On moving to Las Vegas from Reno in 1988, I (Roitman) continued my role as Nevada Representative to the American Psychiatric Association Assembly. I attended the Las Vegas meetings that were attended by the area's powerful, high profile private psychiatrists such as Hal Orchow, Carlos Laborati, and Bill O'Gorman, medical pioneers who have now passed on. This group was lively and the psychiatrists were frank and outspoken. There was little discussion about the incursion of managed care. Everyone seemed flush.

The new private psychiatric hospitals (Charter and Montevista) enjoyed the flush of a relatively unregulated market. Lengths of stays were measured in months, sometimes even one or two years. Payors sent what amounted to blank checks to hospitals and doctors. This rosy environment came out of the traditions of long-term psychoanalytic treatment and state hospital commitments. At that time the public trusted doctors to decide what was best for them. Before the "era of the brain" and advances in psychopharmacology the purpose of psychiatry was to help individuals reemerge from states of "alienation" (early psychiatrists were called alienists) and connect back to their natures. State hospitals were gifts from the community to the shell shocked and bewildered. For asylum, like tuberculosis centers, they were located at a distance from populated areas.

While the alienation of 19th century patients was addressed by having them live in what was termed a moral community where they farmed the hospital's orchards and gardens, the first half of the 20th century was characterized by psychoanalytic inpatient treatment with patients taking up residence in a tranquil and aesthetically pleasing environment while receiving daily psychoanalysis.

The second half of the 20th century brought biological treatments with anti-psychotics such as Thorazine and triggered an expectation that psychiatry would rejoin the medical community and our patients would rejoin their families and communities. Although the promise turned out to be a bit optimistic, biological treatments including electroconvulsive therapy (ECT) replaced working through and healing via talk therapy as the humane way to get people back home rapidly. As a happy benefit, we anticipated that deinstitutionalization would relieve the political and economic pressures on governments that funded the hospitals. The "re-scientification" of psychiatry led to a rethinking of admission and departmental leadership policies in the medical schools, and psychiatry was swept along with the rest of medicine to become more accountable, less of a "hand-holding" profession, and more of an evidenced-based application of research and applied technology.

In contradistinction, in the mid eighties, lengths of stays were still enriched and insurance policies remained open-ended. Psychiatric treatment became more acceptable due to popularizations such as the Bob Newhart Show and Psychology Today magazine, as well as a flood of mental health professionals entering the market. Huge increases in the diagnoses of bipolar disorder, autism and attention deficit disorder, and expansion of psychiatry into child and adolescent areas led to an increased demand on insurance reimbursements. Insurance companies were largely passive responders financing of whatever treatment ordered by the doctor. There were clearly abuses.

Initially there was an excitement about the promise of Heath Maintenance Organizations (HMOs) that were conceived as proactive medical services treating early signs of disease. The HMO would, (theoretically) benefit financially by keeping everyone healthy. In medical school the liberal fringe was singing their praises. What was initially seen as a proactive effort of doctors and nurses evolved into a chimera of administrators and non-medical regulators using tortuous medical rules to justify denials under the thinly veiled arbitrary term, "medical necessity." HMOs are now managed care, a much more diverse definition which places emphasis on the regulation of cost, rather than the prevention of disease. Although the entree of this business model was humane treatment, the outcome is what we are living with now.

The managed care industry made its first major intrusion by standardizing length of stays for medical conditions via DRGs (diagnostic related groups) and angering doctors by challenging their autonomy and sometimes demeaning them in the eyes of their patients. With the appearance of local, and then national, regulatory groups (utilization review companies) authorization and legal permission was obtained to review the charts, and bypass the doctors in order to talk directly to the insurance subscribers (read patients) about their care. No chart? No talk? No money. Doctors felt undermined and criticized. The focus moved away from control of medicine by doctor practice, and toward control of market shares by payors. Thus psychiatric care shifted to brief stays in acute facilities so much so that it is now difficult to find a traditional care environment, aside from a few places back East, even for financially resourceful families.

The reduction in lengths of stays, however, had little scientific foundation (nor did the extended stays). The hospitals, and then the schools of medicine and research centers scrambled to reinvent psychiatry. Aggressive treatments, rapid dosing, presumption of diagnoses, overlapping treatments, and reduction in diagnostic workups became the community standard. Diagnosis was performed through checklists and brief interviews that rapidly matched symptoms with objective criteria rather than understanding the pathogenesis of disease. Medical science is driven by economics. Research seemed to followed practice, rather then the other way around. The tail wags the dog. This cultural switch is relevant to what is happening today in not just psychiatry, but in medicine in general.

