The practice of medicine today involves not only patient care, but complex issues of privacy, patient rights, as well as legal and ethical issues. It is not only physicians who struggle to deal with these questions. State legislatures are beginning to get involved with medical questions as well. In the past few months, I have been asked on several occasions to appear on the board’s behalf before committees of the Nevada State Legislature. Two specific issues have recently been reviewed by the legislature.

The first topic involved questions relating to what specific requirements physicians have for education on suicide prevention. There was a proposal suggested to mandate CME credits in suicide prevention, and although the board does not support this approach, and I spoke in opposition to it, the suicide statistics certainly warrant each physician becoming familiar with suicide risk factors and prevention strategies. Nevada has the highest suicide rate in the nation, with a rate almost twice the national average. Many suicide victims, particularly those 65 years and older, have visited a health care professional shortly before their suicide. As physicians, we need to take an active role in identifying those at risk and seeking appropriate treatment and referrals.

The second matter that has been discussed at the Nevada State Legislature concerns the reporting of medical errors. Lots of documentation was given about types of medical errors, where they are most apt to occur, and how best to minimize errors. Questions were raised as to whether appropriate systems are in place to minimize as well as report errors that occur. This is an ongoing dialog, and as yet no solutions have been proposed.

Certainly it is clear that there are many questions and uncertainties confronting the practice of medicine. I will continue to try to keep physicians informed as issues are raised that may impact the current practice of medicine.

The law governing the practice of practitioners of respiratory care includes language that delineates the status of both graduates, interns and students. Graduates of the National Board for Respiratory Care accredited programs awaiting completion of the certification examination and allowed to practice as interns are addressed in NRS 630.277. Students are included in the section that lists and qualifies non-applicability of the law (NRS 630.047). The entire Nevada Revised Statues (NRS) and Nevada Administrative Code (NAC) covering physicians, physician assistants, and practitioners of respiratory care are available via the Nevada Board of Medical Examiners Web site: www.state.nv.us/medical/. Provided below is the language that speaks to practitioner of respiratory care graduates, interns and students:

NRS 630.277(3) Any person who has completed the educational requirements set forth in paragraphs (a) and (b) of subsection 1 may practice respiratory care pursuant to a program of practical training as an intern in respiratory care for not more than 12 months after completing those educational requirements.

The educational requirements set forth in (a) and (b) of subsection one of NRS 630.277 are:

NRS 630.277
(a) Have a high school diploma or general equivalency diploma.
(b) Complete an educational program for respiratory care which has been
approved by the National Board for Respiratory Care or its successor
organization.

At this time, the Nevada State Board of Medical Examiners is not requiring licenses for interns.

Provisions for the practice of respiratory care by a student are contained in NRS 630.047 subsections (e) and (f). This section of the law lists and qualifies the exemption status of various entities. Practitioner of respiratory care students may provide respiratory care without a license under the following conditions:

NRS 630.047
(c) The practice of respiratory care by a student as a part of a program of
study in respiratory care that is approved by the board, or is recognized by
a national organization that is approved by the board to review such
programs, if the student is enrolled in the program and provides
respiratory care only under the supervision of a practitioner of respiratory
care.

Note that the clinical program of study in respiratory care must first be approved by the Nevada State Board of Medical Examiners. To date, no such clinical programs of study have requested approval and been approved by the board. Licensed practitioners and employers should be familiar with these and all other provisions of the respiratory care statutes and regulations, and should contact the board with questions on applicability of the statutes and regulations.

This article is a snapshot view of two areas of the licensure law that govern the licensing of practitioners of respiratory care. In the next article, we will address the provisions relating to continuing education requirements. The members of the board’s Practitioner of Respiratory Care Advisory Committee, Michael J. Garcia, R.R.T., Steven E. Kessinger, C.R.T. and Donald W. Wright, R.R.T., welcome recommendations for future newsletter topics. Please forward your recommendations to the Nevada State Board of Medical Examiners, attention: Practitioner of Respiratory Care Advisory Committee.

The board has just recently completed its mass mailing of the newly revised statutes and regulations governing medical doctors, physician assistants and practitioners of respiratory care to all licensees of the board. Nevada Revised Statutes Chapter 630 and Nevada Administrative Code Chapter 630 were mailed to all licensees, and the statutes pertaining to medical record keeping were included in the mailings to the medical doctor and physician assistant licensees. The board urges all licensees to familiarize themselves with the board’s statutes and regulations and to keep them handy for reference purposes.

At a recent meeting of the Nevada State Board of Medical Examiners, held on March 1, 2002, a new member to the board’s Physician Assistant Advisory Committee was nominated and approved by the board. Brian S. Lauf, P.A.-C, who lives in Sparks and works in Family Practice at a rural health clinic in Fernley, will serve on the advisory committee. Brian fills the position of Susan M. Morgan, P.A.-C, who served on the advisory committee since 1997, as an alternate and then an appointed member. Brian is currently the president of the Nevada Academy of Physician Assistants and a member of the National House of Delegates to the American Academy of Physician Assistants.

