Abstract
IN BRIEF Dr. Jablonski urges regulators to exercise care in licensing and credentialing physicians who practice outside their areas of formal training.
Physicians complete four years of medical or osteopathic school and, upon graduation, we may legitimately call ourselves doctors. But most physicians would readily acknowledge that residency training is what really prepares them to practice medicine. Most doctors, whether they are MDs or DOs, complete a residency of between three and five years — longer for certain medical and surgical subspecialties.
It is during this all-important training that pediatricians learn to take care of kids, and neurosurgeons gather the knowledge and experience to do delicate brain surgery. Residency is the gateway to competent specialty practice. To be sure, medicine evolves and physicians can and do learn new skills and modalities through numerous legitimate training courses. Still, few physicians would consider it prudent, or ethical, to practice too far outside their area(s) of residency training.
However, various factors, including economic pressures, have resulted in a small but increasing number of physicians “drifting” into areas of practice that fall well outside their formal training. Examples might include the enterprising OB/GYN who has expanded his or her practice to include Botox injections and cosmetic laser procedures, or a family doctor who primarily practices dermatology. Another variation our state board has seen is the “pain specialist” whose qualifications consist of little more than a willingness to write prescriptions for Schedule II drugs.
Licensure in North Carolina, like all other states, grants the licensee the privilege to practice the full scope of medicine. This type of licensure (often referred to in regulatory circles as “GUMP” — general undifferentiated medical practice) has historic roots that precede the pervasive specialization of today's modern medical practice. As many of us in the regulatory and licensing community would attest, no physicians in the 21st century are expected to practice, nor are they capable of practicing, all the disciplines of medicine. Yet, licensure puts no restrictions on what an individual may practice. Licensees are not even limited to practicing either medicine or surgery. (Check your wall license: I'm betting you are licensed by a state board to practice “medicine and surgery.”)
That said, it is the physician's professional responsibility to make sure he or she is competent to practice in a particular area. As long as the licensee is competent through appropriate training, a state board likely will have no issues with “drift.” This allows some flexibility in the practice of medicine, avoids specialty-specific licenses and acknowledges the overlap that occurs in many similar specialties.
By the same token, state boards have a duty under the law to act when a licensee demonstrates he or she is not competent in a particular area of practice. Complaints of substandard care involving an area of practice in which the physician is not trained will, understandably, get closer scrutiny than others.
As a physician who has practiced for nearly 30 years, I can understand and empathize with any colleague who turns to well compensated, primarily cash-based services to maximize earnings and/or minimize contact with insurance bureaucracy. I have been in practice since 1981, arriving on the scene at the end of the “Golden Years” of medicine. Since then, physician fees have remained flat, office visits have gotten shorter, the number of patients seen per day has gotten larger and practice overhead has gone one direction — up.
As a regulator, however, the phenomenon of “practice drift” concerns me.
While most physicians refrain from practicing in areas where they simply aren't competent, some do not. In a recent disciplinary case before our board in North Carolina, a surgeon trained in one discipline (not plastics) built the majority of his practice around doing full-body plastic surgery procedures. The board fielded numerous complaints from patients who were unhappy with their results, and outside expert reviews confirmed that care was below standards. Worse, upon further examination, the board found that the self-reported information on the licensee's page on the North Carolina Medical Board's public website was misleading and, in some cases, incorrect. It would have been impossible for a patient viewing the licensee's information online to tell that this physician had not completed residency training in plastic surgery. In fact, based on incorrect board certification information on the licensee's page, patients might reasonably conclude that the licensee was indeed a trained and board certified plastic surgeon.
Of course, some licensees who practice outside their areas of formal training do provide care that meets accepted and prevailing clinical standards. In these cases, it is still essential that the licensee clearly represent his or her areas of training and other credentials. For example, it would not be ethical for someone who is board certified in family medicine to mention that certification in advertising or signage that promotes cosmetic procedures, for reasons I hope are obvious. Such advertising could lead the public to conclude that the licensee's board certification refers to their cosmetic treatments.
Our board has taken steps to provide greater transparency to patients and others who use our website to find information about physicians. Recent changes to North Carolina law authorized the board to expand the information it provides to the public regarding its licensees. Before this law took effect, the board published the licensees' training institution and board certifications. However, the board did not show the specific area of training (pages would simply state that residency training was at UNC Hospitals in Chapel Hill, not that the residency was in family medicine at UNC Hospitals in Chapel Hill).
The board's expanded information pages, which were updated with additional categories in 2009, ask licensees to state their specific areas of training, as well as their board certifications. We believe this will help patients in North Carolina understand if a physician they are considering is practicing outside his or her area of residency training and prepare patients to ask appropriate questions about the licensee's training and qualifications to do a particular treatment or procedure.
As a community of state boards, we should continue to look at practice drift. It is a phenomenon that is sure to grow in other states, as it has here in North Carolina, and we should be vigilant and proactive in ensuring that it doesn't affect patient safety.
During my year as president of the North Carolina Medical Board, I appointed a special task force to study the question of practice drift. The task force, which included representatives from specialty and primary care physician groups, liability insurance carriers and other interested parties, convened in October 2010. This meeting laid the groundwork for a position statement on physician scope-of-practice, which our board adopted in March 2011.
From task forces to examine this issue to board policy adjustments, there is much we can do to stay engaged and alert — and to provide guidance to help licensees determine whether they have “drifted” too far.
Footnotes
↵Dr. Jablonski is the medical director of a community-based outpatient clinic for the Department of Veterans Affairs in Rutherfordton, North Carolina. He was the first doctor of osteopathic medicine to serve on the North Carolina Board of Medicine, and the first D.O. to serve as its president.
