment of the patients. Such criticism only leads to more warnings and disclaimers. In my practice agreement I clearly state that I do not provide emergency services. MQAC's position raises other questions: How quickly should a physician respond to such a communication? What do they expect the physician to do? Such an unthinking position, like many a knee jerk bureaucratic response, can have unintended negative consequences, for example in this case discouraging use of a superior communication medium to the detriment of patient care.

"Was using marijuana in treatment" raises multiple questions. When? How often? How much? We can use marijuana, "medical" and recreational, legally now in the State of Washington folks. Funny that there's no mention of patients using tobacco "in treatment" even with existence of far more resultant death and disability.

MQAC faults the respondent of repeated use of the phrase "alert, responsive, well-oriented, and euthymic" but fails to explain how this compromises patient care. I am reminded of use of the acronym "PERRLA" in the physical exam. Does the board discourage its use as well? There is no allegation that in any of the cases at any time the phrase did not accurately describe the patient. Would random misspellings make it acceptable? MQAC, and probably whomever it used as a consultant, must surely be out of touch with the realities of current medical practice which increasingly demands use of an electronic medical record, one of the great advantages of which is the ability to use boilerplate. I contend that this criticism leveled at the respondent could apply with equal validity to 90% of physicians practicing in the US today.

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