I practice medicine in America and I live in fear. I live with the fear that all physicians should have, the fear that someday, something you do (or don't do) may hurt someone, or the fear that all of your hard work to help someone in need may be to no avail. That's a good fear. That's a fear that keeps physicians on their toes, keeps them from being complacent, keeps their skills sharp, and their eyes open and their minds keen. It keeps a surgeon from thinking that a common tonsillectomy is "routine", and that the unlabeled clear liquid in that syringe is ok to inject just because the nurse says she drew it up from the right vial. It is a fear that keeps me from sleeping very well when I am on call. That fear is a natural one, inherent in the duty of being a physician, and I accepted that fear when I embarked upon my long journey to become a healer.

I also live with a different fear, an artificial one, a fear that all too many Americans live with these days, but it is a fear that is particularly acute for physicians: the fear of being sued. It is something that I expected to be present when I became a doctor, but I did not expect it to be so pervasive. It taints every interaction I have with the people for whom I care. It distorts the sacrosanct Doctor-Patient relationship, and it virtually turns those people who come to see me for help into potential assailants. If I've made an error, or, if I haven't but I am perceived to have made an error, my reputation, my assets, my very ability to continue to practice medicine in this community are potentially forfeit. The act of caring for a patient then becomes a risk to my person. I liken this situation to another experience in my life. When I was a naval flight surgeon with the marines in the Gulf War, I underwent chemical and biological weapons casualty care training. I was instructed that while caring for these casualties, if I got one drop of neurotoxin from their clothes on me I could die. I accepted that risk, because as a military physician, if I didn't care for these folks, who would? The risk was also present for a finite period of time, and there were well-defined measures I could take to protect myself. The liability risk I face on a daily basis today is certainly less grave but causes me more fear. It is always present and there are few if any measures I can take to protect myself. One misstep, one misfortune, and all I've worked for could be gone. It is my Sword of Damocles that is eternally overhead, ready to drop at the slightest disturbance. And it only takes the perception that I did something wrong.

I can imagine that the personal injury attorneys reading this might say that this is far too dramatic, that my risk is not as great as this, and that I'm just another whining "rich" doctor who is self-absorbed and that the real issue is not my well-being but the well-being of the patients who are hurt by medical malpractice. Fair enough. I would like to individually address these potential criticisms.

The medical liability crisis is certainly quite dramatic, even without the closure of a trauma center or the limitation of pregnant women in finding obstetrical care. I think what is no less dramatic is the degree to which doctors have been forced to change their practice of medicine in an effort to protect themselves from litigation. Fearful of being sued for missing a diagnosis, no matter how potentially obscure, or remote the chances of its presence, we scan and probe and biopsy and bleed our patients. This is done to a level greater than would otherwise be dictated solely by prudent medical practice. Much has been written about the monetary costs of such defensive medicine; I am far more concerned about the other costs. For example, there is the small child who is about to undergo minor surgery, but has a slightly abnormal clotting test. Because there is no family history of bleeding disorder, and because the child never had any problems with clotting when suffering a scrape or cut, the chances are quite slim that this represents a real danger. But because of worry about liability in case there is incidental bleeding after surgery, typically the scheduled surgery will have to be postponed, and the child will have to be subjected to a lengthy workup including several more blood tests and specialist visits. Drawing blood from a small child for such testing is never a benign procedure. The end result is that these additional needle sticks will have considerably traumatized the child, who will very likely still have undergone the surgery because the workup will have been negative. As a physician, my concern over potential litigation can thus lead to a small child being put through pain needlessly and cause him to cry. It causes me to cry too.

My fear of personal ruin due to litigation also prevents me from discharging one of the most basic duties of a physician: to provide comfort. When faced with a patient who has a mass that is almost certainly not cancerous, I can not, dare not say the words, "you'll be fine--don't worry about it." No, I have to say something like, "in my opinion, the chances of this growth being a cancer are low", or "there is a low likelihood that this represents a cancer-but remember, that likelihood is NOT zero." Huh? The patient may leave my office still in bewilderment about their state of health. I would relish the ability to truly relieve a patient's anxiety, but I must continue to do the correct thing medicolegally --- even if it isn't the optimum thing to do medically. If I utter any platitudes, they can be used against me in a court of law.

As a physician, my risk is very great. One perceived error could lead to a lawsuit, which unless dismissed or won by me, would either disqualify me from being able to get insurance here or make it such that my next insurance premium is so high that I could not possibly afford it. I would then have to move out of Las Vegas, the very place where I grew up. The trial attorneys state that jury awards have been high because doctors refuse to settle. How can you settle when you feel you committed no malpractice, and settlement means potential inability to continue to practice? Often settlements are arrived at not because the doctor is admitting that he did something wrong, but because the insurer feels that it would cost too much to continue to a jury trial and that it's just cheaper to settle. The physician is nonetheless saddled with a record of having an adverse event, and is considered a poor insurance risk.

