It’s April 25, 2019 and the Texas legislature it just over 30 days away from closing out another session. This is the second session that the Texas Medical Board has come under Sunset review and still HB 1504 and SB 610 have been slowly moving through the process. The two bills are supposedly identical but rumor has it that what comes out in the end might be a surprise to us all. The thought of an expedited license for out of state physicians has been a big highlight of Representative Paddie and Senator Nichols bill, but does it go too far. And I quote “(d) An applicant described by Subsection (b) who has held a full license and been in active practice for at least five years is considered to have satisfied the examination requirements of this chapter regardless of the type of examination the applicant passed or the number of attempts within which the applicant passed the examination or any part of the examination. Wow! Will Texas really consider allowing an applicant to be licensed based on just any examination and on any number of attempts? I don’t know about you but this needs a much closer look. Hold onto your seats folks the times they are a changing!
In the past five years the Licensure Division of the Texas Medical Board has issued 21,615 physician licenses. Now that number is just a small portion of what the Licensure staff accomplished in those same five years. This same group of folks licenses or issues permits to other health related professionals such as Physician Assistants, Acupuncturists, Surgical Assistants, Physicians in Training, Visiting Physicians, Faculty Temporary Licenses, Visiting Professors, Conceded Eminence physicians, Medical Radiologic Technicians, Medical Physicists, Perfusionists, Respiratory Care Practitioners and Non-Profit Health Organizations.
Back in the day, 1985 to 2010 we didn’t have quite this many license or permit types. I cannot even imagine how an analyst keeps it all straight. Physicians are not easy to license, there are no two docs that are the same for sure. And when you add on all of these other license types and the complexity that goes with each group it is a wonder that the Licensure staff stays on track – but they do – and they do it quite well, but it takes time.
When physicians seeking licensure ask me why Texas is so hard to get a license in I just laughed and say it’s not – it just takes time. You cannot ask a staff the size of the licensure department at the Texas Medical Board to possibly rush through all of these license types – they all take time. Each license or permit type comes with its own set of laws and rules and keeping all of that straight is a headache.
So physicians if you would like to see the medical board perhaps return to taking care of their primary mission – the licensing, registration and discipline of physicians you have an opportunity in the upcoming legislative session. If you are interested in helping solve the issues of licensure I urge you to contact the Texas Medical Association and the Texas Osteopathic Association and get them on the case of getting the Texas Medical Board back to their roots.
Reporting a Colleague- It’s hard! Recently a client of Garanflo and Meyer called to ask what they needed to do about a colleague or friend or partner that they believed was impaired. Well, I had no answer for them and referred them to the Texas Medical Association. When I was with licensure at the Texas Medical Board we never got questions on how and when to report impaired colleagues – it was not something we dealt with.
But recently the Federation of State Medical Board’s daily email listed an article in their daily news clips that had been copied from the American Academy of Pediatrics. The article titled “Reporting an impaired colleague, difficult but necessary” details how an impaired peer may be acting out, etc. I think every Texas physician or physician to be should copy this article and tuck it away. I believe there comes a time in every physicians career that they will be faced with a “hard” decision – reporting a peer.
Reporting an impaired colleague difficult but necessary
- Pediatricians and the Law
Your office manager tells you that your partner has been late for office hours recently, has missed appointments and hasn’t been available when on call. A nurse confides that she’s noticed your partner making untypical charting errors in the past few months. A parent complains about him being impatient and irritable during an office visit.
This uncharacteristic behavior is deeply concerning. You fear some sort of impairment, possibly substance use. What is your responsibility, and what can you do?
The American Medical Association (AMA) Code of Medical Ethics lists the following responsibilities that physicians have toward impaired colleagues (http://bit.ly/2Dh4i2i):
- to intervene in a timely manner to ensure that impaired colleagues cease practicing and receive appropriate assistance from a physician health program;
- to report impaired colleagues in keeping with ethics guidance and applicable law; and
- to assist recovered colleagues when they resume patient care.
Yet one-third of physicians with personal knowledge of an impaired or incompetent colleague do not report (DesRoches CM, et al. JAMA.2010;304:187-193).
