Volume 29 No. 3 MARCH 2005
N E W Sx I T E M S
Purple fingers, purple toes
Bruce T. ADORNATO
Any physician who prescribes warfarin is probably aware of the "purple toe syndrome." It is a very rare idiosyncratic side effect of preferentially inhibiting the synthesis of certain vitamin K dependent coagulation factors, notably protein C, which produces a transient tendency to thrombosis. So, despite administering an anticoagulant, there may be a tendency to thrombose small vessels at the periphery, e.g., toes. The clinical circumstance is the development of local ischemia and purple discoloration of toes occurring 3 to 8 weeks after initiating warfarin. Fortunately, discontinuance of the drug reverses the process and the symptoms and signs reverse to normal.
More complicated is the purple finger phenomenon we witnessed a few weeks ago in the newspapers as Iraqi citizens bravely ignored terror during their first step toward trying to establish a rule of law and institution over tyranny and tribalism. Unfortunately, it will be a long time before any type of normalcy will return to Iraqi lives. Establishing a constitution and rules of law after years of dictatorship seems like a "big project," which may be the understatement of the century. I compare the beginnings of this undertaking to the complexity of our own system of rule making, which while occurring in a different scale and dimension, nevertheless brings me to the subject of this column.
There is a great deal of rule making occurring every day in Sacramento, which I - and I suspect many of you - know nothing about. I was looking up some information about the new SB 1325 (more to follow on that) recently online. The California Medical Association has a website and a "Legislative Hot List" available (cmanet.org), which details all the legislation passed, failed and pending regarding physicians and medical practice in California. The list of what bills in various stages would do, won't do, or have already done is an eye opener. Here are some bill summaries taken from the website:
Allow chiropractors to certify the medical examinations of school bus, private transit and farm vehicle drivers. (On governor's desk for signature)
Allow oral and maxillofacial surgeons to perform cosmetic surgery. (Vetoed by the governor)
Allow physical therapists to examine, evaluate and test for movement disorders. (Scheduled for committee hearings in April)
Remove the requirement that a physician assistant's drug order be reviewed by a physician within 7 days. (Signed into law by governor)
Prevent pharmacies, pharmacy wholesalers, and health plans from selling or releasing physician-specific prescribing data to third parties. (Died in assembly committee)
And these are only some examples from a long list.
For the average doctor, keeping tabs on all this activity is impossible. The best you can do is perhaps bookmark this website and get involved when you can and when the ball is in your court. I do believe we should support the California Medical Association (CMA), which in my experience has a long track record of trying to do the right thing by endorsing laws which not only protect physicians, but more importantly, protect patients, their care and their privacy.
With that said, there is one more interesting issue which came up last year and which resulted in SB 1325, the legislation I alluded to at the beginning of this column.
SB 1325 was advanced by the CMA following an extremely complex turf battle between administration and medical staff at a hospital in Ventura County. The Senate bill, signed into law by Gov. Arnold Schwarzenegger, enacts six principles for medical staff self-governance:
1) The medical staff creates and amends medical staff by-laws (although all bylaw changes are subject to hospital approval).
2) The medical staff establishes criteria for medical staff membership and credentialing.
3) The medical staff enforces quality of care, utilization review, medical records, and medical staff meetings and committee activities.
4) The medical staff elects and removes medical officers.
5) The medical staff collects and spends medical staff dues.
6) The medical staff may hire independent legal counsel at the expense of the medical staff.
You will be happy, I am sure, to know that we have been in compliance with these principles and this represents nothing new for the Stanford Hospital Medical Staff. Nevertheless, it is a good thing to reinforce these institutions, separations of power and clear lines of authority and governance. Many years ago, in this state and many others, there was often blurring between the independence of physicians and corporate hospitals. As large health plans create their own facilities, it is a good thing to have some boundaries between physician staff and hospital administration. Balance of power is always something I would hold up an index finger for.