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Medical Board Report Newsletter of the Texas State Board of Medical Examiners Fall 1999 Volume 21, Number 1 Downloadable versions: Medical Board Report Fall 99 (fall99.doc, MS Word 97, 138KB)

CONTENTS: Governor Appoints Five to Board Texas Physicians Need to Know about Lyme, Other Tick-Borne Diseases For More Information on Lyme Disease Formal Complaints Legislation Passed Affecting Medicine in Texas Texas State Board of Physician Assistant Examiners Texas Medicaid Drug Use Review Triplicate Prescription Program Modifications Board Adopts New Rules Are You Practicing Medicine Without a License? Continuing Medical Education Reminder Texas State Board of Acupuncture Examiners Frequently Asked Questions TxDot Provides New Information on Disabled Person Placards New Legislation makes Social Security Numbers Confidential Birth Announcement Gainsharing Arrangements between Hospitals and Physicians Declared Illegal by Inspector General Disciplinary Actions

Governor Appoints Five to Board Governor George W. Bush has appointed five people to the Texas State Board of Medical Examiners. Their terms run until April 14, 2005. Jose Benavides, M.D. Dr. Benavides earned his medical degree from Nuevo Leon University in Monterrey, Mexico. He is a former chief of staff at Santa Rosa Hospital in San Antonio and has served as president of the Bexar County Medical Society. He has practiced internal medicine and is a clinical professor at the University of Texas Health Science Center in San Antonio. Dr. Benavides replaces Carlos Campos, M.D., M.P.H., of New Braunfels, whose term expired.

David E. Garza, D.O. Dr. Garza graduated from the University of Texas at Austin and earned his medical degree from the Texas College of Osteopathic Medicine. He served an internship at the Osteopathic Medical Center of Texas in Fort Worth and completed a residency at Memorial Medical Center in Corpus Christi. He has served as chief of family practice at Mercy Regional Medical Center, president of the Healthcare Alliance of Laredo IPA and participates in community affairs in Laredo, where he has a family practice. He was vice president of the Texas Society of the American College of Osteopathic Family Physicians and is a Diplomate of the ABFP and Fellow of the AAFP. He is a clinical assistant professor and alumni association board member for the University of North Texas Health Science Center-TCOM. Dr. Garza replaces William A. Pollan, D.O., of Ballinger, whose term expired. Joyce Roberts, M.D. Dr. Roberts, a New Mexico native, earned a BS Ed from Abilene Christian University. She received her premedical training at the University of Texas at Arlington and her medical degree from Texas Tech School of Medicine in Lubbock. She completed an internship and residency in family practice at Lubbock General Hospital. She serves on the boards of Rural Community Health Systems of Texas, Franklin County Child Protective Services and is affiliated with Presbyterian Hospital in Winnsboro. She has a family practice in Scroggins. Dr. Roberts replaces Charles W. Monday Jr., M.D., of Huntsville, whose term expired. Nancy Meredith Seliger Ms. Seliger received a BBA in petroleum land management from t he University of Texas at Austin. She works in recruiting and business development for the Underwood law firm in Amarillo. She serves on the M.D. Anderson Board of Visitors and the board of the Amarillo Museum of Art and also volunteers with the Boy Scouts of America, the Texas Lyceum and the Amarillo Symphony Ball. Ms. Seliger replaces Maria del Consuelo Navar-Clark of El Paso, whose term expired. Paulette Barker Southard Ms. Southard, a native of Alice, has been a teacher and a physician recruiter and is currently in the real estate business in Alice. She graduated from Baylor University. Her civic activities include past president of the Alice Chamber of Commerce, past president of the Rotary Club, past president of the Alice Board of Realtors, past chairman of the Alice 2000 Task Force, and membership on the Alice Planning and Zoning Commission, the Alice and Jim Wells County Highway 44 Task Force, the Alice Independent School District Facilities Study Committee, the Jim Wells County Leadership Committee, the Bull-A-Rama Committee, the Master Planning Association and the Alice Industrial Foundation. Ms. Southard replaces Ann Forehand Sibley of Garland, whose term expired. William H. Fleming III, M.D., of Houston, continues as president of the board; R. Russell Thomas, D.O., of Eagle Lake, is Vice President; and Mrs. Penny Angelo, of Midland, is Secretary-Treasurer.

At its August 26-28 meeting, the Board passed resolutions thanking Dr. Pollan, Dr. Campos, Dr. Monday, Ms. Sibley and Ms. Navar-Clark for their service to the Board and to the citizens of Texas. Texas Physicians Need to Know about Lyme, Other Tick-Borne Diseases For More Information on Lyme Disease Texas physicians need to be aware that tick-borne diseases do occur in Texas and must be reported to the Texas Department of Health. Following is information from TDH on diagnosis, treatment, prevention and reporting of tick-borne diseases. A Guide to the Diagnosis of Tick-Borne Diseases Consider these tick-borne illnesses when the following conditions exist: The patient has visited the Northeast U.S.: Babesiosis (sporadic cases elsewhere); Lyme borreliosis (most prevalent in the northeast, but occurs nationwide); the Southeast U.S.: Rocky Mountain Spotted Fev er (but occurs nationwide); the mountainous areas of the northwest U.S. or Canada: Colorado tick fever, tick-borne relapsing fever; old cabins or caves: TBRF. The symptoms include: a malaria-like illness: babesiosis; Bell's palsy: Lyme borreliosis, TBRF; relapsing febrile episodes: TBRF; diphasic febrile episodes: CTF; migratory joint pain: Lyme borreliosis; ulcerated skin lesions: tularemia; erythema migrans lesion: Lyme borreliosis; maculopapular or petechial rash, extending to palms and soles: RMSF; diffuse maculopapular or petechial rash: ehrlichiosis. Findings include: hemolytic anemia: babesiosis; leukopenia and thrombocytopenia: CTF, ehrlichiosis; lymphadenopathy: tularemia; previous splenectomy: babesiosis. Vectors of Tick-borne Disease Hard ticks: Amblyomma americanum (lone star tick), located primarily in the southern and south-central states, can transmit ehrlichiosis, RMSF, Lyme borreliosis, and tularemia. Dermacentor andersoni (Rocky Mountain wood tick), located in the western and mountain states, can transmit CTF, RMSF, and tularemia. Ixodes pacificus (western black-legged tick), located along the Pacific coast, can transmit babesiosis, ehrlichiosis, and Lyme borreliosis. Ixodes scapularis (black-legged tick), located in the eastern U.S., can transmit babesiosis and Lyme borreliosis. Soft ticks: Ornithodoros hermsi, located in the northwestern states, can transmit TBRF. Ornithodoros turicata, located in the southwestern and southcentral states, can transmit TBRF. Tick Exposure Tick exposure includes a history of the following: attached tick; tick found on clothing and/or hair; exposure to dogs or other animals; leisure activities in