As far as being "rich", I think that at one time, physicians were indeed wealthy, and there may still be a few rich doctors out there, but those few either made their money in endeavors other than medicine, or they are older and made their money when doctors actually got paid what they charged. Unfortunately, the image that physicians are spoiled and rich and overpaid for their services has continued, despite the facts to the contrary. The public truly thinks we get paid more than we do, and this has been propagated in large part by the insurance industry. There is a bill of services commonly known as an "EOB", or explanation of benefits, that patients receive from their insurer after medical services have been rendered. The EOB usually clearly states what the charges of the physician and the hospital and the laboratory are; it may also state that the bill is "paid in full". The patient is left with the impression that the $5000.00 surgical charge that is listed on the EOB is what the provider actually received for his or her services. In reality, the doctor may get a tiny fraction of those billed charges, perhaps a few hundred dollars, which the insurer considers to be "paid in full". (The physician is prohibited from collecting the difference). Physicians as a whole earn a middle-class living, so increases in malpractice insurance rates of five and six digits make a BIG deal to them, and can mean the difference between making a living and being bankrupt. And no, we do not have the power to pass these costs on to the public; we can charge more but the insurer will still pay the same and the bill will still be considered to be "paid in full".

The well being of my family and myself are important to me just as it is with anyone. If financial security were the most important thing in a physician's mind, however, there wouldn't be many physicians. Those smart folks would have become investment bankers, corporate managers or personal injury attorneys. There are a great number of ways of making money easier than the long road involved in becoming a doctor. I sacrificed much of my younger life in this endeavor. While I was incurring debt as well as military obligation in order to finance my medical education, friends of mine were out there earning good money and enjoying free time. Many of those friends who were doing that then are still far more successful (monetarily) than I am today. Most physicians do treat patients who cannot afford to pay and I believe that most are truly altruistic in nature. For all their hard work, devotion and sacrifice, those physicians are now criticized as putting their own needs in front of that of the community. That must feel like being punched in the face and having the person who punched you get mad at you for getting blood on his fist.

I don't actually have the fear of being sued so much because of potential loss of my assets; I honestly don't have that much to lose. No, my fear in being sued runs deeper. The best way to explain why is to illustrate by example. When McDonald's gets sued for spilled hot coffee or Sears Automotive gets sued for a customer injury in the workplace, to some, that's just the cost of doing business in America today. It's impersonal, its corporate, and the blame and liability is spread out over a great number of individuals, the shareholders. When a physician is sued, it's very personal. The physician is impugned; his image is made to appear as incompetent, noncaring, greedy and negligent. The uglier the plaintiff's attorney can make the doctor appear, the greater the chance for high award for he and his client. The physician is left devastated. And he's devastated, even if he wins the case. For someone who has spent a lifetime trying his or her best to help people, this becomes a dubious reward.

As far as those truly hurt by medical malpractice, I feel that they should be appropriately compensated. But the civil justice system as exists today appears to be a poor instrument to achieve that compensation. It has in large part become a device for the enrichment of plaintiff's attorneys, who use it to extort money from solvent targets. It doesn't sufficiently discriminate between the negligent and the blameless, those who are careless and those who truly care, and those who take from the community and those who give. Among all the fears I have, one of the greatest is that we will be powerless to change this flawed system.

Top

Introduction to Online CMEs

By Bernard Sklar, M.D., M.S.

Online CME is a way to earn CME credits, over the Internet, using your computer, from home or office.

What are the types of instruction I may find in Online CME?

There is a wide variety of instruction types, to suit every doctor's preferences. You will find:

Simple Text or Text-and-graphics (like reading a textbook or journal)
Slide-audio or slide-video lectures (like being at a lecture)
Case-based interactive (like treating a "real" patient); you get to make choices according to the clinical presentation
Quiz questions and answers (the program asks you a question, waits for your answer, and then gives you explanations and information based on your answer)
Games where you gain or lose points for your answers
Correspondence courses (a group of doctors study material and correspond with each other by email)

How much does Online CME cost?

Online CME is surprisingly relatively inexpensive! There are more than 2000 credit-hours of Online CME available without charge. Another 16,000 hours cost $5 to $15 per credit-hour while a small minority of Online CME courses cost more than $15 per credit-hour.

What is required of me when I visit an online CME site?

Many doctors may fear a loss of privacy or hidden fees when visiting Internet sites. This is not the case with Online CME sites. There is almost never any fee to look at the site or the list of courses. The site will usually ask you to give some basic information about yourself and to choose a user name and password. In many cases, you can view the instruction without giving any personal information. To earn CME credit, you will need to identify yourself, so the sources may issue your CME certificate. If there is a fee, you usually pay by credit card.

"I get all the CME I need at live meetings; why should I bother doing CME on the Internet?"

Live meetings are important, and they will never be completely replaced by the Internet. But there are some distinct advantages to Online CME:

Online CME is available 24 hours a day, 7 days a week, at home or at the office
You can proceed at your own speed, going back to hear or see important points you might not have picked up the first time through
You have the opportunity to hear lectures by experts, no matter where you or they may be located
There are no travel costs and no costs for closing your office or finding coverage

CMEs on Medical Ethics

Nevada physicians are required to obtain two Category I CME credit-hours in the area of medical ethics to renew a medical license. Here are three web sites which feature CME on medical ethics issues:

Texas Medical Association Ethics CME http://www.texmed.org/cme/ethicscme.asp
Massachusetts Medical Society Ethics in a Managed Care Practice http://www.massmed.org/CME/Courses/01308/Default.asp
American Medical Association Ethics in Patient Care http://www.courses.learnsomething.com/scripts2/content.asp?a=B1190DC21D9211D589FD0050DA10942A&r=ProductDescription&p=7A0C74C0BDE94387A5F8DBD51F89A979

How do I find the CME courses?

