Resources & Information


When doctors “drift,” questions of competency and ethics are key

Image for When doctors “drift,” questions of competency and ethics are key 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 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 the 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 Dr. Jim Thompson, former president and CEO of the Federation of State Medical Boards and a licensee of this Board, has written, 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: you are licensed by the 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, the Board has 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, the Board has 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 the Board, 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 NCMB'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.
The Board has taken steps to provide greater transparency to patients and others who use its website to find information about physicians. As you may recall, 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 went live in December, ask licensees to state their specific areas of training, as well as their board certifications (see the Licensee Information update article in this issue and please report your training information if you have not already done so.) This should help patients 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.

We should continue to look at "practice drift." I will be appointing a special task force to evaluate this phenomenon and provide guidance to help licensees determine whether they have "drifted" too far.