The New Health Dialogue

Yesterday I posted on a recent Public Citizen report that ranked states based on how frequently they discipline their physicians. The citizens' watchdog group concludes that the resources available to state medical boards (including funding, staff, and quality of leadership) is a major factor in how much punishment state medical boards dole out. 

A few thoughts to add. First, it is essential to note that medical boards serve a variety of functions, including licensing physicians in any given state. Boards also assist physicians with laws concerning patient records, what physicians can and can’t do (light-based hair removal? prescribe medicine to their families?), giving expert testimony, and employment. Public Citizen noted there is a lot of variation from state to state.

While the board of medicine is the primary organization that regulates physicians, the credentialing process is another barrier that can prevent flawed doctors from practicing. In a hospital, credentialing is run by the medical staff and overseen by the hospital board. It occurs every few years, which allows physicians to be re-examined for privileges (the rigor depends on the institution). The Joint Commission requires a peer review process of complaints against physicians, which serves as another check. Health insurers also have a credentialing process for physicians who wish to join their network of providers, a remnant of the “managed care revolution” that is still in place. For many physicians, participating in an insurer's provider network is the only way to guarantee a stable panel of patients.

Bad apples still have a way of making it to the grocery store. Sometimes a physician who has had his or her license revoked quietly moves to a new state and begins harming patients all over again. The National Practitioner Data Bank (NPDB) aims to prevent this. Created in 1998, it allows state medical boards and other non-government credentialing bodies access to the names of physicians who have been restricted by a state board of medicine. Although there are no plans to move toward national regulation of physicians, the data bank does try to serve as the connective tissue between 51 disparate medical boards.

Unfortunately, Dr. Bob Wachter and others hold that NPDB is ineffective because many hospitals fail to submit reports detailing physician disciplinary action (see his excellent post on the subject here).  As I heard Dr. Mark D. Smith say once, “there’s no such thing as universal voluntary anything.” I’m not sure NPDB can be effective if half of U.S. hospitals have never submitted a single (!) report. 

Dr. Robert Berenson, an occasional guest blogger, has suggested that instead of working toward improving all physicians a little, state boards of medicine should more aggressively pursue the worst physicians in a state. He suggests that would go a long way toward lowering malpractice premiums. Dr. Berenson also points out that as more complicated procedures have moved from hospitals to outpatient setting,s (both because of improved techniques/technology and reimbursement reasons) physicians are no longer subject to the hospital’s credentialing process. For the bad docs, that's one less hurdle to cross.

The Wall Street Journal’s Laura Landro had a recent article that touched on this very problem. California uses an innovative program to assess whether and when a disciplined physician can start practicing on his/her own again. She wrote:

The primary mission of PACE is to evaluate the competence of troubled doctors whose infractions range from serious medical error and negligence to sloppy record keeping and anger management. Using a mix of computer-based simulations, multiple-choice exams, cognitive-function screenings and hands-on observation, PACE faculty and staff tests doctors' knowledge, skills and judgment, providing remedial courses and a weeklong mini-residency supervised by UCSD medical faculty.

In the end, the teams add their gut instincts to make a final call: can this doctor be safely returned to practice?

According to Lucian Leape, quoted in the WSJ article, if you combine deficiencies in knowledge/skills, abusive behavior toward colleagues/patients, drug/alcohol dependency, stress-related mental-health issues and age-related cognitive decline, at least a third of physicians will have a problem that poses a threat to safe patient care during their career. PACE founder Dr. William Norcross cites two examples in the article: a 74-year-old primary-care physician who demonstrated confusion and disorientation during the PACE sessions and an 80-year-old vascular surgeon whose patient died after surgery from complications that may have been preventable.

Well, does it work?

David Birdsall, chief of staff at the John Muir Hospital campus in Concord, Calif., says the hospital has sent several doctors to PACE who "come back changed people," with better professional standards and people skills. With physicians facing more sources of stress than ever before, he says, some doctors stretch the limits of tolerable behavior or become risks to patients, "and we send them there for their own good before they get to the point of loss of licensure."

Doctors, like all professionals, need discipline. It can come from different sources, but the state board of medicine is the only body that regulates all physicians regardless of where they practice. Giving it authority and resources is key to protecting patient safety. And as  Landro reminds us, “bad” doctors can be retrained and rehabilitated enough so they can resume seeing patients. Safely. Seems like a good idea to me.