ru 15: ma
ROSTER OF
Registered Physicians
IN THE
State of North Carolina
March 1,1992
ISSUED BY
N.C. DOCUMENTS CLEARINGHOUSE
DEC 14 1992
N.C. STATE LIBRARY RALEIGH
BOARD OF MEDICAL EXAMINERS OF THE STATE OF NORTH CAROLINA
Digitized by the Internet Archive
in 2012 with funding from
LYRASIS Members and Sloan Foundation
http://archive.org/details/rosterofregister1992nort
ROSTER OF
Registered Physicians
IN THE
State of North Carolina
ISSUED BY
BOARD OF MEDICAL EXAMINERS OF THE STATE OF NORTH CAROLINA
Board of Medical Examiners
of the
State of North Carolina
Hector H. Henry, II, M.D., President
John W. Nance, M.D., Secretary
Bryant D. Paris, Jr., Executive Secretary
H. Diane Meelheim, Assistant Executive Secretary
MEMBERS
John Thomas Daniel Jr., M.D., Durham
Hector Himel Henry, II, M.D., Concord
John Wesley Nance, M.D., Clinton
F. M. Simmons Patterson, Jr., M.D., Pinehurst
Walter Michel Roufail, M.D., Winston-Salem
Ernest Burton Spangler, M.D., Greensboro
Nicholas Emanuel Stratas, M.D., Raleigh
Kathryn Howell Willis, Zirconia
FOREWORD
This roster is issued by the Board of Medical Examiners of the State of North Carolina.
REGISTRATION REQUIRED AS FOLLOWS:
Physicians - January 1 every even-numbered year
Resident's Training Licenses - January 1 every even-numbered year
Professional Corporations - January 1 every even-numbered year
Physician Assistants - July 1 annually
Nurse Practitioners - July 1 annually
The names of all physicians who are licensed to practice medicine in the State of North Carolina who are currently registered with the Board of Medical Examiners of the State of North Carolina on March 1, 1992, are included in this roster.
The names of physicians who hold resident's training licenses to practice medicine in specified institutions in the state are not included in this roster.
Any information pertaining to omissions or corrections should be brought to the attention of the Board.
Bryant D. Paris, Jr., Executive Secretary
Board of Medical Examiners of the State of North Carolina
1203 Front Street
Raleigh, North Carolina 27609
Mailing address: Post Office Box 26808, Raleigh, North Carolina 2761 1-6808
Telephone (919) 828-1212
TABLE OF CONTENTS
Foreword iii
DOs and DONTs for Physicians v
Position Statements
Acupuncture vii
Administering Collagen Injections vii
Chelation Therapy for Atherosclerotic Diseases vii
Continuing Medical Education viii
Documentation of Physician/Patient Relationship viii
Guidelines on Physical Examinations viii
Individuals Who Aid a Physician ix
Ophthalmologists: Care of Cataract Patients ix
Physician Extenders in Urgent Care Situations x
Prescription Format x
Sexual Exploitation of Patients x
Treatment of and Prescribing for Family Members x
Use of Anorectics xi
Writing of Prescriptions for Controlled Substances xi
Management of Prescribing xii
Spotting the Chemically Dependent or Drug-Seeking Patient xiv
Laws of North Carolina Relating to the Practice
of Medicine xv
North Carolina Administrative Code xxix
Explanation of Specialty Codes lxxvii
Registered Physicians
Listed Alphabetically 1
Registered Professional Corporations
Listed Alphabetically 667
DOs AND DON'Ts FOR PHYSICIANS
Practice Suggestions:
1. Use as much care in writing pre- scriptions as you would use in writing personal checks. Specify amounts and do not leave spaces for x's or o's to be added to raise the amount.
2. Do not leave your personal pre- scription pads in positions accessi- ble to the public.
3. Do not leave signed, blank pre- scription pads in your office.
4. Write prescriptions for controlled substances or mind-altering chemi- cals with ink or indelible pencil (or type) and manually sign the pre- scription at the time of issuance.
5. Do not write prescriptions for large quantities of Schedule 2 or 2N con- trolled substances.
6. Do not prescribe controlled sub- stances without seeing the patient.
7. When you receive a call from a pharmacist requesting information about prescriptions you have writ- ten, respond courteously as, by law, a pharmacist is responsible for any forged prescription he fills.
8. Write a prescription for only one substance on each blank.
9. Do not issue a prescription for con- trolled substances or mind-altering chemicals for a patient in the absence of a documented physi- cian-patient relationship.
