Legislative Affairs - November 2008
Tex Med . 2008;104(11):57-60.
By Ken Ortolon
On a hot, muggy evening in early September, Texas Medical Board (TMB) Interim Executive Director Mari Robinson, JD, stood before a small crowd of skeptical physicians, medical residents, and others at Galveston's Rosenberg Library, answering questions and explaining how the board conducts its business.
Physicians and the public had been invited to the meeting to discuss TMB's regulation of the medical profession. But while Ms. Robinson patiently and thoroughly answered all their questions about how the board's licensing and disciplinary processes work, the atmosphere often was contentious. Some of the physicians in the audience clearly seemed angry or frustrated over what at least one doctor called an "overly zealous" approach to disciplining physicians.
The event in Galveston was one of more than a dozen town hall meetings TMB held across the state this past summer to improve relations among the board, the public, and the medical profession. Whether the physicians who attended that meeting on Sept. 3 walked away with a more favorable opinion of the board is hard to say. But Ms. Robinson and TMB member Tim Turner, who also attended, believe the feedback received at the meetings will help them achieve a "better, more efficient, more effective agency."
And Texas Medical Association officials say they are pleased the board is making an effort to reach out to the profession.
"I think it's extraordinarily important that they made the effort to communicate with the profession," said TMA President Josie R. Williams, MD. "I think the attempt to do these town hall meetings demonstrates that they are genuinely interested in saying, "What is it that we can improve so we can better serve you and the public?'"
TMB launched the meetings in June to hear what physicians and the public had to say about the board's regulation of the medical profession. The decision to hold the meetings came after some lawmakers at a legislative hearing in October 2007 suggested the board needs to change its perception among the medical profession.
The board held the town hall meetings in conjunction with licensing seminars to help entities that recruit and credential physicians streamline the application process and minimize application errors.
"Our purpose for these meetings is twofold," TMB President Roberta Kalafut, DO, said before the first meeting. "First, we want to encourage a more active dialogue with doctors and with the public. The impressions we have as regulators may not mirror the impressions of the licensees. We want to know if there are instances in which our regulations can be modified to make compliance easier for the regulated community.
"And as we work to improve our licensing processes, we want those people who work with applicants every day to have a more thorough understanding of what we need to see on those applications and what the most common errors are," she added. "We want to make licensing of physicians as seamless as possible."
While attendance at the meetings varied greatly - fewer than a dozen attended a July 29 meeting in Lubbock; more than 70 turned out in Fort Worth on July 1 - they certainly generated the active dialogue Dr. Kalafut sought.
In Austin, physicians complained about the board's "prosecutorial" tactics in policing physicians. Some of the 35 physicians who attended the Austin meeting on June 23 said the board is perceived as being harsh and obsessed with minor infractions. "Doctors are presumed guilty from the get-go," dermatologist Toni Funicella, MD, told the Austin American-Statesman .
Dallas County Medical Society officials say only about a dozen physicians attended the meeting there on Aug. 12, but some 40 to 50 patients, attorneys, and protestors showed up. Protestors hung signs on about 40 chairs that said "Dr. John Doe," "Afraid to show up," and "Anonymous Patient."
At the end of the evening, one participant commented that the meeting accomplished nothing, adding, " We have been complaining to the people that we are complaining about," Dallas CMS officials reported.
In Midland, there also appeared to be concern among physicians that just showing up at the meeting on June 17 could lead to action against them. "There was an older fellow from Big Spring who said his younger colleagues were afraid to come because they might have their names written down and it might come back to haunt them," Midland plastic surgeon Terry Tubb, MD, said.
Getting Past the Anger
The contentiousness at the meetings came as little surprise to TMB. Mr. Turner says the board expected that a number of people who already have strong opinions about the board or who have had an issue with the board would show up.
Still, Ms. Robinson says they received valuable suggestions, some of which TMB already is addressing.
"One of the first things we've taken away is that a lot of the physicians really want the board to take a more educative role as one of the goals of the board," she said. "So, in other words, get out there and help educate the physician population about what the different legal requirements are surrounding the practice of medicine, particularly as it relates to administrative type things."
Acting on those comments, the board has asked the Texas Legislature for funding to create educational programs for third- and fourth-year medical students, as well as residents. The programs would cover such issues as how long a physician has to provide medical records requested by a patient, how much the physician can charge for such records, and how long a doctor has to sign a death certificate.
Ms. Robinson says there were several complaints that the 30-day period for completing preliminary investigations of complaints received by the board gives physicians too little time to respond adequately. While state law requires 30 days, Ms. Robinson says the board may ask lawmakers to extend that timeline to 45 days. That would allow TMB to double the amount of time physicians have to respond to such complaints from 14 to 28 days.
"The fact of the matter is if we can tell during that initial response time that there is no violation of the Medical Practice Act, that's better," she said. "It's better for the physician, of course, but it's also better for the agency and the public. It allows us to focus our resources on the cases in which it really does appear that something egregious may be going on. And it allows us to focus more on people who appear to be exhibiting a pattern of behavior."