Current Profile of Psychiatry

After a hiatus from organized medicine, the Nevada Psychiatric Association meetings seemed much different than fifteen years ago. There are residents at the meetings. Medical school faculty members are there, and there is a large body of practitioners from the governmental facilities. There are a scant number of private practitioners. Most doctors are employed. A few months ago, a psychiatrist informed us that she was leaving Westcare Crisis Unit that was opened to rescue the State from its triage problems. She was finding the practice of psychiatry there impossible without trained frontline psychiatric staff and nurses, and the ratios were insane. The broken spirited resignation of our colleagues was profound. We seemed hopeless in regard to our ability to influence policy that led to the stacking of patients in the medical emergency rooms, or the turfing of psychiatric responsibilities to non-psychiatric facilities. We started to moan about more Nevada abuse and neglect. This was much different than the days of Orchow.

We felt as though here in Las Vegas we were in a separate reality where our patients were untouchables to be removed from the halls of these nicely carpeted facilities, transported to and concentrated on a few acres on West Charleston. Differential psychiatric diagnosis was to be extricated from emergency departments. Psych "clients" would be separated out from real patients based on objective criteria employed by technical assistants in ambulances. There were no plans for child services, even though UMC has turned away over 600 child patients without receiving care from their trauma unit last year.

The city seems to be operating under some grand illusion that transport away from city locations to 6161 W. Charleston will help. But the demand is growing; the problem will just more likely be concealed there for a little bit until some atrocity happens, and then an expose (sounds like child welfare perhaps). For a little while, after another ill-advised investment that does not solve the problem, patients will stack up there in greater numbers, remaining undiagnosed and untreated.

Psychiatric conditions effect every segment of the population, rich and poor, insured and not. Family members of all strata have witnessed the handcuffing, transport by ambulance and the sometimes interminable weeks waiting in regular hospitals because there are no active treatments there. These problems are not because of lack of beds. Not every emergency room patient, psych or not should be admitted.

Gurney hallway restraint what happens with acuity because our emergency departments just do not know what else to do. I heard a deeply disturbing radio interview (podcasted on KNPR by Dave Burns, State of Nevada titled, Children's Mental Health Needs). A caring and responsible mother of a teen had to bring her daughter's medication from home and administer it herself while her daughter was restrained for days in the hallway. She needed psychiatry there in the emergency department. More horrifying than the fact that the patient was neglected, untreated and tied up while in crises in a medical facility, was the matter of fact attitude the mother had about this extraordinary scene. This is the standard that this community, and perhaps no other, has come to accept.

The emergency room is just an iceberg tip. Teens are in UMC for months on medical wards with untrained staff who, not knowing any better, enable the psychiatric illness. There is a frightening scarcity of appropriate psychiatric consultation for medical and surgical inpatients with psychiatric problems. The tsunami of Las Vegas population makes it necessary to develop truly full service care at all hospitals, instead of trying to sweep the problem under the West Charleston rug for another few years.

Although Nevada has its traditions of isolation and duplicated services, things have changed. As we noted about the new profile of the NPA, there are thirty residents and their faculty in the school of medicine, many of the doctors are being trained in consultation psychiatry, and since we had no problem filling the classes, it seems reasonable that if the problem is manpower, we can get some more. There is no longer the need to concentrate these patients away from their hospitals family and neighborhoods. Why stigmatize them further with involuntary commitment when they may only need active treatment and discharge?

Psychiatric patients have co-occurring medical illnesses, and many medical patients have psychiatric problems. Duplicating administrations as a result of duplicating medical screen, labs, doctors and nurses in additional facilities, and emergency room policies, and procedures, is an overly simplified understanding of the task of medical differential diagnosis. It is wasteful as well. The money needs to go to consultation labor (psychiatrists and their clinical extenders), not more bricks and administrators. Judgment of priority of treatment needs to be made by a triage physician, not the EMT based on a chief complaint, the impression of a police officer, or the assertion of a hospital family member. Psychiatry is a tool that can be used to violate civil rights, and it seems important for someone with sufficient medical training and experience to be the one to determine diagnosis and treatment, and if necessary involuntary status based on a decent and comprehensive assessment.