10. Do not issue a prescription for con- trolled substances or mind-altering chemicals for yourself.
11. Do not prescribe for members of your family. Treating one's family is not illegal, but the Board wishes to remind you that such prescribing practices may lead to problems. Written records of all prescriptions for controlled substances and the medical indications for them should be maintained, but in many instances such recording is neglect- ed. Also, any prescriptions issued should be within the scope of your normal medical practice. The Board urges you to delegate the medical care for yourself and members of your family to one or more of your colleagues in order to preclude involvement with govern- mental regulatory agencies who monitor physicians' prescribing practices.
12. Do not prescribe amphetamines or central nervous system stimulants for weight control. In 1972, the N.C. Medical Society adopted a resolution which is supported by the Board of Medical Examiners that "...the members of the N.C. Medical Society use no ampheta- mines or methamphetamines for appetite control and that the use of these drugs be restricted to the treatment of narcolepsy, hyperki- netic children and other disorders which in the opinion of the patient's physician will be benefi- cial.."
13. Do not carry large stocks of con- trolled substances in your bag. Addicts look for these in physi- cians' offices and cars.
14. If DEA numbers are printed on prescriptions, they should be incomplete and completed only when the physician validates and signs the prescriptions.
LAWS OR REGULATIONS
1. Sign prescriptions legibly in ink, never in pencil. The body of the pre- scription must be written legibly in ink or typewritten.
2. Prescriptions must contain the following information: full name and DEA # of prescribing physician; name, address and telephone number of prescribing physician's practice; indication of either "product selection permitted" or "dispense as written"; and full name and address of patient.
3. Only in emergency situations should you request pharmacists to fill prescriptions for Schedule 2 or 2N prescriptions over the telephone.
4. Prescribe controlled substances to drug dependent persons only under provisions regulated by law.
5. Dispense controlled substances, including samples, only when dispensing records are maintained for two or more years and containers with safety closure caps are properly labelled according to law. Physicians shall maintain a readily retrievable record of all controlled substances
dispensed (or administered) whether or not the practitioner charges the patient for the controlled substances, including samples.
6. Do not write prescriptions for con- trolled substances for office use. The law requires that you purchase Schedule 2 and 2N controlled sub- stances for your office on official order forms obtained from DEA. Schedule 3-5 drugs must be obtained through a wholesale distributor by means of a requisition.
7. Maintain security for any controlled substances including samples.
8. Take a biennial inventory of all controlled substances including sam- ples.
9. Before disposing of used syringes or needles, render them inoperative.
10. The destruction of an outdated or unwanted controlled substance by a physician or his authorized agent shall be witnessed by a federal or state official who is authorized to enforce the Federal or State Controlled Substances Act.
Suggested reference material regarding prescribing laws:
Code of Federal Regulations, Title 21 of the U.S. Food and Drug Act, Part 1300
to End — published by Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.
North Carolina Controlled Substances Act and Regulations — published by the N.C. Drug Commission, N.C. Department of Human Resources, 375 N. Salisbury St., Raleigh, N.C. 27603.
Below is a listing of addresses and telephone numbers that may be useful to you. Please feel free to write or telephone the North Carolina Drug Commission for additional information pertaining to drug laws and rules and regulations at any time you have a need.
N.C. Drug Regulatory Branch 375 N. Salisbury St. Raleigh, N.C. 27603 Telephone: (919) 733-4555
N.C. Board of Pharmacy P.O. Box 459
Carrboro, N.C. 27510-2165 Telephone: (919) 942-4454
State Bureau of Investigation 3370 Garner Rd., P.O. Box 29500 Raleigh, N.C. 27626 Telephone: (919) 662-4500
Drug Enforcement Administration 75 Spring St. SW, Suite 740 Atlanta, GA. 30303 Telephone: (404) 331-7328
Drug Enforcement Administration 2300 W. Meadowview Rd., Suite 224 Greensboro, N.C. 27401 Telephone: (919) 378-5052
POSITION STATEMENTS
ACUPUNCTURE
On December 5, 1972, the Board of Medical Examiners of the State of North Carolina stated its position that the practice of acupuncture is the practice of medicine.
Therefore, anyone wishing to practice acupuncture in the State of North Carolina, must first be licensed to practice medicine by the Board of Medical Examiners.
ADMINISTERING OF COLLAGEN INJECTIONS
It is the position of the Board of Medical Examiners of the State of North Carolina that by law the procedure of injecting collagen is a medical act as defined in N.C.G.S. 90-18, and therefore if performed by a person other than a licensed physician, must be done under the direct and immediate supervision of a licensed physician.
Further, it is the position of the Board that any advertisement regarding the injection of collagen should not refer to any one other than the licensed physician performing this pro- cedure.
