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C OMME N TARY
Medical Passports
JOSEPH H. FRIEDMAN, MD
[email protected]
“T
h i s wa s t h e b e s t e x a m
participate in the trial.
Rhode Islanders to use medical facilities
I’ve ever had. You really
“You mean I’d have to
outside the state. Later laws stopped the
examined me very well
travel to Providence? You
use of these documents as well. As a
and I feel very fortunate
won’t come to Newport?”
result of the original law and the lack of
to have been directed
One of the early acts
publicity attendant on the withdrawal of
to you and I think you
of the Continental Con-
the laws, many in Rhode Island failed to
explained my situation
gress in 1775 was to abol-
appreciate that these passports were no
better than anyone else.
ish passports and visas
longer required. This led to the current
But I really can’t see you
for travel between the
situation in which many people who
again. I live in Wakefield.”
colonies. This was widely
were born in Rhode Island find them-
This occurred this week.
accepted by the revolu-
selves either unable to cross state lines
tionaries and even sup-
or to travel distances beyond 10 miles.
tient that Providence was also in Rhode
I explained to the pa-
ported by the Loyalists, but the various
They learned this from their parents and
Island, so that, unlike seeing a doctor
colonies’ governors,
in Boston, a medical passport was not
appointed by the king,
There are other theories,
required. However, it seems that crossing
were not agreeable, as
however, of why people
the Pawtuxet River represents a bridge
the passports were a
born in Rhode Island won’t
too far for some South County residents.
source of income. Of
When I moved my practice from War-
course, after the colo-
travel. Two are genetic.
teachers and simply
passed on this out-ofdate information.
There are other theories, however, of why
people born in Rhode
wick to Providence six years ago, one
nies won independence and the country
Island won’t travel. Two are genetic. Epi-
of my patients, a 72-year-old man with
was unified, the notion of passports
demiological studies have shown that
Parkinson’s disease, told me he wouldn’t
made no sense and was abolished.
the resistance to travel clearly runs in
be able to see me anymore. It was too far
However, in a little known response
families. While this is partly explained
and too difficult to get to. “But you don’t
to a highly contentious law restricting
by the previous theory, that is, nurture
drive,” I responded. “Your son drives
trade between colonies, the Legislature
rather than nature, several tantalizing
you, and you live in Lincoln, so it’s about
of the State of Rhode Island enacted
clues have been found with genome-
the same distance. I doubt your son will
a law requiring notarized inter-state
wide association studies, employing
mind.” “Well, it’s too complicated, just
traveler documents to travel outside the
anti-logarithmic epicritical fusion func-
too much.” “Have you ever been to
state. These were obtained in the depart-
tional analysis. The implicated genes
Boston?” I asked. “Sure. My dad took
ment of Public Affairs, a bureau that was
have been linked to particular speech
me to see the Red Sox when I was 12.”
absorbed by other state departments in
patterns (eg, “cod” for “card” as well
Thirty years ago, the first study ever
1952. However, many people in Rhode
as use of the word “bubbler”) and an
done to slow progression of a neuro-
Island were, and remain unaware, that
insatiable appetite for quahogs.
degenerative disorder was initiated. This
this occurred. As part of the law, these
A third theory, which is also genetic,
was a study to slow Parkinson’s disease
travel documents for “routine travel”
is based on the observation that the
and I was the principal investigator for
and commercial travel were withdrawn.
self-imposed travel restriction in Rhode
the Rhode Island site. A patient from
However, a proviso in the bill developed
Island is north-south only. People who
Newport called, excited to be able to
the so-called “medical passports” for
won’t travel north will travel west, or
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RHODE ISLAND MEDICAL JOURNAL
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C OMME N TARY
east, even across the ocean. This theory,
longitudinal travel alters the sleep-wake
You are invited to submit your own for
which has little actual data to support
cycle, while simultaneously reducing
possible publication.
it, is based on a subtle difference in
pleasurable responses and increasing
melatonin secretion that occurs as peo-
the likelihood of an addictive response,
ple travel on longitudinal meridians.
which in this case would be a negative,
Author
Those who avoid travel have higher than
or aversive response.
Joseph H. Friedman, MD, is Editor-in-chief
Happy April Fool’s day! v
normal melatonin increases with going
An interesting observation was made
north and larger decreases when going
by anthropologists who have found a
Professor and the Chief of the Division
south during the appropriate seasons.
similar reluctance to travel on north
of Movement Disorders, Department of
This increase in melatonin is thought to
south lines in one aboriginal group in
Neurology at the Alpert Medical School of
de-regulate a trans-ketolase involved in
Australia but not in others. This appears
Brown University, chief of Butler Hospital’s
the synthesis of gene regulator phyoto-
to be unrelated to level of education,
Movement Disorders Program and first
kine type b flat minor, found primarily
supporting a physiological explanation
recipient of the Stanley Aronson Chair in
in neuronal cells in the hypothalamus,
rather than a learned response.
Neurodegenerative Disorders.
linked to circadian rhythm and dopa-
Undoubtedly more hypotheses exist to
mine reuptake. It is hypothesized that
explain this Rhode Island phenomenon.
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of the Rhode Island Medical Journal,
Disclosures on website
APRIL 2016
RHODE ISLAND MEDICAL JOURNAL
8
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C OMME N TARY
Pain management: Considering the medical, legal aspects in patient care
HERBERT RAKATANSKY, MD
P
ain relief is one of
“Standards of care”
terminal prostate cancer and intractable
the oldest and most
describe appropriate clin-
pain that allegedly was treated inade-
imperative moral obli-
ical care protocols but
quately. His family was awarded $15
gations of physicians.
also generate the possibil-
million in a judgment against a nursing
Hippocrates taught:
ity of consequences from
home and its staff.
