ABSTRACT:
Background: State medical boards (SMBs) are tasked with protecting the public but vary in rates of severe disciplinary actions taken against physicians who harm patients. Prior work yielded a SMB-informed list of 56 policy recommendations for protecting the public from egregious wrongdoing by physicians. However, these recommendations have not seen widespread adoption by boards.
Objective: The purpose of this study was to identify lessons learned from SMBs who recently successfully implemented innovative policies that protect the public.
Methods: We conducted in-depth semi-structured interviews with executive directors and board members from 7 SMBs across the United States and its territories.
Results: A total of 13 themes were identified reflecting lessons learned that other boards could adopt when implementing new policies. Advice emerging from interviews included both people-focused and process-focused lessons, spanning domains such as proactively anticipating and acting on barriers to policy implementation, leveraging networks of different stakeholders, using data to inform policy change and case investigations, and attending carefully to board composition and capacity building.
Conclusions: The lessons identified provide valuable guidance and a helpful starting point for SMBs seeking to cultivate change in their board's policies and practices.
Keywords:
- Change management
- egregious wrongdoing by physicians
- in-depth interviews
- policy implementation
- state medical boards
Introduction
State medical boards (SMBs) are responsible for protecting the public via licensing, regulating, and disciplining physicians.1 Although there are many ways for physicians to run afoul of rules and more than 4,000 physicians on average are subjected to disciplinary actions each year,2-4 only less than 25% of these cases involve the kind of egregious wrongdoing (eg, sexual abuse, unnecessary invasive procedures, improper prescribing of controlled substances) that directly harms patients and merits serious disciplinary actions.5-9 By “serious disciplinary actions” we mean those that have “a clear impact on a physician's ability to practice,” such as license revocations, suspensions, and voluntary surrenders while under investigation.3 When physicians engage in egregious wrongdoing, they typically do so across years, harming multiple patients before SMBs or law enforcement intervenes.5
Protecting patients from such egregious wrongdoing is a primary mission of SMBs. Yet, there is a ninefold variation across SMBs in rates of severe disciplinary actions taken against physicians who inflict harm.3 This variability can be attributed to a multitude of factors, including but not limited to constraints imposed by state legislation, ambiguity about what type of behaviors necessitates severe disciplinary action, inadequate access to resources, and concerns about undue scrutinization of physicians.10-12
Our team's prior consensus-panel work yielded 56 SMB-informed policy recommendations and laid a foundation for cultivating greater uniformity, effectiveness, and transparency in board actions and policies to protect the public from egregious wrongdoing.13-15 These recommendations span 5 domains:
1) Board composition and characteristics
2) Board website, outreach, and education
3) Internal board operations and investigations
4) Coordination and information sharing between stakeholders, and
5) Licensing and disciplinary considerations.
Many of these policy recommendations align with guidance from the Federation of State Medical Boards (FSMB), such as the Report and Recommendations of the FSMB Workgroup on Physician Sexual Misconduct.10, 16
Although these and similar recommendations have been published and presented at the FSMB annual meeting, most have not seen widespread adoption across SMBs.7, 13, 15, 16 There are likely many barriers boards face to actually implementing these policy recommendations. Some boards may not be aware of what these barriers are or how to overcome them. Other boards may simply not know where to start with policy change. Implementing new policies and practices requires a skillful approach to change management, which involves adopting strategies that support individuals, teams, and leaders in making changes within their organization.17-19 While there is not a one-size-fits-all approach that SMBs must take to implement new board policies that protect the public, it can be helpful to learn from those boards who have been successful in these efforts.
The purpose of this study is to identify lessons learned and strategies that support policy implementation from SMBs who have successfully implemented some of the aforementioned policy recommendations. Examples of policies these boards adopted include defining explicitly which types of alleged misconduct trigger special procedures to protect the public (eg, license suspension or revocation), purposefully communicating and coordinating with community partners (eg, law enforcement, government agencies) about investigations, and convening role- and gender-diverse investigative teams.
Methods
Recruitment and Participants
Building on relationships established through the authors’ prior consensus panel project, we reached out to current and recent leaders within the FSMB and affiliated SMBs to identify SMBs that had recently successfully implemented an innovative policy aimed at addressing severe wrongdoing in medicine. This convenience sampling approach led to the recruitment of one individual from a total of 7 SMBs, representing 10% of the 70 SMBs in the US and its territories. They agreed to participate in a 60-minute in-depth semi-structured Zoom interview to understand their board's experience with implementing policies intended to protect the public from egregious wrongdoing by physicians.