CHELATION THERAPY FOR ATHEROSCLEROTIC DISEASES
WHEREAS, the use of chelation therapy for atherosclerotic vascular diseases (e.g., coronary artery disease, cerebral vascular disease, peripheral vascular disease) has been advocated by some medical practitioners without evidence of well-controlled clinical stud- ies to demonstrate that the use of the drug utilized in the chelation therapy for atheroscle- rotic is both effective and safe; and
WHEREAS, current medical literature does not support the theories of decalcification of atherosclerotic plaques presented by those advocates of chelation therapy, but does question their proposed explanation of pathogenesis and mechanism of action therapy for atherosclerotic diseases; and
WHEREAS, the United States Food and Drug Administration (FDA) does not approve edetate disodium (EDTA) for treatment of atherosclerosis, although the FDA does approve EDTA for chelation treatment of heavy metal poisoning; and
WHEREAS, patients on whom EDTA is used are at risk for kidney injury, emboli (e.g., calcium, fat-filled plaques), and other medical complications which may make such therapy dangerous; and
WHEREAS, the willingness of the ill to believe medical claims, even though unsup- ported by medical evidence, may be a factor in giving people a false sense of security and preventing appropriate therapy.
Now, therefore, be it RESOLVED that it is the opinion of the Board of Medical Examiners of the State of North Carolina that chelation therapy is of no proven benefit in the treatment of atherosclerotic disease and should not be used for this purpose until its clinical efficacy is established by formal, controlled, clinical trials approved by the United States Food and Drug Administration. Moreover, treatment with chelating agents, includ- ing EDTA, has some associated toxicity and should not be considered a completely benign procedure.
CONTINUING MEDICAL EDUCATION
Within the standards of acceptable and prevailing medical practice for North Carolina physicians engaged in the active clinical practice of medicine, obtaining regular continuing medical education is an integral part of maintaining professional competence to practice medicine with a reasonable degree of skill and safety for patients.
The Board of Medical Examiners of the State of North Carolina strongly encourages its licensees who are actively engaged in the clinical practice of medicine to obtain, and main- tain documentation of, not less than one hundred fifty (150) hours every three years of continuing medical education as directed by the Physicians' Recognition Award require- ments of the AMA. The majority of these hours should be applicable to respective practice specialties. (Membership in the AMA is not required for the Physicians' Recognition Award.)
DOCUMENTATION OF PHYSICIAN/PATIENT RELATIONSHIP
It is the position of the Board of Medical Examiners of the State of North Carolina that a valid physician/patient relationship is documented by the presence of medical records and should contain the following as outlined:
1. an appropriate history and physical or mental examination for the patient's chief complaint as appropriate to the specialty;
2. diagnostic tests when indicated;
3. a working diagnosis;
4. treatment; and
5. documentation by date of all prescriptions written for drugs, with name of medication, strength, dosage, quantity and number of refills.
GUIDELINES ON PHYSICAL EXAMINATIONS
It is the position of the Board of Medical Examiners that proper care is needed to avoid charges of sexual misconduct by physicians. Patient complaints of sexual misconduct by physicians are the most sensitive and difficult matters the Board investigates. In order to prevent misunderstandings and protect physicians and their patients from allegations of sexual misconduct, the Board offers the following guidelines:
1. Maintaining patient dignity should be foremost in the physician's mind when under- taking a physical examination. The patient should be assured of adequate auditory and visual privacy, and should never be asked to disrobe in the physician's immedi- ate presence. Examining rooms should be safe, clean, and well maintained, and should be equipped with appropriate furniture for the examination and treatment (examining able, chairs, etc.). Gowns, sheets and/or other appropriate apparel should be made available to protect patient dignity and decrease embarrassment to the patient while promoting a thorough and professional examination.
2. A third party should be readily available at all times during a physical examination, and it is suggested that the third party be actually present when the physician per- forms an examination of the sexual and reproductive organs or rectum. When appro- priate, the physician should have a third party present when examining a patient.
3. The physician should individualize the approach to physical examinations so that the patient's apprehension, fear, and embarrassment are diminished as much as possible. An explanation of the necessity of a complete physical examination, the components of that examination, and the purpose of disrobing may be necessary in order to mini- mize the patient's apprehension and possible misunderstanding.
4. The physician and staff should exercise the same degree of professionalism and cau- tion when performing diagnostic procedures (i.e., electrocardiograms, electromyo- grams, endoscopic procedures and radiological studies, etc.) as well as surgical pro- cedures and post-surgical follow-up examinations when the patient is in varying stages of consciousness.
5. The physician should be alert to suggestive or flirtatious behavior or mannerisms on the part of the patient, and should not be in a compromising position.
6. The physician shall not exploit the physician/patient relationship for sexual or any other purposes. Moreover, such an allegation against a physician constitutes grounds for investigation on the basis of unprofessional conduct.