The Federation of State Medical Boards (FSMB) defines physician impairment as the inability of a physician to practice medicine with reasonable skill and safety as a result of mental disorder, physical illnesses or conditions, or substance-related disorders including abuse and dependency of drugs and alcohol (http://bit.ly/2zkPknl).
Physicians with substance use disorders (SUDs) have been described as “impaired.” Approximately 8%-15% of physicians will be impaired by psychiatric illness or SUDs at some point in their careers (Boisaubin EV, LevineRE. Am J Med Sci. 2001;322:31-36).
Clinical features of physicians with SUDs may include changes in mood/affect, decreased productivity, apathy toward patient care, increasing mistakes, inconsistent hours, complaints from patients or other colleagues, deterioration in appearance or physical health, and changes in social interactions. Physicians with SUDs suffer emotionally and may exhibit signs of mood swings, irritability, depression and disillusionment.
Physicians face unique occupational risk factors for developing SUDs, including high stress levels, pressure to succeed, long practice hours and ease of access to controlled substances. While alcohol use is most common among physicians with SUDs, prescription drug use, particularly for opioids and benzodiazepines, is higher among doctors than the general population.
Most states have a legal requirement for licensed providers to report physicians exhibiting signs of SUDs. Nearly every state has established a physician health program (PHP) to rehabilitate and monitor physicians with SUDs and other conditions. These programs often are associated with the state medical board (SMB) and/or medical society. PHPs have unique expertise in the care of impaired physicians and are equipped to support them throughout the recovery process, from evaluation through treatment and long-term monitoring.
In some states, reports may be made to the PHP rather than the SMB. Typically, the physician experiencing substance use problems may self-refer for evaluation by contacting the clinical staff at a PHP. Additionally, family members, colleagues or other concerned individuals may contact the PHP about a physician in need of assistance. This may prompt assessment, evaluation and intervention.
If the PHP determines treatment is necessary and the physician complies voluntarily, the PHP can serve as a confidential buffer with the SMB. If the physician does not comply, he or she could be reported to the SMB and face serious consequences such as licensure suspension and revocation. Those risks are greater if the physician is reported to the SMB without the involvement of the PHP.
Colleagues also may intervene without the PHP. There is no easy or foolproof way to do so. Here are some considerations:
- Note and document concerning behaviors and events as they occur. Maintain a record of specific aberrant behaviors, performance deficiencies and breaches of professionalism. Firsthand observations are useful.
- Before intervening, obtain legal guidance. Your medical malpractice insurer may provide risk-management and legal resources.
- Know and follow all relevant legal, professional and institutional requirements.
- Set up a meeting to share concerns and show support. Participants should be kind and empathetic, express positive regard for the physician’s ability, and avoid accusations, blame, arguing or negotiating.
- Present facts about the physician’s behavior in a way that lessens denial and encourages treatment. The meeting should not be conducted as an attack or confrontation.
- Provide resources such as how to contact your state’s PHP and note that there may be advantages to self-reporting.
- Be clear about expectations and consequences.
- Take appropriate steps to preserve your colleague’s privacy and reputation.
- Have policies and procedures for employees and shareholders delineating how physician impairment due to SUD will be addressed. These may cover issues such as leave of absence, time off for disability and disciplinary action, including termination or forced suspension. Work with an attorney to ensure the documents meet legal requirements.
Most state laws provide some immunity to those who appropriately report impaired physicians in good faith. Workplace policies and documentation of the problem are invaluable should a lawsuit arise. The risk of reporting is minimal compared to the patient safety and liability risks of allowing an impaired colleague to continue to practice.
While reporting friends or colleagues with suspected SUDs to a PHP or SMB can be difficult, physicians have a duty to their patients and profession to report and assist them. The good news is that over 70% of PHP graduates return to work with no signs of relapse or malpractice five to seven years post-treatment (DuPont, RL et al. J Subst Abuse Treat. 2009;36:159-171).
Dr. Santucci is a member of the AAP Committee on Medical Liability and Risk Management
Tort Reform is 15 years old!