wooded areas (i.e. camping or hiking); outdoor employment (i.e. forest management). Preventive Measures Wear light-colored clothing so ticks are more easily seen. Wear long-sleeved shirts and long pants; tuck shirts into pants and pants into socks. Periodically examine skin, clothing, hair. Use insect repellants or acaracides applied to skin (i.e. DEET) or clothing (i.e. permethrin). Inspect and remove ticks from pets frequently. Proper Tick Removal Remove tick as soon as possible. Use tweezers to grasp tick at attachment site as close to skin as possible. Gently pull tick straight out using slow, steady pressure without twisting. If removal with fingers is necessary, use protective barrier. Avoid contact with tick fluids; do not crush, squeeze, or puncture tick. Do not apply hot matches, nail polish, petroleum jelly, or other chemicals to tick. Carefully clean site with soap and water. Send ticks to the Texas Department of Health for testing. For more information call (512) 4587676 or (512) 458-7228. Rocky Mountain Spotted Fever RMSF is a serious disease that is transmitted by infective ticks. The initial symptoms, which follow an incubation period of three to 14 days, are "flulike": there may be sudden onset of high fever, headache, chills, and muscle aches. A rash often appears a few days later. This rash spreads rapidly over the entire body and may even be seen on the palms of the hands and soles of the feet. Prompt medical attention is extremely important because RMSF can be fatal if treatment is delayed. The illness can be cured with antibiotics. Causes of RMSF In Texas, several species of ticks, including lone star ticks, American dog ticks, and brown dog ticks can carry spotted fever organisms (rickettsia). Hungry ticks usually position themselves on grass or small bushes and wait for a potential host to pass by. If the tick drops onto a human's legs, it often crawls upward toward the head looking for a space to attach. Ordinarily, infection takes place when disease-causing rickettsia are inoculated into the skin via the bite of a feeding tick. Quick removal of ticks is important because they often must be attached several hours before there is disease transmission. People who remove ticks from domestic animals can also become infected if they crush ticks between their fingers, causing rickettsia to penetrate the skin. Thus, whenever ticks are handled, it is important to wash hands immediately. The peak months for RMSF in Texas are April through July, though the disease can occur year-round. Lyme Borreliosis Lyme borreliosis is a disease that can cause skin, joint, heart and nervous system problems. It may affect people of all ages, possibly continuing months or years if not adequately treated. It was named after the town of Lyme, Connecticut, where it was first described in 1976. In 1984 the disease was found to be present in Texas and it is now the most frequently diagnosed tick/insect-borne disease in the country. Illness usually begins in the spring or summer and is typically divided into three different stages, often with

apparent recovery between stages. The different stages may overlap but can occur independently. Lyme Disease Causes Lyme disease is caused by a specialized type of bacteria called a spirochete. It is usually transmitted by the bite of an infected tick or flea, although other insects that feed on animal blood may be involved. Symptoms Stage I: Skin lesions and associated flu-like symptoms A variable time (as few as three days or as many as 28 days) after exposure, symptoms that mimic the common flu appear. They may include many of the following: fatigue/lethargy, headache, fever and chills, stif f neck, myalgias (generalized muscle aches, sometimes with severe cramping), joint pain, backache, sore throat, enlarged lymph nodes, abdominal pain, nausea, vomiting, dizziness, and nonproductive cough. Except for the fatigue and lethargy, which are often constant and can be incapacitating, the symptoms tend to be intermittent and changing. Fever is usually of a low grade, but sometimes becomes high, especially in children. This stage of the disease may last for months with one set of symptoms predominating for awhile only to change to another very different manifestation. Primary skin lesion(s): Along with the flu-like symptoms, many victims (about 35 percent) develop an unusual skin lesion. The small red area around the insect bite begins to expand. The generally circular area may be as large as 14 inches, but often is smaller than one inch. The lesion may become lighter colored in the center, leaving a red ring on the outside, and may be confused with "ringworm." Sometimes the center remains intensely red and hard, occasionally even forming blisters, which later burst and form a heavy dark scab. This type lesion could easily be mistaken for a spider bite. Sometimes the lesion does not expand at all but fails to heal and repeatedly scabs and drains for several weeks. Secondary skin rashes: Nearly 80 percent of people with Lyme disease develop other rashes. The secondary rash may appear at the same time as a primary skin lesion or may appear later. Often these rashes recur periodically. The character of the rash may vary from one time to another and can often change in appearance rather quickly. The rash may at times look like hives, poison ivy, chicken pox, or insect bites. The rash may also appear as splotchy areas, circular areas or irregular areas of redness. Stage II: (Nervous system and heart involvement) Nervous system: Early Lyme disease is often manifested by excruciating attacks of headache and neck pain or stiffness, sometimes lasting for hours. About 15 percent of infected people develop more severe neurological problems such as these: sleep disturbances; difficulty concentrating; poor memory; emotional instability; irritability; double vision; numbness/weakness in extremities or face; eye pain and/or ear pain.

Heart: Within several weeks of infection about 10 percent will have heart involvement, which is usually temporary (one to six weeks) and rarely recurs. Most commonly this involves episodes of an unusually forcible, rapid or irregular heart beat. Stage III: (Joint and nervous system involvement) Joint involvement: About 60 percent will develop arthritis evident as intermittent joint pain, usually involving larger joints. Onset of arthritis may be weeks or months (rarely up to two years) after initial infection. Attacks last for a few days, and may recur a few weeks later. In about 10 percent of cases, the arthritis becomes chronic. Nervous system involvement: Some patients may develop neurologic symptoms such as chronic fatigue, psychiatric problems or a multiple sclerosis-like illness. Disease spread Lyme disease is spread by tick or flea bites. Tick or flea infestations may result in more than one person becoming ill at the same time. A pregnant woman can transmit the disease to her unborn child. Diagnosis 1. The appearance of a typical primary skin lesion (an expanding lesion with a lighter colored center following a tick or flea bite) is considered diagnostic for Lyme disease. 2. Without the primary lesion the diagnosis must be made on clinical signs and symptoms plus positive results from a blood test available from TDH. Lyme disease vaccine now available The Food and Drug Administration approved the first vaccine for Lyme disease in December 1998. LYMErix, made by SmithKline Beecham, should be considered for anyone age 15 to 70 who lives in Lyme-endemic states and spends time outdoors. SmithKline has not completed tests on LYMErix's safety for children and expects test results later this year. The vaccine has not been tested on the very elderly, pregnant women or those with chronic diseases such as rheumatoid arthritis. The vaccine requires two shots given about a month apart, then a third shot a year later. LYMErix offers about 50 percent protection after the first two shots and about 80 percent protection after the three-shot series. The vaccine blocks Lyme by creating antibodies that recognize an outer protein of the bacteria in the tick's saliva, neutralizing it at skin level. SmithKline began shipping LYMErix in January and advertises it in most Lyme-ridden states. Reporting Requirements Texas law requires physicians to report certain diseases to TDH. Detailed rules on the reporting of notifiable diseases and conditions and the duties of local health authorities may be found in Article 97, Title 25, Texas Administrative Code.

The following tic k-borne diseases must be reported on a weekly basis to local health departments by name, age, sex, race/ethnicity, date of birth, address, telephone number, disease, date of onset/occurrence, physician and method of diagnosis: ehrlichiosis, Lyme disease, relapsing fever and Rocky Mountain spotted fever. For more information, call the TDH Infectious Disease Epidemiology and Surveillance Division at (800) 252-8239. Formal Complaints The following Formal Complaints were filed with the State Office of Administrative Hearings since the last publication of the Medical Board Report regarding the licensees listed below: Physicians

Lic. No.

Date Filed

Robert J. Byrnes, D.O.

J1904

9/13/99 3.08(3), 3.08(4), 3.08(4)(C), 3.08(4)(D), 3.08(4)(E), 3.08(16)

Rafael M. Cappiello, M.D.

E6745

8/25/99 3.08(18), 3.08(21)

Joye M. Carter, M.D.

K1383

7/28/99 3.08(4), 3.08(5), 3.08(15)

Arthur B. Conde, M.D.

D3766

9/8/99

Bernard J. Dolenz, M.D.

C7391

8/24/99 3.08(2)

Jacques S. Jaikaren, M.D.

F2731

9/2/99

Ronnie L. Nelms, D.O.

D6833

7/15/99 3.08, 3.08(4)(E), 3.08(4)(F), 3.08(18)

Robert V. Ricketson, M.D.

J2758

9/21/99 3.08(3), 3.08(4), 3.08(4)(B), 3.08(4)(D), 3.08(4)(E), 3.08(4)(F), 3.08(16), 3.08(18), 3.08(21)

Pedro I. Rivera, M.D.

G6380

9/8/99

Dan A. Willis, M.D.

E2944

9/13/99 3.08(5), 5.08(K)

Anthony W. Vila, D.O.