Finding the CME courses you want to look at can be challenging when you first get started, because there are more than 200 web sites offering more than 10,000 activities and more than 19,000 credit hours. There is no single central place on the Internet which will show you exactly the instruction you want. However, here a few places to start:

Visit the Annotated List of Online CME www.cmelist.com/list.htm. Choose your area of interest or medical specialty from the list at the top of the page; then choose from the sites or courses that interest you.

For example, a family doctor might start from the Family Practice section:

http://www.cmelist.com/family_practice.htm of the Online CME List and then go to the American Academy of Family Physicians site http://www.aafp.org/x3297.xml or to FamilyPractice.com http://www.familypractice.com/, a very nice site produced by the American Board of Family Practice.

An internist could start at the Internal Medicine section http://www.cmelist.com/internal_medicine.htm of the Online CME List, and then go to Clinical Problem Solving Cases http://cpsc.acponline.org/, sponsored by ACP/ASIM, or to Johns Hopkins Advanced Studies in Medicine

http://www.asimcme.com/htmlfiles/cme_prog.html.

A cardiologist might start at the Cardiology section http://www.cmelist.com/cardiology.htm of the Online CME List and then go to CardioVillage (University of Virginia) http://www.cardiovillage.com/ or to Baylor University's extensive list of cardiology offerings

http://www.baylorcme.org/specialty.cfm?menu_id=38.

Other specialists will find web sites offering CME in 22 additional specialty areas, from Allergy to Urology, linked from the main page of the Online CME List http://www.cmelist.com/list.htm.

Some other ways to find Online CME

The Online CME List, described above, is a good way to find Online CME sites (collections of many CME courses or activities). To find specific individual CME courses (usually one to two hours in length), visit one of the sites described below. Each of these sites gives you the ability to search for individual courses by entering keywords or choosing from a list of subjects.

Medscape

Medscape www.medscape.com has about 150 CME courses in multiple specialties at any one time; most courses offer 1.5 free credit hours; most are text or slide-audio lectures. Registration is unobtrusive and easy. Once you have registered and chosen your medical specialty, each time you re-visit Medscape, you will automatically be taken to your specialty area. With your permission, Medscape will send you periodic emails about CME courses that may interest you.

Doctor's Guide

Doctor's Guide www.docguide.com offers descriptions of, and links to, about 1000 online CME courses. These courses you find are not produced by Doctor's Guide, but Doctor's Guide gives you enough information to help you decide whether to visit the course. When you visit the linked course, you may have to register again and if the instruction is not free, you will have to pay for credit. As with Medscape, you can set up a home page for your specialty and receive emails about courses of interest.

CE Medicus

CE Medicus http://www.cemedicus.com/ offers access and free CME credit to about 450 online CME activities created by six CME providers. Once you register at CE Medicus, all courses are free and no additional registration is needed. CE Medicus will also keep track of all your CME requirements and all your CME activities if you wish.

What do I do now?

Follow the links to any of the Online CME sites described or to your specialty society's home page or to any online CME site you may have heard about. I'm sure you will find it an interesting and informative experience.

*Editor’s Note: CCMS members can receive free CME courses on the internet with World Medical Leaders at www.wml.com. Please call CCMS at 739-9989 for your log-in information.

Top

Malpractice Filings

Top

President’s Message

By Warren Evins, M.D., PhD, 2002-2003 CCMS President

Medicine is in a state of turmoil. The medmal liability crisis in Las Vegas continues to worsen. Hospital beds are inadequate to serve residents of a growing Las Vegas. Local emergency departments are so backed up that ambulances have long waits to turn over patients' care. The county is threatening to close or limit UMC Quick Care hours, where 20% of Las Vegas residents are seen, more visits than all local emergency departments combined occur, and extensive indigent and after hour care happens. Six new hospitals are to be built. Nurses and other health care staff cannot be found now to keep all hospital beds open. Physicians are moving away to practice in physician-friendly states. In addition, legislators in Carson City are requesting the introduction of 200+ bills that affect doctors, about one-fifth of all proposed legislation.

72nd Nevada State Legislature

Most legislators do not have adequate time to read and study all proposed legislation. Many issues are important to physicians. Without two full time lobbyists (Scott Craigie and Larry Matheis) our legislators would not understand, nor be concerned, how a bill affects us. Our lobbyists talk with legislators and their staff. They attend legislative committee meetings and testify, presenting our viewpoint. Multiple meetings can occur simultaneously (Assembly and Senate).

Individual physicians, their spouses, and the public can supplement and reinforce the impact of our lobbyists when they communicate with their Senator or Assembly member. Some legislators say that they do not recognize the full impact of proposed legislation unless they hear from many of their constituents.

For any bill, some legislators may be more important. Included are the chamber's leadership and the chairperson and members of the committee to which the bill is referred.

Bills and Bill Draft Requests (BDRs)

Bills are designated as Assembly or Senate, a number, and may be introduced by one or more members or a committee. Bill draft requests are numbered and can be requested anonymously. We are following a lot of proposed legislation. Examples follow:

Malpractice: SB97 O'Connell (KODIN initiative in an amendable form), AB9-Marvel, AB40-Oceguera (to lengthen filing limits), SB122-Titus, 80-Collins, 104-Shaffer, 107, 122-Titus, 161-Angle, 248 -O'Connell, 835, 857, 980, 1056. Board of Medical Examiners: 223, 508, 707, 709, 834. Medicaid: 482, 746, 763, 764, 775, 885. Physician licensing: 973-Ohrenschall (require Geriatrics training for relicensure), 985, 1036, 1046.

