License Renewal

Every two years, the state has an obligation to its inhabitants, or not even inhabitants but also those who traverse borders to get their care, that the people offering that care in exchange for their livelihood have a threshold of training and character that justifies this.  It's a little harder to certify skill, but education makes a reasonable surrogate, or at least one that is easy to document, not very different than quality measures imposed on us in practice that give the illusion of quality in lieu of the real thing.

My three licenses have come from my state of residency training, lapsed many years ago as the maintenance requirements became increasingly onerous and expensive, justifiable only for those still hostage to that Board for their livelihood.  I have maintained one in my state of residence, where I also maintained a solo practice for 20 years and in the state where I practiced for my final eight years, retiring a few months ago.  On the off chance that I might want to do some locums tenens in one of those states, and the fee not being too exorbitant, I opted to maintain them one more time.  One comes due in a few weeks, renewal submitted electronically with MasterCard authorization, with a prompt email notice of approval.  Pennsylvania has a retired physician option which waives the educational requirements but not the fee so it pays to just do the Continuing Medical Education for now.

Unless one has been accused of activity unbecoming of a physician, which is not a lot of people other than maybe malpractice accusations which need to be acknowledged but do not disqualify, the barrier to renewal rests with the CME needs.  Like my other states, and a fair number of my insurance credentialing criteria, Pennsylvania requires 100 hours of CME spread over two years.  Category 1, the type that gets certificates of completion is usually the most difficult to obtain and sometimes requires a fee, only has to be 40 of those hours.  Much more, and the Commonwealth might have to deal with de-licensing their rural physicians who either do not have access readily or would need too much time away from  the practice to accumulate that much, which would run counter to the mission of making competent medical care available.  City slickers, which is me, just pick from the Grand Rounds or online options.  And since Category 2 can be interpreted loosely, medical writing in my case, consultation, lectures, mentoring medical students, it is readily available to rural physicians and accumulates in the course of ordinary physician activities. 

But there is always fine print.  Twelve of those hours need to be in risk management education, which can be interpreted rather broadly.  Medpage Today used to have an agreement with the University of Pennsylvania to certify what qualifies as risk management and offer a UPenn certificate of completion.  The University dropped their participation but Medscape Today kept the same classification, so when in doubt it is safe to assume that qualifies.  It comes in quarter hour increments so you could be doing dozens of those articles and questions to come to 12 hours.  Grand Rounds with appropriate titles do not require a learning exam, so that's probably the fastest way to accumulate these over two years.  I got six that way, the rest online.

My home state of Delaware found itself in a pickle a decade or so back when a pediatrician turned out to be a sexual abuse predator.  As unusual as this is, Delaware followed by many other states including Pennsylvania, enacted a series of child protective laws and require all licensees who might have occupational contact with children to take a course in what those laws are and answer some questions to make sure they are understood.  It's fairly easy, but takes a full three hours, for physicians who are highly literate and used to taking reading comprehension tests to do this.  The requirement may be more difficult for some of the holders of other occupational licenses or others without a state license but occupational contact with children who have little formal education or familiarity negotiating a computer course.  Printed certificate in CME folder.

Finally Pennsylvania officials are still uncertain whether their docs are the cause of a dangerous expansion of opiate use among the state's citizens, or maybe the best resource for its resolution.  A two hour CME module on opiate prescribing was added to module, probably irking the pathologists and radiologists whose patients are beyond pain. 

Done.  $360 added to my next credit card bill.  Maybe an audit somewhere in the next year or two to see if I am more truthful than our current President, which I perceive myself to be.

Those fees are a big windfall for  the Commonwealth of Pennsylvania, which has a lot of doctors.  There are disciplinary proceedings that the Board reports from time to time but I do not think I have ever personally known a doctor cited.  Level of skill varies, but I think everyone exceeds its threshold.  While I am technically permitted to do brain surgery but don't know how, some self-screening occurs and for those who really want to practice above their level of skill, there are other credentialing mechanisms of hospital staff membership that keep the medical Walter Mitty's in check.  And when all is said and done, those 140 hours of CME category 1 that finally accrued probably added less to my skill than the board might have hoped, except for the 22 obtained at my national specialty meeting.  But pursuing medical knowledge for the sake of mastering it has its psychic dollars, so I really didn't mind the effort.  And it's likely the last time except for a minor provision I will need to satisfy for Delaware in the coming months.

Unrestrained PRN

Sometimes we get complacent.  A very nice diabetic came to the hospital about 10 days back having been at our other campus not long ago.  He had a foot wound requiring two toe amputations here.  Glucose management at the other hospital seemed more difficult than it was here, with the continuation of insulin dosing proving too much, particularly the nightly basal dose which brought the dawn glucoses too low.  With some minor revisions the glucose control coasted along, his BP remained decent on medicine and his underlying cardiovascular disease mandated high dose atorvastatin which he continued uneventfully.  He always seemed pleasant, never seemed in any distress, a placid and pleasant fellow who never complained, at least not to me.

Ordinarily I take a look at my medicines on daily rounds.  The computer makes this easy by putting an asterisk next to the medicines I ordered.  There were antibiotics and there were analgesics ordered by other people to which I did not pay a lot of attention, his being in the hands of medical and surgical colleagues who do this professionally.

As he prepared for discharge I went over the list and noted a prn q 4h oxycontin order.  When I called up how much he actually took, it turns out that he has been requesting 4 doses a day on roughly a q4h while awake pattern every day for 5 consecutive days.  It seemed like a much larger amount of medicine than I would have anticipated for somebody who never looked uncomfortable at any of my visits.  Needless to say there are questions relating to his medical care and there are better ways to manage ongoing anticipated pain.  Was his pain control adequate or was there incomplete treatment of its source?  Does he really desire euphoria more than analgesia?  Does the prn nature of the order create a conflict between a patient in pain now and a surgical nurse who is otherwise occupied at the time with other patients whose needs are more immediate?

And who should be the one noticing this aberration?  I asked some of the nurses on the ward at the time if they note excessive prn use of opiates as the patients start demanding it of them repetitively.  Generally no, as no single nurse dispenses more than two in any shift and doesn't really come passively on the overall utilization.  I asked the pharmacist.  There really is no automatic mechanism to detect this.  Every day  there is a group meeting to discuss the progress and discharge planning for each patient.  Needless to say, this would not continue past discharge, but it whizzes by the daily sessions.  And then there is the surgical resident.  They look at wounds at the bedside.  Looking at medicines is a distraction from their surgical tasks.

So as we deal professionally with excess opiate utilization as a public health crisis, how much of that was our own creation, initial legitimate prescribing with a blind eye to use that seems excessive.  We have no mechanism to intercept that other than individual diligence in paying attention to medicine orders and administration.  Alas, good systems work better than astute people, and our system here seems absent.