The vast majority of doctors in Texas will never run the risk of having their license suspended or revoked because they practice good medicine and behave professionally. They are competent, compassionate, and adhere to high standards. However, those who deviate from these standards may face a number of disciplinary consequences. The purpose of the Texas State Board of Medical Examiners (TSBME) is to protect the public by regulating the practice of medicine through licensure, discipline, and education. Soon after my term on the Texas board began in 1999 it became obvious to me that, while the licensing and disciplinary departments of the agency appeared to be humming along at full throttle, the educational efforts of the board were quiet by comparison.
To keep the public informed, we have a user-friendly and nearly encyclopedic website (www.tsbme.state.tx.us) and a biennial Web-based newsletter. Additionally, board members try to visit at least one of the eight medical schools in Texas each year to drive home important points for physicians-in-training. Despite these efforts, agency staff and board members continued to receive an inordinate number of calls and complaints regarding the licensure process. In 2002 in-house protocols were adjusted to expedite the licensure process, and the number of calls has since dropped. However, even with these improvements a fair number of frustrated license applicants, together with a small percentage of applicants who provide false or misleading information, demonstrate that some still are not well informed.
Likewise, it seemed that many of the physicians allegedly deficient in skill, knowledge, judgment, ethics, character, or self control could use a refresher course in professionalism — a code of conduct that, were it adhered to by more physicians with potential problems, would likely save precious resources used to investigate allegations, generate disciplinary orders, enforce those orders, and deal with those who fail to cooperate accordingly. As in the licensing department, other significant changes at the TSBME have resulted in tougher policies, a reduced backlog of open investigations, and quicker overall turnaround time for new investigations.
I believe my colleagues on the board would agree that our time is most often spent in a reactive posture when deciding whether or not to take action against a physician’s license, and when crafting an order that best suits a particular case. When it comes to protecting the public after the fact, we must respond to the facts presented. Board members spend up to 30 days a year for six years in Austin, working hard to do the right thing for the public. We are proud of our work, and are taking a tougher stance these days on physicians who pose a threat, including those who fail the honesty test when applying for a license. However, despite our commitment and the diligent work of board staff, there continues to be a steady trickle of complaints to the TSBME regarding alleged medical misadventures, ethical lapses, and impairment. Often it is a combination of these flaws that brings a physician to our attention. This fuels a sense of frustration at the board that perhaps the message regarding the consequences of bad medicine and bad habits is just not getting through to some folks.
While this certainly applies to disciplinary actions, the licensing process has similar challenges, too. Although we have no control over what international and out-of-state graduates learn regarding licensure in Texas, we feel that graduates from local schools stand a better chance of successfully navigating the process. Furthermore, all applicants do have access to our website, and our application is self-explanatory, more brief than previous versions, and easier to complete. When applications for licensure do fall out for review, an air of suspicion often surrounds the decision process. Poor academic performance, negative faculty reviews, and inconsistencies on the application thrust board members and staff once more into a reactive mindset to determine if a problem truly exists. Occasionally, new licenses are granted only if the physician agrees to certain restrictions or conditions before they are allowed to practice.
No shortage exists when it comes to critics of board rules, staff, or actions, however. Occasionally, tough board members are themselves the subjects of criticism. We are either too tough or too lenient, or too late or too quick on the draw; it all depends on the source. Caution and haste, naturally, are a matter of perspective. During the past two years, board members and staff have had to react to myriad, and often conflicting, criticisms of our work from the media, consumer groups, professional organizations, legislators, and, of course, disgruntled physicians. One reason is that the board’s actions and new policies will never satisfy every individual or special interest group all the time. This is the rule rather than the exception, and not unique to the TSBME or to other types of regulatory agencies. Moreover, because this is government work, when our decisions do happen to please someone or some agency, it is likely to fall short of their expectations.
The changes within the board touched on above will be sure to satisfy some of the critics, but just their mention has enraged others. When it comes to fulfilling the mission of the TSBME, it is rare for all stakeholders to agree on any one issue. However, although we may be “caught in the crossfire,” public protection is and must remain our priority.
Recently, additional funding was approved by the 78th Legislature and has been earmarked primarily for investigation, litigation, and compliance. But with this funding also come more responsibilities, so the effectiveness of educational endeavors by the board will continue to be limited by budgetary constraints. It is the natural tendency of doctors as human beings to forget some of what was taught in school, and the problem is compounded by the fact that it is likely that those most at risk are not the ones most likely to stay current or to seek guidance.
Taking a broad view, it seemed as though the TSBME could benefit from another tool to keep physicians informed. Although many critics would agree that the board just needs a bigger or better hammer (recent legislation has addressed this), the TSBME could also use something more along the lines of a compass to help physicians remain current on licensing and disciplinary issues.