The establishment of Westcare, a non-psychiatric facility staffed primarily by non-psychiatric personnel, not Joint Commissioned, not reimbursable, devoid of accountability for psychiatric treatment standards sets a precedent for the way medical services are disrespected. Although I appreciate and value Westcare stepping up to the plate and helping us with this humanitarian crisis, this dilution of psychiatry should alarm the general medical community. The state of psychiatry in the state of Nevada is a blind extension of Nevada's traditions and its lack of medical direction in regard to broad policy. My concern is as costs and administration continues to dominate medical decisions, procedures and public policies, the definition of what a hospital is, and what doctors do will continue to deteriorate.

We have seen psychiatry's problems become everyone's problems. In response the Clark County Medical Society and the Nevada State Medical Association have adopted a resolution to encourage the integration of psychiatric services in all Nevada hospitals. However, our opinions and our resolution about the need for psychiatry in full service hospitals are being cast aside. Of course with any community plan there are certain problems that need to be addressed, such as recruitment, reimbursement and improving the culture that surrounds psychiatric care.

And we need to do what we can as physicians to assure the public that if there are some major community crises, the hospitals will have the staff, the experience and the tools to help with panic and stress. People see the hospitals as places where they can get help for these problems, and will continue to present to the emergency departments regardless of the plans to transport them to a secluded location.

After years of practicing in this field, there is still rarely a day where we don't detect the probing influences of economics, government, and special interests trying to control the decisions made in the examining room. They are distracting, and often controlling. But more and more political processes demand the active participation of physicians representing patient interests. In this regard, due to the diversity of patients, we need to act and speak like physicians, rather than Republicans, Democrats, Christians, Muslims or Jews.

Ironically, this issue of promoting consultation liaison instead of centralization is financially conservative as well as humane, being that dollars would be spent on medical manpower to consult, treat and triage in existing facilities, rather than erect, administrate, staff, transport back and forth, duplicate instruments and diagnostic machinery, and clean, quality assure, heat and cool more space. Accurate identification and aggressive treatment can prevent hospitalization. Addressing all co-occurring disorders can reduce medical stays, and pathology.

Even if we don't win our (unanimous) position on psychiatry integration, it seems to me that we need to have one, or else we will be defined by others. This psychiatric crisis provides such an opportunity for us to stand up for all patients, not just psych patients. Showing support to keep our medical community unified is something we have already gotten our minds wrapped around, and I encourage all of you who have had the terrible pain of psychiatric symptoms in one way or another touch your lives, your medical practices, and perhaps your families to please be alert. How the community treats the medical specialty of psychiatry is relevant to your personal and professional lives. It is destructive and humiliating to be restrained for weeks, untreated, and then committed. Active treatment on site regardless if the problems are big or small can prevent this repetition of the abuse of psychiatric patients, which unfortunately is another horrifying tradition.

(The opinions expressed in editorials are those of the author(s), and not necessarily those of the Clark County Medical Society.)

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CCMS Welcomes New Office Manager

Jamie Alberti is the new Office Manager for the Clark County Medical Society. She was born in Davenport, IA and resided for the majority of her life in Dallas, TX. She graduated from the University of North Texas in 2004 with a Bachelor of Arts in Psychology, emphasizing on Industrial and Organizational Psychology and is currently pursuing her Masters of Business Administration with an expected graduation date of March 2008. While in undergraduate school, she created and ran a successful promotional company for local businesses and artists until she relocated to Las Vegas in 2004. She began her career here as an Office Manager for a local commercial service company and was quickly promoted to General Manager. Her duties included overseeing 70+ employees, daily operations, contract negotiation, sales, accounting, quality control, and human resources. She then became the Director of Graduate Development at a local Allied Health Care Institute where she assisted the graduates in career preparation and finding gainful employment in their field of study while overseeing all students completing their externships. She has vocational interests in the arts, education, traveling, photography, and music.

Miss Alberti joined the Clark County Medical Society in July 2006. She looks forward to utilizing her excellent administration skills to further the goals of the Medical Society, serving the Medical Society's interests, and fostering growth in Medical Society membership.

