1. Risk Management, Medical Ethics And Other Issues Facing The Alternative Cancer Practitioner ABEIM Cancer Conference September 14, 2002 Presented by Richard Jaffe Esq.

2. Regulatory Agencies and Their Jurisdiction Over the Practitioner Federal –FDA: Drugs: off label usage Devices: class III use, even if device is approved Supplements: primarily claims issues/manufacturers –FTC Advertising: false or deceptive Substantiation: FDA standards for drugs Not usually a problem for practitioners

3. Regulatory Agencies and Jurisdiction Over the Practitioner State agencies: Department of Health: mini FDA acts – Only FDA approved drugs and devices can be used Medical Board – Primary jurisdiction over practitioners – Texas; Little risk for substandard conventional care – Board looks for easy medical cases; ie unconventional care – No causation or injury required! (In contrast to malpractice) – Limited administrative due process; Very limited judicial review – Specific regulations for advertising and complimentary care

4. Advertising: Broadly Construed “(1) Advertising and advertisement - Informational communication to the public in any manner designed to attract public attention to the practice of a physician. Advertising may include oral, written, broadcast, and other types of communications disseminated by or at the behest of a physician. The communications covered include, but are not limited to, those made to patients, prospective patients, professionals or other persons who might refer patients, and to the public at large. The communications covered include signs, nameplates, professional cards, announcements, letterheads, listings in telephone directories and other directories, brochures, radio and television appearances, and information disseminated on the Internet or Web.”

5. 164.3. Misleading or Deceptive Advertising. No physician shall disseminate or cause the dissemination of any advertisement that is in any way false, deceptive, or misleading.

6. Advertising Is Prohibited If It: 1) contains material false claims or misrepresentations of material facts which cannot be substantiated; Or (2) contains material implied false claims or implied misrepresentations of material fact; Or (3) omits material facts; Or (4) makes a representation likely to create an unjustified expectation about the results of a health care service or procedure; Or

7. More Prohibitions ( 5) advertises or assures a permanent cure for an incurable disease; Or (6) compares a health care professional's services with another health care professional's services unless the comparison can be factually substantiated; Or (7) advertises professional superiority or the performance of professional service in a superior manner if the advertising is not subject to verification; Or

8. More Prohibitions No Testimonials 8) contains a testimonial; What is a testimonial? A testimonial - an attestation or implied attestation to the competence of a physician's service or treatment. Testimonials also include expressions of appreciation or esteem, a character reference, or a statement of benefits received. Testimonials are not limited to patient comments but may also include comments from colleagues, friends, family, actors, models, fictional characters, or other persons or entities

9. Even More Prohibitions 9) includes photographs or other representations of models or actors without explicitly identifying them as models and not actual patients; or (10) causes confusion or misunderstanding as to the credentials, education, or licensure of a health care professional; or (11) represents that health care insurance deductibles or copayments may be waived or are not applicable to health care services to be provided if the deductibles or copayments are required; or (12) represents that the benefits of a health benefit plan will be accepted as full payment when deductibles or copayments are required; or (13) states that a service is free when it is not, or contains untruthful or deceptive claims regarding costs and fees. If other costs are frequently incurred when the advertised service is obtained then this should be disclosed. Offers of free service must indeed be free. To state that a service is free but a third party is billed is deceptive and subject to disciplinary action; or (14) makes a representation that is designed to take advantage of the fears or emotions of a particularly susceptible type of patient; or (15) advertises or represents in the use of a professional name, a title, or professional identification that is expressly or commonly reserved to or used by another profession or professional; or (16) claims that a physician has a unique or exclusive skill without substantiation of such claim; or (17) involves uninvited solicitation such as door to door solicitation of a given population or other such tactics for "drumming" patients; or (18) fails to disclose the fact of giving compensation or anything of value to representatives of the press, radio, television or other communicative medium in anticipation of or in return for

10. Standards for Physicians Practicing Integrative and Complementary Medicine. 200.1. Purpose. The purpose of this chapter is to recognize that physicians should be allowed a reasonable and responsible degree of latitude in the kinds of therapies they offer their patients. The board also recognizes that patients have a right to seek integrative or complementary therapies..

11. 200.2. Definitions. (1) integrative and complementary medicine - those health care methods of diagnosis, treatment, or interventions that are not acknowledged to be conventional but that may be offered by some licensed physicians in addition to, or as an alternative to, conventional medicine, and that provide a reasonable potential for therapeutic gain in a patient’s medical condition and that are not reasonably outweighed by the risk of such methods

12. Texas State Board of Medical Examiners 200.3. Practice Guidelines for the Provision of Integrative and Complementary Medicine. A licensed physician shall not be found guilty of unprofessional conduct or be found to have committed professional failure to practice medicine in an acceptable manner solely on the basis of employing a health care method of integrative or complementary medicine, unless it can be demonstrated that such method has a safety risk for the patient that is unreasonably greater than the conventional treatment for the patient’s medical condition.

13. Guidelines 1) prior to offering advice about complementary health care therapies, the physician shall undertake an assessment of the patient. This assessment should include but not be limited to, conventional methods of diagnosis and may include non-conventional methods of diagnosis and shall be documented in the patient’s chart. Such assessment shall include the following. (A)Adequate medical records. (B)Documentation as to whether conventional medical treatment options have been discussed with the patient and referral input, if necessary; (C) documentation as to whether conventional medical options have been tried, and if so, to what effect or a statement as to whether conventional options have been refused by the patient; (D) if a treatment is offered which is not considered to be conventional, documentation of at least a verbal informed consent for each treatment plan must be included (including documentation that the risks and benefits of the use of the treatment were discussed with the patient or guardian); (E) documentation as to whether the complementary health care therapy could interfere with any other ongoing conventional treatment.

14. Guidelines: What Do You Need to Treat? Documented treatment plan with stated goals where success or progress can be monitored and assessed Plan must consider: history, prior findings, need for further testing, referrals, or other treatments Documented periodic review of care Complete and accurate medical records

15. Endpoint If you do all of the above then: “The board will presume such practices are in conformity with the medical practice act.”

16. Risk Management Highest Risk Cancer Patient to Treat Unconventional primary therapy for early stage cancer. Limited protection from malpractice. The more curable the disease, the less justified unconventional care is from a licensure/disciplinary prospective. Under Texas law and the law of most jurisdictions, if a type and stage is cancer has a very high cure rate, unconventional care will be viewed as a violation of the medical practice act.

17. Risk Management: Moderate Risk Cancer Patients Adjuvant to conventional therapy –Less responsibility, so less likely to be blamed by patient, family or board –But will require knowledge of other treatment –Contraindications, or antagonistic effects –Biggest problem: interaction with conventional doctor; –My view: complaints much more likely from co- treating physician than patient: –Solution: be very careful, document everything and have support for therapeutic recommendations

18. Risk Management Lowest Risk Cancer Patient End stage cancer patient refractory to other treatments –Most protection from malpractice because of no causation –Limited licensure exposure if follow guidelines –But there are no guarantees! Fully document informed consent

19. My Advice Know your limitations Don’t promise more than you can deliver Don’t be afraid to declare a treatment failure, and refer the patient out (especially if providing primary cancer therapy) Fully document informed consent Maintain exemplary medical records