INDIVIDUALS WHO AID A PHYSICIAN
It is the position of the Board of Medical Examiners of the State of North Carolina that the use of physician extenders be restricted to those covered by the Medical Practice Act and the Nursing Practice Act (i.e., Physician Assistants and Nurse Practitioners), and that the credentialing of such individuals by hospital credentialing committees should follow the above-mentioned laws .
The hospital activities of other individuals who aid a physician should be limited to manual assistance during procedures and only in the presence of a physician. This does not exclude hospital staff from routinely making notations in patients' charts regarding com- pletion of doctors' orders; i.e. nurses, dieticians, x-ray technicians, lab technicians, psychi- atric technicians, etc. However, it is the position of the Board that, at no time, such indi- viduals be allowed to make any entry in the patients' medical charts or order any medica- tions even if immediately countersigned by the physician.
OPHTHALMOLOGISTS: CARE OF CATARACT PATIENTS
The evaluation, diagnosis and care for cataract surgical patients is primarily the respon- sibility of the operating surgeon. The operating surgeon may not delegate to optometrists, nurses, or anesthesiologists the responsibility for performing an adequate preoperative examination. The surgeon must thoroughly examine each patient on whom he performs surgery prior to time for that surgery. This thorough examination shall include a review of the patient's history and an independent diagnosis by the operating surgeon of cataracts requiring surgery. The operating surgeon shall have a detailed discussion with each patient regarding the diagnosis and the nature of the cataract surgery, advising the patient fully of the risks involved. All surgical decisions must be made by the operating surgeon.
Following surgery, the operating surgeon must perform the 24 hour postoperative examination on every patient on whom he performs surgery, including clear documenta- tion of such examination in the patient record. In the case of an emergency, the operating surgeon shall ensure that another ophthalmologist performs the 24 hour postoperative examination. Following the 24 hour postoperative examination, the operating surgeon shall provide postoperative care for each patient on whom he performs surgery until the healing process is complete. It is not improper to involve non-physicians in postoperative care, so long as the operating surgeon maintains responsibility for the patient's postopera- tive care and examines the patient in the period following surgery to assess the healing process and the long-term results. Even in the case of repetitive surgical procedures, a record should be kept including detailed surgical notes describing each patient, his or her condition, the procedures, methods, prostheses, results, prognosis, medication relative to the surgery, and significant variations in each surgical procedure. The act of severing a suture following ophthalmologic surgery is a medical act which can only be performed by the operating surgeon or by those health care practitioners to whom this act may be legally delegated.
It is improper to permit non-physicians to prescribe medication except as provided by statute. In instances where the surgeon communicates and collaborates with an optometrist prescribing other than topical pharmaceutical agents not used for the purpose of examining the eye, that communication and collaboration must be contemporaneous with the issuance of any prescription and specific for each patient.
PHYSICIAN EXTENDERS IN URGENT CARE SITUATIONS
It is the position of the North Carolina Board of Medical Examiners that it is not the prevailing and accepted practice of medicine by supervising physicians to allow physician assistants and nurse practitioners in urgent care centers to treat any patient with a poten- tially dangerous medical condition without that patient being seen at the time of treatment by that supervising physician.
PRESCRIPTION FORMAT
It is the usual and accepted standard of care in North Carolina that a DEA controlled substance (2, 2N, 3, 3N, 4 and 5) should be written on a separate prescription blank. Multiprescription blanks may be used for non DEA controlled medication prescriptions.
SEXUAL EXPLOITATION OF PATIENTS
It is the position of the Board of Medical Examiners of the State of North Carolina that entering into a sexual relationship with a patient, consensual or otherwise, while a physi- cian/patient relationship exists is unprofessional conduct and grounds for the suspension or revocation of a physician's license. Formal actions taken by the Board of Medical Examiners are released to the public through news media and medical organizations.
TREATMENT OF AND PRESCRIBING FOR FAMILY MEMBERS
It is the position of the Board that, generally, a physician should not prescribe for fami- ly members. Treating one's family is not illegal, but the Board wishes to remind physi- cians that such prescribing practices may lead to problems. Written records of all prescrip- tions for controlled substances and the medical indications for them should be maintained, but in many instances such recording is neglected. Also, any prescriptions issued should be within the scope of the physician's medical practice. The Board urges physicians to dele- gate the medical care of themselves and their family members to one or more of their col- leagues in order to preclude involvement with governmental regulatory agencies who monitor physicians' prescribing practices. Furthermore:
1. Treatment of the immediate family members should be reserved for minor illnesses, temporary or emergency situations.
2. Appropriate consultations should be obtained for the management of major or extended periods of illness.
3. No Schedule II, III, or IV controlled substances should be given or prescribed except in emergency situations.
4. Records should be maintained of written prescriptions or administration of any Schedule II, III, or IV controlled substances.