Dot Freel will move to half time on September 1. Dot will continue putting together the County Line and serve as the Executive Director of MedPac and Treasurer of the Southern Nevada Medical Industry Coalition PAC.

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PRESIDENT’S MESSAGE

By Florence Jameson, M.D., 2006-2007 CCMS President

STOP AND READ THAT FAX

Stop, don't throw away that fax before you have read, copied and shared the urgent information on that fax! I'm sure by now your staff may be getting tired of seeing faxes from Clark County Medical Society on the candidates that need our support, candidates that will support us and access to health care in Nevada. It is the beginning of the political season, a most important moment for all of us in medicine. Please alert your staff not to disregard CCMS' important faxes. On the contrary, be sure to instruct staff to copy the information on each fax to give to patients and friends.

We need to pass out relevant information from CCMS to our patients. It is ideal to personally hand out this information to our patients. They trust and respect our opinion. Let them know that these elections are vital to health care in the state, as they are! Tell them that you need them to help maintain access to medical care in Nevada, that their vote is very important. We must elect representatives in the Senate and Assembly who will defend Question 3. You must know that there are candidates who would love to unwind the progress that we have made. You must know that there are candidates whose platform it will be to unwind the progress that we have made. It is imperative to identify these people early on and to encourage appropriate voting.

Tell your patients to vote. This encouragement will take you 30 seconds times the number of your patients. This will be the most important step you can take to help preserve quality health care in Nevada.

November 2006 is coming quick. Encourage your patients to vote early, avoid the rush. In the Texas election of 2003 the decisive votes for Tort Reform were cast in early voting. The results of that election were history by election day! It is extremely important to encourage our patients to vote early.

Human nature is such that we tend to procrastinate, wait until the last minute to do the important. We must rise above and encourage our patients to rise above this aspect of human nature and to become passionate about the cause for which we are voting.

Our cause is one of the highest of causes. We are committed to the maintenance of good physical and mental health care. As the saying goes, without your health, what do you have?

In this crazy, upside down world we live in today we sometimes lose focus, forget our principles and our causes. We get sidetracked by our shrinking compensation, high overhead, low reimbursements, and forget the bigger picture. Worst of all we think and begin to believe that we truly are the slaves and targets of the HMOs, targets for lawyers, not appreciated by patients, etc…

Some of you may say that: "I can't make a difference, what can I do to improve our lot?" The truth is that you can make a difference. You already have made such a difference with Question 3 and it is imperative that we continue this momentum. Yes! If each one of us takes seriously our opportunity to improve our lot, we will! Together we are stronger. Together we will contact and educate the patient population on the significant issues. Above all, we must work to get a Supreme Court elected that will uphold the validity of Question 3.

I ask you: "Please read your faxes. Educate yourself. Educate your patients, with handouts and banners in your front office. Encourage voter registration and early voting. Vote yourself. Inform family and friends of the issues that face us. Let your neighbors know the issues regarding our candidates."

Together we will be a powerful force again for progress in health care. We will help to change the landscape of medicine here in Nevada for the better. Thank you in advance for your commitment to this worthy cause. I know that I can count on you to help make a difference. God bless you.

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Clark County District Court Medical Malpractice Filings

Against Health Care Providers, Jan 2001 – July 2006

2001 2002 2003 2004 2005 2006

Jan 39 33 108 61 41 50

Feb 20 14 98 72 63 61

Mar 35 30 169 123 64 38

Apr 37 34 111 81 70 58

May 37 35 126 65 14 71

Jun 27 24 103 90 65 83

Jul 19 100 114 45 66 74

Aug 54 51 76 67 33

Sep 20 65 105 79 36

Oct 37 83 110 59 26

Nov 38 184 59 78 68

Dec 9 170 67 47 30

Sum 372 823 1246 867 581

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Member News

Congratulations and Welcome to the Clark County Medical Society New Members –

August 2006

· Tanveer Akbar, MD - Internal Medicine, 1200 S MLK Blvd, 2nd FL, Las Vegas, NV 89102

· Ali Arbabi, MD - Family Practice, 4880 S Wynn Rd, Las Vegas, NV 89103

· Lesley R Dickson, MD - Psychiatry, PO Box 360001, N Las Vegas, NV 89036

· Eric S Farbman, MD - Neurology, 880 Seven Hills Dr 200, Henderson, NV 89052

· Robert C Hayes, MD - Family Practice, 4880 S Wynn Rd, Las Vegas, NV 89103

· Nancy M Hsiao, MD - Internal Medicine, 7918 W Sahara Ave, Las Vegas, NV 89119

· Byron Kilpatrick, MD - Family Practice, 595 W Lake Mead Blvd 400, Henderson, NV 89015

