JAMA Forum: Hiding in Plain Sight: Medical Boards and the Public’s Health

By Jesse X. Yang, MD, and Joshua M. Sharfstein, MD

tjf-logo-stack-feature-345x210The last few years have not been easy for a number of state medical boards. In December 2010, the New Haven Independent faulted the Connecticut Medical Board for permitting physicians to practice who had lost their licenses elsewhere. That same month, the St. Louis Post-Dispatch criticized the Missouri Medical Board for sending frequent, confidential “letters of concern” that “go in a physician’s file but carry no repercussions” in lieu of more serious disciplinary actions.

 In February 2012, the Minneapolis Star Tribune reported that since 2000, the Minnesota Board of Medical Practice failed to discipline at least 46 Minnesota physicians“after authorities in other states took action against their licenses for such missteps as committing crimes, patient care errors or having sexual or inappropriate relationships with patients.” The story also noted that “more than half of the 74 physicians who lost their privileges to work in Minnesota hospitals and clinics over the past decade were never disciplined by the Minnesota board.”

 These reports led Senators Chuck Grassley (R, Iowa) and Orrin Hatch (R, Utah) and former Senator Max Baucus (D, Montana) to request that the Department of Health and Human Services Office of Inspector General conduct an evaluation of “state medical board performance, including the timeliness and consistency of decision making.” Subsequently, challenges facing medical boards were identified in other states, including Massachusetts, California, and Maryland.

Physician licensure is a critical link in the health quality chain. One dangerous physician can injure scores of patients directly through poor care, or indirectly, through careless prescribing that leads to substantial drug diversion. Yet despite the front-page stories, there is far less professional or academic attention paid to medical boards than there is of more complicated questions of medical errors.

Maryland provides a case study in challenges facing medical boards—and in how engagement of academic medicine and the broader physician community can lead to progress.

In Maryland, a 2011 legislative audit of the Maryland Board of Physicians found that the number of cases not resolved within 18 months was more than 150 per year. For cases in which the state board recommended charges, the average number of days between a case being opened and final board action was 1013 days.Other deficiencies included a lack of transparency, inconsistent record keeping, and unclear sanctioning guidelines.

The report sparked negative media stories and a strong response from policymakers. Soon afterwards, the executive director of the board of physicians retired. Legislators passed a new provision allowing the governor to appoint the board chair instead of having the chair elected from within the board. In addition, legislators deferred the planned reauthorization of the board for a year to provide an opportunity for a more comprehensive external review.

Released in July 2012, this review was led by University of Maryland at Baltimore President Jay Perman, MD, and involved a team of experts from the University of Maryland Francis King Carey School of Law and the Kentucky Board of Medical Licensure. Key recommendations included:

Splitting the board into 2 panels. In this model, both panels investigate separate cases. Then, to prevent biased investigators from being involved in the adjudication of a case, the results of the investigation are passed to the other board where final decisions are made. This model results in twice as many case resolutions and a fairer process.

Better training for board members. One goal of formal training would be to handle complex cases more expeditiously.

Improved transparency. The report recommends that more information be made available to the public, including “the annual report, open meeting agendas, minutes . . . the website should also include more informative guidance about the complaint process, the different types of discipline, the charging process, and time limits on what can be investigated.”

 Adoption of clear guidelines for case resolution. Guidelines will “ensure transparency for licensees and the public and accountability for the Board’s actions.”

To its credit, Maryland’s largest physician organization, MedChi, largely supported these recommendations. Local medical leaders recognized that a better organized board would produce more fair and timely outcomes for physicians.

With the support of physician groups and the academic expert team, legislators adopted the expert recommendations during the 2013 legislative session. Changes at the board are under way. Sanctioning guidelines are now in place, the board has 2 panels, and board training is part of routine practice. The website is improving, the backlog is eliminated, and monthly performance data on licenses, complaints, and disciplinary actions are now made available through StateStat. Maryland’s medical board is even receiving some favorable media coverage.

There is much more work yet to be done, in Maryland and elsewhere. Beyond fixing issues with physician discipline, medical boards can play an important role in preventing problems such as inappropriate prescribing of pain medications. Well-functioning boards play a critical role in protecting and promoting public health.

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About the authors:

Jesse Yang, MD

Jesse Yang, MD

 

Jesse X. Yang, MD, is a resident in internal medicine at Columbia University Medical Center.

 

 

 

 

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

 

Joshua M. Sharfstein, MD, (@drJoshS) is Secretary of the Maryland Department of Health and Mental Hygiene. He has previously served as the Principal Deputy Commissioner of the US Food and Drug Administration and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.

 

 

 

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 



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