The New Health Dialogue

A recent report from Public Citizen on physician discipline got us thinking. And writing. Today we'll focus on state boards, and tomorrow we'll look more broadly at professional regulation, and how to rehabilitate troubled physicians.

Professional autonomy and self-policing can be a challenge for many professions. For physicians, it falls mostly to state medical boards to enforce professional standards. According to the Federation of State Medical Boards, there are 70 state medical boards authorized to regulate allopathic (Doctor of Medicine, or M.D.) and osteopathic (Doctor of Osteopathic Medicine, or D.O.) physicians.

The structure and authority of medical boards vary from state to state. Some boards are independent and maintain all licensing and disciplinary powers, while others are part of a larger umbrella agency, such as a state department of health. State medical boards are typically made up of volunteer physicians and members of the public who are, in most cases, appointed by the governor and paid a nominal stipend. Most also have professional and administrative staff, including an executive officer, attorneys, investigators and licensing personnel. The state legislature determines the financial resources of most boards. Some boards are funded directly from physician licensing and registration fees.

In the study Ranking of State Medical Boards’ Serious Disciplinary Actions: 2007-2009, Public Citizen used the simple method of a three-year moving average of disciplinary actions (per 1,000 doctors) collected by the state board of medicine and divided it by the number of practicing physicians in that state. It then used these numbers to rank the states (plus DC) best to worst. 

Before I go on -- because I do think it's worth paying attention to this -- I want to note that, however much fun I have had with back of the envelope math on this blog, I worry that the Public Citizen calculation may be too blunt. It measures how many times a state board of medicine disciplines a physician, viewed as a figure per 1,000 doctors to allow equitable comparisons across states. To me, that’s like saying one state has the fastest drivers because it hands out the fewest number of speeding tickets per 1,000 drivers. Isn’t it possible that the drivers in that state are safer?

For example, Drs. Baicker and Chandra rank Minnesota 10th best in quality (out of 51), which makes me skeptical that the North Star state, home to the renowned Mayo Clinic, necessarily has the physicians in most need of discipline -- Public Citizen ranks it 51st out of 51 on the disciplinary action scale. Is it possible that their doctors need less discipline, than, say, Texas (38th out of 51)?

Caveats aside, Public Citizen's work warrants attention. The report notes that state boards of medicine are likely to do a better job disciplining if they receive all the physician license fees (as opposed to putting those fees into a state’s general fund), have adequate staffing, conduct thorough proactive investigations (rather than only reacting to complaints), maintain independence from state medical societies and other parts of the state government, and -- of course -- if they have excellent leadership.

Some state boards of medicine include laypeople or "citizen members." In Virginia, for instance,  there are three (all with law degrees, interestingly). Outside of medical malpractice cases, (read Joanne Kenen's recent posts here and here and her recent magazine article here), the state board of medicine is the only body governing whether physicians are practicing outpatient medicine appropriately. (Inpatient care has another layer via its hospital credentialing process.)

Reducing the burden for assessing blame helps state medical societies as well: relying on “preponderance of the evidence” (51 percent or more certainty of guilt) rather than “beyond reasonable doubt” (98 percent or more certainty of guilt) or “clear and convincing evidence” (75-80% or more certainty of guilt) as the legal standard for discipline.

Dr. William Harp, executive director of the Virginia Board of Medicine, says that his state’s rise from 39th in 2007 to 19th in 2009 can be attributed to speed. They aim to close 90 percent of disciplinary cases within 250 days. Virginia has appropriately prioritized patient safety cases above those dealing with advertising and billing. The state also set up a point system to make decisions less subjective when determining a punishment of reprimand versus probation. This has encouraged two-thirds of accused physicians to work with the board of medicine to agree to a conclusion of the matter, rather than elevating the matter to a formal hearing. 

Dr. Harp’s embrace of Public Citizen’s report leads me to believe that a number of physicians agree they are under-regulated. For that reason alone this report should be respected, even if it is (in my view) a rough approximation of the problem.

(Reading this, Joanne asked me how many of the cases are for bad medical care per se as opposed to things like insurance fraud or substance abuse. The Public Citizen report doesn't address that explicitly, although Dr. Harp's comments suggest that safety is a growing factor in at least some states.)

I first learned of this story through FierceHeathcare. For more, see the piece in Modern Healthcare. I also drew on the expertise of Julie Barnes, acting director of the New America health program, who is an attorney.  I'll be back tomorrow with a few more thoughts on what protects us from bad docs -- and how to help troubled doctors get back on track.