· Peter Mansky, MD - Psychiatry, 4811 W Charleston Blvd 2-382, Las Vegas, NV 89117

· Thomas S Roben, DO - Internal Medicine, 9499 W Charleston Blvd 150, Henderson, NV 89117

· Shekh S Saghir, MD - Internal Medicine, 1200 S MLK Blvd, Las Vegas, NV 89102

· Reynaldo A Santos, MD - Pediatrics, 3150 N Tenaya Way 260, Las, Vegas, NV 89128

· Darren R Swenson, MD - Internal Medicine, PO Box 750998, Las, Vegas, NV 89136

· Craig T Tingey, MD - Orthopaedics, 7200 Cathedral Rock Dr 170, Las Vegas, NV 89128

· Dean S Tsai, MD - Internal Medicine, 2825 Siena Heights, Henderson, NV 89052

· Jon L Siems, MD - Ophthalmology, 1000 S Rampart Blvd 10, Las Vegas, NV 89145

· Edward S Ashman, MD - Orthopaedics, 2650 N Tenaya 301, Las Vegas, NV 89128

· Marcelino C Belizario, MD - Internal Medicine, 1200 S MLK Blvd, Las Vegas, NV 89102

· Thomas C Kim, MD - Orthopaedics, 2650 N Tenaya Way 301, Las Vegas, NV 89128

· Frank C Lee, DO - Emergency Medicine, 1200 S MLK Blvd, Las Vegas, NV 89102

· Susan A Miko, DO - Internal Medicine, 4880 S Wynn Rd, Las Vegas, NV 89103

· Alison M Nguyen, MD - Diagnostic Radiology, 2950 S Maryland Pkwy, Las Vegas, NV 89109

· Mark S Scheller, MD - Anesthesiology, 3590 Sahara Ave 216, Las Vegas, NV 89102

· Gary R Skankey, MD - Infectious Disease, 3006 S Maryland Pkwy 780, Las Vegas, NV 89109

· Robert Toledo, DO - OB-Gyn, 98 E Lake Mead Pkwy 204, Henderson, NV 89015

· Joseph F Urgan, MD - Pathology, 2020 Palomino Ln 100, Las Vegas, NV 89106

· Stephen H Chen, MD - Diagnostic Radiology, 2950 S Maryland Pkwy, Las Vegas, NV 89109

· Yung H Cho, MD - Radiology, 2020 Palomino Ln 100, Las Vegas, NV 89106

· Whitney B Edmister, MD - Radiology, 2020 Palomino Ln 100, Las Vegas, NV 89106

· Robert A Kilpatrick, MD - Pediatric Emergency Medicine, 3006 S Maryland Pkwy 505, Las Vegas, NV 89109

· Neha H Mehta, MD - Pediatrics, 3006 S Maryland Pkwy 505, Las Vegas, NV 89109

· Marc K O’Connor, MD - Pediatric Emergency Medicine, 3006 S Maryland Pkwy 505, Las Vegas, NV 89109

· Theresa M Vergara, MD - Pediatric Emergency Medicine, 3006 S Maryland Pkwy 505, Las Vegas, NV 89109

· Michael S Zbiegien, MD - Pediatric Emergency Medicine, 3006 S Maryland Pkwy 505, Las Vegas, NV 89109

· Harold Zilberman, MD - Pediatric Emergency Medicine, 3006 S Maryland Pkwy 505, Las Vegas, NV 89109

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

Kurt A Buzard, MD - Ophthalmology
Harry W Donias, MD - Cardiothoracic Surgery
Michael D Gouvion, MD - Diagnostic Radiology
Margaret A Terhar, MD- General Surgery

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

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NEVADA STATE BOARD OF MEDICAL EXAMINERS LEGISLATIVE INITIATIVES FOR THE 2007 SESSION OF THE NV LEGISLATURE

The following are the proposals for statutory changes the Nevada State Board of Medical Examiners is considering pursuing with the Nevada Legislature during the 2007 Legislative Session.