Although the boards were nearly evenly distributed across quartiles for the frequency of serious disciplinary actions, they had all recently implemented one or more noteworthy policy changes aimed at protecting patients.3 Participants represented boards across the country, including the East Coast (n=3), West Coast (n=2), South (n=1), and Midwest (n=1), all with unique governance and staffing structures. Of those who participated (n=7), 4 were current or very recent executive directors who are attorneys and 3 were current or very recent physician members. This study was approved by the Washington University Institutional Review Board (IRB #202401038).
Data Collection
This study was led by a team of empirical bioethics scholars with expertise in egregious wrongdoing by physicians, physician regulation, and industrial/organizational psychology. The team also had prior established relationships with the FSMB and other SMBs through earlier work engaging members of SMBs to develop consensus on policies that boards can adopt to further protect the public. We conducted 60-minute interviews via Zoom. The project lead Tristan McIntosh conducted the interviews, and research assistant Haley Oetterer took detailed notes during interviews. Participants were provided interview questions in advance of the interview so that they had ample time to read and think about their answers. The semi-structured interview questions are illustrated in Table 1. This also allowed them to gather relevant information to respond to questions in detail. The interview guide was developed in consultation with FSMB leadership.
Semi-structured interview questions
During the interview, participants were asked about the specific policies implemented by their board, factors that motivated policy change within their board, challenges their board faced when implementing new policies, and external stakeholder engagement. They were also asked about their board's internal processes for refining and implementing new policies, unexpected consequences from implementing new policies, evaluating the effectiveness of new policies, lessons learned, and potential areas for improvement with future policy implementation efforts. Interviews were audio-recorded, transcribed, and de-identified by the research team.
Data Analysis
We analyzed the interview data using an exploratory inductive thematic approach, given the very limited prior empirical work on SMB policy change.20-24 Specifically, Tristan McIntosh and Haley Oetterer independently read through all 7 interview transcripts to identify cross-cutting themes and lessons learned. They then met to discuss and refine the common themes identified across interviews. The final agreed-upon themes comprised the codebook, which Haley Oetterer then applied to excerpts in all interview transcripts. Tristan McIntosh then reviewed all code applications, and the team met to discuss and resolve any coding discrepancies until there was complete agreement across interview transcripts. Coded excerpts were analyzed by reading all excerpts for a given code, summarizing the nuanced insights reflected in that code, and identifying illustrative quotes. The research team then met to discuss and finalize consensus about the overall meaning of each theme.
Results
A total of 13 distinct themes emerged from interviews, each reflecting a lesson for other boards. We divide these themes into 2 clusters: 1) people-focused lessons and 2) process-focused lessons. In what follows, we describe each theme and share illustrative quotes.
People-focused Lessons Learned
Theme 1: Attend to board capacity building and composition.
All participants (7/7) raised considerations related to board staffing as important for implementing board policy changes. Many participants recognized the need for an adequate number of staff to create diverse teams that review and handle cases. This is because teams comprised of individuals from different demographic (eg, gender, race) and professional backgrounds can help others unearth and consider different perspectives, address unseen areas and biases, and make better decisions when handling cases.
Participants also noted that boards must be able to secure resources to hire and retain an adequate number of staff. This was widely acknowledged as a challenge, especially in terms of justifying the need for additional staff to the state legislature:
“It's kind of squeezing the toothpaste tube…to get more staff typically in government you need to identify like why do I need my staff right? So we open all these complaints. And we start to do all of this activity. So you need more staffing…it's a really, really hard thing to explain when you're sitting across from a victim, that we're government and we have a resource issue.” [Board 4].
Participants also raised concerns related to board member turnover, either due to imposed term limits or people electing to leave the board. Specifically, some participants noted the difficulties of maintaining important relationships with stakeholders external to the board and retaining internal institutional board knowledge and the board's culture when people routinely rotate off the board. Participants recognized that this challenge is exacerbated by the amount of time it takes to onboard newcomers to the board:
“…somebody has to have a relationship with the legislators. And some boards I know that the members are only allowed to serve for X number of years…One of the downsides of having time limitations is…you lose all of your institutional knowledge…One thing that's very helpful is…the executive director that has you know the relationship with the members of the general assembly. Again, executive directors don't have time limitations normally…” [Board 1].