THE USE OF ANORECTICS
It is the position of the North Carolina Board of Medical Examiners that under special circumstances anorectic agents may fill a limited adjunct role in the treatment of obesity in individual patients, if such treatment primarily involves diet, exercise, behavior therapy and frequent supervision by the physician.
If used, anorectic agents should be used for short term, non-repetitive periods of not more than twelve weeks.
Anorectic agents may produce drug dependency in some patients.
The policy of the North Carolina Board of Medical Examiners regarding the use of amphetamines and methamphetamines for treatment of obesity is still in effect. There are no indications for use of these drugs in weight control.
WRITING OF PRESCRIPTIONS FOR CONTROLLED SUBSTANCES
It is the position of the Board that prescriptions for controlled substances or mind-alter- ing chemicals should be written in ink or indelible pencil or typewritten and should be manually signed by the practitioner at the time of issuance.
No prescription for controlled substances or mind-altering chemicals should be issued for a patient in the absence of a documented physician-patient relationship.
No prescription for controlled substances or mind-altering chemicals should be issued by a practitioner for himself.
MANAGEMENT OF PRESCRIBING
The majority of physicians who are asked to appear before the Board are required to do so because of their lack of information about the management and responsibilities involved in prescribing controlled substances. The March 1991 edition of the Bulletin con- tained an article entitled "Management of Prescribing with Emphasis on Addictive or Dependence-Producing Drugs," and we would like to reiterate certain points addressed in that article.
First and foremost: "It's not what you prescribe, but how well you manage the patient's care, and document that care in legible form, that's important. The prescribing matters that come before the Board are almost always related to the prescription of controlled sub- stances, and the majority of subsequent disciplinary actions could have been avoided if the physician had followed a few basic steps.
Step 1 : Before you prescribe anything, start with a diagnosis which is supported by his- tory and physical findings.
Step 2: Create a treatment plan which includes the use of appropriate non-addictive modalities, and make referrals to appropriate specialists.
Step 3: Before beginning a treatment regimen of controlled drugs, make a determina- tion through trial or through a documented history that non-addictive modalities aren't appropriate or they don't work.
Step 4: Make sure you are not dealing with a chemically dependent or drug-seeking patient.
Step 5: Take the time to explain the relative risks and benefits of the drug and record in the chart that this was done.
Step 6: Maintain regular monitoring of the patient, including frequent physical monitoring.
Step 7: Make sure you are in control of the drug. Keep detailed records of the type, dose, and amount of the drug prescribed. Monitor, record and personally control all refills. Do not authorize office staff to refill prescriptions without consulting you.
Step 8: Maintain regular contact with the patient's family. The family is a good source of information on the patient's response to the therapy regimen, behavioral changes, and whether the patient is obtaining drugs from other sources or is self-medicating with drugs or alcohol.
Step 9: Maintain adequate records.
Management of Prescribing with Emphasis on Addictive or Dependence-Producing Drugs
The North Carolina Board of Medical Examiners is charged by the Governor to protect the citizens of the State from harmful physician management. A significant number of physicians who are asked to appear before the Board are required to do so because of their lack of information about the management and responsibilities involved in prescribing controlled substances. Frequently, the inadvertent offender is a physician with a warm heart and a desire to relieve pain and misery, who is always pressed for time and finds himself prescribing controlled drugs on demand over prolonged periods without adequate documentation. These are often for chronic ailments such as headache, arthritis, old injuries, chronic orthopaedic problems, backache and anxiety. (Terminal cancer pain management is not a consideration here.) The purpose of the Board of Medical Examiners in presenting the following information is to help licensed physicians in North Carolina consider and reevaluate their prescribing practice of controlled substances. Practicing physicians who become new Board members have often mentioned the abrupt education they received in their own prescribing patterns. Moreover, there have been many requests to the Board from physicians requesting detailed information on prescribing in certain specific situations.
It's not what you prescribe, but how well you manage the patient's care, and document that care in legible form, that's important.
The prescribing matters that come before the Board are almost always related to the prescription of controlled substances. We feel that a majority of instances where physi-
cians have been disciplined by the Board for prescribing practices could have been avoid- ed completely if they had followed the steps that are being outlined here.
To prevent any misunderstanding, it's necessary to state what the Board does not have.
It does not have a list of "bad" or "disallowed" drugs. All formulary drugs are good if prescribed and administered when properly indicated. Conversely, all drugs are ineffec- tive, dangerous, or even lethal when used inappropriately.
