In pain management battle, Oregon is taking a firm stand
Physician disciplined for allowing patients to suffer needlessly
An Oregon physician received the dubious honor of being the first physician to be disciplined for failing to treat his patients’ pain, including cases in which he allowed terminally ill patients to suffer needlessly.
The landmark action represents what some are saying is evidence of a major shift in how the medical community and the public perceive palliative care. For hospices, the case could serve as a rallying point to remind physicians of their obligation to treat pain and educate the public.
In September, Paul A. Bilder, MD, of Roseburg, OR, acknowledged the Oregon Board of Medical Examiners’ ruling that he had showed unprofessional conduct, and gross and repeated acts of negligence in six cases involving seriously ill or dying patients. (See article, p. 127.) The state’s Board of Medical Examiners is composed of nine doctors and two public members appointed by the governor to oversee the practice of medicine. The board’s charge is to protect the public from poor medical care.
Oregon is the first state to equally investigate and discipline physicians for underprescribing and overprescribing pain medication, according to Last Acts, a Robert Wood Johnson-funded organization that focuses on improving care of the dying. New York and Nevada have shown a similar interest in Oregon’s policy, says Susan Tolle, MD, an internist and director of the Center for Ethics in Health Care at Oregon Health Sciences University, and a proponent of disciplining doctors who underprescribe.
A few state medical boards have investigated complaints of doctors undertreating pain, including those in California. No other state, however, has taken action against a doctor primarily for undertreating pain, according to the Federation of State Medical Boards.
For those seeking to improve pain management, the Bilder case represents the latest step toward that end.
Recently, the Joint Commission on Accreditation of Healthcare Organizations issued its first pain management standards for hospitals and other health care settings and the Health Care Financing Administration has made pain management part of its conditions participation for hospitals.
"Undermedication goes on daily," says Karen Woods, executive director of the Washington, DC-based Hospice Association of America. "The fact that it became news and focused attention on the issue is good. It’s a reminder that patients deserve adequate pain treatment and serves as an educational tool."
Gross negligence
Bilder signed a stipulated order that the board approved, acknowledging that his treatment of six patients showed unprofessional or dishonorable conduct, and gross or repeated acts of negligence. Since his acknowledgment, Bilder has declined to comment about the case.
As a result of Bilder’s acceptance of its finding, the board is requiring the physician to complete the Physicians Evaluation Education Renewal program (PEER), a one-year program in which another physician will work with Bilder to make improvements in the way he deals with patients in pain. The appointed physician will also make a recommendation to the board as to whether PEER should be continued beyond the one-year period. Participation in the program is mandatory.
Also, Bilder must complete a course on physician-patient communication and continue meeting with a psychiatrist who will give regular reports to the board for at least a year.
The actions of the board seem to belie testimony of others who describe Bilder, a pulmonary disease specialist for more than 20 years, as a compassionate and hard-working doctor who thought he was doing what was right for his patients.
The board also learned that Bilder often engaged in power struggles with nurses, had communication lapses with patients and families, and lacked current knowledge about proper pain treatment. But Tolle acknowledges that the medical industry partly failed Bilder.
With that in mind, Tolle also praised the board for not meting out its most severe punishment, instead opting for a plan that would allow Bilder to learn.
"There’s a lot of things we aren’t taught in medical school," she says. "Medicine keeps changing, but one must continue to take some responsibility for keeping up with changing medical information."
While on the surface, the Bilder case may serve as a warning for physicians, Tolle says Bilder represents a physician who is on the extreme when it comes to pain management treatment.
"We’re not talking about just a knowledge deficit here," Tolle says. "There are cases where you can find some people to agree with a physician’s actions; but this is a case where few could condone his actions. This guy was four standard deviations out there."
Still, Tolle says there are lessons to be learned from the Bilder case. Most important of them all is proper physician communication with the patient and others, including hospice nurses, about pain medication needs.
"I do think this is already having an impact here in Oregon," she says. "When hospice nurses — because some of the cases involved hospice — call, physicians are listening to them more. This case underscores the lesson that [physicians] need to listen to others — patients, their families, hospice nurses, and colleagues."
A shifting tide
For physicians like Bilder who started their practices 20 years ago, their treatment of patients’ pain would not have been brought to the board. But Tolle describes a new climate, particularly in Oregon, where voters approved the nation’s only law allowing assisted suicide. The passage of an assisted suicide law sent a message that end-of-life care needed improvement, she says.
So how did Bilder get from there to here? The answer lies in the barriers — more so in breaking them down — doctors faced in prescribing pain medication. The Bilder case is a case study in how professional and public perception of pain management can be shifted.
In the ’80s and early ’90s, Oregon was much like any other state. The war against drugs was at its peak, and the battle lines extended to the use of prescription painkillers. Government investigators paid particular attention to physicians who prescribed higher amounts of drugs, such as Dilaudid, in their efforts to root out fraud and abuse in government-sponsored health care programs.
Also, physicians were conservative with their use of pain drugs out of fear of addicting their patients. Rather than be punished for overprescribing drugs, it made more sense to physicians to err on the side underprescribing.
In the ’80s, the same board that disciplined Bilder clamped down on doctors who gave patients too much pain medication. The tide began to shift in Oregon in 1995 when state lawmakers adopted an intractable pain law that guarantees proper pain management for patients with chronic or terminal illnesses. After considering evidence of patients suffering needlessly, the board also became concerned about doctors who don’t give patients enough pain medication. The shift from intolerance to acceptance was also fueled by research that showed pain patients generally don’t become addicted to medication. In addition, the 1997 debate over physician-assisted suicide again pointed to the need for better pain management.
The change in Oregon was sparked by the removal of barriers that prevented physicians from prescribing adequate amounts of pain medication to their patients, says Tolle. Most notably, she says, was the board’s realization that pain treatment was woefully lacking and affecting the quality of care Oregon patients were receiving.
It is with that lesson in mind that Tolle offers the following advice for hospices trying to convince outside physicians about the value of palliative care:
• Continue education efforts. Offer education opportunities to area physicians who are looking for additional guidance. Also, work with referring physicians to provide support and advice in using pain medication.
• Provide pain medication consultants. Hospices should make their medical directors available for consultations or provide a hotline for physicians to call if they are unsure about proper use of pain medication.
• Focus on regulatory barriers. Hospices often focus on educating their referring physicians about proper pain management. With other leaders from other segments of the health care industry in their state, they can focus on removing barriers or implementing programs that encourage use of pain medication through changes in policy or state laws.
Woods says hospices should use this case as a way to remind physicians that they must treat pain with the same diligence as they do the disease a patient has been diagnosed with. The Bilder case can be used as a catalyst to get physicians to begin rethinking their approach to palliative care.
"Hospices can use this as an opportunity to offer themselves as an educational sources," she says. "It’s one of those situations you can use to talk with physicians and your referral sources. This case just may cause people to listen more."
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