Theme 2: Carefully frame and communicate clearly about policy change initiatives.
Most participants (6/7) recognized the need for skillful framing of policy change efforts to support implementation. For example, participants advised that, to garner widespread nonpartisan buy-in, policy change initiatives should be framed as steps toward protecting the public because “…everyone's in favor of saving lives” [Board 2]. Additionally, some participants felt that providing adequate rationale and being “…transparent with your commission about why and how you're doing this [policy change]…” [Board 7] was beneficial for motivating change and cultivating support among board staff.
Several participants emphasized that policy implementation is “an ongoing process” [Board 3] that takes significant time, with some taking over a year to make final policy revisions. One participant specifically recommended the analogy of a research study to test and refine new policies:
“…we're going to do this as a research study and we're going to treat it like a pilot program and we're going to gather data and we're going to report back…this is an iterative process. We are learning from this and if it doesn't work, now we've got the data to go back to the board and say this is not working…having their leadership say, we're gonna try it…we're gonna get the data and see if it's working or not…” [Board 5].
Participants also recognized that it takes time for licensees to get into compliance with new policies and that giving them enough time to make these changes is warranted. Despite careful framing, clear communication, and provision of sufficient time, participants also recognized the risk that some people may not fully “hear” messages about policy changes in a way that translates into behavior change. One participant cautioned against making assumptions about what people understand about a new policy:
“…whether when you think you've said something clearly, maybe you haven't because what you've looked at forever and feel is…clear often you've left out a lot of words and assumptions that others don't know.” [Board 6].
Theme 3: Develop and leverage relationships with stakeholders to raise awareness and strengthen impact.
Most participants (6/7) placed emphasis on building a robust network of stakeholders to raise awareness about and gather input on planned board policy changes, identify early champions who can amplify new policy initiatives, and support successful policy implementation. Stakeholders mentioned included state legislators, lobbyists, law enforcement, medical societies, and other relevant agencies. There was particular emphasis on building relationships with legislators:
“We have some partners in the House and we have some partners in the Senate. And it's kind of a two-way street…They will come to us when they feel that we need to do something differently…we go to them when we feel like we need some legislation that's going to protect the public…We went to [the House and Senate]…and said, listen, FSMB just wrote these guidelines and, we want to change the law so that we're in compliance with these guidelines.” [Board 1].
Advice was also provided about how to identify which stakeholders to build relationships with and the value that these relationships bring:
“That's all about relationships and leveraging your existing relationships…you can see which of your congressmen are involved in the committees that address the opioid crisis. A little bit of research quickly uncovers who your contact should be…within your group, you kind of find out who's got contacts or who's willing to make that first call…The magic leap is building strong relationships early with people that control the parts of the process that you don't control…we don't give credit as much as we need to for how important relationships are.” [Board 2].
Explicitly inviting the perspectives of other stakeholders was considered beneficial to incorporating multiple viewpoints as decisions are made about changes to board policies:
“Having the executive director of the medical society come to every meeting is really important…[they] can ask questions…hears firsthand and doesn't just get the information filtered through…make sure you've got multiple eyes on it and multiple input…So that you provide a clear and maybe cohesive message.” [Board 6].
Theme 4: Form dedicated teams and roles within the board to make progress and maintain accountability.
Several participants (5/7) saw value in forming special roles and teams within the board to focus on and make demonstrable progress toward priority areas. Examples of dedicated roles and teams include a sexual misconduct unit, a disciplinary committee, a multidisciplinary case review committee, a legislative liaison, and a victim witness coordinator. It was recommended that teams are appropriately sized so that decisions can actually be made and implemented: “We wanted to keep it kind of a small group. We worried that getting too many people at the table would mean that we don't ever advance this concept…we had something like 6 to 8 people…” [Board 5].
Participants advocated for multidisciplinary teams to investigate cases:
“…every case is reviewed by an attorney as well as a member of our medical staff. And monthly we have meetings in which there are lawyers, members of our investigative team, where we discuss cases where we have come to different conclusions…having that multidisciplinary multi-functional team of staff looking at every case meeting to talk about differences, I think that's a big help…there are a lot of eyes looking at every case bringing different perspectives and experiences to those case” [Board 3].
