Texas Medical Board – 96th Legislative Session is a wrap

The Texas Medical Board issued a statement (see below) memorializing some changes to Texas law as well as much needed monies for board staff. The changes to licensure will certainly boost the numbers of out of state physicians that will move to Texas. Stay tuned to gandmconsult.com for updates.


JOINT STATEMENT ON CONCLUSION OF 86TH LEGISLATURE The 2019 legislative session was a success for the Texas Medical Board (TMB). The staff and board worked hard to provide the information needed by the Legislature to pass our Sunset bill and adopt the majority of our legislative appropriations requests. Sunset The adoption of TMB’s Sunset bill was the most important development for TMB this session. TMB began the Sunset review process over four years ago in 2015. Many Sunset items were adopted in 2017, but the full 12-year extension of TMB and numerous other items were not adopted until this year. As such, TMB will be up for Sunset review again in 2031. The Sunset bill also creates expedited and alternative pathways for physician licensure in Texas. This will greatly help out-of-state physicians and board certified physicians become licensed here. The new legislation allows for additional examination attempt limits based on the amount of time the physician has been licensed in another state. TMB is happy to now have the legal means to help greater numbers of quality physicians come to Texas. Additional Sunset bill changes include increased flexibility with non-disciplinary Remedial Plans, the means to legally remove certain dismissed complaints from licensee public profiles faster, and clarifying language on board appeals of State Office of Administrative Hearings findings of fact and conclusions of law. These changes will help to provide a better balance of protecting the public while also ensuring due process for licensees. Legislative Appropriations Request (LAR) The Legislature also provided additional funding to TMB after carefully reviewing our LAR items. TMB will receive additional funds to address technology, cybersecurity, and staffing needs. The Legislature granted TMB seven additional positions and two additional positions for the Texas Physician Health Program (PHP). All but two additional positions requested were granted. These new positions will greatly help TMB and PHP to provide faster services to the people of Texas and licensees. Additionally, TMB received nearly 40 percent of the requested salary increases to address recruitment, retention, and turnover so we can continue to recruit the best talent across TMB and PHP. The requested increases came from an independent, third-party salary survey which showed TMB positions were paid an average of 9.7 percent below market value. The approved funding will result in almost every position receiving a salary increase. Conclusion We thank the Texas Legislature for taking the time to seriously and carefully listen to TMB regarding the Sunset and LAR processes. We also thank Governor Abbott for signing our Sunset bill. Finally, we thank our staff and all TMB-related boards for their tireless dedication to the TMB mission. Our mission is to protect the people of Texas. Our goal is to always fulfill our mission with maximum efficiency, effectiveness, and transparency. We look forward to 12 more years of doing just that. Respectfully, Sherif Zaafran, M.D., FASA Stephen ‘Brint’ Carlton, J.D. President, Texas Medical Board Executive Director, Texas Medical Board

It is an exciting time to consider coming to Texas!

Texas Medical Board – Mental Health Questions

The Texas Medical Board’s May 2019 bulletin begins with a article from the board’s President addressing the mental health questions that appear on the board’s different licensure applications. Way back in the day the board staff sought guidance from universities, those versed in the American with Disabilities Act and other state medical boards in formatting the mental health questions. Those questions have come under review again after the Federation of State Medical Boards urged their member boards to soften these probing questions. I found it refreshing for the board’s President to reinforce the board’s purpose – public protection. At Garanflo and Meyer we are acutely aware of the stigma that some may believe will be applied if they respond with “yes” to any of the mental health questions, but we work very hard to help applicants understand the reason behind these questions, how the review process will proceed and how the board staff is respectful in their handling of all mental health statements and records.


I believe that this article on mental health, the mental health questions and the history of those questions will be most useful. Denise Meyer

Will the Texas Medical Board Continue?

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!

Texas Medical Board Licensure Division is Rocking and Rolling!!!

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!

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

by Karen A. SantucciM.D., FAAP
  • 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

Copyright © 2018 American Academy of Pediatrics

Happy Birthday Tort Reform!!!

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!






The Corporate Practice of Medicine – UGH!

The Corporate Practice of Medicine has been around Texas for many decades.  It is one of the most confusing areas of law when it comes to hospitals, physician groups, doctors and just about anyone related to the practice of law.  Many have attempted to explain the corporate practice of medicine but still those of us that have been around docs and their practices still don’t understand how it all works.

Today the Texas Medical Association produced a Facebook post that details trouble between a hospital system and a Hospitalist group.  It seems like someone is being accused of making money by trying to influence the way in which physicians were making decisions.  Ugh!

Below you will find a link to the article.  I hope that those of you that understand it much better than me can make a diagram, powerpoint, whatever to help us all understand.


So you went to a Caribbean Medical School?

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 and more clerkships!

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!

Texas Medical Board has new Executive Director

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
General Counsel.”

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!