C3239

9/2/99

Physician

Alleged Statutory Violation*

3.08(4), 3.08(18)

3.08(2), 3.08(4)

3.08(1), 3.08(2)

3.08(4), 3.08)(4)(C), 3.08(4)(E), 3.08(4)(F), 3.08(18)

Assistant Brian M. Resnik

PA001165 9/2/99

18(5), 18(9), 18(12)

* Explanation of violations (to view the entire Medical Practice Act, see the Board's web site at www.tmb.state.tx.us; from the home page, go to "Medical Practice Act.") 3.08: The Board may refuse to admit persons to its examinations and to issue a license to practice medicine to any person and may take disciplinary action against any person for any of the following reasons: 3.08(1): submission of false or misleading information to the board; fraud; 3.08(3): intemperate use of alcohol or drugs that could endanger the lives of patients; 3.08(4): unprofessional or dishonorable conduct likely to deceive or defraud the public or injure the public; 3.08(4)(B): failing to keep complete and accurate records of purchase and disposal of drugs; 3.08(4)(C): writing prescriptions or dispensing drugs to a known abuser of narcotics, controlled substances or dangerous drugs; 3.08(4)(D): writing false or fictitious prescriptions for dangerous drugs or controlled substances; 3.08(4)(E): prescribing or administering a drug or treatment that is nontherapeutic; 3.08(4)(F): prescribing, administering or dispensing dangerous drugs or controlled substances in a manner not consistent with public health and welfare; 3.08(5): violation of board rules; 3.08(15): aiding or abetting the unlicensed practice of medicine; 3.08(16): inability to practice medicine with reasonable skill and safety by reason of illness, drunkenness or excessive drug use; 3.08(18): professional failure to practice medicine in an acceptable manner consistent with public health and welfare; 3.08(21): suspension, revocation or other disciplinary action by another state; 5.08(K): failing to furnish copies of medical records requested.

Physician Assistant Act: 18(5): habitual use of intoxicants or nontherapeutic drugs so as to be unable to safely perform as a physician assistant; 18(9): acting in an unprofessional or dishonorable manner likely to deceive, defraud or injure the public; 18(12): suspension, revocation or restriction of license by another state. Legislation Passed Affecting Medicine in Texas The 76th Legislature, which met January through May of this year, passe d a number of laws that affect the Board and the practice of medicine. Following is a summary of these laws: HB 27, Medical Records: Requires that physicians provide records in 15 days (changed from 30 days). Also requires the board to appoint a custodian of records if a doctor is removed from practice or in the event of the physician's death, incapacitation or abandonment of records. HB 110, Physician Profiling: Requires the Board to make additional physician information available, including all medical education and graduate medical education, specialty certification, length of active practice, any convictions or board discipline, certain malpractice information as well as other information about services provided. The bill requires that the Board make this information available by September 1, 2001. HB 573: Allows charity work in a medically underserved area for category II CME as long as it is not in the area the physician practices. HB 670: Allows Texas veterans applying for disability benefits to receiv e medical records free from health care providers and health care facilities. HB 677: Allows psychiatric residents in a Texas postgraduate training program to complete a certificate of medical examination for mental illness. HB 692: Makes social security numbers of license holders confidential. HB1051: Expands the practice of optometry to include treatment of glaucoma, but precludes surgery or the use of lasers by optometrists. Also defines surgery. Creates an Optometric Health Care Advisory Committee, including two therapeutic optometrists appointed by the Texas Optometry Board, two pharmacologists appointed by the Texas State Board of Pharmacy, and two board-certified ophthalmologists appointed by the Texas State Board of Medical Examiners. HB 1987: Establishes a single common pathway for licensure and streamlines the licensure process. Requires all parts of the exam to be passed within three attempts but allows exceptions under certain specific circ*mstances. HB 2453: Allows physicians to form jointly owned entities with optometrists.

HB 3083: Allows physicians licensed in a contiguous state to order home health or hospice care as long as the service provided in Texas is provided by a licensed provider. HB 3216: Allows the Board to do core credentialing of demographic data, professional education, training and licenses. Implementation of this bill is not required because funding was not furnished. SB 30: Requires parental notification of abortion on a pregnant unemancipated minor unless the physician gives at least 48 hours notice of the physician's intent to perform the abortion to a court -appointed managing conservator or guardian, or unless a judge issues an order authorizing the minor to consent to the abortion. SB 1131: Establishes due process guidelines for hospital credentialing of physician assistants and advanced practice nurses. SB 1207: A major rewrite of the licensure statute, including changes made in HB 1987. SB 1223, Acupuncture: Excludes from board membership any person who owns, operates, or has a financial interest in a school of acupuncture. Allows LVN's to practice acudetox. SB 1294: Substitutes language in the Health and Safety Code, Section 311.0025, to prohibit improper, unreasonable or medically unnecessary billing by hospitals or health care professionals. SB 1340: Mandates that rules be written to regulate anesthesia performed outside a licensed hospital or ambulatory surgical center. Rules are to be established jointly with the Texas State Board of Nurse Examiners. To view these bills, go to the Legislature's web site at www.capitol.state.tx.us. To receive a copy of a bill, contact the Legislative document distribution divisions at the following addresses: House Document Distribution John H. Reagan Building, Room G-9 15th and Congress Austin, TX 78701 (512) 463-1144 Senate Bill Distribution Sam Houston Building, Room 190 201 E. 14th St. Austin, TX 78701 (512) 463-0252 Texas State Board of Physician Assistant Examiners Governor George W. Bush has appointed three new members to the Texas

State Board of Physician Assistant Examiners for terms running until February 1, 2005. Pamela Baker has a Bachelor of Science in biology from Mary Baldwin College in Virginia and a Master of Science in environmental science from Texas A&M University, Corpus Christi. She has taught biology and physical science in San Antonio and Austin. She c urrently works in real estate in Corpus Christi. She is also involved with the Downtown Rotary Club of Corpus Christi, the Texas Association of Realtors, the Pan American Round Table and the Texas Academy of Sciences. She replaces Emanuel Bodner, whose term expired. G. Al Bendeck, PA-C, is a physician assistant at Slaton Medical Clinic in Slaton. He replaces Frank Ambriz, PA-C, whose term expired. Stephen D. Benold, M.D., has practiced as a family physician in Georgetown for 22 years. He is a graduate of Rice University and Southwestern Medical School. He is a former president of the Texas Academy of Family Physicians. In addition to his family practice, he has been a jail physician and medical director for Williamson County EMS for 20 years. He replaces Joe Mendoza, M.D., whose term expired. Tony Hedges, D.O., of Littlefield is president of the board, and Michael Belgard, PA-C, of San Augustine, is secretary. At its August 5-6 board meeting, the board passed resolutions thanking Mr. Bodner, Mr. Ambriz and Dr. Mendoza for their service to the Board and to the citizens of Texas. Texas Medicaid Drug Use Review By Jennifer Seltzer, Pharm. D. Issues Involving Drug-Induced Liver Toxicity Trovafloxacin/Alatrofloxacin: The Food and Drug Administration has restricted the use of trovafloxacin (Trovan®) and alatrofloxacin (Trovan-IV®) due to excessive reports of hepatic toxicity. Pfizer received reports of 140 cases of hepatic events associated with trovafloxacin and alatrofloxacin use from February 1998 through May 1998, including 14 cases of liver failure and six deaths. Several of the severe hepatic cases cited appear to be due to a hypersensitivity -type reaction. Underlying disease states as well as concurrent medications may have also contributed to the emergence of hepatic toxicities associated with trovafloxacin and alatrofloxacin use. Pfizer and the FDA are recommending that trovafloxacin and alatrofloxacin only be used in the following conditions: 1) the infection is serious and life- or limb-threatening; 2) therapy is begun only in hospitals or long-term care facilities; and, 3) the physician believes the benefits of therapy outweigh the potential risks involved. Trovafloxacin and alatrofloxacin should not be prescribed for outpatient use. Treatment duration with these therapeutic agents should not exceed 14 days as prolonged use increases the risk of liver toxicity. 1. News. Limits placed on trovafloxacin, alatrofloxacin following reports of liver failure. Am J Health-Syst Pharm 1999;56:1388.