The Physician Assistant Advisory Committee, at the request of the board, reviews and makes recommendations to the board regarding matters relating to physician assistant practice, supervision and regulation.

Physician assistants have played an integral part in delivering quality health care in the last thirty years and have a respected niche as medical providers. In the past ten years, state laws that regulate and govern physician assistants have become more uniform and standardized as the American Academy of Physician Assistants have set up Guidelines and Model State Legislation that have helped achieve consistency in practice from state to state. Although there are variations in some regulations from state to state, all states license physician assistants to practice medicine with physician supervision and a physician-directed team health care delivery concept.

Regulations of physician assistants involve credentialing and licensing, scope of practice, definition of supervision and delegated prescriptive authority. Nevada is one of twenty states that mandate continuing competence requirements of certification, re-certification by the National Commission of Physician Assistants and on-going continuing medical education to hold a current license. Physician assistants and supervising physicians are encouraged to review and familiarize themselves with Nevada Administrative Code chapter 630 and Nevada Revised Statutes chapter 630 regarding physician assistant scope of practice, definition of supervision and prescriptive authority. Both new physician assistants and supervising physicians and those already in practice can benefit from in-depth familiarization with the Nevada Administrative Code and Nevada Revised Statutes, as they were developed to protect the public health, safety and welfare, and promote safe and effective medical practice.

In the past, the most common quality assurance complaints made to the Nevada State Board of Medical Examiners concerning physician assistants have been involved with failure to comply with physician assistant governing regulations, particularly those requiring two-party notification to the board of employment termination [NAC 630.340(2)] and the physician assistant's responsibility to notify the board in writing of any changes relating to supervising coverage [NAC 630.360 (4)].

The applicable governing Nevada statutes and regulations are readily available online at http:/www.state.nv.us/medical/ or by calling the board at 775/688-2559 or 888-890-8210 (toll-free from within Nevada) and requesting a copy.

The current Physician Assistant Advisory Committee members are Brian S. Lauf, P.A.-C, Nancy E. Munoz, P.A.-C and John B. Lanzillotta, P.A.-C. You are welcome to contact them or the board with any questions on physician assistant practice issues. The committee members may be reached by calling the board office in Reno at 775/688-2559 or 888-890-8210 (toll-free from within Nevada).

We currently facilitate two groups in Las Vegas. One group is for physicians and physician assistants, and the other is for practitioners of respiratory care. Both groups have 12 participants at present. The Diversion Program also has a facilitated group in the Reno area. In addition to the facilitated groups, both northern and southern Nevada have Caduceus groups that meet on a weekly basis. The Caduceus groups serve as a place for the physician and physician assistant to be with peers and discuss issues pertaining to chemical dependency in a supportive environment.

I want to thank the Nevada Hospital Association, as well as all of the medical facilities in Nevada, for their support of the Diversion Program. I would like to give special recognition to the following hospitals and/or medical centers for contributing to the Nevada Health Professionals Assistance Foundation in the year 2001 in the amount of $50,000, which was critical to the success of the Health Foundation in maintaining the quality of the Diversion Program during this year.

Churchill Community Hospital                             Humboldt General Hospital
St. Rose Dominican Hospital                             Sunrise Hospital Medical Center
Tahoe Pacific Hospital                                        Washoe Health System
University Medical Center                                   Mountain View Hospital
William Bee Ririe Hospital                                 Carson Tahoe Hospital

I am hopeful that the foundation will once again, in this year 2002, continue to receive financial support from the medical facilities in all of Nevada. Dr. Vic Rueckl, Dr. Timothy Coughlin, Dr. Rex Baggett, Dr. Roger Belcourt and I are available to the hospitals for presentations on addiction, disruptive behavior, or to explain the role and functioning of the Diversion Program. We can also answer any questions you might have about diversion and ways to help a colleague or friend who is unable to ask for help himself. Particularly in this time of insurance difficulties, we can all recognize the importance of maintaining physician health and well-being. The foundation can and will assist you with any difficulties you are experiencing with physician health.

Referrals to the Diversion Program come from a variety of sources, although the majority of those referrals come from partners, colleagues and hospitals. In all cases, no records are kept at the medical board level. Confidentiality and anonymity are the goals of both the medical board and the foundation. Information is gathered and verified before the Diversion Program takes action. Should circumstances necessitate, appropriate intervention is planned. Every effort is made to help the physician in a kind, respectful, confidential and therapeutic manner. If evaluation or treatment is indicated, we have three facilities we are utilizing; Talbott Recovery, in Atlanta, Georgia; Farley

Center in Williamsburg, Virginia; and Betty Ford Professionals Recovery Program in Palm Desert, CA. Each participant in the Diversion Program is monitored for five years. Monitoring includes random urine drug screening, weekly Caduceus group, weekly therapy group, and attendance at 12-Step meetings. The success rate for addicted physicians is very high, particularly when intervention is accomplished as early as possible and when colleagues are willing to step in and help their peers.