But it was also recognized that multidisciplinary teamwork can be “tiring” or “difficult” and
“…comes with challenges and I think you might have to learn how to work with a team. As a team, understand each other's approaches…the number one thing I would say in terms of best practice is to have…a multi-functional multidisciplinary team involved in the investigation and review of cases.” [Board 3].
It was also acknowledged that having adequate staff for dedicated roles and teams was a privilege that not all boards have: “Something that we have the luxury of that I know a lot of boards struggle with is we've got dedicated staffing for this…” [Board 4]. Despite these team-specific challenges, participants viewed the benefits of teamwork as outweighing the challenges in supporting board policy change and patient-centered case investigations.
Theme 5: Educate, understand, and consider perspectives of the public.
Several participants (4/7) articulated the value in understanding and addressing public perspectives and information needs when developing and implementing new policies and practices. In particular, participants emphasized perspective-taking as boards engage and communicate with the public. One board member raised the risk of patient reluctance to publicly share their views when boards solicit their input:
“…that was a big challenge, to make sure that the patients’ voices [are] heard by our board members even though they [patients] were not willing to speak publicly…there were so many patients who would want to have a private conversation or would send communication saying we're not doing enough but they didn't really want to sit down at the table for valid reasons…it was challenging to feel like we were representing what patients want when we weren't really hearing directly from them…” [Board 5].
Similarly, one participant warned against biases that might lead some board members to not take patient perspectives seriously:
“The panel…essentially didn't find the patients credible…enough that they wanted to take action against one of their own fellow doctors …with sexual misconduct in particular, there's a reluctance on the part of physicians to really think that one of their own could have done something this awful or this terrible.” [Board 7].
Related to understanding public information needs, participants raised the importance of transparency and effective communication when educating the public about board function and processes and about expectations for receiving appropriate care. Participants cautioned against making assumptions about what the public knows about state medical boards and appropriate healthcare practices. They encouraged conveying clear and realistic expectations and providing up-to-date information to the public:
“…an incredible, incredibly important next step is the educational component…the ideal version would be…distinct programming for…consumers in the public…it would be really a refresher of the education that's out there because a lot of it's very much outdated. I think what still stands in the public's conscience is from 15-20 years ago.” [Board 2].
One participant gave a specific example about how they developed a one-page document with a QR code posted in doctors’ offices that linked out to a brochure explaining what to expect during a physical exam. Another participant mentioned how their board solicited feedback from the Rape, Abuse, & Incest National Network (RAINN) about the tone and word choice of their public-facing documents so that the language used in future communications validates patient experiences. Another participant also articulated the importance of educating the public about what state medical boards actually do, especially given past portrayals of boards by the media:
“…sometimes because of the nature of our board…there's a lack of explanation and understanding of our process. And I think it hurts us more than it helps us. Especially when the media gets these stories wrong because they're not taking the time to really understand. And they have an angle…that really has a chilling effect on people.” [Board 4].
Theme 6: There needs to be a board leader with decision-making authority to champion policy reform.
Some participants (3/7) recognized the importance of having someone in a designated leadership position to champion policy change efforts as a means of motivating and holding the board accountable for actually making policy changes. Specifically, some participants mentioned the need for board leaders to be decisive about policy changes despite possible resistance from other board members: “…she's kind of one of those people who just put her foot down and said we're not doing it the old way anymore and we're doing it this way…” [Board 7].
To address potential pushback from board members, participants mentioned setting clear expectations that everyone on the board consistently follows new policies once they are established:
“There were a couple of board members who thought this [new policy] was a bad idea, that they were more sympathetic to the physicians…They were really coming from the position of “We keep asking one more thing”…another regulation, more red tape, more bureaucracy…But we had enough…If it fails miserably, we will regroup. But it's worth trying and we're gonna do it. And so I think that having some of those strong leaders on the board was critical. And we also have a culture at our board where once the decision is made, we're going to speak as one voice. And so even when people may vote differently, when the policy is adopted, we make it really clear that this board is going to be unified in saying you have to comply with the law. This is now the law and that's what we expect.” [Board 5]
Theme 7: Provide board members with guidance and support when new policies are being implemented.