2. Doctor's Guide to Medical & Other News. Pfizer relabels antibiotic Trovan for serious infections. www.pslgroup.com/dg/1060B6.ht m 3. Pharmacist's Letter 1999;15:37. Hydrocodone/Acetaminophen analgesic combinations: Patients prescribed the hydrocodone/acetaminophen drug combination may inadvertently be at risk for developing acetaminophen-induced hepatotoxicity when either utilizing large doses of this treatment combination or receiving treatment for prolonged time periods. Most reported cases of acetaminophen hepatotoxicty have been associated with acute ingestions of large quantities of the medication. Hepatotoxicity may also occur after long-term exposure with lower doses (< 4 g). Most patients manifesting hepatic changes/toxicity following therapeutic acetaminophen doses develop chronic liver dysfunction, which improves upon drug withdrawal in most patients. However, one report described the development of fulminant hepatic failure in three patients, which proved fatal in two of the three patients following acetaminophen administration in therapeutic doses. Patients with a history of alcohol abuse, concurrent prescriptions for enzyme-inducing drugs (e.g., phenytoin, isoniazid), certain viral illnesses associated with hepatic dysfunction, or a poor nutritional state may have an increased susceptibility to the toxic effects of acetaminophen so that at therapeutic or near therapeutic doses hepatotoxicity may result. Clinicians should be alert to the potential for acetaminophen hepatotoxicity in patients receiving higher doses of acetaminophen combination products. 4. Makin AJ, Williams R. Acetaminophen-induced hepatotoxicity: Predisposing factors and treatments. Adv Intern Med 1997;42:453-83. 5. Csete M, Sullivan JB. Vicodin-induced fulminant hepatic failure. Anesthesiology 1993;79:857-60. Update On Ketorolac (Toradol®) Use The nonsteroidal anti-inflammatory drug, ketorolac (Toradol®), is indicated for use in short-term management of moderately severe acute pain responsive to opioid analgesia. The maximum intravenous or intramuscular ketorolac dose is 120 mg/day in patients younger than 65 years of age and 60 mg/day in patients 65 years of age and older, patients with renal impairment, and patients weighing less than 50 kilograms. The maximum oral dose for ketorolac is 40 mg/day. A "black box" warning was developed for Toradol® in December 1994 limiting the total duration of therapy, parenteral and oral combined, to five days due to an increased risk of serious adverse events with prolonged use. Serious adverse events have included peptic ulcers, gastrointestinal bleeding, gastric perforation, increased bleeding risks, and renal toxicity. The incidence of these adverse events is significantly greater with ketorolac use than with other available NSAIDs. Although not FDA-approved, ketorolac has been successfully utilized for longer than five days to manage cancer pain in terminal cancer patients and reduced the need for some opioid analgesics. Gastrointestinal bleeding and renal toxicity were reported in a few patients.

In February 1995 the Texas Department of Health Medicaid Vendor Drug Program designated 20 tablets as the maximum prescription fill quantity limit for Toradol® to aid health care professionals in expediting this "black box" warning. Providing patients with multiple prescriptions for Toradol® may place patients at undue risk for developing serious unwanted effects, although in terminal cancer patients, the benefits may outweigh the risks involved. 6. Ketorolac Product Information. Roche Laboratories, March 1995, August 1995. 7. Drugdex® Editorial Staff. Ketorolac. In: Gelman CR, Rumack BH, Hess AJ, eds. Drugdex® System. Englewood, CO: Micromedex, Inc. (Edition expires 1999). Did You Know...? The nonsedating antihistamine, astemizole (Hismanal®), will no longer be marketed in the United States. Due to continuing problems with drug interactions and the potential for serious toxicities, Janssen has chosen to discontinue astemizole as the clinical benefits no longer exceeded the associated risks accompanying use of this product. Patients requiring nonsedating antihistamine therapy should consult with the clinician prescribing the medication to discuss alternative treatments. The FDA recently approved zaleplon (Sonata®) for short -term use in the management of insomnia in adults, including elderly patients. Like zolpidem (Ambien®), zaleplon is a GABAa omega-1 selective receptor modulator nonbenzodiazepine hypnotic. However, zaleplon is not a sleep maintenance drug. Zaleplon demonstrates an elimination half-life of only 30 minutes which allows this compound to remain at the binding site for only a short time period. Subsequently, zaleplon is rapidly eliminated after sleep commences, allowing the patient's natural sleep processes to take over. Therefore, zaleplon may be ingested either at bedtime or some time later after the patient has attempted to fall asleep, provided that the patient has at least four or more hours of time remaining in bed. In clinical trials, patients receiving zaleplon did not show evidence of grogginess or hangover effects, which are commonly noted with other sleep medications. The recommended zaleplon dose for nonelderly adults is one 10 mg capsule nightly, while elderly patients should be prescribed one 5 mg capsule. Prescribing the COX-2 inhibitors, celecoxib (Celebrex®) and rofecoxib (Vioxx®), concurrently with warfarin may result in enhanced warfarin activity. Recent post-marketing reports have demonstrated increases in prothrombin time and some bleeding events predominantly in the elderly population when COX-2 inhibitors are administered concurrently with warfarin. While the COX2 inhibitors have no effect on platelet aggregation or bleeding time, adjuvant administration with warfarin results in increased warfarin effects. Anticoagulant activity should be monitored, particularly in the first few days, when COX-2 inhibitor therapy is initiated, discontinued or modified in patients receiving warfarin concomitantly. 8. Astemizole (Hismanal®). Facts and Comparisons' DrugLink 1999;3:57.

9. Doctor's Guide to Medical & Other News. FDA approves Sonata for treatment of insomnia. www.pslgroup.com/dg/120FC2.ht m (August 16, 1999) 10. Wyeth Sonata short-term psychom*otor symptoms allows mid-night dosing. FDC Reports 1999;61:4. 11. Product Information. Celecoxib. Searle Pharmaceuticals, May 1999. 12. Product Information. Rofecoxib. Merck & Co., May 1999. Prepared by Jennifer Seltzer, Pharm. D., Drug Information Service, The University of Texas Health Science Center at San Antonio, and the College of Pharmacy, The University of Texas at Austin, in association with the Texas Medicaid Vendor Drug Program. The above article is provided for informational use only. Physicians should exercise their clinical judgment as to the appropriateness of treatment options on a case-by-case basis. The article should not be construed as a position statement of the Board. The Board thanks Jennifer Seltzer for contributing the guest article. Triplicate Prescription Program Modifications In 1997 the 75th Legislature passed HB 1070, which calls for Texas pharmacies to report Schedule II prescription information electronically to the Texas Department of Public Safety, beginning September 1, 1999. It will no longer be necessary for pharma7cies to submit copies of triplicate prescriptions. The 76th Legislature in 1999 passed SB254, which replaced the triplicate prescription with an official prescription. The official prescription will be phased in and pharmacists will be able to accept either prescription until further notice. The phase-in will allow current supplies of triplicate prescriptions to be depleted. The changes should not affect the prescriber ordering prescriptions from DPS. DPS reports that it does not yet have a vendor for the new forms, and until a contract is awarded the department will continue to supply triplicate forms. Prescribers are encouraged to order their normal quantities of forms, or slightly higher quantities. It is unknown what the cost of the new forms will be, but, like triplicate prescriptions, they will be provided at cost. When a contract has been awarded, information and instructions for ordering will be provided to all registrants at the address they have on file in the Controlled Substances Registration Section at DPS. Under HB1070 and SB 254 there is no requirement for reporting prescriptions administered or dispensed directly to patients by prescribers, so those forms are no longer needed. Triplicate and official prescription forms are required for all Schedule II prescriptions filled in pharmacies.