“Cure sometimes, treat
violating them. A doctor
A more significant precedent was
often, comfort always.”
who under or over treats
established in California in 1998. Wil-
Pain relief, however, is
pain may be accused of
liam Bergman had advanced lung cancer
fraught with difficul-
malpractice just as he
and was treated initially in a hospital
ties due to conflicting
would for violating any
and then by hospice, where he died. His
medical, legal and social
standard of care.
family felt he had been inadequately
incentives. Standards that
In 2000 the Joint Com-
treated for pain in the hospital. They
define best practices may help resolve
mission required that hospitals have
complained to the California Medical
these conflicts.
policies that mandate formal assess-
Licensure Board but no action was
ment of pain and assess its relief. Patients
taken. The family then sued both the
Since there is no objective measure
of pain, we depend only on the reports
from patients. Given the subjectivity of
pain, the doctor is placed in a difficult
position.
“Standards of care” describe appropriate clinical care protocols
but also generate the possibility of consequences from violating
Our efforts at pain control may
them. A doctor who under or over treats pain may be accused
result in over prescription. The opi-
of malpractice just as he would for violating any standard of care.
oid epidemic is partially the result
of over enthusiastic prescription of
are asked routinely and repetitively
hospital and the attending physician,
these effective medications. Recently
to quantify their pain.
Dr. Wing Chin. They were accused not
a particularly egregious doctor was
Detailed guidelines for chronic opioid
of malpractice; rather they were accused
convicted of murder following patient
use were endorsed by the American Pain
of elder abuse. The hospital settled. Dr.
deaths from overdosing. And the fear
Society and the American Academy
Chin was found guilty at trial and the
of consequences from prescribing too
of Pain Medicine in 2008. (1) Recent
family was awarded $1.5 million.
much medication may result in under
guidelines issued by the RI Board of
treatment and suffering from inadequate
Medical Licensure for the use of opi-
relief of pain.
oids in non-cancer chronic pain are
In California the law defines “fail-
Elder abuse is a state issue and the
laws vary.
Patient satisfaction is increasingly a
yet another standard of care. Even the
ure to provide health care for medical
factor in evaluating doctors and may
American Bar Association (for its own
needs” as elder abuse. California law
affect their compensation. Addicted
reasons) believes that “Adequate pain
now requires doctors who do not wish
patients who visit their doctors and,
and symptom relief be considered a basic
to provide opioids for severe, intractable
properly, do not receive the drugs they
legal right and clinical duty.”
pain to inform patients that there are
request may report dissatisfaction,
In 1991 a North Carolina jury consid-
stating that their pain was not relieved.
ered the case of Henry James who had
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other doctors who will.
APRIL 2016
RI elder abuse law (42-66-4.1) defines
RHODE ISLAND MEDICAL JOURNAL
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C OMME N TARY
abuse as “willful failure by a caregiver
perceptible effect. Her only relative (and
considered a transgression of a stan-
with a duty of care to provide goods or ser-
proxy) was her son. When he heard of the
dard of care and the doctor and hospital
vices necessary to avoid physical harm,
use of morphine he absolutely denied
might have been subject to a malpractice
mental harm.…” “Willful” is defined
permission. Pastoral, social service,
suit. Even more significantly, failure to
as “intentional, conscious and directed
case management and multiple med-
relieve the pain might have been consid-
toward a purpose.” It seems reasonable
ical consultations did not change his
ered to be elder abuse with its attendant
to conclude that conscious decisions
decision. The case was presented to the
civil and criminal consequences.
not to prescribe medication to relieve
ethics committee.
Medically appropriate institutional
pain could be interpreted as “willful.”
The ethics committee considered the
and governmental policies that protect
Massachusetts Law (19C, 1) defines
principles of beneficence and autonomy.
patients of all ages by ensuring adequate
abuse as “an act or omission which
It was clear that a competent adult with
pain relief also protect the doctors and
results in serious physical or emotional
the capacity to make medical decisions
other caregivers who provide relief
injury.…” The law in Connecticut is
may refuse any and all treatments
of suffering in accordance with these
very similar.
including pain medication. It was felt,
policies. Therefore it is essential that
The precedent for considering inade-
though, that the refusal of pain medica-
doctors, both individually and collec-
quate pain relief as elder abuse cannot
tion by a proxy was not in this patient’s
tively through the Rhode Island Medical
be ignored. Critical is the fact that elder
best interest and that such an order
Society (RIMS), participate actively in
abuse damages generally are not covered
(not to give pain medication) need not
the formulation of these policies and
by malpractice insurance.
be honored. The hospital had a written
standards of care, both at their institutions and at the governmental level. v
There is yet another smaller but vul-
policy about pain relief but it did not
nerable population. Several years ago
address this unusual situation. That
an elderly patient with chronic, severe
patient was afforded proper pain relief.
dementia was admitted to the Miriam
More importantly, the pain policy was
Hospital for treatment of an infection.
amended to include a process to address
She had decubiti and though she was
future similar situations. A stepwise
nonverbal, she demonstrated evidence
protocol now protects, in a timely
Author
of severe pain when she was moved
way, these vulnerable patients who are
and had her decubiti treated. This
unable to speak for themselves.
Herbert Rakatansky, MD, FACP, FACG,
is Clinical Professor of Medicine
Emeritus,The Warren Alpert Medical
School of Brown University.
pain appeared to be relieved by 1 mg
The continued failure to relieve
of morphine, a dose that had no other
this patient’s pain might have been
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Reference
1. Chou R et al. Clinical Guidelines for
the Use of Chronic Opioid Therapy in
Chronic Noncancer Pain. The Journal of
Pain. 2009 Feb;10(2):113-130.
APRIL 2016
RHODE ISLAND MEDICAL JOURNAL
11
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