Physician drift hurts medicine

By HEDDY-DALE MATTHIAS,

Nearing the end of my career, I’ve been inundated with examples of my colleagues practicing “outside” their training, board certification and “scope of practice.” I am concerned about this “practice drift” towards lucrative, cash-based procedures performed in physician offices.

“Practice drift” may occur in three ways:

 

1. “Upward drift” is the practice of medicine “above” the physician’s level of training, such as a family practice physician performing vascular surgery or dermatology.

 2. “Downward drift” is the practice of medicine “below” the physician’s training, such as a thoracic surgeon practicing family practice or hormone replacement therapy.

3. “Daffy drift” is performing procedures or administering services without any scientific or medical basis of efficacy.

In most states a license to practice medicine allows the unrestricted practice of medicine and surgery. (Look at your physician license.) Boards of medical licensure do not, and apparently, cannot, dictate what a physician may do in his or her office. (Although the Mississippi Board of Medical Licensure regulations state that physicians practicing outside their training must petition the board for approval, this happens infrequently, if at all.) The board can only regulate false advertising.

The only regulatory “agency” that matches training/expertise/board qualifications with the practice of medicine and surgery are surgery center and hospital credentialing committees. Most reputable institutions spend a great deal of time ensuring that a physician is actually trained and qualified for privileges (medical and surgical) performed at their organizations, for legal protection, and, hopefully, for ethical reasons.

Surgeons, especially, must submit, via board certification and training/procedure documentation, evidence of proficiency. If a surgical procedure is new, a physician must demonstrate training and usually requires monitoring by a qualified physician. This is well and good, as it should be, to protect both patients and facilities alike.

However, in an effort to generate billing/cash-flow, to avoid the mind-numbing morass of federal, state and insurance regulations, many physicians have allowed their practices to “drift” outside their areas of training and expertise to quick and easy cash-based office practices.

This “drift” not only includes physicians but has gathered great speed in dental and nursing practices.

Some examples:

Physicians should not administer services they know have no proven efficacy simply because their patients demand it. This is “daffy drift.” It includes intravenous fluids, intravenous water-soluble vitamins, B12 injections without B12 deficiency, testosterone preparations without documentation of “age-specific” testosterone levels, other homeopathic “vitamins” and other compounds, “organic” hormone replacement therapies, etc. This is clearly prohibited by the Mississippi Board of Medicine.

“Whole Body Cryotherapy,” performed by either physicians, nurse practitioners, or providers with absolutely no medical training whatsoever, is advertised on local billboards for weight loss, sports injuries, general and skin “rejuvenation” and other anti-aging aspects. “Core Cryotherapy,” a national chain, uses gasiform nitrogen to rapidly lower the skin surface temperature to 30 to 32 degrees F in a cryosauna temperature ranging between minus 238 to minus 272 for two to three minutes of treatment. The website recommends 7-10 treatments for various ailments, and weekly “maintenance” therapy after that. Cost estimates are from $40 to $70 per treatment. It is not covered by health insurance.

There are many small studies using whole body cryotherapy, which included elite male athletes, and most studies claim there is little long-term efficacy over conventional cold therapies such as ice and ice baths. A 2015 Cochrane review determined “there is insufficient evidence to support the claims of its benefits or safety. The FDA has not cleared or approved any whole-body cryotherapy devices. There are no controlled clinical trials regarding skin rejuvenation or weight loss.”

I have yet to understand how this therapy is lawful by anyone at this time, especially those with no medical training whatsoever. But, “buyer beware.”

 

In Mississippi, Botox and fillers are administered by family practitioners, nurse practitioners, dentists, radiologists, neonatologists, pediatricians, pathologists, anesthesiologists, internists and probably the old lady who lives up the street. Those most qualified, plastic surgeons and dermatologists, probably administer less than half the Botox in Mississippi, although this is merely a guess.

Like the majority of other states in the U.S., the Mississippi Board of Dental Examiners has allowed the injection of Botox and intradermal fillers for a few years. How this is justified under the Mississippi Dental Practice Act is unclear. The removal of wrinkles and creases for cosmetic reasons is not the practice of dentistry. (There are some disorders treated by oral surgeons that can justify the use of Botox.) At least dentists are very familiar with nerve anatomy of the face, unlike the majority of providers who administer Botox.

Last week, I found a Mississippi osteopath’s website extolling the wonders of hyperbaric oxygen for “rejuvenation.”  This is clearly nonsense. This website also advertises the “Vampire Facelift,” which includes Botox, fillers and platelet-rich plasma injection of the face.

However, the most egregious cases of drift are of physicians and nurses practicing completely outside their residency training and “up-drifting.” We have physicians trained in relieving surgical pain now performing surgeries, such as phlebectomies and CO2 facial lasers.

Many of my colleagues will attack my criticism. So be it. A weekend or six-week “Holiday Inn course” will never replace a full residency training program, despite those practitioners arriving home with certificates of “board-certification” in a nonsensical, non-existent specialty such as “aging medicine” or “rejuvenation medicine.”  I believe that if you want to be a surgeon, do a surgical residency. If you wish to be a plastic surgeon or dermatologist, do a residency program. However, I’m most concerned that many of these physicians have not obtained approval from the Mississippi Board of Medicine to perform services outside their training as required by regulations. I suspect that the Mississippi Board of Nursing is unaware of these practices.

I am not without sympathy regarding the financial difficulties of traditional medical practice in the present day. I do understand.

However, I believe that physicians are called to abide by higher ethical standards than entertaining every lucrative, consumer-driven service coming down the pike encouraged by an enthusiastic salesperson and visions of “green” dancing in our eyes.

Heddy Dale-Matthias is a Northside physician. She lives in Roses Bluff.

 

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