Another provision in HB 1070 allows prescribers to request prescription information regarding their patients or their own practices. Before this element of the program is implemented, DPS must establish rules regarding the request and release of information. When rules have been written and published, DPS will notify registrants directly or by publication. Board Adopts New Rules The Board approved the following proposed rule changes that were published in the Texas Register: Chapter 161, General Provisions, amendments to section 161.1 to outline responsibilities of Board committees. Chapter 163, Licensure, rule review, repeal of sections 163.1-163.12 and new sections 163.1-163.17 to incorporate changes mandated by Senate Bill 1207. Chapter 166, Physician Registration, amendment to section 166.1 regarding a requirement that physicians notify the board of a change of address within 60 days. Chapters 173, Applications and 175, Schedule of Fees and Penalties, rule review, repeal of Chapters 173 and 175, and new Chapter 175, Fees, Penalties, and Applications. Chapter 179, Investigation Files, rule review and amendment to section 179.2 regarding responses to written inquiries. Chapter 183, Acupuncture, amendments to sections 183.7 and 183.13 relating to the time frame for the requirement of physician referral, the maximum number of treatments performed before referral to a physician, and referrals from chiropractors. Chapter 187, Procedure, amendment to section 187.39 that will increase the administrative penalty for failure to obtain required continuing medical education. In accordance with House Bill No. 1, 75th Legislature, Regular Session, 19981999, Article IX, Section 167, the Board reviewed the following rules with no amendments to current text: Chapter 164, Advertising; Chapter 165, Medical Records; Chapter 168, Persons With Criminal Backgrounds; Chapter 169, Authority of Physicians to Supply Drugs; Chapter 180, Rehabilitation Orders; Chapter 188, Complaint Procedure Not ification; Chapter 190, Disciplinary Guidelines; Chapter 191, District Review Committees; Chapter 196, Voluntary Surrender of a Medical License; Chapter 198, Unlicensed Practice. For copies of these rules, see the Board's web site at www.tmb.state.tx.us, or write the Board at MC 901, P.O. Box 2018, Austin, TX 78768-2018. Are You Practicing Medicine Without a License? Section 3.01(d) of the Medical Practice Act states in part that practicing medicine as defined in this Act without an annual registration receipt for the current year has the same force and effect as and is subject to all penalties of practicing medicine without a license. So, although renewal penalty fees are not assessed for the first 30 days after the expiration date, a physician cannot practice without a current annual registration permit. The Board sends renewal notices to the practitioner's last known mailing address at least 30 days prior to expiration. Address changes are accepted only in writing. If you have not notified the Board of a change in mailing address, you may do so by sending a written notice to the following address: Texas State Board of Medical Examiners MC-241

P. O. Box 2018 Austin, TX 78768-2018 Or fax it to (512) 305-7008 Be sure to include your license number and sign your notification. Allow at least three working days for your renewal form and fee to be processed. See page 23 for a change of address form. Continuing Medical Education Reminder As a prerequisite to the annual registration of a physician's license, 24 hours of continuing medical education are required to be completed in the following categories: 12 Formal Hours� Category 1 or 1A designated for AMA/PRA Category 1 credit by a CME sponsor accredited by the Accreditation Council for Continuing Medical Education or a state medical society recognized by the Committee for Review and Recognition of the Accreditation Council for Continuing Medical Education; approved for prescribed credit by the American Academy of Family Physicians; designated for AOA Category 1-A credit required for osteopathic physicians by an accredited CME sponsor approved by the American Osteopathic Association; or approved by the Texas Medical Association based on standards established by the AMA for its Physician's Recognition Award. At least one formal hour must involve medical ethics and/or professional responsibility. 12 Informal Hours - Informal self-study, hospital lectures or grand rounds. If you have questions, call the Permits Department at (512) 305-7020. For information on CME courses, call TMA at (512) 370-1300; TOMA at (512) 708-8662; or the Texas Academy of Family Physicians at (512) 329-8666, or check their web sites: TMA: www.texmed.org, TOMA: www.txosteo.org or TAFP: www.tafp.org Texas State Board of Acupuncture Examiners Governor Appoints Board Members, Others Continue to Serve The Texas State Board of Acupuncture Examiners was created by the Legislature in 1993. Members include the following, including appointments recently made by Governor George W. Bush: Cheng Ming Chang was born in Taiwan. His education includes a degree from the Institute of Occupational Health International Research Center for Acupuncture Science in Taiwan, the Institute of Present Day Chinese Medicine in Hong Kong and a Master of Acupuncture from the Research Center of Oriental Medicine in Singapore. He is a licensed acupuncturist in California and Texas and was appointed to the American Institute of Chinese Medicine in Sacramento. He currently practices acupuncture in San Antonio. His term expires in January, 2001.

Everett G. Heinze Jr., M.D., is a member of the Austin Diagnostic Clinic and serves as secretary-treasurer of the Board. He is board certified in Neurology and Internal Medicine. He has been using acupuncture in his neurology practice since 1974. He is Co-medical Director of Rehabilitation and Comedical Director of Pain Management at St. David's Medical Center in Austin. Pedro V. Garcia Jr. is a native of Brownfield. He received a Bachelor of Science in Occupational Education with specialization in health administration from Wayland Baptist University and is currently working on a Masters in Business Administration at Wayland. He is employed in patient accounting at University Medical Center in Lubbock. He is involved in the Lubbock Hispanic Chamber of Commerce, is a board member of Fiestas del Llano, Inc., a member of LULAC Council 4522 and a member of the Children's Miracle Network at University Medical Center. His term expires in January, 2003. Meng-Sheng Linda Lin received her Doctor of Medicine degree from Peking Union Medical College. She was a postdoctoral fellow with the World Health Organization at M.D. Anderson Hospital and Tumor Institute, University of Texas Health Science Center. Dr. Lin is a licensed Texas acupuncturist and practices at the Acupuncture Center in Richardson. Her term expires in January, 2003. Dee Ann Newbold is licensed to practice acupuncture in Hawaii and Texas. She has a Bachelor of Science in Education from Nebraska Wesleyan University and has done postgraduate studies in acupuncture and oriental medicine in North America and Europe. She is former president of the Texas Acupuncture Association and the Texas Association of Professional Acupuncturists and serves on the advisory board of the Academy of Oriental Medicine in Austin. She practices acupuncture at the Acupuncture Medicine and Research Centre in Austin. Jacquelyn Diane Pearson, a public member of the Board, is a stockbroker in Plano. A native of Tennessee, she received a degree from North Texas State University and has worked for a mortgage company and a public oil and gas company. Her term expires in January, 2003. Claire H. Smith, a public member, lives in Dallas. Her term expires in January, 2005. Marshall D. Voris, Ph.D., Ed.D., is an acupuncturist at the Delos Mind-Body Institute in Corpus Christi. His term expires in January, 2005. Annette M. Zaharoff, M.D., is presiding officer of the board. Dr. Zaharoff received her medical degree from Wayne State University School of Medicine in Michigan and completed her residency at the University of Texas Health Science Center in San Antonio. She also completed a sports medicine fellowship. She practices physical medicine and rehabilitation in San Antonio and is a member of the U.S. Tennis Association Sports Science Committee. Her term expires in January, 2001.

