License to practice
By Robert E. Porter, M.D.
Doctor, it seems that you have a real problem. Based upon multiple patient complaints regarding prescriptionwriting, missed diagnoses, inappropriate tests, and unnecessary surgery, it is the judgment of your peers on the Board of Registration in Medicine that your license to practice medicine is in jeopardy. If you wish to continue practicing in this state, you must submit to a comprehensive evaluation of your capabilities and abide by the remediation recommendations of the testing center. If you fail to cooperate, a formal hearing process will be initiated, and it will be considerably more expensive for you than the suggested evaluation/remediation package. The multiple complaints against you are enough to summarily suspend your license until this process is complete . . ."
This hypothetical scenario is being played out at state medical boards throughout the country. In 1999, more than 4,500 actions were taken against physicians practicing in the United States; some 3,800 of those actions were prejudicial or punitive and dealt mostly with prescribing violations, substance abuse, or unprofessional conduct.
Claims: A physician's ability to practice medicine is usually brought into question when patients complain to a state medical board; malpractice judgments are reported; drug and alcohol abuse has been documented; sexual misconduct has occurred; the physician seems to be experiencing cognitive deterioration; or there have been other claims of physician discompetence (performance falling somewhere between competence and incompetence). A state medical board review committee composed of physicians and nonphysicians reviews each claim, notifies the doctor in question, and seeks a resolution. When a resolution or successful arbitration seems impossible, a state medical board can, as one option, demand that the physician undergo a comprehensive evaluation of his or her medical practice skills.
There is now only one facility in the country that uses national standards to conduct such assessments. In April of this year, the Federation of State Medical Boards and the National Board of Medical Examiners got together to create the first national clinical assessment centerthe Colorado-based Institute for Physician Evaluation. The organizations anticipate opening as many as three or four more centers in the next five years. State medical boards can refer physicians to the institute for a comprehensive three-day evaluation that includes a battery of standardized and personalized assessments measuring a physician's medical knowledge, communication skills, problem-solving abilities, and documentation skills. In addition, the assessment includes a physical exam, neuropsychological screening, and an observable doctor/patient interaction using a standardized patient.
The institute then generates a comprehensive report outlining the physician's strengths and deficits and may offer recommendations for remediation. The physician is permitted to review the report before it is forwarded to the state board but is not allowed to make any changes. While the cost is not inconsequential it can be as much $7,500 for an assessment and $5,000 for remediation it's a bargain when compared to the expense of litigating a complaint or even to the price of continuing medical education.
Correction: If the physician refuses to participate, the state board can issue an "order to comply." Should the institute's report indicate serious deficiencies, suggesting that the physician represents a threat to public safety, the state medical board can summarily suspend the physician's license pending further evaluation and correction of the defi- ciencies. When possible, the institute's review panel will recommend remediation strategies to the referring board; some may be as simple as a three-day prescription-writing course, and others as comprehensive and lengthy as a full-time postgraduate training refresher.
The state medical board uses the information provided by the institute, along with other testimony, to resolve the complaint and, hopefully, avoid costly, drawn-out litigation. The physician, however, still has the option of resolving the complaint through due process and a formal hearing.
Competency: This national assessment program goes a long way in providing objective information in what can often be an adversarial, contentious, painful process for all involved. While the Colorado program can only handle about 200 referrals a year, within five years, when the other centers open, many more physicians will be able to undergo this type of comprehensive assessment. However, these centers will not deal with alcohol and drug abuse problems or with sexual boundary violationssuch issues need to be resolved before a physician is referred for evaluation.
Is the national assessment center concept the final answer in measuring physician competency? No, but it is a giant step forward in maintaining public protectionthe primary charge to all medical boardsby offering an objective means of evaluating physicians whose ability to practice medicine may have deteriorated. I believe that medicine is the only profession to provide this service. When a physician's ability to practice is questioned, a state medical board can demand that the physician undergo a comprehensive evaluation of his or her medical practice skills.
Illustration by Suzanne DeJohn
Porter, an associate professor of surgery (orthopedics) emeritus at DMS, serves on the board of directors of the National Board of Medical Examiners, chairs the oversight committee of the United States Medical Licensing Exam (USMLE), and is chair of the postlicensure assessment program committee. He is also past president of both the New Hampshire Board of Medicine and the Federation of State Medical Boards.