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Editorial: Conscientious Objection; A Doctor Battles Regulators

It’s hard to imagine a stronger endorsement than the one Dr. Michael Schorsch received from a patient he has been treating at his Lebanon office for six years now. “If I hadn’t met this man, I’d be dead right now,” a 44-year-old patient whose first name is Joe told staff writer Chris Fleisher for a profile published in the June 23 Sunday Valley News.

The patient requested that he not to be fully identified, mostly because Schorsch’s specialty is the treatment of opiate addiction, a condition that still carries a considerable stigma. The patient was hardly alone in his admiration. A number of people who have been treated by Schorsch spoke highly of his commitment and the quality of his care while also noting the desperate need for the type of treatment he provides.

Much less impressed is the Vermont Board of Medical Practice, which sanctioned the 62-year-old doctor in May for failing to comply with several of its standards. Schorsch has decided not to renew his Vermont medical license, which should not impede his ability to see patients because he still has a New Hampshire license. Not that New Hampshire medical authorities are enthralled either. In 2011, the New Hampshire board found that he had committed technical violations but allowed him to keep his license.

The interesting twist is that there’s no contradiction between his patients’ high opinion of Schorsch’s medical care and his run-in with the Vermont board. Schorsch ran afoul of the board largely because he failed to fully document individual patients’ care and didn’t give them urine tests when he was supposed to. Those failures arose not from incompetence or neglect, but as a matter of choice. The required documentation, Schorsch believes, merely eats up precious time he now spends interacting with patients, and he thinks some of the required urine tests do little more than undermine the doctor-patient relationship that is essential to treating substance abuse.

“The degree of documentation that they expect is not only useless, unsubstantiated scientifically, puts a barrier between me and the patient in terms of trust, sucks up a bunch of my time, but on top of everything else, it doesn’t provide any useful information or direction in terms of caring for the patient,” he told Fleisher.

And judging from the effusive testimonials offered by his patients, Schorsch has some claim on the right to diverge from convention.

Another factor must be considered: There’s an acute shortage of the type of medical care that Schorsch provides. Opiate addiction is a growing problem in the Upper Valley and nationwide, and the gap between the number of people who need treatment and receive it is especially pronounced in Vermont and New Hampshire, according to the U.S. Department of Health and Human Services. Moreover, Schorsch’s treatment often involves buprenorphine, a synthetic opioid that, unlike methadone, blocks the effects of other opiates — precluding the possibility that patients might use it to enhance other substances. Schorsch regards buprenorphine treatment as the best available, but patients have difficulty taking advantage of it because only a limited number of doctors offer it.

So, stipulating that Schorsch is a gifted practitioner, that his cowboy approach to the practice of medicine is integral to his effectiveness and that there’s a crying need for the type of treatment he offers, is the Vermont professional board subordinating patients’ health to mindless rule enforcement?

Hardly. Comprehensive documentation is important in health care and particularly so in drug treatment, if only to track the drugs being dispensed. Taking a broader view, it’s also easy to grasp why standards of care are essential, and why physicians can’t be allowed to pick and choose which ones make sense for them. Schorsch may have made a thoughtful and conscientious choice to deviate from the standard, but that doesn’t mean every physician would. As misguided as it may seem in this particular case, it’s hard to see how a professional board has any choice but to apply its standards consistently.

Schorsch’s defiance, we hope, will at least prompt the professional boards to examine existing standards and make sure they’re not impeding the delivery of top-notch care. And we hope his situation also serves to spotlight the serious and still-growing need for effective drug-treatment. It’s true that a regulatory regime’s inability to accommodate a conscientious nonconformist won’t aid the effort, but that’s just another reminder that clashing goods can’t always be reconciled.

Related

Letter: DHMC Is Part of the Problem

Monday, July 8, 2013

To the Editor: The Valley News is to be commended for the recent article and editorial that focused on the opioid abuse epidemic in the Upper Valley and across the U.S. (“Addiction Doctor Defends Unconventional Approach,” June 23). Especially useful for the public is the identification of those in a position to answer questions. Dr. Ben Nordstrom, director of addiction …