A few participants (3/7) recognized the need for leaders of policy change initiatives to provide board members with different types of information and support, especially as board members and staff leave and join the board. This need for support is brought by the disruptive nature of policy change and the socioemotional labor board members and staff have to undergo, especially in cases involving sexual misconduct: “It was quite, emotionally impactful for the investigators, the board members, all of the board's staff to go through the process…” [Board 5]. One participant warned about the risk of staff burnout:
“…the challenges is once you identify the problem, then you own the problem…a very weighty acknowledgement of a problem to which there are not easy answers. You know that things are happening that we should be addressing differently…There's a huge personal responsibility with that…I think there can be a lot of burnout with it.” [Board 4]
One participant encouraged directly asking what resources (eg, information, training) board members and staff need to facilitate new policy implementation:
“We also regularly meet in regard to these [sexual misconduct] cases, to say, what's the problem?…Are there resources you need or, you know, don't let these things sit around…that internal kind of managerial emphasis also helped…we're going to do this and here are the tools that I'm going to give all of you…” [Board 7].
Process-focused Lessons Learned
Theme 8: Proactively anticipate and address challenges to policy change efforts.
All (7/7) participants recognized the importance of proactively anticipating roadblocks and consequences resulting from policy change initiatives: “You want to make sure that your regs don't have unintended consequences. You don't want your regs to be hurtful in any way, which is why the process takes as long as it does.” [Board 2].
One of the main challenges raised by participants was the likelihood that members of the physician community would push back against certain policies or ask for exceptions to new board policies. Participants reiterated the importance of remaining consistent and firm in policy decisions despite requests for special considerations:
“I think the one piece or one bone of contention…with the sexual misconduct bill was requiring CME…some doctors…that don't really come in contact with patients…Those guys wanted to know, why do I have to do a 2-hour sexual misconduct course. The answer is that it's impossible to start carving things out and making exceptions. Because then what ends up happening is that you make an exception for one situation and then somebody else comes up with another situation where they want an exception.” [Board 1]
Another noteworthy challenge raised by participants was recognizing that the knowledge informing current policies and the standard of care changes over time and that boards need to adapt to this evolving knowledge:
“…the science has changed over time. Especially in regard to something like, prescribing extended-release Narcotics…was at one time thought to be the best thing and then not thought to be the best thing…we know more about the problem…when you stumble onto a major problem…you have to come up to speed with knowledge.” [Board 6].
Many other possible challenges were identified, including overconfidence by those investigating cases that their current approaches do not need improvement, complexities in how new board policies apply to large health institutions versus solo practitioners, and the capacity for the volume of cases to increase substantially as a result of board policy changes. One of the main pieces of advice given to address challenges to policy implementation was to be proactive and not wait for a major event to happen to make changes to board policies. Other advice included identifying early support for policy change and leveraging that early support to build consensus among others over time:
“…it can be up to like a 7 year process of change…I had to identify my early adopters and get them on board and then we gradually got our group…I have experienced around the 12 to 18 month process where your outliers either get on board or they get gone. Because they know it's not changing…you have to find your believers and then kind of do that consensus building with staff.” [Board 4].
Another piece of advice was recognizing and accepting that not everybody will be happy with policy changes and that is to be expected:
“The public looks at boards and says…you're a bunch of doctors who are overseeing regulation of doctors, protecting the profession…and over here you have, say, the state medical association who's like, you're way too tough on these doctors. And could we be less public about regulation of doctors?…it's that kind of constant balance…don't expect accolades. Somebody's always going to be unhappy with the decision about what we're doing at disciplinary cases one way or the other.” [Board 7].
Theme 9: Use data to inform policy change while recognizing the limitations of data.
All participants (7/7) championed the strategic use of data to inform the development and monitoring of policy changes. Creating a formal data strategy was specifically recommended:
“I don't think most boards do an effective job of evaluating what they do because it's based on anecdotal evidence, it's not based on data analytics…So we're taking a very systematic, deliberate approach, going and looking at what [data] we collect, why we collect it, how we collect it. With the overall goal of developing a data strategy so…we can evaluate the effectiveness of what it is we're doing. We can actually use the data to determine that.” [Board 3]
However, participants also recognized that many boards do not have the infrastructure or tools to analyze data appropriately, given the costs associated with data analytics: “A lot of boards use software systems that were just never designed with data analytics in mind…I think every board will tell you they want to do [data analytics]…boards don't have the time, the money or the resources to do it. They want to. It's not a matter of want to. It's not quick. It is not cheap.” [Board 3].