At its August 9 Board meeting, the Board passed resolutions thanking board members Lisa Lin and Nancy Land, whose terms expired, for their service to the Board and to the citizens of Texas. Frequently Asked Questions Q. Do physician licensure applications of International Medical Graduates take a longer time to process than U.S./Canadian physician licensure applications? A. On June 4, there were 200 physician licensure applications complete waiting for the Board to issue a license. Of these, 67 percent (64 percent IMGs) were completed within 120 days. As those figures show, most IMGs' applications are completed at the same rate as all physician licensure applicants. There are two main reasons why processing of IMG physician licensure applications may be delayed: (1) the international postal system and (2) the additional time needed to translate documents submitted in a language other than English. Another delay that may occur to a very small number of IMGs each year is when an applicant is a graduate of a medical school from which the Board has never licensed, and additional information about this international medical school must be collected. This delay happens only to the first graduate who applies for licensure from that school. In the future, with the use of the Federation of State Medical Boards' credentialing and verification service, it is anticipated that IMGs' physician licensure application processing time will shorten considerably. District Review Committee Member Elected TOMA President Rodney M. Wiseman, D.O., who serves on the Board's District Review Committee Number Two, was elected president of the Texas Osteopathic Medical Association for 1999-2000. He was installed June 19 during TOMA's 100th Annual Convention and Scientific Seminar in Dallas. Dr. Wiseman received a B.S. degree from the University of Houston and his Doctor of Osteopathic Medicine degree from the University of North Texas Health Science Center/Texas College of Ost eopathic Medicine in Fort Worth. He served his internship at the William Beaumont Army Medical Center in El Paso. As an army medic in the Vietnam War, Dr. Wiseman received the Bronze Star. He is board certified in Family Practice and has a private family practice in Whitehouse. TxDot Provides New Information on Disabled Person Placards Changes in law passed by the 76th Legislature affect disabled person placards. SB 132 allows physicians licensed to practice medicine in Texas and in adjacent states to sign the Application for Disabled Person Identification Placards and/or License Plates, Form VTR-214. SB 21 added sections to allow institutions and facilities to obtain disabled person placards and/or license plates for vans or buses operated by facilities for the transportation of residents in a facility, institution or retirement

community. The manager or administrator of such a facility must complete the initial application form VTR-214 REV. 8/99. Earlier forms may be accepted as long as the license number issued by the Texas Department of Human Services is entered in the space for driver's license number. The disability statement normally completed by a physician is not required. HB 1032 provides that for disabled person placards issued after September 1, the disabled person or applicant is required to have additional information regarding the type of disability prior to issuance of the placard. The application, Form VTR-214, has been revised to include a statement from the physician regarding the nature of the disability. The physician may check one of two boxes. If the person has a "mobility disability," a blue Permanent Disabled Person Placard will be issued. All other permanently disabled persons will receive red Permanent Disabled Person Placards. Mobility Disabilities In order for the county to issue a blue placard, the physician will mark the first box, indicating one of the following disabilities: cannot walk without an assistance device, or cannot ambulate without a wheelchair or similar device. Non-Mobility Disabilities If the physician selects the second box, the disabled person will be issued a red placard indicating one of the following disabilities: legally blind; cannot walk 200 feet without stopping to rest; restricted by lung disease; has a cardiac condition with functional limitation classified as Class III or Class IV as set by the American Heart Association; is limited in ability to walk by arthritic, neurological or orthopedic condition; or has another debilitating condition that, in the physician's opinion, limits or impairs the person's ability to walk. Parking Restrictions Some disabled person parking places may be color-coded with blue or red spaces. If so, the disabled person using a blue placard may park in either blue or red spaces. Persons using red placards may park only in red spaces. Vehicles displaying disabled person license plates may only park in red spaces unless a blue placard is also displayed from the rearview mirror. Temporary Disabled Person Placards Temporary disabled person placards will continue to be issued as in the past. They will remain red and will expire six months after issuance. Vehicles displaying red temporary disabled placards may park only in red-coded spaces. New Legislation makes Social Security Numbers Confidential The 76th Legislature passed HB 692, which states in part: "The social security number of an applicant for or holder of a license, certificate of registration, or other legal authorization issued by a licensing agency to practice in a specific occupation or profession that is provided to the licensing agency is confidential and is not subject to disclosure under the open records law." The law was passed in the House on March 18 and in the Senate on May 17 and went into effect after being signed by Governor George W. Bush on May 29.

Birth Announcement Congratulations to Board member Jenat Turner, J.D., and her husband, Brian, on the birth of their fourth son, Samuel Robert, on May 2. Gainsharing Arrangements between Hospitals and Physicians Declared Illegal by Inspector General By Samuel S. Crocker and Michael E. Clark. On July 7, the Office of the Inspector General of the U.S. Department of Health and Human Services issued a Special Advisory Bulletin that said that contingency fee or "gainsharing" arrangements between hospitals and physicians are "clearly" prohibited by Sections 1128A(b)(1) and (2) of the Social Security Act. This law imposes a civil monetary penalty on hospitals that knowingly make a payment directly or indirectly to a physician as an inducement to reduce or limit services provided to Medicare or Medicaid beneficiaries under their care and on physicians who receive such payments. Penalties for violation of the CMP provision of the Act can range up to $2,000 per day for each Medic are or Medicaid patient involved. In light of the fact that gainsharing arrangements between hospitals and physicians involving Medicare and Medicaid are common, the Bulletin says that, "in exercising its enforcement discretion, and in the absence of any evidence that a gainsharing arrangement has violated any other statutes or adversely affected patient care, the OIG will take into consideration whether a gainsharing arrangement was terminated expeditiously following publication of [this] Bulletin." Given this window, hospitals and physicians should promptly review and terminate any gainsharing or other such incentive programs to avoid possible action by the OIG. Under gainsharing agreements, hospitals and physicians join together to reduce the cost of patient care without reducing the quality of care. As an inducement, hospitals typically agree to give physicians a percentage share of any reduction in the hospital's costs for patient care that are attributable to the physician's efforts. While the payments may take various forms, the prohibitions apply to any arrangement under which physicians are or may be paid to reduce patient care. In other words, payments to physicians "need not be tied to an actual diminution in care, so long as the hospital knows that the payment may influence the physician to reduce or limit services to his or her patients." The Bulletin also specifically states that it applies to so-called "whole hospitals," or joint ventures between hospitals and physicians, or where a hospital is "restructured and legally incorporated as a separate hospital" that is owned in part by the physicians who perform surgery at the hospital. Although this notice is addressed to hospitals, its prohibitions apply equally to physicians and any other providers involved in gainsharing arrangements involving Medicare and Medicaid recipients. Acknowledging the desirability of controlling the cost of medical care, the Bulletin notes that "hospitals may align incentives with physicians to achieve cost savings through means that do not violate [the] Act. For example, hospitals and physicians may enter into personal services contracts in which hospitals pay physicians based on a fixed fee that is fair market value for services rendered, rather than a percentage of cost savings. Such contracts

must meet the anti-kickback statute (section 1128B(b) of the Act)." Any such arrangements, notwithstanding the admirable aim of involving physicians in cutting costs, should be carefully scrutinized. The government created the problem of differing financial interests between hospitals and physicians with different reimbursem*nt methodologies to compensate them for providing services to program beneficiaries. Under Medicare Part A, the government reimburses hospitals for their costs in providing patient care by means of a prospective payment methodology, which limits institutions to a flat rate based on the major diagnosis related group involved in the patient's care. In comparison, Medicare reimburses physicians under Medicare Part B according to the value of the services provided, within certain limitations. Hospitals reasonably believed that contractual arrangements which saved the government money and did not affect the quality of patient care would be perfectly legal. According to the Bulletin, this is not the case. The OIG expressly acknowledges that reducing hospital costs is "in the best interest of the nation's healthcare system," but adds that in view of the "clear" statutory prohibitions on reducing patient care it cannot sanc tion gainsharing arrangements without the express authorization of Congress. This is certainly a call to legitimize a mechanism that hospitals throughout the country have routinely employed to reduce the cost of medical care to all patients. Congress should respond. Any hospital, physician or other healthcare provider who is a party to a gainsharing arrangement should discuss how they can eliminate their exposure to sanctions with competent legal counsel. The OIG released a follow up letter on August 19 to clarify its Special Advisory Bulletin by narrowing its earlier pronouncement and indicating that hospitalphysician incentive plans which involve only Medicare or Medicaid beneficiaries in managed care programs are not subject to the CMPs; moreover, physic ian incentive programs under Medicare+Choice managed care are also likely legal under HCFA guidelines. This article was contributed by Michael Clark and Samuel Crocker, partners in Gardere Wynne Sewell & Riggs' Health Care Practice Group. They also contributed the Medical Board Report article on Y2K computer problems that appeared in the Fall, 1998, issue. The article is presented for informational purposes and does not represent the policies of the Texas State Board of Medical Examiners, which thanks Mr. Clark and Mr. Crocker for providing the information. Disciplinary Actions Physicians Adegbite, Samson G., M.D., Buffalo, NY, Lic. #J6843 An Agreed Order was entered on 5-14-99 suspending physician's license. Action due to unprofessional conduct and disciplinary action by another state.