Ms. Robinson says the board also is asking the legislature for funding to hire a full-time physician to be involved in the initial analysis of standard-of-care complaints. Currently, nurse investigators review those complaints. Having a physician review those complaints would enable the board to do a better job of determining early which cases really involve serious standard-of-care issues.
Naga S. Bushan, MD, president of the Lubbock-Crosby-Garza County Medical Society, says that would go a long way toward improving physicians' comfort level with the board.
"If a physician is involved, it gives the practicing physician more confidence that a knowledgeable person is looking at the case," he said.
While some physicians left the town hall meetings with their attitudes toward TMB unchanged, others say they believe the meetings were helpful in improving the relationship between the profession and the agency.
"The meeting went well here," Dr. Tubb said of the Midland meeting. "They seemed genuinely interested in improving relationships with physicians out here in Midland-Odessa."
Dr. Bushan also believes the meetings were productive, especially if the board follows through on some of the doctors' suggestions. "If they take our comments seriously and implement them, I think the physicians will gain more confidence in the process."
Ms. Robinson says the primary purpose of the board is to protect the public. "I think that's well known at this point. However, if we can reach that same goal in a way that is less burdensome to the licensees and to the public, that's what we're looking to do."
Dr. Williams believes the meetings represent an "honest attempt" by the board to address issues of concern to both physicians and the public. At the end of the day, physicians recognize that the board's mission is to protect the public and they want a strong and independent medical board, she says.
"There are some things that we may want to work on with regard to their processes, but it is in our best interest and, given due process, the best interest of our patients to have a strong medical board."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
We Learned a Lot From the Doctors
By Mari Robinson, JD, interim executive director, Texas Medical Board
Over the course of 14 weeks this summer, the Texas Medical Board (TMB) conducted 13 town hall meetings, visiting every region of the state. Almost 450 people came to the meetings, the majority of whom were physicians. Board members and staff listened to complaints, heard some good ideas, and answered questions about the board and its practices.
We have begun to act on some of the good suggestions we heard this summer and at meetings earlier in the year:
- Administrative violations: Many doctors suggested that TMB should devote far less attention to administrative violations and concentrate more of its resources toward prosecuting doctors who pose a threat to the public. We agree. Earlier this year TMB instituted a "fast track" procedure for administrative violations. The procedure allows minor violations to be processed and resolved quickly.
- Education: Many suggested TMB provide more education for the profession to help physicians avoid violations in the first place. We agree that both licensees and the public are better served if a violation never occurs. To that end, TMB included in its Legislative Appropriation Request to the Texas Legislature a request for funding for an educational component. If it is approved, we will offer three levels of instruction. The first would target medical students. The second would be for doctors just completing their residencies, and the third would be for midcareer doctors.
- Complaint response time: A frequent complaint was that TMB does not allow a physician sufficient time to respond during the initial 30-day review period before a complaint is filed for investigation. Because the time line is statutory, it requires a legislative fix. We have been talking to key legislators about extending this initial review time to 45 days so the physician will have 28 days to provide an initial response. Currently, 41 percent of jurisdictional complaints are dismissed after this initial review. If more physicians can provide better responses at this stage, both TMB and the licensees will benefit from saved resources.
It is clear from the comments we received at the meetings that there is lot of mistrust of TMB, much of it related to misinformation. A possible source of misunderstanding is the confidentiality that surrounds individual cases. That said, the perception of TMB can be exaggerated and inaccurate, like a caricature. The board recognizes that the physicians who face board orders make up a very small subset of the 59,000 physicians licensed in Texas. However, the board is charged with enforcing the laws surrounding the practice of medicine in this state and will do what is required to fulfill that charge.
We also heard that there is frustration in the medical community about the rapidly increasing number of complaints filed every year and the time it takes to resolve them. While a case is pending, a doctor must work under a cloud of suspicion, even in those cases in which the complaint eventually will be dismissed. And the process, we readily admit, is taking too long. The number of complaints the board receives shot up a couple years ago and shows no signs of easing, resulting in a longer resolution time for all complaints. When we receive complaints, we are compelled by law to investigate them. The increase has placed an added burden on our staff and has slowed the process. We have asked the Texas Legislature for additional employees and appropriations to help break the logjam. Unnecessarily prolonged investigations are a disservice to both the public and to physicians being investigated and detract from our mission of public protection.
The goal for these meetings was to dispel misperceptions and ease frustrations by offering a candid discussion, answering questions, and presenting ideas in an open, informal setting. We also wanted to collect ideas about what TMB could do to make adherence to the rules easier for physicians - without compromising on our vital core mission, which is to protect the public. We wanted to achieve a higher level of interaction between the regulator and the regulated.
On these counts, the meetings were successful. TMB learned a lot from the doctors who attended our meetings, and participants left with a better appreciation of what the board seeks to do and the reasoning behind the methods used to accomplish it.
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