1. Amend NRS 630.254(1), to add the requirement that a licensee notify the Board of a change of address in writing, and increasing the amount of the fine for failing to timely notify the Board of a change of address.

"1. Each licensee shall maintain a permanent mailing address with the Board to which all communications from the Board to the licensee must be sent. A licensee who changes his permanent mailing address shall notify the Board in writing of his new permanent mailing address within 30 days after the change. If a licensee fails to notify the Board of a change in his permanent mailing address within 30 days after the change, the Board:

(a) Shall impose upon the licensee a fine not to exceed [$100] $250; and

(b) May initiate disciplinary action against the licensee as provided pursuant to subsection 9 of NRS 630.306.

2. Any licensee who changes the location of his office in this State shall notify the Board in writing of the change before practicing at the new location.

3. Any licensee who closes his office in this State shall:

(a) Notify the Board in writing of this occurrence within 14 days after the closure; and

(b) For a period of 5 years thereafter keep the Board apprised in writing of the location of the medical records of his patients."

Rationale: This is to insure that licensees notify the Board properly and timely of changes of address. During the last license renewal mailing, 267 of the licensees' renewal applications were returned to the Board with bad addresses. During the mailing to licensees to secure information about in-office surgeries which use anesthesia, 551 were returned to the Board with bad addresses. Although failure to keep the Board apprised of new addresses is a violation of the Nevada Medical Practice Act, Chapter 630 of NRS, the Board does not pursue disciplinary action against licensees for this violation. But to enforce it, requiring the notification to be in writing will insure that the Board gets valid information on the location of its licensees, and a larger fine will insure that the licensees will comply with their statutory requirements, or face some enforceable sanction.

2. Amend NRS 630.255, to require that address changes be made to the Board in writing, and increase the fine for failure to comply to $250.

"2. Each inactive registrant shall maintain a permanent mailing address with the Board to which all communications from the Board to the registrant must be sent. An inactive registrant who changes his permanent mailing address shall notify the Board in writing of his new permanent mailing address within 30 days after the change. If an inactive registrant fails to notify the Board in writing of a change in his permanent mailing address within 30 days after the change, the Board shall impose upon the registrant a fine not to exceed [$100] $250."

Rationale: The same as for the amendment to NRS 630.254, with regard to written notification of change of address and for the increase in the amount of the fine for noncompliance.

3. Amend NRS 630.301(3), as follows:

"3. The revocation, suspension, modification or limitation of the license to practice any type of medicine, as well as any other disciplinary action, taken by another state, the federal government, another country [by] or any other jurisdiction, or the surrender of the license or discontinuing the practice of medicine while under investigation by any licensing authority, a medical facility, a branch of the Armed Services of the United States, an insurance company, an agency of the Federal Government or an employer."

Rationale: Adds other, lesser disciplinary actions taken against a licensee in any other jurisdictions as grounds for initiating disciplinary action, and informs the Board of any discipline taken against its licensees in other jurisdictions.

4. Amend NRS 630.020(1), defining the practice of medicine, to include the performance of autopsies.

"1. To diagnose, treat, correct, prevent or prescribe for any human disease, ailment, injury, infirmity, deformity or other condition, physical or mental, by any means or instrumentality, including autopsies."

Rationale: This is to insure that autopsies performed in Nevada are performed by physicians who are licensed to practice medicine in Nevada.

5. Amend NRS 630.306(5), (6) and (11), dealing with inability to practice or deceptive conduct.

"5. Practicing or offering to practice beyond the scope permitted by law or performing services which the licensee knows or has reason to know that he is not competent to perform, or are beyond the scope of his training."

"6. Performing, without first obtaining the informed consent of the patient or his family, any procedure or prescribing any therapy, including those which by the current standards of the practice of medicine are experimental."

"11. Failure by a licensee or applicant to report in writing, within 30 days, the revocation, suspension or surrender of his license to practice medicine, or any other disciplinary action taken by another state, the federal government or another country on his license to practice medicine, in another jurisdiction."

Rationale: Provides additional grounds for the Board to consider for discipline of a licensee or grounds to consider for denying an applicant for licensure, where disciplinary actions less than revocation, suspension or surrender have been imposed on a licensee or applicant in another jurisdiction.