Health policy: AB51, AB55, SB32, SB50, SB82, SB98, SB101, R-25, 54, 59, 69, 70, 75, 84, 241, 512, 650, 706, 720-Neal, 742, 743, 778, 812-Hardy, 816, 912, 931, 988, 1060, 1061, 1120, SCR: 3, 4, 5. Patient referrals: 710-Titus. Re-establish Medical Screening Panel: 927-Mabey. Physician/patient protection: 868. Continuity of care: 819-Gustavson. Surcharge to pay for malpractice increases: 758-Wiener. Patient discounts: 1048. Change pain prescribing: 1055-Schneider. Mental Health: 480, 678, 969, 984, 1075, 1089. Retroactive insurance de-authorizations: 813-Mabey. HMO/MCOS: AB79, SB23-Neal, 213, 792, 995. Insurance: SB11, SB64, 130, 393, 655, 726, 762, 814, 1111. Indigent care: 167, 168. Workers comp: 275, 466, 782, 794, 1085, 1103.

Nursing: AB22, SB83, SB93, 729. Drugs: AB33, AB119, AB144, 26, 66, 127, 152, 165, 268, 326, 349, 530, 590, 656. Hospitals: SB94, SB95, 245, 354, 921. Allow psychologists to admit to hospitals: 404. Scope of practice: 695. Ban panel fees: 683-O'Connell. Rx help desk: 203-Buckley. Ban balance billing: AB70-Giunchigliani. Change taxes: 74-Ohrenschall, 79, 541. Extend filing limits on silicone implants: AB50. MD criminal law changes: AB24. Change Good Samaritan law: 116. Enhance penalty for assault on healthcare worker: AB53. Professional business practices: SB24, SB65.

Without CCMS and NSMA how could physicians protect their practices?

CCMS Elections

There are different styles of leadership. The CCMS mission is serve the needs of physicians, their patients, and the Clark county community with responsibility and integrity. We advocate for physicians, patients, and the community's health, in part through pubic education and legislative analysis. Our leaders work behind the scenes and occasionally with public testimony.

A few physicians think that an effective way to influence legislation and the public is by threats, refusing or withdrawing medical services (to some legislators!), rude behavior, and emphasizing that legislators can be voted out of office (even after landslide victories).

Inserted in this County Line issue is the Nominating committee's proposed slate. These members have met minimum participation requirements. However, any member may run by petition.

Elections will be held in April/May. When it comes time to vote, please vote wisely. Do not let CCMS be taken over by ardent malcontents, boisterous complainers, and emotional naysayers. Physicians' influence and image depends on its leadership.

Keep Our Doctors in Nevada (KODIN)

Medical professional liability reform needs everyone's help. Call legislators using the KODIN 1-800-784-4730 number, talk with patients and friends, install a display in your office, send money, etc.

Physicians are encouraged to visit the Capitol in Carson City to personally lobby for the KODIN initiative. KODIN representatives plan to conduct physician media training in Carson City before the hearings. Thursday, April 3 is set as KODIN Legislative Day. Two other days, at least one in March, will be designated when committee hearing schedules are available.

Keep our Doctors in Nevada

P.O. Box 50154, Henderson, NV 89016

Tax ID # 47-0889225

Top

New Members for January 2003

Congratulations and Welcome to the Clark County Medical Society

Abdolreza Raissi, MD, Orthopaedic Surgery, 2800 E Desert Inn Rd #100, Las Vegas, NV 89121
Aubrey Swartz, MD, Orthopaedic Surgery, 5836 S Pecos Rd #D305, Las Vegas, NV 89120

Membership Applicants To Go Before Credentialing Committee

If you have any pertinent information about the following membership candidates, please contact:

Clark County Medical Society, 2590 E. Russell Rd., Las Vegas, NV 89120

Kayvan Taghipour-Khiabani, MD Plastic Surgery

For information on becoming a member of the Clark County Medical Society, call Marlaina Burns at 739-9989

The Status of Mandatory Competency Testing in Nevada

By Larry Matheis, NSMA Executive Director

The two issues in mandatory competency testing in Nevada involve (1) medical student clinical skills competency testing, and (2) mandatory competency testing for re-licensure. These issues are somewhat related and may be discussed at the Nevada Board of Medical Examiners meeting in Las Vegas on Friday March 7th and Saturday March 8th at the Embassy Suites (4315 Swenson Street). There have been no proposed regulations, written reports (available to the public) or public workshops making it unlikely that there can be any final actions on a significant new policy.

The issues of requiring new licensees to take a clinical skills assessment exam and adopting some form of "continuing competency" evaluation for license renewals are national initiatives by the National Board of Medical Examiners and the Federation of State Medical Boards. The Nevada BME has expressed frequently its desire to be a leader in implementing this latter group's proposals.

The first issue would primarily affect medical students and would require them to take the "Clinical Skills Assessment Examination". There is considerable national debate about the validity of this exam, its cost, and the requirement that students would need to travel to regional testing sites. While NSMA supports the evaluation of medical students’ clinical skills, the current level of medical student debt, the costs incurred by an individual student in registering for and traveling to the examination, as now conceptualized, would be prohibitive. The medical students at the University of Nevada School of Medicine have requested NSMA to oppose the adoption of this policy at this time which is also the position of the AMA nationally.