It does not have some magic formula for determining the dosage and duration of administration for any drug. These are aspects of prescribing that must be determined within the confines of the individual clinical case, and continued under proper monitoring. What's good for one patient may be insufficient or fatal for another.
What the Board does have is the expectation that physicians will create a record that shows:
— Proper indication for the use of the drug or other therapy
— Monitoring of the patient where necessary
— The patient's response to therapy on follow-up visits
— All rationale for continuing or modifying the therapy
Step 1 : First and foremost, before you prescribe anything, start with a diagnosis which is supported by history and physical findings, and by the results of any appropriate tests. Too many times a doctor is asked why he or she prescribed a particular drug, and the response is, "Because the patient has arthritis." Then the doctor is asked, "How did you determine that?", and the answer is, "Because that's what the patient complained of." Nothing in the record or in the doctor's recollection supports the diagnosis except the patient's assertion. Do a workup sufficient to support a diagnosis, including all necessary tests.
Step 2: Create a treatment plan which includes the use of appropriate non-addictive modalities, and make referrals to appropriate specialists, such as neurologists, orthope- dists, psychiatrists, etc. The results of the referral should be included in the patient's chart.
Step 3: Before beginning a regimen of controlled drugs, make a determination through trial or through a documented history that non-addictive modalities aren't appropriate or they don't work. A finding of intolerance or allergy to NSAIDs is one thing, but the asser- tion of the patient that, "Gosh, Doc, nothing seems to work like that Percodan stuff!" is quite another. Too many of the doctors the Board has seen have started a treatment pro- gram with powerful controlled substances without ever considering other forms of treat- ment.
Step 4: Make sure you are not dealing with a drug-seeking patient. If you know the patient, review the prescription records in the patient's chart and discuss the patient's chemical history before prescribing a controlled drug. If the patient is new or otherwise unknown to you, at a minimum obtain an oral drug history, and discuss chemical use and family chemical history with the patient.
Step 5: It's a good idea to obtain the informed consent of the patient before using a drug that has the potential to cause dependency problems. Take the time to explain the rel- ative risks and benefits of the drug and record in the chart the fact that this was done. When embarking on what appears to be the long term use of a potentially addictive sub- stance, it may be wise to hold a family conference and explain the relative risks of depen- dency or addiction and what that may mean to the patient and to the patient's family.
Refusal of the patient to permit a family conference may be significant information.
Step 6: Maintain regular monitoring of the patient, including frequent physical moni- toring. If the regimen is for prolonged drug use, it is very important to monitor the patient for the root condition which necessitates the drug, and for the side effects of the drug itself. This is true no matter what type of controlled substance is used or what schedule it belongs to. Also, remember that with certain conditions, drug holidays are appropriate. This allows you to check to see whether the original symptoms recur when the drug is not given — indicating a continuing legitimate need for the drug or whether withdrawal symp- toms occur — indicating drug dependence.
Step 7: Make sure YOU are in control of the supply of the drug. To do this, at a mini- mum you must keep detailed records of the type, dose, and amount of the drug prescribed. You must also monitor, record and personally control all refills. Do not authorize your office personnel to refill prescriptions without consulting you. One good way to accom-
plish this is to require the patient to return to obtain refill authorization, at least part of the time. Records of cumulative dosage and average daily dosage are especially valuable. A thumbnail sketch of three cases will illustrate our point here. In the first case, a physician prescribed Tussionex to a patient for approximately five years for a cumulative dosage of nineteen and one half gallons. In the second case, a physician prescribed Tylenol 3's to a patient for slightly more than a year at the average daily rate of 30 per day! The third case is very similar, except that it was Tylenol 4's at the rate of 20 per day. Some quick obser- vations:
— No physician who was aware of that kind of prescribing would have continued with it.
— Few, if any, patients could have been consuming that much Tylenol with codeine. In all likelihood, they were reselling it.
Another important part of controlling the supply of drug is to check on whether the patient is obtaining drugs from other physicians. North Carolina law allows any current treating physician to have access to a patient's prescription profile. Checking with pharma- cies and pharmacy chains may tell you whether a patient is obtaining extra drugs or is doctor shopping. Doctor shopping is illegal in North Carolina. If you are aware it is occurring, contact your local police, SBI or the Board of Medical Examiners.
Step 8: Maintaining regular contact with the patient's family is a valuable source of information on the patient's response to the therapy regimen, and may be much more accu- rate and objective than feedback from the patient alone.
The family is a much better source of information on behavioral changes, especially dysfunctional behavior, than is the patient. Dysfunctional changes may be observable when the patient is taking the drug, or when the drug is withdrawn. These changes, at either time, may be symptoms of dependency or addiction.