Participants also mentioned the small number of cases involving egregious wrongdoing and that it takes a long time to accrue enough data to detect significant trends: “Part of the quandary that we find ourselves in is we don't have hundreds of these [sexual misconduct cases] a year…it's very difficult to identify trends when you only have say 2 dozen a year…it's difficult to identify trends and techniques that could improve our investigation process or improve our disposition process.” [Board 7].
One participant offered the solution of creating agreements or compacts with other boards where they “chip in” to pay for a shared data analyst or combine data to increase the number of cases in the database. Although it was acknowledged that there may be legal hurdles with this approach, it would enable boards to share both the burden of cost and the resource of data analytics.
Participants also detailed the type of metrics their boards track and indicated how they use those metrics to inform policy changes. Such metrics include examining the number of license suspensions and revocations, number of consent orders, number of complaints received, how many complaints were closed versus those that resulted in disciplinary action, and instances of recidivism. One participant gave the example of comparing differences between “…the notice, the charging document, versus the recommendation from our hearing officer…and…the final determination” [Board 4] to examine consistency or possible bias in board actions. Participants also recommended examining chart documentation and linking the information in a physician's license application with disciplinary information to help detect indicators of “red flags” when investigating cases.
Some participants recommended conducting retroactive analyses as a means of doing a board self-audit to reevaluate board processes and policies: “We've done a couple of retrospectives where we went and pulled every case involving an allegation of sexual misconduct and kind of did a 360…it essentially served as a check on ourselves.” [Board 7]. However, there were some concerns about possibly stoking fear among licensees about “fishing for cases” and that obtaining some data might only be possible via subpoena. Despite these limitations, participants were enthusiastic about being consistent and objective in evaluating board processes and outcomes.
Theme 10: Share information transparently among stakeholders.
Most participants (6/7) were keen about providing clear and consistent communication about board policies, processes, and changes to a range of stakeholders, including licensees, other board members, the public, and other constituents (eg, governor's office, allied health professional societies, lobbyists): “…being upfront with why the changes were being made and transparent, I think helped a lot.” [Board 7].
Participants viewed educational initiatives as playing a key role in communicating updates, expectations, and other information. Educational initiatives were recommended both for the public and licensees. Providing the public with information about the board's purpose and processes was also recommended to cultivate greater understanding and transparency among the public and media:
“People really just generally don't know who we are. It's becoming really apparent that we needed to do a public information campaign…we're really trying to increase our transparency. And we've done a series of videos that we have on our website. We call it the “get to know”, we tell people how things are happening and what we're doing.” [Board 4].
With regard to providers, participants recommended putting important information, policy or rule updates, and expectations in writing, and leveraging the board website to communicate this information to licensees. There was a clear emphasis on not assuming licensees are aware of policy changes: “I don't think they know that the regs were updated…highlighting the changes and how practices should change to meet the new regulations.” [Board 2]. In addition to leveraging the board website, participants recommended sharing critical information in periodic newsletters:
“We've tried to communicate case examples in our newsletter…for a lot of our physicians it's protective for them as well…I can name more than a handful of physicians who have said if only there was someone else there with me…trying to get those physicians to share their story…has been really helpful too.” [Board 5].
Some participants also encouraged sharing policy changes with other entities: “…I have been sort of trying to push this out to the other boards and especially the nursing board, to try to put pressure on them to adopt some similar to the extent that I'm able to…having a lot of those conversations with them and trying make this sort of a policy for our whole state.” [Board 5].
Participants acknowledged the importance of building and maintaining good interpersonal relationships with licensees and other constituents, such as lobbyists. This is because having quality interpersonal dynamics can create greater opportunities to “dispel myths” and work through disagreements. To help create positive dynamics, it was recommended that boards solicit stakeholder input on policy changes and “look for opportunities where everybody can get what they want…[or] close to what they want” [Board 1]. Taking this approach was recommended to cultivate buy-in and support for new policies.
Theme 11: Leverage the rulemaking process if legislative change is impractical.