I cannot believe it! 15 years ago the Texas Medical Association provided the power to push the Texas legislature to much needed reform when it came to medical malpractice. The result was a huge. And I mean huge there was a huge increase in physician licensure applications at the board. In the year that I retired from the Texas Medical Board, 2010, we had over 3,000+ applications and then in 2017 over 4,700+ physician applications and from the looks of things 2018 is going to be even bigger.
Tort Reform did have a backlash. There were many that complained that the state would be flooded with physicians who were fleeing other states, but that has not been true. The requirements for licensure have remained some of the toughest in the United States and that has not deterred applicants. I believe that the vast majority of physicians strive hard to practice good medicine. So visit the link at the end of this article for more information. And as Jaime and love to say WELCOME TO TEXAS!
Hallelujah the doctors keep on coming!
So you went to a Caribbean Medical School and now you’re having issues with the Texas Medical Board! Well, welcome to an age old issue. Simple answer – become board certified before applying to Texas or during your licensure process. But, many Carib students find themselves in a pickle when it comes to getting into Texas for licensure when they have clinical rotations that don’t meet the TMB rules/statutes.
It is really very simple!
Texas requires that a student must have completed clinical rotations in Internal Medicine, Psychiatry, Pediatrics, OB/BYN, Surgery and Family Medicine, those are absolutes. In addition to those rotations a student must complete enough other rotations that combined with their basic science weeks add up to 130 weeks. All required rotations, listed above, and enough other rotations must be completed in hospitals that have either an ACGME or AOA accredited residency program in the SAME subject. In other words, IM or FM cannot be used to cover anything other than IM or FM.
And then there is the whole issue of how board staff figures weeks. And you might need affiliation agreements or data from ACGME. If you find this all confusing give us a call at G&M and we’ll help you out with the process. 888-400-1580
Clerkships, the nightmare of IMGs!
Clerkships, Clerkships and more Clerkships! It seems like the flood gates have opened and more graduates of schools that have geographically separated campuses are encountering problems with licensure in Texas.
Geographically Separated Campuses is just a politically correct way to say – I did my basic sciences on the school campus and my clinical sciences elsewhere. It appears that no matter the age of the school, ie; St. George’s or AUC or Ross or the experience of their faculty and staff students are increasingly finding difficulty finding the right clerkships to meet Texas standards.
Here is a little hint – when planning your clinical rotations and if you are fairly certain your future is in Texas then make sure you can document the relationship between the hospital you are doing a clerkship in and an entry on the ACGME or AOA program sites. For example, if you are doing a Peds rotation at say Specialty for Children, Capital Plaza, Austin, TX you want to be sure that you walk away with a copy of the affiliation agreement that Specialty for Children has with Dell Children’s for specifically the year you did or are doing your rotation. You see, the TMB staff cannot currently see anything after the 2012-2013 AMA green book on the ACGME site, so they need documentation that where you did your rotation, if it was done at a lower level participating site, was indeed accredited for the time period when you were in rotation. Make sense? I hope so!
April 2018 saw a new page for the Texas Medical Board. The board chose a new Executive Director, Mr. Stephen Brint Carlton. According to the board’s bulletin, “Mr. Carlton, of Orange, Texas, has experience as a county judge and prosecutor for Orange County, and prior to that was in private law practice. He holds a Master of Health Administration from the University ofFlorida at Gainesville and his Juris Doctor and Master of Business Administration degrees from St. Mary’s University in San Antonio. Carlton also has a Bachelor of Science degree from the University of Texas at Austin.Carlton holds the rank of Major in the United States AirForce Reserve, and joined the United States Air Force as a first lieutenant, Medical Service Corps officer, after
graduating from the University of Florida. He spent nearly four years on active duty stationed at the 17th
Medical Group, Goodfellow Air Force Base, Texas. He was responsible for disaster management and group
practice management as a health administrator. Mr. Carlton also deployed to the 386th Expeditionary Medical
Group, Ali Al Salem Air Base, Kuwait for six months in2009 and helped coordinate aeromedical evacuation
missions for Operations Iraqi Freedom and Enduring Freedom “Our committee worked diligently on the agency’s executive search this past year and we are very excited with the skills and talent that Mr. Carlton will bring to the agency,” said Dr. Sherif Zaafran, M.D., Board President.“We look forward to working with Mr. Carlton on fulfilling the Board’s core mission of public protection. I alsowant to acknowledge Scott Freshour, who served as acting Executive Director leading the agency during the the interim. We’re very thankful for his continued leadership.” Mr. Freshour resumed his previous role as the agency’s
Welcome to the TMB Mr. Carlton! Garanflo and Meyer wishes you great luck. You have inherited an amazing staff. We hope you can convince the Texas Legislature to provide you will additional staff and resources and perhaps hold off the inclination for the Sunset Committee to add yet more licensing types!