The second issue involves the so-called "continuing competency" evaluation. The Nevada BME considered including in its 2001 bill draft request (Preliminary Proposed Amendments/Additions by Staff to Nevada Revised Statutes Chapter 630 - Nevada State Board of Medical Examiners - May 15, 2000), the following: "Effective July 1, 2003, the board may not grant biennial registration to any physician who has not within the ten (10) years prior to that biennial registration passed the Special Purpose Examination" (SPEX exam). The outcry by physicians about this ill-conceived idea of requiring every physician to retake the basic clinical sciences portion of the SPEX resulted in the Board's withdrawal of the proposed language from their BDR.

In June 2000, the Nevada BME created a "Committee to Study Post-Licensure Continuing Competency Evaluations" (Chaired by Board member Donald Baepler, PhD). Some of the Committee members and Board staff have attended national and international meetings at which this issue has been discussed. Apparently, although no State has adopted such an approach, several countries have experimented with "continuing competency" exams.

In his verbal reports to the Board in September and December of 2002, Dr. Baepler has expressed the need to move slowly on this initiative and to consider a number of options rather than a mandatory single exam (and that might have to be a newly invented exam rather than the SPEX, which really isn't designed for this purpose), which he no longer views as particularly useful in determining the continuing competence of physicians. He has discussed the possibility that several alternative methods to certify continuing competency could be accepted by the Board: (1) specialty board recertification could be accepted; (2) specialty board certification and credentialing by a JCAHO accredited facility could be accepted; (3) to quote Dr Baepler from the December 2002 meeting: "Then if you're not board certified, if you have privileges at two hospitals with a sufficient case load, 25 minimum each hospital, because a hospital has to have some number of incidences to evaluate you on, we would accept that as well, because it does constitute a, a rigorous evaluation" which will probably need a bit more clarification as a third acceptable alternative; (4) a rural physician exemption for physicians who don't have board certification, multiple hospital affiliation or sees sufficient volume of patients to meet any of the 1st three options, could be required to take a specialized 20 hours CME approved by the Board; and, (5) those who don't fit any other category would be required to take the SPEX, or some other unspecified monitored test.

Again, there has been no written report or proposal so far. These comments by Dr. Baepler reflected an update on the current thinking of his committee. (His comments are available in the transcript of the NSBME's December 5, 2002 meeting as posted by the Clark County Medical Society on the its web site (www.clarkcountymedical.org). The report and discussion are near the end of the meeting, starting on page 132 of the transcript.)

No State has adopted mandatory reexamination or recertifying criteria for all licensed physicians. According to a recent discussion with the other State medical societies, only the Texas State licensing board is actively considering

adopting a similar approach, and it is facing such a negative reaction from practicing physicians that the Texas legislature may prohibit the change. The California board reportedly has begun a study.

While this may be disputed, it is generally true that the introduction of a fundamentally new licensing procedure and criteria requires statutory changes (as did the Board in 2000, when they considered proposing statutory changes in their bill draft request). We expect a March report on the Committee's discussions, and the Committee may be ready soon for workshops to solicit input from physicians and other interested parties. It would be surprising if any Board action could be considered at the March meeting.

Both of these initiatives would have significant impact on the costs of practice as well as the Board's cost (and staffing). Neither seems to be the result of a specific problem with the current licensing and renewal processes. No State has adopted either of these initiatives. A basic question is whether there is a compelling reason to make such fundamental and costly changes? At some point, if the Board continues to pursue these initiatives, they will have to develop convincing explanations for the proposals. It's pretty certain that the State Legislature (as well as the physician community) will take some convincing on this matter.

Top

CEO Editorial

By Weldon (Don) Havins, M.D., J.D., CCMS CEO and Special Counsel

This month's editorial space is deferred to the excellent article by Donald E. Mohs, M.D.

In this season of the legislators, there are many Bills, introduced and that will be introduced. These may profoundly affect the practice of medicine, both good and bad from the physician perspective. NSMA publishes a legislative update via fax which should be read by all. The previous issue of the County Line listed contact information of legislators. Constituent communications are particularly effective. Email, phone, and fax as well as snail mail all work. Identify the Bill by number and express your concerns or support. Your silence provides the opportunity for a legislator to infer your apathy regarding the matters. Never be afraid to try something new. Remember, amateurs built the ark, professionals built the Titanic.

The next issue of County Line will examine a few of the Bills and again provide legislator contact numbers in a relevant committee membership format. Some sagacious wit once said "even if you are on the right track, you'll get run over if you just sit there."

It's medical license renewal time. The Nevada Medical Practice Act requires 2 AMA category I Ethics credit hours to renew a medical license. CCMS (along with co-sponsor UNSOM) is offering a free Ethics course to our members, hospitals are offering Ethics courses, and there are online Category I CME Ethics courses available (for a fee). Due to the persistence of our NBME president, Dr. Cheryl Hug-English, the new licenses come in the form of a plastic card. No more pathetically semi-shredded, shriveled paper license stuffed somewhere into an inaccessible area of our wallets. Our thanks and appreciation to Dr. Hug-English.

In the miscellaneous section in our website, www.clarkcountymedical.org, there is a letter from the consumer organization, Public Citizen, to the FTC Chairman, Timothy Muris, asking the FTC to launch an immediate investigation into the New Jersey physicians "job actions", a collective activity considered a "classic form of a group boycott" in violation of section 5 of the Federal Trade Commission Act, 15 USC 45.

It is worth reading.