Some participants (4/7) thought that rulemaking is an underutilized board process and that rules “amplify, explain, and operationalize” laws. Participants differentiated rulemaking from policies and legislation: “Statutes tend to be broader and less specific…rulemaking, which…has some binding aspects to it and that is also done through the legislature but is easier to have changes made and it typically has more detail than the statute.” [Board 6].
A specific example of rulemaking was provided in the context of physician sexual misconduct:
“We actually have a set of rules a lot of boards don't have that define sexual misconduct rules and we make it a rule and a violation of our medical practices act. So whereas some boards have to rely upon expert witnesses, we make it a straight medical practices act violation and we've done that via the rulemaking process.” [Board 4].
However, it was acknowledged that “…laws have the most teeth, and then rules, and guidelines have a little bit of teeth, but you know not as much teeth as a rule or a law” [Board 1] and that in certain cases it may take several months for proposed rule changes to be approved by the governor's and secretary of state's offices.
Theme 12: Provide quality trauma-informed training to board members and staff.
Another strategy identified by several participants (4/7) was providing quality-controlled trauma-informed training to board members and staff. Moreover, participants noted it was worth the investment of time and resources to hire outside subject matter experts to provide routine, board-wide training about trauma-informed approaches to investigations, especially for sexual misconduct cases. One participant noted that for their board members, participating in these trainings was a requirement prior to handling any case involving sexual misconduct:
“…[the training is] about why victims sometimes have bad memories, or why victims sometimes don't report their experiences immediately or, all the stereotypes that go along with some of what you might see…training is meant to allow you to address that bias that you may have but it's also kind of a clearing the house for questions…anybody who's touching these cases has to go through that [training] before. Otherwise you don't deal with them…from a baseline competency standpoint…It's just a basic qualification…” [Board 7].
Participants acknowledged that this type of training helps cultivate widespread awareness about trauma and how it affects patients and investigations:
“We knew we needed…trauma-informed training…we felt like we needed agency-wide awareness…a 3 to 5 day intensive trauma informed training…with all of our investigators and our attorneys…the sex piece of things that just makes how we do these cases different…” [Board 4].
One participant explained the benefits of trauma-informed training:
“…[the training] was so powerful to the board members. And then we had this big case about 6 months later and it was like thank God we had that training…We have changed that culture…sometimes our board members will say, well, it's kind of “he said, she said” and I still don't like that term. But especially in sexual misconduct, I'm not hearing them use that. Instead, we focus on what does the evidence show? What does…the medical record show, what does the…patient tell us?” [Board 5].
It was recognized, however, that there can be real challenges with getting all board members to embrace the importance of trauma-informed training:
“…our principal challenges were at the staff level, such as getting everyone to buy in that there is a problem that we need to correct. And the problem is how we investigated and/or reviewed investigations to determine prosecutorial decisions. So there had to be a little bit of a mind shift with PSM [physician sexual misconduct] cases. Well, it's an ongoing process…We are hopeful and remain hopeful that through continued training people will understand. But the problem with training is it's the whole idea of, you can lead a horse to water, but you can't make it drink…we keep with the training and even if a hundred percent of people don't have complete buy in.” [Board 3].
Theme 13: When a crisis or bad press does happen, leverage these events to mobilize change.
Some participants (4/7) recognized that bad press or scandals may happen and that when they do, boards should conduct a board self-assessment. Doing so can help propel boards to identify areas for change in policies and practices and to prevent those types of events from happening in the future. As one participant articulated:
“…we had a case of sexual misconduct that was really in the news…we took some time after that to convene a sexual misconduct work group and that work group focused on our statutes, our rules, our policies, and what we should be doing to better, train ourselves. How can we address this from a patient centered approach to make sure that other people don't have to go through this situation…” [Board 5]
It was also acknowledged that even when some scandals that come to light are not directly linked to the board, there still may be expectations by the public and other stakeholders to ensure that a similar scandal does not happen at other boards:
“For the PSM, we didn't really, need or seek buy-in from stakeholders…once Larry Nassar broke out and once the Atlanta Journal Constitution articles came out [about the investigation uncovering 450 cases of physician sexual misconduct where many of these physicians were allowed to continue practicing medicine (25)]…Everybody essentially came to us and said, what are you doing? How is this not going to be a problem in [your state]? So we didn't really need to get buy in because there was a high expectation that we do something.” [Board 3]
Discussion
Across interviews with board members and directors of 7 SMBs, we identified strategies and lessons learned that can support successful implementation of new board policies intended to help boards act more effectively when reports are made. These lessons reflect actionable people-focused and process-focused strategies for boards to implement as they work toward policy change. The most common advice was about the importance of having adequate staffing to support policy change, being proactive in identifying and responding to challenges with policy change, and using insights from data to make decisions about policy change. Other salient themes pertained to communicating transparently and developing good relationships with a range of stakeholders. It is clear that those leading policy change initiatives must attend to not only board processes, but also the people involved in executing these processes.
