Columnist Ellen Goodman wrote in her September 11 piece on the subject, "The War on Drugs has done its collateral damage on sick civilians. But now in Oregon a doctor is also disciplined for prescribing Tylenol when the patient needed morphine."
Oregon is the first state to investigate and act against physicians who do not adequately treat patient pain - most states take the opposite approach, investigating providers who "overuse" opioid analgesics. Dr. Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health Sciences University, explained that the Oregon Board had decided that it would take action on both ends of the spectrum - overtreatment and undertreatment. Tolle said that this policy has been a remarkable change for a group that ten years ago was seen as creating a climate in which physicians so feared investigation that they routinely underprescribed opioids.
"The pendulum is swinging back in Oregon, and this could easily start to happen in other states," Tolle said. "This is a way to push providers, and to let them know the climate of the Board. Although this had been the Board’s stated policy, now that it has acted, it will be more believable. There is credibility. And the hearing of doctors will be improved when hospice nurses call to say a patient is in pain."
Tolle noted that the board chose not to punish Bilder by lifting his license, but to take a constructive approach in which he will have to participate in intensive education about pain relief and undergo psychiatric evaluation. (Doctors disciplined for overprescribing opioids must also participate in intensive education programs.) Although some pain advocates feel that the Oregon board should have suspended Bilder’s license, others say that the Board’s action marked a small victory for better pain management.
"Other boards, like California, have refused to hear such cases," said Joanne Lynn, M.D. "This is a step in the right direction."
Tolle said that the Federation of Boards of Medical Examiners is now looking at the issue to determine how it could set national standards regarding sanctions for physicians who underprescribe pain medication. "In the Bilder case, you have such gross negligence that everyone would agree he had been negligent. But it can be easy to get into extremes. The Federation is interested in creating a policy that is constructive and focuses on quality care," she said.
In its testimony to various policymakers, Americans for Better Care of the Dying has often called for medical boards to take such disciplinary action and commends the Oregon Board of Medical Examiners for taking a lead in this endeavor. Oregon’s largest newspaper, The Oregonian, ran a week-long feature on pain management, including resources and detailed information for patients and families; read it at www.oregonlive.com.
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