Tinian Medical Clinic in crisis?

The following article appeared in the local newspaper today:

Saipan Tribune, December 18, 2008

Tinian clinic is 'in crisis' Due to lack of doctors

By Kristi Eaton, Reporter

The lack of a full-time physician at the Tinian Health Center has become a “crisis,” according to the Medical Licensing Board and the Tinian physician assistant.

The Tinian clinic has been without a full time physician on staff since July, when Dr. Ronaldo Toledo resigned.

To cope with the loss, the Medical Licensing Board has repeatedly issued emergency orders allowing physician assistant Terri Clawson to prescribe drugs with certain stipulations, including close supervision by a doctor.

Members of the Licensing Board voiced concern that Clawson had not been in close contact with Dr. Christine Brown and had prescribed a high number of narcotic drugs, a concern Clawson said she feels is unnecessary.

“I guess I'm a little concerned that you were concerned that I didn't have any daily, twice daily or five times daily phone calls to Dr. Brown,” she told members of the board during a meeting, adding that she was comfortable with the work she was doing.

Brown signed off on all the prescriptions after evaluating the charts and notes, Clawson added.

The issue has brought to light the need for regulations regarding physician assistants and the scope of authority they can have in prescribing narcotics in the CNMI especially in remote locations, said board member Janet McCullough.

McCullough expressed the need for the Tinian Health Center to find a full-time doctor, the difficult task it may be.

“I think the board certainly understands the hardship and, in fact, we really want to find the right fit. And Tinian is unique as a community and we understand that, but we also would like to emphasize that the situation that Terri has unfortunately found herself in the last several months is not because of any roadblocks we have put up. But because, really, Tinian has not hired a physician,” McCullough said.

Joey [should be Freddie] Hofschneider of THC said the clinic has been actively recruiting doctors and came close on two occasions. The clinic was about to hire one doctor but received a recommendation not to, he said.

“[The doctor] was right there,” he said. “It would have solved all those problems.”

“The second one, we really thought we were going to get as of a week ago or two weeks ago,” he added. “The mayor and the Tinian Heath Center are mindful of the pressures placed on you [the Licensing Board], you've got to ensure the regs are followed. But the reality is recruiting doctors on Tinian has been difficult,” Hofschneider added.

The Tinian clinic is working with the Department of Public Health to try to recruit a doctor to the island, something that has not always been the case, he said.

“What has happened in the past is we had some bad experiences,” he said. “At certain points in time, the municipalities of Tinian and Rota would try to bypass the Secretary of Health and try to hire doctors wherever they may be. We recently had two very bad experiences with doctors.”

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Here is the background, as I understand it:

As a Physician Assistant, Terri is required to work under a supervising physician. When Dr. Toledo left Tinian, Terri no longer had authority to work at the Tinian clinic. Until a new doctor could be found, the Medical Board on Saipan was gracious enough to provide an 'exemption' to Terri so that she could work under 'remote supervision', using a doctor located on Saipan. Dr. Brown was chosen by the Medical Board as her 'remote' doctor.

This seemed to be a good solution, until Tinian could find a new MD willing to relocate to Tinian. Each month the Medical Board renewed this 'exemption' permitting Terri to continue to work. Then, in November, and for reasons I do not fully understand, the Terri’s exemption was not renewed and Terri was unable to work at the clinic without the exemption. Because this left Tinian with inadequate medical coverage, the Governor interceded and issued a directive permitting Terri to return to work.

Part of that order was for the Medical Board to assign a new supervising physician (which they did), and for he and Terri to meet with the Medical Board on the 16th (which they did, and that is what the newspaper article is about).

Unfortunately, the Medical Board and the new supervising physician could not come to an agreement as to how to properly manage the Tinian clinic using remote supervision.

Note: PAs work under remote supervision in many areas of the country, and has become a useful tool for communities that cannot attract MDs. For example: Alaska, with its many islands, has used PAs as the sole medical provider with remote physician supervision on their small islands and in small communities for years.

The AAPA (American Academy of Physician Assistants) website has a good summary of the PA practice regulations in the states. This can be found at:

http://www.aapa.org/gandp/statelaw.html

So for now, Tinian Health Center struggles with what to do next. Freddy Hofschneider, the acting resident department head is working diligently with the Mayor, the Secretary of Health, and the Governor to find a solution that will allow the people of Tinian to receive great health care while conforming to CNMI law and medical board regulations.

Only time will tell what will happen next...