The family is also a good source of information on whether the patient is obtaining drugs from other sources, or is self-medicating with other drugs or alcohol.
Step 9: To reiterate, one of the most frequent problems faced by a physician when he or she comes before the Board or other outside review bodies is inadequate records. It's entirely possible that the doctor did everything correctly in managing a case, but without records which reflect all the steps that went into the process, the job of demonstrating it to any outside reviewer becomes many times more difficult. Luckily, this is a problem which is solvable.
Note Much of the above was taken from information from continuing medical educa- tion seminars conducted by the Minnesota Board of Medical Examiners and from their newsletter of the fall of 1990. We express our appreciation to them.
SPOTTING THE CHEMICALLY DEPENDENT OR DRUG-SEEKING PATIENT
Current Behavior. Must be seen right away, frequently after hours or late in the after- noon; must have a specific narcotic right away; reluctant to provide reference information such as primary physician; not a permanent resident - visiting or travelling through town; refuses lab tests; presents characteristic types of pain - low back, root canal, migraines; lost or stolen prescription needs replacing; blood in urine (from pricked finger) to simulate kidney stone.
Medical History: Gives evasive or vague answers; may admit excessive use of ciga- rettes, alcohol or prescription drugs; exaggerates medical problems; history of frequent trauma or bizarre infections; general debilitation; unexplained sweating or chills.
Social History: Repeated auto accidents or DUIs; employment difficulties; child abuse or severe family problems; family history positive for members with chemical dependency.
Psychological History: Mood disturbances; suicidal thoughts; lack of impulse control; thought disorders; sexual dysfunction.
Physical Examination: Overt debilitation; physical findings not proportionate to com- plaints; unsteady gait; slurred speech; inappropriate pupil dilation or constriction; nystag- mus; cutaneous signs of drug abuse.
Laws of North Carolina Relating to the Practice of Medicine
Chapter 90.
Article 1. Practice of Medicine.
Sec. 90-1
90-2. 90-3. 90-4. 90-5. 90-6.
90-7. 90-8.
90-<
90-10. 90-11
90-12. 90-13.
90-14. 90-14.
90-14.2.
90-14. 90-14
90-14
90-14. 90-14.
North Carolina Medical Society
incorporated. Board of Examiners. Medical Society nominates Board. Board elects officers; quorum. Meetings of Board. Regulations governing applicants for license, examinations, etc.; appointment of subcommittee. Bond of secretary.
Officers may administer oaths, an subpoena witnesses, records and other materials. Examination for license; scope; con- ditions and prerequisites. Provision in lieu of examination. Qualifications of applicant for
license. Limited license. When license without examination
allowed. Revocation, suspension, annulment
or denial of license. . Judicial review of Board's deci- sion denying issuance of a license. Hearing before revocation or sus- pension of a license. Service of notices. .4. Place of hearings for revocation
or suspension of license. ,5. Use of trial examiner or deposi- tions. ,6. Evidence admissible. .7. Procedure where person fails to request or appear for hearing.
Sec. 90-14
90-14.9
90-14. 90-14. 90-14. 90-14.
90-15 90-15. 90-16.
90-17 90-18
90-18 90-18.
90-19, 90-21
Appeal from Board's decision
revoking or suspending a
license. Appeal bond; stay of Board
order. Scope of review. Appeal; appeal bond. Injunctions. . Reports of disciplinary action
by health care institutions;
immunity from liability. . License fee; salaries, fees, and
expenses of Board.
1 . Registration every two years with
Board.
Board to keep record, publication of names of licentiates, tran- script as evidence; receipt of evidence concerning treatment of patient who has not con- sented to public disclosure.
(Repealed.)
Practicing without license; practic- ing defined; penalties. .1. Limitations of physician assis- tants.
2. Limitations on nurse practition-
ers. 90-20. (Repealed.) . Certain offenses prosecuted in
superior court; duties of
Attorney General.
Article ID. Peer Review.
90-21.22. Peer review agreements.
Medicine and Allied Occupations.
Article 1. Practice of Medicine.
§ 90-1. North Carolina Medical Society incorporated. — The association of regu- larly graduated physicians, calling themselves the State Medical Society, is hereby declared to be a body politic and corporate, to be known and distinguished by the name of The Medical Society of the State of North Carolina. The name of the society is now the North Carolina Medical Society.
§ 90-2. Board of Examiners.