6. Amend NRS 630.364(2), to extend statutory immunity from civil liability to include the Board's peer reviewers and contractors which provide Diversion program services to the Board's licensees.

"2. The Board and any of it members and its staff, counsel, investigators, experts, peer reviewers, committees, panels, hearing officers and consultants and contractors, their employees and volunteers, who provide Diversion program services to licensees, are immune from any civil liability for: …."

Rationale: The Board is processing more and more cases and complaints. This provision is to insure immunity from civil actions for the peer reviewers who render opinions upon which the Board relies for the basis of its complaints, and to protect the organization which provides Diversion services to the Board's licensees.

7. Amend NRS 630.265(4), in order to take the Board out of the decision-making process of the Medical School concerning the activities of residents.

"4. The holder of a limited license may practice medicine only in connection with his duties as a resident physician or under such conditions as are approved by the director of the program [and the Board]."

Rationale: The Board should not be involved in having to approve a resident moonlighting during his residency. This is a decision that the director of the residency program should make for each individual resident student.

8. Amend NRS 630.025, the definition of a "Supervising physician," to delete the term "who employs."

"Supervising physician" means an active physician licensed in the State of Nevada, and in good standing with the Board, who [employs and] supervises a physician assistant or physician assistants."

Rationale: Not all supervising physicians employ the physician assistants that they supervise. Many P.A.s now work in group practices or are employed by medical corporations. Thus, the current language is limiting, and should be deleted.

9. Amend NRS 629.031, which defines providers of health care to include physician assistants.

"1. "Provider of health care" means a physician licensed pursuant to chapter 630, 630A, 633 of NRS, dentist, licensed nurse, licensed physician assistant, dispensing optician, optometrist, practitioner of respiratory care, registered physical therapist, podiatric physician, licensed psychologist, licensed marriage and family therapist, chiropractor, athletic trainer, doctor of Oriental medicine in any form, medical laboratory director or technician, pharmacist or a licensed hospital as the employer of any such person."

Rationale: Licensed physician assistants are clearly health care providers and should be added to this statute and included as such.

10. Add to Chapter 630 of NRS a section authorizing the issuance of a restricted medical license to an eminent, world-renowned, foreign-trained physician to work in an authorized medical research facility or at the University of Nevada Medical School, teaching, researching or practicing clinical medicine in that facility only, in that program only, and only for so long as that physician is engaged at that facility or the medical school.

"NRS 630.___. Special Restricted license to practice medicine in approved medical research facilities or the University of Nevada Medical School.

1. Except as otherwise provided in NRS 630.161, the Board may issue a special restricted license to practice medicine in this State, to eminent, world-renowned, foreign-trained physicians, to work in established medical centers of excellence in Nevada, or at the University of Nevada Medical School, teaching, researching and practicing clinical medicine within that program, and that program only.

2. A person who applies for a special restricted license pursuant to this section is not required to take or pass a written examination as to his qualifications to practice medicine, but must meet all of the requirements of the regulation adopted by the Board regarding the issuance of such license.

3. This special restricted license shall expire and terminate automatically when the holder of the license is no longer engaged by the medical center of excellence or the University of Nevada Medical School program for which he was granted such license.

4. If the person who holds a special restricted license issued pursuant to this section ceases to practice medicine in this State in such medical facility or at the University of Nevada Medical School:

(a) The facility or the School of Medicine shall immediately notify the Board; and

(b) Upon receipt of such notification, the special restricted license will automatically expire.

5. The Board may renew or modify a special restricted license issued pursuant to this section unless the restricted license has expired automatically or has been revoked."

Rationale: Nevada is opening up world-renowned medical research centers of excellence, and the University of Nevada Medical School is opening up research and clinical teaching residencies which require eminent, world-renowned, foreign-trained physicians to teach, research and practice clinical medicine in those fields in order to benefit the citizens of the state of Nevada with superior medical care.

11. Amend NRS 630.020 by adding paragraphs to define the use of lasers and the injection of botox as the practice of medicine.

Move the current paragraph 4 to become paragraph 6. Insert new paragraphs 4 and 5.

"4. The revision, destruction, incision or other structural alteration of human tissue is the practice of medicine. Since laser and intense pulsed light therapy involve the revision, destruction, incision and removal of human tissue, both fall within the definition of the practice of medicine.