Banta, Miguel B. Jr., M.D., Fort Worth, TX, Lic. #D6942 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension, and placing the physician on probation for five years under certain terms and conditions. It is further ordered that the physician be assessed an administrative penalty in the amount of $1,500. Action due to abetting the unlicensed practice of medicine. Barth, Thomas L., M.D., Lewisville, TX, Lic. #E0800 An Agreed Order was entered on 5-14-99 suspending the physician's license. Action due to conviction of felony or crime involving moral turpitude, unprofessional conduct, violation of laws connected with practice of medicine, and practice inconsistent with public health and welfare. Bischoff, Scott B., M.D., Sugarland, TX, Lic. #H6055 An Agreed Order was entered on 8-28-99 assessing an administrative penalty in the amount of $5,000. Action due to unprofessional conduct. Bonilla, Jaime, M.D., Houston, TX, Lic. #E2416 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician, assessing an administrative penalty in the amount of $5,000, and placing his license under certain terms and conditions. Action due to the conviction of a felony or crime involving moral turpitude, and the intemperate use of alcohol or drugs. Cannon, Richard A., M.D., Richmond, TX, Lic. #C6271 An Agreed Order was entered on 8-28-99 restricting the physician's license and placing the physician on probation for 10 years under certain terms and conditions. Action due to practice inconsistent with public health and welfare. Castaneda, Manuel F., M.D., Galveston, TX, Lic. #G6798 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension, and placing the physician on probation under certain terms and conditions. Action due to unprofessional conduct. Clark, Cordell, M.D., Dallas, TX, Lic. #F8827 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician and restricting the physician's license for three years under certain terms and conditions. Action due to unprofessional conduct, violation of Board rules, violation of laws connect ed with the practice of medicine, and practice of medicine inconsistent with public health and welfare. Coppola, Joseph C., M.D., Houston, TX, Lic. #E6290 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension and placing the physician on probation for five years under certain terms and conditions. It is further ordered that the physician be publicly reprimanded and assessed an administrative penalty in the amount of $10,000. Action due to unprofessional conduct. Danks, Kelly R., M.D., Fayetteville, AR, Lic. #H7718 An Agreed Order was entered on 8-28-99 suspending the physician's license. Action due to the intemperate use of alcohol or drugs, unprofessional conduct, and disciplinary action taken by another state.

Davis, Anthony A., M.D., Baytown, TX, Lic. #H2329 An Agreed Order was entered on 8-28-99 suspending the physician's license. Action due to the conviction of a felony or a crime involving moral turpitude, violation of laws connected with the practice of medicine, writing false or fictitious prescriptions, nontherapeutic prescribing or treatment, intemperate use of alcohol or drugs, impairment due to illness or chemical abuse, and disciplinary action taken by peers. Davis, Carl C., Jr., M.D., Baytown, TX, Lic. #E9598 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension, and placing the physician on probation for five years under certain terms and conditions. Action due to practice inconsistent with public health and welfare and disciplinary action taken by peers. Ellis, Neely J., M.D., Houston, TX, Lic. #C3647 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension, and placing the physician on probation for five years under certain terms and conditions. Action due to the intemperate use of alcohol or drugs, unprofessional conduct, and nontherapeutic prescribing or treatment. Fernandez, Carlos H., M.D., Houston, TX, Lic. #D9438 An Order was entered on 5-17-99 suspending the physician's license. Action due to violation of probation. Fry, Lee P., M.D., San Angelo, TX, Lic. #D1639 An Agreed Order was entered on 5-14-99 restricting the physician's license for four years under certain terms and conditions. Action due to practice inconsistent with public health and welfare. Garcia, Eduardo A., M.D., Houston, TX, Lic. #J6446 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician and restricting his license under certain terms and conditions. Action due to abetting the unlicensed practice of medicine and failure to supervise delegates. Golden, Mitchell K., M.D., Mount Vernon, TX, Lic. #H7151 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician. Action due to violation of Board rules and practice of medicine inconsistent with public health and welfare. Goswami, Anilkumar P., M.D., Odessa, TX, Lic. #E7095 An Agreed Order was entered on 8-28-99 accepting the permanent and voluntary surrender of the physician's license. Action due to concerns of the Board. Hinkley, Bruce S., M.D., Arlington, TX, Lic. #D9497 A Temporary Suspension Order was entered on 7-26-99 temporarily suspending the physician's license due to evidence and information that the physician's continuation in the practice of medicine would constitute a continuing threat to public welfare. The allegations related to the application for temporary suspension are to be the subject of a disciplinary hearing as

soon as can be accomplished under the Administrative Procedure Act and Medical Practice Act. It is further ordered that the Temporary Suspension Order shall remain in effect until such time as it is superseded by a subsequent order of the Board. Iversen, Michael G., M.D., Fort Worth, TX, Lic. #H8992 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension and placing the physician on probation for five years under certain terms and conditions. Action due to violation of laws connected with the practice of medicine, failure to keep drug records, prescribing or dispensing to a habitual user, nontherapeutic prescribing or treatment, administering dangerous drugs in an improper manner, violation of Board rules, and practice inconsistent with public health and welfare. Just, Robert J., M.D., Round Rock, TX, Lic. #K0850 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician, assessing an administrative penalty in the amount of $10,000, and restricting the physician's license for five years under certain terms and conditions. Action due to fraud or deceit in application for and use of license and unprofessional conduct. Ketterer, Cynthia L., M.D., El Campo, TX, Lic. #K3771 An Agreed Order was entered on 8-28-99 restricting the physician's license for five years under certain terms and conditions. Ac tion due to the intemperate use of alcohol or drugs. Koppersmith, Daniel L., M.D., Houston, TX, Lic. #H3691 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician, assessing an administrative penalty in the amount of $5,000 and placing his license under certain terms and conditions. Action due to unprofessional conduct. Krusen, Donna I., M.D., Plano, TX, Lic. #H4474 A Temporary Suspension Order was entered on 6-25-99 temporarily suspending the physician's license due to evidence and inf ormation that the physician's continuation in the practice of medicine would constitute a continuing threat to public welfare. The allegations related to the application for temporary suspension are to be the subject of a disciplinary hearing as soon as can be accomplished under the Administrative Procedure Act and Medical Practice Act. It is further ordered that the Temporary Suspension Order shall remain in effect until such time as it is superseded by a subsequent order of the Board. McClintock, Laura L., D.O., Fort Worth, TX, Lic. #J9755 An Agreed Order was entered 5-14-99 publicly reprimanding the physician. Action due to unprofessional conduct and practice inconsistent with public health and welfare. McCorkle, Ricky A., M.D., Sherman, TX, Lic. #G7286 An Agreed Order was entered on 8-28-99 extending the five-year probation of the suspension imposed by the Board Order dated May 16, 1998, for one additional year, under certain terms and conditions. It is further ordered that