Implications for Boards
We recognize that no two SMBs are the same and that having complete uniformity in policies across boards is unrealistic, especially given the role that federalism plays within the SMB system.26 However, adopting a continuous improvement mindset is an essential step for protecting the public. Boards should closely examine which of their current policies are and are not working toward this end and also make decisions about what new policies are needed. This may initially seem like a daunting task given the time, personnel, and other resources needed for policy change to come to fruition, but boards must start somewhere. While some policy changes will require legislative change, there are other ways to put new policies into action, such as through rulemaking or guidelines. Boards can start by prioritizing short-, mid-, and long-term goals for policy change and coupling these decisions with the advice gleaned from this study to take concrete action. It is also worth noting that as boards adopt additional policies (eg, educating the public about boards and how to report), this may increase the number of reports made to the board, and boards may want to prepare for the possibility of an influx of reports.
Limitations
The study has a few limitations. First, only 7 SMBs were represented, which reflects approximately 10% of the SMBs in the United States. While the participants interviewed represent a diverse range of SMBs, other boards may have different insights, concerns, and experiences. It is likely that there are other boards doing excellent work toward implementing new policies to protect the public, and these experiences were not captured in this study. Moreover, only one individual from each of the 7 boards was interviewed. It may be that different individuals from the same board have different opinions and understandings about that board's policy implementation efforts to date. Additionally, interviews did not capture how boards demonstrated observable outcomes of adopting new policies. Future research should systematically measure board outcomes of adopting new policies for protecting the public. Peer-to-peer sharing of this information is also worthwhile. Overall, we think that the lessons learned identified in this study are noteworthy and relevant to most, if not all, SMBs across the nation.
Conclusion
We identified both people-focused and process-focused recommendations that boards can turn to as a starting point for making internal policy changes intended to protect the public. The medical regulation community would benefit from greater awareness of these recommendations and related organizational change management guidance. We recommend future research explore how the varied needs, structures, regulatory constraints, and overall dynamics of different boards affect policy change efforts.
While each of the themes that surfaced in our discussions with boards contain wisdom, some of the recommendations require balancing. For example, five of seven boards discussed policy changes regarding sexual abuse and four of seven discussed improper prescribing of controlled substances, while none discussed policies focused on physicians who perform unnecessary procedures for profit.8, 27 We agree strongly that sexual abuse and improper prescribing are high-priority issues that negatively impact patients; but few discussed how they set priorities in policymaking or triage cases, and it is possible that the theme of responding to public scandals and crises may lead, for example, to more policy attention on opioid prescribing than on medically contraindicated surgeries that are profitable.14
We hope that the guidance provided in this paper, which is derived from boards that have successfully implemented innovative policy and practice changes, empowers boards to take the next step in adopting new policies that protect patients.
Acknowledgments:
The authors would like to thank the 7 individuals who participated in interviews for their time and sharing their experiences and expertise. The authors would also like to thank FSMB leadership for their support of this project.
Footnotes
Open Access: © 2025 The Authors. Published by the Journal of Medical Regulation. This is an Open Access article under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC, https://creativecommons.org/licenses/by-nc/4.0/), which permits use and distribution in any medium, provided the original work is properly cited, and the use is noncommercial.
Funding/support: This study was supported by a Greenwall Foundation Bridging Bioethics Research & Policy Making Grant (PI: McIntosh).
Other disclosures: N/A
Ethics statement: This study was approved by the Washington University Institutional Review Board (IRB #202401038).
Author contributions:
TM: Study concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript
HO: Acquisition of data; analysis and interpretation of data; critical revision of manuscript for important intellectual content
JD: Study concept and design; critical revision of manuscript for important intellectual content
- Received September 9, 2024.
- Revision received November 21, 2024.
- Accepted December 19, 2024.
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