Commentary - December 2008
Tex Med . 2008;104(12):3.
By Lee S. Anderson, MD
I read the article, "The Voice of Polite Dissent," by Terry D. Tubb, MD, PA, in Texas Medicine in September 2008 (pages 55-56). It is certainly easy to understand and feel his pervasive frustration with the practice of medicine and the regulatory environment in which we live. While I share his feeling of frustration with the ongoing onslaught of quality indicators, etc., I do think we can derive some additional insight from the situation.
First, the Federation of State Medical Boards is a compilation of allopathic and osteopathic medical boards from the United States and internationally that standardize criteria for initial licensure and evaluation of physician behavior. It is primarily a physician-driven system with responsibilities to state organizations.
After serving eight years on the Texas Medical Board, and, specifically, the year that testing for relicensure was raised, I think I have some insight into the situation. The whole reason for testing is to be proactive in searching out physicians with cognitive, mental, or substance abuse issues that colleagues, family members, and patients are reluctant to address.
With the assaults of the legal system brought on by doctors on county medical society grievance committees, insurance review committees, and physician rehabilitation committees, the movement for regulation over the years began to be consumed by the medical boards, not only in Texas, but in the United States, so peer review could occur without financial retribution to the societies and individual physician.
Now, with the advent of Proposition 12 and caps on liability, the attorneys have basically moved out of the plaintiffs' business. This is good for physicians, but not necessarily for all patients. With Proposition 12 in place, there is virtually no significant legal pressure to influence physician behavior and identify people at risk.
It was left, therefore, to the Texas Medical Board to address this issue as part of the fabric of being able to pass Proposition 12.
It has been a board rule for many years that physicians relocating to Texas, regardless of age, must be tested if they have not taken a major proctored test in the previous 10 years or they are ineligible for licensure. It was noted that we have many physicians who relicense every year without difficulty. Others could be identified in the licensure process if they had trouble with cognitive examinations, such as a special purpose examination, which is a general medical examination and which is easily studied for and completed by physicians who have ordinary cognitive skills or better. The purpose of that rule is to prevent people with significant mental dysfunction from entering into the physician workforce in our state. We felt our already licensed physicians who might have acquired some degree of dementia or substance abuse with secondary dementia or other physicians at risk not identified by other means should meet the same criteria. Physicians across the state violently opposed it, perhaps without recognizing the additional responsibility that puts on us as a profession if we do not have a testing mechanism to find people at risk. It is unlikely that colleagues will turn in colleagues. We cannot tolerate a "brotherhood of silence" without risking the health of the citizens of Texas.
For myself, I was board certified in ophthalmology in 1982 and have not been tested since, except on a day-to-day basis in my office. The 24 hours of continuous medical education that the Texas Legislature requires me to obtain do not have to be in ophthalmology. So how can patients in Texas have the confidence that the physician they are seeing is not only mentally qualified, but also mentally awake to deal with their health care issues? In the grand scale of things, I can see no other alternative mechanisms, and none have been presented so far.
I remember sitting in the waiting room as the president of the Texas Medical Board, in the Texas Medical Center, waiting for my daughter to have her first baby. It crossed my mind at that point that I hope the system we have in place currently works!
Dr. Anderson is an ophthalmologist in Fort Worth. He served on the Texas Medical Board from 1997 to 2005 and was its president from 2000 to 2005.
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