Top

The Nevada Health Care Providers Guide to HIPAA Privacy Standards

The HIPAA Privacy Standards become effective on April 14, 2003. To assist in your implementation, healthcare attorney Kelly Testolin has drafted the “Nevada Health Care Provider’s Guide to the HIPAA Privacy Standards.” The Guide is available to all members on our web site at www.clarkcountymedical.org.

This Guide stands apart from other HIPAA-related materials for a number of reasons.

Brevity. In just 30 pages (with 20 pages of model forms and exhibits), the Guide tells Nevada physicians how to deal with most of the issues they will encounter under the Privacy Standards, and alerts them to the unique features of the Privacy Standards that are not yet well understood.
Directness. The Guide tells Nevada physicians what to do to make their operations HIPAA-compliant in a simple, straightforward manner.
Simplicity. The text of the Guide is as close to layman’s language as is possible.
Integration with Nevada’s Confidentiality Laws. The Guide tells Nevada physicians how to simultaneously comply with the Privacy Standards, Nevada confidentiality laws and the federal drug and alcohol abuse regulations in accordance with HIPAA’s pre-emption rules.
Integration with Nevada’s Law Concerning Minors. The Guide is the only available resource that tells Nevada physicians how to comply with HIPAA’s rules concerning the control of health information by unemancipated minors and/or their parents, as these considerations involve correlation of the Privacy Standards with Nevada law.

Top

2003 LEGISLATIVE CALENDAR

MARCH

10 Legislator's Bill Drafting Must Be Completed

17 Last Day for Legislator's Bill Introductions and Committee's Bill Drafting Must Be Completed

24 Last Day for Committees' Bill Introductions

APRIL

11 Committee Passage (From First House)

22 First House Passage

MAY

16 Committee Passage (From Second House)

23 Second House Passage

28 Exempt Bills From Committee

31 Conference Reports Go To Drafting

JUNE

2 Legislature Adjourns (Sine Die)

Top

Update on University Medical Center

Note: The following material is condensed and edited from an e-mail newsletter sent to Clark County Employees.

The Hospital's operating deficit has forced staff reductions and position downgrades. UMC has lost approximately $18 million for the first six months of the fiscal year (July, 2002 - December 31, 2002). [UMC] took great pains to ensure that these cuts did not affect core services and patient care. Staffing changes were made strategically after a review of the hospital's entire workforce. The personnel reductions are being made as part of an ongoing effort to reduce the hospital's losses and eliminate UMC's reliance on subsidies.

The personnel changes made resulted in 37 employees being laid off, 14 employees being downgraded in position and pay, and 128 vacant positions being eliminated. Approximately 70% of these impacts were at the quick and primary care centers which have seen a 15% decrease in patient volume in the past year. The most dramatic reduction in service will take place at the McCarran Quick Care, 1769 E. Russell Road, which currently operates 24-hours-a-day, seven days a week. Early in March the McCarran Quick Care will shorten its hours of operation to 7 a.m. to midnight, seven days a week.

In conjunction with these attempts to reduce cost are the efforts of the consulting firms and Audit Department. The Lewin Group has been contracted to conduct an analysis of the UMC quick and primary cares, physician contracts, medical school contract and staffing patterns at the hospital. While a final report is scheduled for the end of February, the results will have to be weighed with the report by Deloitte and Touche. These studies are interdependent. Deloitte and Touche's review of the inpatient billing practices and receivables are intended to improve collection efforts. While findings have not been completed, Deloitte and Touche has stated that there are issues with billing function. [UMC is] also reviewing how [they] interpret the EMTALA laws for the hospital and quick and primary cares. Part of the federal EMTALA law regulates the manner in which medical providers request financial information. The purpose of the law is to prevent "dumping" of non-insured patients.

There has been no determination made on whether to close down any additional quick care clinics, nor has a decision been made to sell any of them.

Based on information requested by the Lewin Group and prepared by UMC personnel, the quick and primary cares have significantly reduced their net contribution margins over the past year. The net contribution margin is the amount of money UMC earns from directly operating the quick cares from referrals to UMC attributable to these outpatient sites. Lewin Group calculated the fiscal year 2002 net contribution margin to be $800,000, or close to a breakeven scenario.

In order to increase patient volume, UMC will begin a scaled-down advertising program to promote the quick care network. The advertising program will start up this month and run through the end of the fiscal year.

The Lewin Group will be making staffing comparisons at UMC based on staffing patterns at other public hospitals nationally.

The Clark County Audit Department has completed an audit of the long-term care placement function. The report is in draft form but indicates that various functions involved in the long-term care placement can be streamlined to eliminate duplication of effort, and to improve communications within the hospital and to County agencies. The report also points out the difficulty in placing long-term care patients, especially those with funding problems or behavioral, mental or non-acute medical problems.

In conjunction with the operational reviews, a public participation program has been designed to educate and incorporate public input. The community participation plan will ensure that the major stakeholders and the public have input into policies that will be shaped to address the challenges at UMC. The public participation program contains three major components: stakeholder focus groups, public hearings and the creation of a UMC Citizen Task Force.

The UMC Citizen Task Force will be charged with evaluating all the information that is provided from the consultants' reviews, the stakeholder focus groups, and the public hearings. Task Force members will become educated on the key issues and challenges facing UMC and will be asked to develop a set of consensus-based recommendations for the Board of County Commissioners to consider as they develop future policy for UMC. The Task Force will also be asked to develop and recommend a UMC Vision and Mission Statement for the Board of County Commissioners to adopt. The Citizen Task Force will convene for a period of approximately six months and be comprised of members representing gaming, business, banking, real estate, academia, health care, general labor and the law. [FYI] see attached list of the 10-member UMC Citizen Task Force.