After board meetings in Fall 1999 these educational challenges were clear. Soon thereafter fellow board member Larry Price, D.O., described the effectiveness of a well-thought-out presentation to a group of students at Texas A&M College of Medicine, who envisioned a way of addressing these challenges. Visits by board members to medical schools are sporadic, inconsistent in their message, and even less consistent in terms of attendance by medical students and residents (one meeting during a busy testing schedule in Houston was attended by a handful of students). To address these issues, the idea of making a video to present a standard, meaningful message was conceived. The original intent was to produce a video that would promote greater understanding among current and future physicians regarding the regulation of medical practice in Texas. It was hoped that the video would decrease complaints from applicants regarding licensure and about physicians holding a Texas license.
At a meeting of the board of the Texas Society of the American College of Osteopathic Family Physicians (TxACOFP) in Fall 1999, this idea was presented during casual conversation and the seed was planted. A plan of action was created, and a script was written. Because the TSBME lacked sufficient resources to produce and distribute the video, the University of North Texas Health Science Center at Fort Worth Texas College of Osteopathic Medicine agreed to donate the equipment and human resources needed to complete the project. Because our goal was to issue a copy of this video to every medical student in Texas, TxACOFP sought additional assistance through a grant from private foundations. While these efforts were underway, another TxACOFP board member, Pat Hanford, D.O., received enthusiastic support when he shared this idea with his colleagues on the board of the Texas Medical Foundation (TMF).
The TMF not only agreed to provide the necessary funding, but also graciously and enthusiastically adopted this project. During the next three and a half years, collaboration between the TMF and TSBME solidified the message and presentation. They re-wrote the script while preserving the original idea and intent. The TMF also expanded the concept of how to distribute the final product to current and future Texas physicians and to anyone else who would want a copy — all free of charge. We were overjoyed — but not surprised — by the TMF’s desire and ability to accomplish the task. The premier of The TSBME: A Glimpse of Licensure and Discipline was in Austin on July 11, 2003, at the Bob Bullock Texas State History Museum. It will also be available online soon, and physicians may receive one hour of ethics CME credit after viewing it.
After viewing the finished product, I believe the TMF has produced an excellent educational tool that will raise awareness, as well as benefiting the public and the medical profession by achieving the following:
Guiding current and future physicians through the basics of the licensure application process
Educating viewers regarding the most common reasons doctors get in trouble with the board
Outlining the range of consequences of unsafe and unprofessional behavior, hopefully resulting in fewer complaints about board policy and rules, and fewer complaints about wayward physicians
Doing all this at no cost to the public, which expects excellent health care, nor to the TSBME, whose budget is derived entirely from a fraction of physician’s registration fees
On another level, this video demonstrates the power of collaboration between the public and private sectors. In this case, entities representing professional, peer review, and government regulatory interests partnered to promote public protection through physician education. Organized medicine likewise has embraced this work, as its current and future members stand to benefit as well. It became one of those rare examples of something all parties could agree on.
On a personal level, seeing this project through from start to finish has been quite fulfilling, and has provided all who made it happen with a similar sense of satisfaction. The intent was to be proactive, practical, and innovative, while being consistent with the goals of the TSBME. Because the spirit of this endeavor was to be preventive, rather than punitive, it also was in line with the mission of the TMF. The only downside was the realization that it would take a “miniseries” to cover every important message doctors might need to hear. Nevertheless, the big-ticket issues were touched upon, and this first video lays a firm foundation for other projects that may follow, perhaps creating a ripple effect to other regulatory agencies in Texas and beyond.
Ultimately, health care professionals need to understand state laws related to their practice, maintain proficiency in knowledge and skills, know their limitations, maintain proper boundaries, always be compassionate, use common sense, and hold themselves to high personal and professional standards of behavior. A number of errant, impaired, or ethically challenged health care professionals will always pose a threat to their patients and their profession, and pose a challenge to regulatory agencies. This is human nature. It is with great hope and anticipation, though, that this video and other tools like it will have a positive impact in this regard.
Many thanks go to the TMF for their generosity and leadership. Thanks in particular go to Executive Director Phil Dunne, Director of Business Development Tom Manley, Lolly Lockhart, Ph.D., R.N., and the officers and members of the TMF board. Thank you also to the TxACOFP officers for their vision, to TSBME Executive Director Donald W. Patrick, M.D., J.D., to the TSBME staff, and to everyone else whose efforts enabled these public and private organizations to combine their efforts as good citizens, for the good of all citizens.
