Monitoring the profession: An interview with FSMB chief James N. Thompson MD

For most doctors, the term "state medical board" probably conjures up images of a physician being disciplined. But medical board officials want doctors to know that the boards also license physicians, promote quality care and protect patients and the profession.

The Texas-based Federation of State Medical Boards is a key player in helping boards meet those goals. The federation advocates on behalf of boards and addresses issues by developing policies that boards can use for guidance.

The federation and its member boards are tackling areas such as sexual boundaries between patients and physicians, scope of practice, physician competence and international medical schools' credibility. AMNews reporter Damon Adams recently talked about these and other matters with James N. Thompson, MD, president and CEO of the federation.

AMNews: What are medical boards doing to be more aggressive in cracking down on sexual misconduct? How is the Federation of State Medical Boards responding to the issue?

Dr. Thompson:We've revised the [FSMB] policy on sexual boundaries, and it focuses a lot on several aspects, one of which is education of physicians. We think it's critical that medical educators inform students and residents of the important role they have in the doctor-patient relationship and that this should not be violated. There are expansions of the last policy that include relationships with family members of patients. There's a focus now about the inappropriate nature of having a sexual relationship with a family member of one of your patients.

This version also has an expanded section on discipline and the evaluation of physicians who are found to be violating sexual boundaries. The policy also calls for a greater cooperative relationship between state medical boards and state physician health [programs] so that there can be an early intervention if there's a mental or psychological problem with a physician that could be addressed by appropriate medical care.

AMNews: Are medical boards doing a good job of policing the profession? Why or why not?

Dr. Thompson: My sense is they're doing as good a job as one might expect, considering the limitations. First, we need to remember that state medical boards consist of volunteers who basically give of their time to come and meet, usually on a monthly basis. The challenges they face are really enormous. For a state medical board to make a judgment on a physician requires that there be a complaint. They're not really policemen. They're not watchdogs. State boards respond to complaints about physicians.

Secondly, a large number of our [boards] have very limited resources, have limited autonomy, and this impedes their ability to effectively regulate the practice of medicine and discipline errant physicians. We believe the best and strongest functioning boards are those boards that have considerable autonomy and sufficient resources to have their own investigators and have decision-making so that they can in fact take action against errant physicians.

AMNews: What are the federation and medical boards doing to make sure international medical graduates are qualified and are from reputable schools abroad? Why is this more of an issue now?

Dr. Thompson: The state medical boards rely to a large extent on certification from the [Educational Commission for Foreign Medical Graduates]. That provides a great service to licensing authorities that in large part don't have the resources or wherewithal to investigate all of the international medical schools. The ECFMG does several things, one of which is maintain a list of accepted international medical schools. To get on this list, a medical school has to have been recognized by its minister of health or the equivalent in that country.

What has prompted the recent questions is the emergence of offshore medical schools that have attracted a number of U.S. citizens, and there have been some serious questions raised about the quality of the educational programs in those offshore schools. California and New York currently have programs in place to assess international medical schools. California does so for the purpose of licensure, and New York does so for the purpose of clinical training. A number of states are relying upon these assessments to make judgments about the quality of the educational product of international medical schools. We had a special committee on undergraduate medical education looking at how state medical boards might get more information about international medical schools. One of the recommendations called for the federation to develop a clearinghouse along with other organizations such as the ECFMG that would help serve as a source of information to the state boards. (Note: That measure has passed, and an implementation process is being developed.)

AMNews: What are the summits for the Physician Accountability for Physician Competence? What is the goal of that and where does it stand?

Dr. Thompson: The summits are designed to get a national consensus on how the health care community in the future will measure and evaluate the continued competence of physicians. This resulted from several factors, one of which was the increasing call from the public for accountability and transparency in the assessment of physician competence. The Institute of Medicine report and other reports have called for greater accountability from our regulatory authorities. The federation's house of delegates responded to that by charging a committee to look at how we might achieve a mechanism for maintenance of licensure similar to the maintenance of certification process that the American Board of Medical Specialties has.

This resulted in our having two summits in 2005 looking at how we might get a coordinated mechanism nationally bringing health care organizations and other related organizations together to begin a dialogue on the continued competency of physicians. We agreed to align around some core values and things such as periodic demonstration of competence, practice-based assessment, quality improvement and a commitment to professional development. One of our first steps is going to be to try to gain a consensus on what constitutes competent medical practice.

The participants at the December summit developed a draft document that includes a public statement defining the competent physician. In addition, they're looking at drafting a document similar to a document that exists in the United Kingdom called "Good Medical Practice," and it basically defines for the public and for the profession what a good physician should be expected to do. We're in the process of drafting a comparable document for this country and that will be a subject of the third [summit].

AMNews: What were the lessons learned about licensing after Hurricane Katrina? What has the federation done to ensure licensing problems don't occur in similar natural disasters and emergencies?

Dr. Thompson: There are a number of lessons learned for physicians who were either displaced or trying to get into Louisiana to volunteer. One of the critical lessons is it's important to have your credentials verified by a credentials verification organization. Secondly, the states learned that it's important that they have emergency planning, including communications systems and a place for backup data to an off-site location.

One of the great concerns that we have, and that the state medical boards have, is that a time of emergency seems to attract unlicensed practitioners or known predators into an area. What we saw, regrettably, in Hurricane Katrina was a knee-jerk response to waive licensing requirements both for physicians going into Louisiana and for displaced physicians from Louisiana going to other states. All that was totally unnecessary because we have the capability of verifying licensure status within hours through our database at the federation. The waiving of licensure requirements could have been avoided and [prevented] the potential risk of putting patients at risk to being exposed to unlicensed practitioners or known predators.

AMNews: What have the federation and boards done to address scope-of-practice legislation?

Dr. Thompson: The state medical boards have adopted policy that looks at scope-of-practice issues, and it has done so primarily for the purpose of giving guidelines for state medical boards and state legislators to use when making judgments about whether there should be an expansion of scope of practice. Our document doesn't say who should do what, but basically gives guidelines for legislators: ... What is the scope of the formal education? Is there an accreditation process? Is there a regulatory mechanism that includes licensure and certification for that type of practitioner? Should someone wishing to expand their scope of practice be allowed to independently practice or be required to collaborate or even be under supervision under someone else when they practice?

AMNews: What legislation is being considered on the state level that would affect how medical boards license and discipline physicians?

Dr. Thompson: There's not a lot right now. Several of the things that are growing in interest are the concern about assuring the public that physicians are maintaining their competence throughout the lifetime of their practice. ... Secondly, a number of states are requiring reporting of malpractice information. It's not clear at this time what that information means other than providing additional information about an individual's practice.