the physician be assessed an administrative penalty in the amount of $2,500. Action due to unprofessional conduct. McFarland, Bruce R., M.D., Corpus Christi, TX, Lic. #H3353 An Agreed Order was entered on 8-28-99 revoking the physician's license, staying the revocation, and placing the physician on probation for 10 years under certain terms and conditions. Action due to the intemperate use of alcohol or drugs and unprofessional conduct. Miranda, Roberto, M.D., Smithville, TX, Lic. #E2740 An Agreed Order was entered 5-14-99 restricting the physician's license for three years under certain terms and conditions. Action due to practice inconsistent with public health and welfare. Moore, Milton D. Jr., M.D., Houston, TX, Lic. #G7692 An Agreed Order was entered 5-14-99 assessing an administrative penalty in the amount of $1,000. Action due to failure to supervise delegate. Munro, Ian R., M.D., Dallas, TX, Lic. #H1162 An Agreed Order was entered on 8-28-99 publicly reprimanding the physician and assessing an administrative penalty in the amount of $100. Action due to violation of Board rules. Murphy, James M., M.D., Mesquite, TX, Lic. #G6219 An Agreed Order was entered on 8-28-99 assessing an administrative penalty in the amount of $5,000. Action due to violation of Board rules. Olson, Dean R., D.O., Grand Ledge, MI, Lic. #C4487 An Agreed Order was entered 5-14-99 restricting physician's license under certain terms and conditions. Action due to intemperate use of alcohol or drugs, unprofessional conduct, and disciplinary action taken in another state. Patel, Piyush V., M.D., Midland, TX, Lic. #G2452 An Agreed Order was entered on 8-28-99 assessing an administrative penalty in the amount of $2,500. Action due to unprofessional conduct. Perez, Raoul, M.D., Livingston, TX, Lic. #F5897 An Agreed Order was entered 5-14-99 assessing an administrative penalty in the amount of $7,500. Action due to practice inconsistent with public health and welfare. Piazza, Kenneth M., M.D., Jasper, TX, Lic. #E8112 An Agreed Order was entered on 5-14-99 in which the physician voluntarily and permanently surrendered his license and retired from the practice of medicine. Action due to conviction of felony or crime involving moral turpitude, unprofessional conduct, nontherapeutic prescribing or treatment, and practice inconsistent with public health and welfare. Ramey, John A., M.D., San Diego, CA, Lic. #D3784 An Agreed Order was entered on 8-28-99 restricting the physician's license under certain terms and conditions. Action due to the practice of medicine

inconsistent with public health and welfare and disciplinary action taken in another state. Renshaw, Ralph R. Jr., M.D., Sherman, TX, Lic. #C5846 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension, and placing the physician on probation for three years under certain terms and conditions. It is further ordered that the physician be publicly reprimanded. Action due to the practice of medicine inconsistent with public health and welfare. Roberts, Gary F., M.D., Mesquite, TX, Lic. #J1371 An Agreed Order was entered on 8-28-99 restricting the physician's license for five years under certain terms and conditions. Action due to unprofessional conduct. Sauceda, Francisco B., M.D., San Antonio, TX, Lic. #H8375 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension and placing the physician on probation for five years under certain terms and conditions. Action due to intemperate use of alc ohol or drugs. Sernaker, Harry L., M.D., McAllen, TX, Lic. #J1385 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension and placing the physician on probation for three years under certain terms and conditions. Action due to disciplinary action taken by another state. Stogryn, Ronald S., M.D., San Antonio, TX, Lic. #F6123 An Agreed Order was entered 5-14-99 restricting the physician's license for three years under certain terms and conditions. Action due to unprof essional conduct, abetting the unlicensed practice of medicine, and disciplinary action by peers. Swift, Leon J., D.O., Arlington, TX, Lic. #H4739 An Agreed Order was entered on 8-28-99 restricting the physician's license for five years under certain terms and conditions. Action due to unprofessional conduct by his failure to participate in AA or to provide required information to his treating physician in violation of an Agreed Rehabilitation Order. Takase, Kouji, M.D., Houston, TX, Lic. #G1839 An Agreed Order was entered 5-14-99 assessing an administrative penalty in the amount of $1,500. Action due to practice inconsistent with public health and welfare. Thompson, Lloyd G., M.D., Dallas, TX, Lic. #C9161 An Agreed Order was entered on 8-28-99 suspending the physician's license, staying the suspension, and placing the physician on probation for five years under certain terms and conditions. It is further ordered that the respondent be assessed an administrative penalty in the amount of $5,000. Act ion due to the conviction of a felony or crime involving moral turpitude and practice inconsistent with public health and welfare.

Titus, Patrick A., M.D., Houston, TX, Lic. #C8730 An Agreed Order was entered on 8-28-99 restricting the physician's license for five years under certain terms and conditions. Action due to nontherapeutic prescribing or treatment, and practice of medicine inconsistent with public health and welfare. Tyler, Michael E., M.D., San Antonio, TX, Lic. #E7525 An Agreed Order was entered on 8-28-99 wherein Dr. Tyler agreed to pay an administrative penalty of $5,000. The Order was in settlement of disputed claims. Williamson, Thomas L., M.D., Phoenix, AZ, Lic. #H7105 An Agreed Order was entered 5-14-99 restricting physician's license under certain terms and conditions. Action due to unprofessional conduct, impairment due to illness or chemical abuse, and disciplinary action by another state. Wooldridge, Douglas W., M.D., Wellesley, MA, Lic. #F0835 An Agreed Order was entered on 8-28-99 acc epting the voluntary and permanent surrender of the physician's license. Action due to concerns of the Board. Zepeda, Russell W., M.D., Mammoth Springs, AR, Lic. #H0977 An Agreed Order was entered 5-14-99 suspending the physician's license; however the suspension was stayed and the physician was placed on probation for five years under certain terms and conditions. Action due to writing false or fictitious prescriptions, nontherapeutic prescribing or treatment, administering dangerous drugs in an improper manner, and practice inconsistent with public health and welfare. Physician Assistants Cobb, Timothy L., Alice, TX, Lic. #PA00511 An Agreed Order was entered 4-30-99 suspending the physician assistant's license. Action due to conviction of a felony and unprofessional conduct. Douglas, Robert M., Abilene, TX, Lic. #PA00831 An Agreed Order was entered 4-30-99, canceling the physician assistant's license. Action due to habitual use of substance which impairs safe practice, and unprofessional conduct. Fandre, Steven E., Coppell, TX, Lic. #PA00241 An Agreed Order was entered 4-30-99 publicly reprimanding the physician assistant with no continuing restrictions. Action due to violation of Board rules. Jackson, Dennis R., Washington, DC, Lic. #PA01593 An Agreed Order was entered 4-30-99 canceling the physician assistant's license. Action due to unprofessional conduct. Pike, Randy E., San Antonio, TX, Lic. #PA00816 An Agreed Order was entered 4-30-99 publicly reprimanding the physician

assistant with no continuing restrictions. Action due to violation of Board rules. Racz, Suzanne E., Plano, TX, Lic. #PA00805 An Agreed Order was entered 4-30-99 suspending the physician assistant's license. Action due to violation of Board rules. Acupuncturists Vuu, Lam, Houston, TX, Lic. #AC00079 An Agreed Order was entered 5-14-99 placing license under certain terms and conditions. Action due to violation of Board rules. Correction: A disciplinary action summary in the Spring 1999 issue the Medical Board Report was incomplete. The following is the correct summary: Gunderson, Erik Waters, M.D., Plano, TX, Lic. #J3111 An Agreed Order was entered 4-10-99 assessing an administrative penalty in the amount of $250. Action due to violation of Board Rules and false, misleading or deceptive advertising. For printed copies of the newsletter or to be placed on the mailing list, write to the board at MC 251, P.O. Box 2018, Austin TX 78768, or call the Public Information Office at (512) 305-7018.