(a) In order to properly regulate the practice of medicine and surgery, there is estab- lished a Board of Medical Examiners of the State of North Carolina. The Board shall consist of eight members. Seven of the members shall be duly licensed physicians elected and nominated to the Governor by the North Carolina Medical Society. The other member shall be a person chosen by the Governor to represent the public at large. The public member shall not be a health care provider nor the spouse of a health care provider. For purposes of board membership, "health care provider" means any licensed health care professional and any agent or employee of any health care institution, health care insurer, health care professional school, or a member of any allied health profession. For purposes of this section, a person enrolled in a program to prepare him to be a licensed health care professional or an allied health professional shall be deemed a health care provider. For purposes of this section, any person with significant financial interest in a health service or profession is not a public member.
(b) No member appointed to the Board on or after November 1, 1981, shall serve more than two complete consecutive three-year terms, except that each member shall serve until his successor is chosen and qualifies.
(c) In order to establish regularly overlapping terms, the terms of office of the mem- bers currently serving on the Board shall expire as follows: to on October 31, 1982; two on October 31, 1984; three on October 31, 1986. Terms of Board members shall expire in direct relation to their date of appointment by the soci- ety; the terms of the two members first appointed shall expire in 1982, and the terms of the three members last appointed shall expire in 1986. No initial physi- cian member of the Board may serve another term until at least three years from the date of expiration of his current term. The Governor shall appoint the public member not later than October 31, 1981.
(d) Any initial or regular member of the Board may be removed from office by the Governor for good cause shown. Any vacancy in the initial or regular physician membership of the Board shall be filled for the period of the unexpired term by the Governor from a list of physicians submitted by the North Carolina Medical Society Executive Council. Any vacancy in the public membership of the Board shall be filled by the Governor for the unexpired term.
§ 90-3. Medical Society nominates Board. — The Governor shall appoint as physi- cian members of the Board physicians elected and nominated by the North Carolina Medical Society.
§ 90-4. Board elects officers; quorum. — The Board of Medical Examiners is authorized to elect all officers and adopt all bylaws as may be necessary. A majority of the membership of the Board shall constitute a quorum for the transaction of business.
§ 90-5. Meetings of Board. — The Board of Medical Examiners shall assemble once in every year in the City of Raleigh, and shall remain in session from day to day until all applicants who may present themselves for examination within the first two days of
this meeting have been examined and disposed of; other meetings in each year may be held at some suitable point in the State if deemed advisable.
§ 90-6. Regulations governing applicants for license, examinations, etc.; appoint- ment of subcommittee. — The Board of Medical Examiners is empowered to prescribe such regulations as it may deem proper, governing applicants for license, admission to examinations, the conduct of applicants during examinations, and the conduct of examina- tions proper.
The Board of Medical Examiners shall appoint and maintain a subcommittee to work jointly with a subcommittee of the Board of Nursing to develop rules and regulations to govern the performance of medical acts by registered nurses, including the determination of reasonable fees to accompany an application for approval not to exceed one hundred dollars ($100.00) and for renewal of such approval not to exceed fifty dollars ($50.00). The fee for reactivation of an inactive incomplete application shall be five dollars ($5.00). Rules and regulations developed by this subcommittee from time to time shall govern the performance of medical acts by registered nurses and shall become effective when adopted by both the Board of Medical Examiners and the Board of Nursing. The Board of Medical Examiners shall have responsibility for securing compliance with these regulations.
§ 90-7. Bond of secretary. — The secretary of the Board of Medical Examiners shall give bond with good surety, to the president of the Board, for the safekeeping and proper payment of all moneys that may come into his hands.
§ 90-8. Officers may administer oaths, and subpoena witnesses, records and other materials. — The president and secretary of the Board may administer oaths to all persons appearing before it as the Board may deem necessary to perform its duties, and may summon and issue subpoenas for the appearance of any witnesses deemed necessary to testify concerning any matter to be heard before or inquired into by the Board. The Board may order that any patient records, documents or other material concerning any matter to be heard before or inquired into by the Board shall be produced before the Board or made available for inspection, notwithstanding any other provisions of law providing for the application or any physician-patient privilege with respect to such records, docu- ments or other material. All records, documents, or other material compiled by the Board are subject to the provisions of G.S. 90-16. Notwithstanding the provisions of G.S. 90-16, in any proceeding before the Board, in any record of any hearing before the Board, and in the notice of charges against any licensee, the Board shall withhold from public disclosure the identity of a patient including information relating to dates and places of treatment, or any other information that would tend to identify the patient, unless the patient or the rep- resentative of the patient expressly consents to the disclosure. Upon written request, the Board shall revoke a subpoena if, upon a hearing, it finds that the evidence the production of which is required does not relate to a matter in issue, or if the subpoena does not describe with sufficient particularity the evidence the production of which is required, or if for any other reason in law the subpoena is invalid.
§ 90.9. Examination for license; scope; conditions and prerequisites. — It shall be the duty of the Board of Medical Examiners to examine for license to practice medicine or surgery, or any