Individual stakeholder focus groups will be scheduled with individuals representing a variety of groups such as: healthcare providers, labor, employees, private hospitals, physicians, and the uninsured themselves. This information will then be conveyed to the Citizen Task Force for them to incorporate into their discussions, evaluation and recommendation development.

Staff will also hold community public hearings with the Task Force to give the general public an opportunity to receive information and provide input regarding UMC directly to the UMC Citizen Task Force. The Task Force will take the comments gathered and incorporate them into their discussions.

UNIVERSITY MEDICAL CENTER CITIZEN TASK FORCE

* Bill McBeath, President & COO, The Mirage;

Bill Martin, President & CEO, NV State Bank;

Bob Forbuss, President, Strategic Alliance (business consulting group) and Former President, Las Vegas Chamber of Commerce;

Dr. Jeff Waddoups, Associate Professor of Economics, University of Nevada Las Vegas Department of Economics;

Bobbette Bond, Participant Services Manager, Culinary Health Fund;

Dr. Reva Anderson, Executive Director, Sista To Sista (participating organization in Clark County Health Access Consortium);

Patti Allen, President, Health Strategies, Inc.;

Dr. Otto Ravenholt, Former/ retired Chief Health Officer, Clark County Health Department;

Tony Sanchez, Attorney, Jones, Vargas, President Latin Chamber of Commerce;

Ron Tiberti, Owner, Tiberti-Blood Construction

*Appointed Chair, UMC Citizen Task Force

Top

Calendar of Events

March 7 to March 8 - Nevada Board of Medical Examiners meeting at Embassy Suites, 4315 Swenson, in Las Vegas.
April 15 - Deadline for Write-In Nominations to be included on CCMS Election Ballots.
May 1 - CCMS Election Ballots mailed to members, with closing of the polls at 5 p.m. on May 15.
May 31 - CCMS Installation Dinner. Time and location to be announced.

Top

Minutes Synopsis

(Members can receive a full copy of meeting minutes by calling 739-9989.)

CLARK COUNTY MEDICAL SOCIETY BOARD OF TRUSTEES MEETING

Tuesday, January 21, 2003; 6:00 P.M.

Action Items

The minutes from the November 21 Board meeting and the minutes from the December 17 Executive Council meeting were approved.
With the expenses down, there should be enough in reserve to cover the expenses for this fiscal year. Revenue is down about $43,000 compared to the revenue last year at this time but expenses are down $72,500 compared to the expenses last year at this time. The financial report was approved unanimously.

Committee Reports

Two new members, Abdolreza Raissi, MD and Aubrey Swartz, MD, were approved for membership.
Packets inviting membership were mailed to the 31 newly licensed physicians in Clark County.
The Mini-Internship was conducted last week, and the follow-up dinner last Thursday was a great success. It was suggested the program be repeated in the fall.
There is very little money left in the MedPac BankWest account. MedPac income taxes are to be prepared soon.
Scott Craigie, who is the NSMA lobbyist, has contracted to be the KODIN lobbyist. Mr. Craigie will be a strategist in the major campaign to try to get KODIN passed at this legislative session. Money is needed to defend the provisions of the Initiative in the anticipated constitutional challenges sure to arise.
Board of Trustees are automatically assigned as delegates for the NSMA annual meeting to be held in May in Reno at the Atlantis Hotel and Resort. A meeting of the Delegates will follow the Board meeting.
Nominations for 2003 elections must be selected by March. Dr. Evins asked that any one interested in an officer position, or if their term is up and they would like to continue to be a trustee, to notify CCMS staff.
The Government Affairs Committee met in December and discussed “any willing provider” issues and the liability limits hospitals require for staff privileges. A letter will be mailed to each Clark County hospital Chief of Staff asking them to lobby for eliminating the medical staff requirement of $1 million/$3 million medical liability insurance.
Dr. Jones formally informed the Board of the suicide of UMC fourth year resident Andrew Bruton.

Alliance Report

The Membership Dinner was a great success. The Alliance's next big event will be their Armani fashion show to be held in March with the proceeds to go to two causes; Feed the Families for Effective Autism Treatment (FEAT) and the scholarship accepting a new student into Horizon's academy.

President’s Report

Dr. Evins announced the death of Jeffrey Arenswald, a Dermatologist and member of the Society since 1998.

Old Business

There was discussion regarding the "Any Willing Doctor" bill.
The bill to reconstitute an improved medical dental screening panel was endorsed by the Board.
The bill to amend the Open Meeting Act in several ways was endorsed by the Board.
The bill to change the authority of the NBME was endorsed by the Board.
These three bills, the Medical Dental Screening Panel, the Open Meeting Law and the Public Interest Act for the NBME, will be submitted to the Delegation for submission to the NSMA House of Delegates.

New Business

Deb Barton will soon begin working on the new pictorial directory. A photography company will provide CCMS with pictures they take of members for the pictorial directory in exchange for the list of members and their phone numbers so that they can attempt to schedule sessions with the photographer.
The County Line newsletter and applications will be sent to all non-member physicians in Clark County as a membership drive one time.
The bill draft, UCCSN Board of Regents Plan to Double the Capacity of the Programs of Nursing within the System, was endorsed by the Board.
AHEC will hold a Bio-Terrorism CME activity here at the Clark County Medical Society in April.
CCMS will place a $500 half page ad in the UNSOM graduation album as was done last year. The ad will specifically invite the graduates to join the Society.