(a) A licensed physician with appropriate and specific training in acceptable laser surgery and intense pulsed light therapy may delegate certain procedures to certified or licensed non-physicians in compliance with appropriate statutes and regulations. The physician must directly supervise the non-physician to protect the best interests and welfare of each patient. Laser treatment involving the globe of the eye must be performed by licensed ophthalmologists.

5. The injection of botox, cosmetic and chemotheraputic substances is considered the practice of medicine and may not be delegated to medical assistants or any other staff with comparable or lesser training."

Rationale: The protection of the public requires greater restriction and control of the use of lasers and intense pulsed light therapy, and the injection of botox and other cosmetic or anesthetic substances. These procedures should be performed by, or under the direction of, a licensed physician.

12. Amend NRS 41.505, to include Physician Assistants.

"NRS 41.505 Physicians, physician assistants, dentists, nurses ….

1. Any physician, physician assistant or registered nurse …. An emergency medical attendant, registered nurse, physician assistant or licensed practical nurse who obeys an instruction given by a physician, physician assistant, registered nurse or licensed practical nurse and thereby renders emergency care, at the scene of an emergency or while transporting an ill or injured person from the scene of an emergency, is not liable for any civil damages as a result of any act or omission, not amounting to gross negligence, in rendering that emergency care."

Rationale: Add physician assistants to the list of those who can render emergency care and are provided immunity from civil liability for so doing.

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Southern Nevada Health District Report

Should health professionals lead by example?

By Donald S. Kwalick, MD, MPH, Chief Health Officer, Southern Nevada Health District

By Donald S. Kwalick, MD, MPH, Chief Health Officer, Southern Nevada Health District

An on-line publication recently published an interesting discussion regarding overweight physicians and whether we should be held to a higher standard than the public when it comes to issues of weight and fitness. Four physicians weighed in on the topic (no pun intended) and expressed varying opinions.

This topic has a special interest to those who deal with public health issues and preventive health care. In the realm of public health this discussion also extends to issues such as tobacco use and includes professionals such as health educators and those representing the health district as public officials.

The physicians' opinions were quite varied on the topic of "tight white coat syndrome." At one end of the spectrum the opinions expressed stated that overweight physicians dispensing advice to patients on fitness and weight loss would be seen as hypocritical at best. Another physician who had struggled with his own weight issues also agreed he needed to heed his own advice in order to maintain credibility with his patients. Physicians on the opposing side of the discussion maintained it was important to advise patients on weight loss and fitness issues, but argued physicians have many demands placed on them and should not be seen as ineffective if they were overweight. It was also argued that overweight physicians may be more empathetic to patients who may have dealt with anti-fat bias and therefore better able to build constructive patient/doctor relationships.

As a public health physician I have seen first hand the effectiveness of social marketing campaigns. I believe that health care professionals, especially those who are directly involved with public health and preventive health issues, are integral to the success of our initiatives and must serve as role models in order for our efforts to be effective.

Our social marketing campaigns have had a measurable effect on tobacco use in Nevada. Our youth oriented tobacco control program has contributed to a decrease in adolescent smoking from more than 25 percent in 2001 to less than 20 percent today. Would this program be as effective if the health educators involved didn't believe in the messages they were helping to disseminate, or model the healthy lifestyle they promote? I believe the credibility of these programs would suffer if the staff administering the programs did not also serve as role models.

However, in Nevada, employees are protected for participating in a "lawful act." Nevada Revised Statutes state it is unlawful to discriminate against hiring, or to fire an employee, for lawful use of any product outside of work that does not adversely affect their job performance or the safety of other employees.

Even so, an argument could be made that smoking by an employee of an organization that promotes non-smoking does adversely affect their job performance. However, I am realistic that the political environment of Nevada is not receptive to this interpretation of the law.

Additionally, I do want to stress that I do not see the issues of tobacco use and weight as completely congruent.

I strongly believe that nobody should smoke - ever. However, I recognize that people can be healthy at a variety of weights and that meeting recommended fitness levels can be difficult for those who spend more time taking care of others than themselves.

I also believe that the previously mentioned physician who struggles with his own weight issues can be an effective role model as he works to maintain his weight and work a fitness routine into his schedule. As health care professionals we don't have to be perfect to serve as effective role models. We do have to demonstrate that we buy into the healthy lifestyles we promote.

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Psychiatric Medicine in Southern Nevada