The ‘Bounds of Medical Practice’ and the ‘Standard of Care’

The ‘Bounds of Medical Practice’ and the ‘Standard of Care’ – Alexander DeLuca, M.D., MPH; Comment in response to: Instruction to Hurwitz Jurors by John Tierney; TierneyLab; 2007-04-22.

In fields of medicine involving controlled substances, especially addiction medicine and pain medicine, the doctor-patient relationship has been grossly distorted by drug war imperatives imposed by the federal govt through the Controlled Substances Act.

This distortion is profound and significant. One manifestation is the ‘chilling effect.’ Allow me to save some keystrokes and quote myself from ‘The Dissembling DEA and the Myth of the Chilling Effect’:

“The ‘chilling effect’ is the withdrawal, for fear of litigation, by physicians from the appropriate treatment of pain. It is important to note that much of the public health damage here is caused not by the doctors accused of wrongdoing, rather it is caused by doctors-in-good-standing who, faced with a patient in pain and therefore at risk of being targeted by the DEA, modify their treatment in an attempt to avoid regulatory attention.

“This distortion of the doctor-patient relationship is complex and can be gross or subtle. Examples include a blanket refusal to prescribe controlled substances even when clearly indicated, or selecting less effective and more toxic non-controlled medications when a trial of opioid analgesics would be in the best interests of a particular patient. At the very least, some degree of suspicion and mistrust will surely arise in any medical relationship involving controlled substances.”

Here’s a clue that a particular field of medicine is ‘distorted.’ For most common conditions the quality of care most docs provide is fairly close to “the standard of care” which is what the textbooks say you should do, and which is generally in line with core medical ethical obligations such as holding the interests of the individual patient before you above ALL other interests (including the policeman’s). For example, the care you’d get for an acute asthma attack is pretty much the same no matter what ER you walk into, and it’ll be pretty much by-the-book.

So, in most medical fields we could say: “How most reputable doctors practice approaches the (textbook) ’standard of care.’”

This is NOT true in the fields of addiction and pain medicine. For example, modern textbooks recommend ‘titration to effect’ (simplistically: gradually increasing the opioid dose until the pain is relieved) as the procedure by which one properly treats chronic pain with opioid medications. Yet the overwhelming proportion of physicians in the America DO NOT practice titration to effect for fear of becoming ‘high dose prescriber’ targets of the DEA.

So, regarding the medical treatment of pain in America, we have the deeply disturbing situation that what most doctors do is at odds with and below the ’standard of care.’ Literally, in the treatment of chronic pain, an ethical physician attempting to practice in good faith how the textbooks say you should practice IS AN OUTLIER, deviating from what most reputable physicians would do.

What the prosecution tries to do in war on docs cases is conflate the concepts ‘bounds of (legitimate) medical practice’ and ‘the standard of care’ with ‘what most reputable physicians would do.’

And they obviously have no difficulty finding physicians willing to accept money for saying they couldn’t conceive of writing this or that prescription, or that the defendant’s prescriptions were ‘absurd’ or ‘outrageous’ or ‘outside the bounds’ of legitimate practice (by which they mean the way they and 95% of everyone they know practices).

If the prosecution can successfully confuse the jury in this way, ethical docs attempting to practice to the standard of care will be convicted as drug traffickers or racketeers on the basis of being ‘outside the bounds.’

..alex…

Alexander DeLuca, M.D., MPH Policy Analyst, Pain Relief Network http://www.painreliefnetwork.org/ http://www.doctordeluca.com/

[END]

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90Comments2007-04-24+02%3A53%3A58Alexander+DeLuca

Comment by:
Bill

Absolutely dead on. Physicians need to be able to treat their patients without fear. Too many doctors make decisions regarding pain medication based on fear which is all federal law enforcement wants. It plays directly into the 2 most important benchmarks they think they have. Number of investigations per year and decrease in the number of certain prescriptions written. Both benchmarks are the essence of the “chilling effect.”

The marketing machine that belongs to the “War on Drugs” has so successfully demonized pain medication and pain patients that many doctors, faced with either, act out of fear and suspicion instead of education, experience, compassion and empathy.

What if somehow this had been done with insulin or birth control or any myriad of other necessary treatments? Aren’t we all sort of “addicted” to insulin? Isn’t too much of it harmful or even fatal? How many EMS calls and/or ER visits per year are due to profound hypoglycemia? Has anyone ever been criminally prosecuted after a patient suffered a DVT/PE after taking birth control? Isn’t that harmful and dangerous? Seems silly just mentioning it doesn’t it?

The notion that prosecutors and investigators have, that the practice of “pain management” serves only to purposefully “addict” pain patients so they will have to come back, is not well founded in science as far as I know. It is very retarded thinking but seems to be at the root of current strategy within the US Attorney’s Office, the DEA and maybe more of the DOJ. This needs to be exposed by those in the beltway. Congress needs to inform the medical community how medications approved by the FDA can be disapproved by the DOJ simultaneously.

Bill