The next meeting will be Tuesday, February 18, 2003 at 6 PM.

There being no further business, the meeting was adjourned by Dr. Evins at 8:20 pm.

Top

Corrections

The University of Nevada School of Medicine has informed the Clark County Medical Society that the January issue County Line article on page 3 regarding Dr. Andrew Bruton contained three factual errors:

During the time Dr. Andrew Bruton was a resident in OB/GYN, the following has occurred:

1. There has been a significant decrease in resident work hours. Although the ACGME will implement new standards effective July 1, 2003 the University of Nevada School of Medicine had already modified its work schedule to bring the residents work week within the anticipated standards established by the ACGME. This change occurred a year early.

2. In fact, the number of babies delivered by the residents has decreased dramatically over the last three years in part because the School of Medicine has hired four Nurse Midwives to assist the residents and the faculty attending physicians.

3. The article stated that the Chairman of the OB/GYN Department at the School of Medicine received two warning letters from the residency accrediting body. The Chair did not receive two warning letters. A report from an ACGME site visit in 2000 cited an excessive obstetrical workload at that time. However, the Program was reviewed, most recently in August 2001, and in a letter dated November 13, 2001 from the ACGME to the Director of the OB/GYN Residency Program there were no citations relating either to the number of hours worked by the residents or the number of babies delivered by the residents. As of November 13, 2001 the Program was fully accredited and remains in that status today.

CCMS regrets any negative effects the erroneous information received and published by CCMS may have caused.

An incorrect e-mail address was listed for State Senator Barbara Cegavske on page 8 in the 2003 Nevada State Legislative Contact Information chart in the February County Line. Her correct e-mail address is bcegavske@sen.state.nv.us.

Top

Alliance Message

By Karen Schroeder, 2002-2003 CCMS Alliance President

What a wonderful opportunity we had this past week. It was a time to honor our members and to remember, as Tommy Lasorda said, "The difference between the impossible and the possible lies in a person's determination". We as an Alliance were determined for more than 50 years to do something for our community and our physician spouses. This month we honor not only our fifty-year member, Agnes Phillips but all members of the Clark County Medical Society Alliance. Our Nevada State Medical Association Alliance President, Rene Rores was here in Las Vegas to help us with bestowing that honor. The delicious luncheon was held in the Palm Room at the Four Seasons. All members attending received a rose corsage and a box of chocolates. Those twenty-year and up members received a crystal heart box and our fifty year member, Agnes Phillips took home a beautiful engraved clock.

We continue to gather children's books ages preschool to grade four for our ongoing effort to support Spread the Word Kids to Kids. Anyone having books to donate may bring them to any Alliance function or drop them off at the Medical Society office.

Our legislature is back in session. Many things that will directly affect all of us will be decided and we will soon have new laws. I encourage you to fulfill your responsibility as a citizen in Nevada to have your voice heard. Call your State Senate and Assembly members and tell them how you want them to vote. I also encourage you to call 1-800-784-4730 and ask your legislators to address the "Keep Our Doctors in Nevada" initiative. Remember piles of snowflakes will be noticed.

Top

CME Calendar

· Cardiovascular Consultants 691-9154

· Clark County Medical Society 739-9989

3/22 - “Contemporary Health Law Ethics,” 8:45 - 11 a.m., 2 CME hours

Future Programs Planned

April - “Bioterrorism,” “Obesity”

May - “Ophthalmology,” “Expert Witness”

June - “End of Life”

August - “Patient Consent and Rights”

· St. Rose Hospital 616-5832

· Southwest Medical Associates 242-7347

3/13 - “Management of the Acute Abdomen,” 7:30 a.m.

· Sunrise Hospital 731-8210

· UMC 383-2425

3/1 - “ACLS Initial Training For Physicians Only,” 8 a.m., 8 CME hours

· Valley Hospital 388-4847

3/11 - “Weight Loss Surgeries,” noon

3/25 - “Common Dermatology Problems for Primary Care Physicians,” noon

4/8 - “Alzheimer’s Disease Update,” noon

4/22 - “PET/CT Scan: The New Synergy, noon

5/13 - “Ocular Trauma and Corrective Surgery,” noon

5/27 - “Hepatitis C,” noon

· Valley Hospital & the American Diabetes Association 369-9995

3/8 - “The 2003 Las Vegas Diabetes Symposium,” 9 a.m., 4 CME hours

*Special Note: CCMS members can receive free CME courses on the internet with World Medical Leaders.

To have your CME courses listed on our calendar, please contact Deborah Barton at 739-9989 prior to the deadline of the 12th each month.

Top

CLARK COUNTY HEALTH DISTRICT DISEASE STATISTICS* - JANUARY 2003

DISEASE CASES REPORTED YEAR TO DATE

1/02 1/03 2002 2003

VACCINE PREVENTABLE DISEASES

DIPTHERIA 0 0 0 0

HAEMOPHILUS INFLUENZA 0 1 0 1

(invasive)

HEPATITIS A 3 1 3 1

HEPATITIS B 3 4 3 4

INFLUENZA

Contents

Guest Editorial: A Healer's Lament