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Aug 14 2009

Helping licensees stay out of trouble: Yes, we do that too

 Categories:  President’s Message Comments:   comments  Print Friendly Version  |   Share this item
Image for Helping licensees stay out of trouble: Yes, we do that too The North Carolina Medical Board has often been accused of lying in wait for licensees to do wrong, eager to jump out of hiding and say, "Gotcha!" While it is certainly not the Board's intention to ambush its licensees, there is at least a kernel of truth behind this perception.

The NCMB has about 50 employees to regulate medical practice in 100 counties and more than 35,000 licensees. The reality is that the Board barely has the resources to adequately respond to the more than 2,000 complaints it gets annually. While I and my fellow Board members see a need to be more proactive in helping licensees avoid problems, it often seems an unrealistic goal.

The Board has been concerned that it is constantly dealing with variations on the same theme, the vast majority of times. We see different practitioner--and occasionally a licensee who does not learn his or her lesson the first time through the process--making the same missteps and errors.

During my term as president, I was determined to do something about this. I asked my fellow Board members and the Board staff to take a serious look at ways we might assist licensees in acquiring new skills and information aimed at avoiding some of the most common problems we see in the course of our regulatory work. In February, the Board dedicated part of a retreat to brainstorming ways it might achieve this, and came up with an action plan. Now one of those action items is nearing implementation.

While the Board does see examples of inappropriate and substandard care, most often the mistakes we see have to do with dysfunctional communication. For example, a patient may find his or her physician's tone insulting or dismissive. A practitioner may make personal comments the patient finds inappropriate. Or there may be incomplete communication about possible clinical outcomes and side effects of care, which can set up unrealistic expectations for the likely outcome of treatment.

Practicing the healing arts centers on the relationship between the physician and patient. In family medicine we often speak of the "therapeutic alliance." This relationship is not unique to any one specialty. Indeed, it is essential to practicing in any part of the healing arts. As I often explain to my patients (usually the ones who are giving me heartburn), the relationship between a physician and patient is akin to an alliance between two nations. Each has responsibilities and rights. The physician has the responsibility to make an appropriate evaluation, to give each patient the information he or she needs to make a reasonable choice and to help each patient form an actionable plan of treatment. The patient has the responsibility to give accurate information and to follow the treatment plan they have consented to. Both the physician and patient have the right to disagree, but in a respectful manner.

Where does the Board come into all this? Well, when the physician-patient relationship breaks down, the result is often a patient complaint to the Medical Board and, frequently, a medical malpractice claim. Too often, the breakdown deals with some aspect of poor communication. I believe that more than 80 percent of the complaints the Board sees begin with dissatisfaction sown with the seed of miscommunication.

As physicians, we spent more than a decade in postsecondary school training to help people. Yet many of our patients feel that they are not helped, but harmed, either physically or emotionally, by an encounter with a physician. The imposition of the clinical skills portion of the U.S. Medical Licensing Exam (USMLE) is just one concrete example of patient dissatisfaction. As some of you may recall, the clinical skills portion of the examination was imposed by non-physicians who felt that many doctors lacked the skills to perform an adequate clinical assessment, or were deficient at communicating clinical information coherently to patients. The growing number of public Internet sites that invite patients to "review" their physicians is another example, and there are countless others.

Medical schools have made changes in their curricula to incorporate communication skills into physician training. Everyone will benefit if those changes result in better clinician communicators. But what of the practicing physician who is "communication-challenged?" Many of these doctors end up before the Medical Board. Some are referred to comprehensive, multiple-day communications courses in states from California to Ohio. A few are required to get in-depth psychiatric evaluation and, if necessary, treatment. But these are extreme measures. They are typically not appropriate for doctors with relatively minor communication issues that nonetheless are causing major problems with patients.

So your Medical Board sought a solution to this problem. Board staff and a few Board members looked for reasonable alternatives to the costly and lengthy out-of-state courses that communications-challenged licensees are most often referred to. I thought, conservatively, it might take up to two years to identify courses we might recommend to licensees as alternatives. I am happy to say I was mistaken.

Through truly outstanding work by staff, this initiative has come to fruition less than ten months after the Board started its search. The Board expects to begin referring licensees to in-state communication courses (specialized to the needs of clinicians) offered by a Triangle-area vendor in September and hopes to begin making referrals to a second North Carolina-based vendor shortly thereafter. The Board will also provide information on the course offerings on its website and in this newsletter in hopes that licensees who might benefit from them will seek training before a communications gaffe brings them to the Board's attention.

Your Medical Board identified a problem and acted decisively to try and solve it. We hope that these locally-developed courses will become a widely-used resource for all physicians who wish to improve their interactions with patients, not simply physicians whose words have gotten them into trouble. If these courses are used and taken to heart by the large number of physicians who could benefit from them, we might just usher in a new era in medical communication.

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