When on the receiving end of a Medical Board investigation or patient lawsuit over pain management, the palliative remedy of lawyer assistance through the proceeding offers little true relief for the physician’s “pain”. Successful management of patient chronic pain conditions involves good patient history/screening, continuity of care and careful documentation. Documentation is the best prophylaxis against Medical Board investigations and civil lawsuits.
Today’s political and social climate on narcotic use places chronic pain management on the skyline with the Medical Board. Despite the legislature’s passage of superficial protection for patients and physicians in the Intractable Pain Treatment Act (Business and Professions Code 2241.5) and the Patient Bill of Rights regarding pain treatment (Health and Safety Code 124961) physicians venturing into chronic pain management, especially those without special training and expertise, are at risk for heightened scrutiny. Use of opioids places physicians at the apex of the Medical Board’s skyline. Following the Medical Board’s treatment guidelines and documenting compliance leads to successful, safe treatment for both patient and physician.
What documentation affords the best protection for a physician?
The following outline is a useful guide. A patient’s chart should reflect each of these aspects of the care provided: (1) a history and physical addressing any substance abuse history (or lack thereof); (2) an history & physical which reveals a chronic pain condition which has been refractory to non-opioid treatment; (3) a treatment plan reflecting continued assessment of the effectiveness of treatment, such as decreased pain and increased physical or psychological function; (4) an informed consent for the use of narcotics, and for patients with abuse history, a signed pain treatment “contract”; (5) at least semi-annual, and better yet, quarterly or monthly review of the patient’s progress; (6) consultation with others such as a pain management specialist, psychologist/psychiatrist, orthopedist, neurologist, or perhaps an addiction specialist (documentation of the consultations reflects an effort at coordinating care and ruling out other forms of potential treatment); (7) charting efforts to verify those prescriptions reported to be “lost” to drains, toilets, dogs or “thieves” were in fact so lost. Over the phone early refills of “lost” narcotic prescriptions without such documentation are trigger points for Medical Board investigators.
For general practitioners, perhaps the safest approach is to “punt” to the specialist. However, specialists on the receiving team should be well coached by the above principles. The field of chronic pain management is not necessarily an even, level field. It can be slippery and laden with potholes for those venturing onto it. Documented adherence to these treatment and charting guidelines is state of the art protective gear for chronic pain management.
This article appeared in the July 2006 issue of MD News Magazine.
Robert W. Frank is a shareholder at Neil Dymott Hudson and concentrates his practice on the defense of healthcare professionals and general civil litigation. Mr. Frank may be reached at (619) 238-1712.