Do you know a colleague who needs help?

For confidential, expert assistance:

Nevada Health Professionals Assistance Foundation
Carol R. Bowers, R.N.,C.D., Executive Director
(702) 233-6393 OR (702) 521-1398 fax: (702) 242-3560

                                                                                                                                                                RATIO OF
                                                                                                                                                                    ACTIVE
                                                                                                                                                            IN-STATE M.D.'S
                                                                                                                                                                PER 100,000
YEAR *                 ACTIVE IN-STATE                 NEW LICENSES                 STATE POPULATION             POPULATION

1980                             1,158                                     201                                     800,000                             144
1981                             1,196                                     285                                     851,150                             140
1982                             1,308                                     234                                     878,260                             148
1983                             1,367                                     199                                     905,660                             151
1984                             1,366                                     205                                     933,010                             146
1985                             1,442                                     192                                     969,370                             148
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1986                             1,524                                     134                                  1,010,280                             151
1987                             1,487                                     142                                  1,057,030                             141
1988                             1,611                                     216                                  1,124,650                             143
1989                             1,666                                     199                                  1,197,260                             139
1990                             1,811                                     202                                  1,283,490                             141
1991                             1,895                                     233                                  1,300,000                             146
1992                             2,014                                     241                                  1,348,400                             149
1993                             2,144                                     308                                  1,389,000                             154
1994                             2,322                                     333                                  1,493,000                             155
1995                             2,424                                     331                                  1,583,000                             153
1996                             2,686                                     427                                  1,638,000                             158
1997                             2,760                                     442                                  1,741,000                             159
1998                             2,965                                     391                                  1,875,000                             158
1999                             3,113                                     377                                  2,034,000                             153
2000                             3,295                                     411                                  2,115,000                             156
2001                             3,523                                     383                                  2,133,000                             165

YEAR                 REVOCATION            PROBATION             SUSPENSION             MISCELLANEOUS *           TOTAL
2001                         12                                 4                                                                     4                             20
2000                         12                                 1                                                                     3                             16
1999                         10                                 1                                                                     4                             15
1998                           8                                 5                                                                     3                             16
1997                           8                                 2                                                                     6                             16
1996                           9                                 7                                                                     4                             20
1995                           1                                 1                                2                                 21                              25
1994                           2                                 4                                                                     8                             14
1993                           1                                 3                                1                                  10                             15
1992                           3                                                                   1                                   9                             13
1991                           3                                                                                                      10                             13
1990                           1                                 2                                                                    11                            14
1989                           2                                 1                                 1                                   8                            12
1988                           6                                 4                                 2                                   5                            17
1987                           2                                 4                                 3                                   3                            12
1986                           2                                 1                                 1                                   3                              7
1985                         11                                 3                                 3                                  11                           28

587 practitioners of respiratory care were licensed for the first time by the BME during 2001. The chart below reflects a breakdown of the number of licensed practitioners of respiratory care practicing in Nevada, by county, on December 31, 2001.

YEAR                                     2001

COUNTY
Carson City                             11
Churchill                                   5
Clark                                     399
Douglas                                  12
Elko                                         6
Esmeralda                                0
Eureka                                     0
Humboldt                                 4
Lander                                     2
Lincoln                                     2
Lyon                                      10
Mineral                                    2
Nye                                         7
Pershing                                  0
Storey                                     1
Washoe                               122
White Pine                              2
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
TOTAL                                 587

For year 2001 there were 194 physician assistants holding licensure in Nevada. 46 physician assistants were licensed for the first time by the BME during 2001. The chart below reflects a breakdown of the number of licensed physician’s assistants practicing in Nevada, by county, from 1992 through 2001.

YEAR                 1992             1993          1994           1995        1996        1997         1998         1999         2000         2001

COUNTY
Carson City             5                 5                 5                 3             3             2             5             7                9            11
Churchill                 0                 0                 0                 0             0             0             0             2                2              3
Clark                     40                 44             58                 72          72             77          94           118           116         129
Douglas                 0                  0                 0                 0             0             0             1             1                2             4
Elko                      1                  2                 4                 4             4             7             9             6                6             6
Esmeralda             0                  0                 0                 0             0             0             0             0                0             0
Eureka                   0                 0                 0                 0             1             1             1             1                1             0
Humboldt               0                  0                 0                0             0             0              0             0                0            1
Lander                   0                 0                 0                 0             0             0             0              0                0            0
Lincoln                  1                  2                 1                 1             1            0             0              0                 0            0
Lyon                     0                  0                 0                 0             1            2             2              4                 4             2
Mineral                 1                  2                 2                 2             2             1             1              1                 1             2
Nye           &