At its October 2017 meeting the Texas Medical Board (TMB) struck the decades old 10 year rule stating that the rule impeded doctors from coming to Texas. Just for full disclosure G&M Consulting was opposed to this measure. What G&M proposed was a change to the rule making those physician who had been active members of hospital staffs exempt from the rule but requiring physicians who had not been under any formal peer review still have to comply with the rule. Only time will tell if the board’s decision was correct but in the meantime WELCOME to Texas all of you physicians who have not wished to re-up your boards or take the SPEX exam. Any questions – give us a call 888-400-1580.
Since the early 90’s physicians coming into Texas had to have been examined by some type of test in the 10 years prior to their application for licensure. The Texas Medical Board had instituted this measure when the state bean to see a very large increase in applicants flooding in from out of state. The board wanted to be sure that some how the medical knowledge of these incoming applicants was up to date. So, applicants had a choice between a national exam such as USMLE, FLEX, COMLEX or NBOME, or board certification or recertification. To some this rule has been a blockade of sorts to licensure.
During the 2017 Texas legislative session, Senator Buckingham, proposed that physicians not have to maintain board certification – interesting! As the bill began to move opposition to the bill reared its head by hospitals who as part of their credentialing did not wish to be dictated to by the legislature when it came to who would qualify for their staff memberships. But what about all the physicians who are not involved in formal peer review? So, the bill changed, but still some decided that the TMB needed to change its rules and so it did.
Again, only time will tell if there is impact at the initial licensure stage.
Well Hurricane Harvey has been a beast and will continue to wreck havoc on Texas for some time. There are quite a few emergency shelters open and those shelters will be looking for volunteer physicians. If you have time and can give of your services visit the Texas Medical Board website at www.tmb.state.tx.us. On the home page you will find several categories where physicians and physician extenders can obtain information on emergency permitting. TMB staff are working round the clock to comply with the governor’s order to get physicians and other medical personnel in quickly. Texas needs you and NOW!
Hurricane Harvey Response – Visiting Physician Temporary Permit
The Texas Medical Board is issuing expedited temporary permits for out-of-state physicians assisting with the Hurricane Harvey emergency response in Texas. The temporary permit is good for 30 days and there is no charge. All physicians applying must be sponsored by a licensed Texas physician, which may include a facility based physician such as a department director where the visiting physician will be practicing. Applications will be reviewed and immediately expedited upon verification and status of the out-of-state physician’s license.
Please fill out the form with sponsoring physician information and include “HARVEY” in the procedure section of the form.
Email completed forms to: TMBtransition@tmb.state.tx.us
So, the Texas Legislature during their only special session this summer decided to approve the TMB, Texas Medical Board, continuing operation for two years. Yes, only two years! That means that in two years the TMB staff will once again be before the legislature proving their worth – and in the meantime they will be once again spending ridiculous amounts of time gathering more data and explaining to legislators and their staffs why there needs to be a TMB! I of course am not privy to all the whys but this action once again proves to me that the Texas legislature has not clear direction on what it’s priorities need to be. The TMB is probably one of few agencies that not only funds itself but plenty more – the agency via license and registration fees generates millions of dollars and keeps maybe one third. If I was a physician in this state I think I would pull a California and demand that my associations – Texas Medical Association and the Texas Osteopathic Association get deeply behind some legislation to pour more money into the TMB so that additional staff resources could be obtained. And maybe, just maybe before any more small agencies are added to the already overloaded TMB staff TMA and TOMA might, just might oppose such an action and get the TMB back to what they are supposed to be about – the licensing and regulation of physicians!