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Aug 3 2010

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

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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.

 Comments on this article:

many, many internist and family care physicians practice extensively in the psychiatric area, mostly in prescribing. I am a psychiatrist and i see awful errors in polypharmacy and/or psychotropic cocktails. patients are harmed; efforts to correct are frequently met with resistance as these patients have established a rapport with their doctors over the years and believe they can do no wrong? part of the problem is the drug companies’ pushing their wares to anybody with a medical license. psychotropic pharmaceuticals are solicited regardless of specialty. while it is true that even psychiatrist gather a lot of their information about new products from these ‘drug reps’ we have become wary with all the recent evidence of misrepresentation of products and side effects. the internist or ob/gyn doctor may get a false sense of security from these mini psychopharmocology courses given by these reps.while i agree it may be more convenient and less expensive to have all ones medical needs met by one doctor, i think this is dangerous, especially now in the rapidly expanding environment of neuroscience/behavioral discoveries and pharmaceutical research and discovery. i would never consider managing a patient’s diabetes; i cannot understand why an internist would believe themselves competent (without formal psychiatric training or in depth exposure and supervision)to manage bipolar illness or even schizophrenia??

By william c. bowens, m.d. on Aug 07, 2010 at 8:03am

Is the Board encouraging “drifing” physicians to qualify in the areas they are venturing into? Are training centers putting too many roadblocks before the ones who wish to do it? I feel it happened to me, and although I refrained from drifting, the experience left dissatisfaction and unanswered questions.

By Alesandro Barchiesi on Aug 08, 2010 at 9:16am

I agree with Dr. Bowens; however Internists are often the first to identify and initially treat illnesses for which subspecialty care is available.  Subspecialists also expect Primary Care Physicians to follow patients they may feel don’t need continued subspecialty care.  This may include continuation of medications begun by the subspecialist.  Patients often request their PCP refill medications until they are able to follow-up with a subspecialist.  Subspecialists will often “release” a patient from their care. A patient may also fail to follow-up with the subspecialist.  If for example a patient with CAD follows up with a Cardiologists, then they may receive more frequent testing than if they follow-up with their PCP.  As an Internist, I feel my scope of practice is expanding due to a number of reasons.  Subspecialty care is not available in all areas, obtaining an appointment may take a considerable amount of time, insurance co-pays are higher for specialists.  Although medicine is becoming more and more segemented, I feel Internists are being asked/expected to “drift” into numerous areas by both patients and specialists.

By Taylor on Aug 11, 2010 at 11:16am

There used to be a phenomenon called physician integrity, which loosely meant a doctor would do the right thing because it was the only way to practice.  Although it is now a dated concept at variance with all the regulators who have never met the doctors nor have any idea of there integrity, much less their skills, it is still a valid concept.  I believe I can determine what I am capable of better than a high school graduate at XYZ Insurance company or a Board member who has never met me.

By Gerald R Burns on Sep 01, 2010 at 6:20pm

Dr Bowens—I am a Family Medicine Physician.  Many patients with psychiatric disease I try to refer to psychiatrists, however, as you probably know there is a huge shortage of psychiatrists—even more than primary care doctors.  I did receive basic training in these diseases in residency and feel competent to initiate first line medications.  I also practice in a small town with the nearest psychiatrist being over an hour away.  My practice is to initiate what I think will work best and try to get the patient in to see psychiatry but sometimes that can take months.

By dr mitchell, do on Sep 03, 2010 at 12:49pm

I tend to agree. However, I think a certain amount of “drift” is inevitable in the scope of primary care. However, things get dangerous when dermatologists start opening vein clinics, psychiatrists host “Botox parties” and the like. Just remember that moderation is in order; the medical board should police serious cases, but borderline cases may be addressed based on results; if patients are dissatisfied, they will discourage further drift via litigation.

By jpoynter on Sep 03, 2010 at 1:06pm

I completed IM residency in 1977 and Rheumatology fellowship in 1981. A great deal of what I do and use today, the science, the medications, even procedures like musculoskeletal US weren’t part of that training, so I have “drifted” a great deal. Defining “drifting from your formal training” is a minefield that I have assumed has already been covered by CME.

By Richard Jimenez on Sep 03, 2010 at 1:25pm

This article is right on target and long overdue.  It is not “anti-physician”.  It is pro-patient.

By Benjamin H. Bloom, M.D. on Sep 03, 2010 at 1:45pm

I am an Internist. I NEVER wanted to “drift” but primary care is a MAJOR hassle these days. I have forty charts on my desk with “prior authorizations of meds” I CONSTANTLY have to fight the medicaid hmos fill out disability etc ad nauseum. THIS is what drives us to do these things

By drpoundsign on Sep 03, 2010 at 1:56pm

in my area, it is impossible to get a new patient appointment with a psychiatrist for 3 months, and many do not accept any insurance, or have very limited acceptance.

I have seen irrational polypharmacy, and particularly, the wholesale use of benzos by MANY psychiatrists.  As an internist working in substance abuse (with over 30 years experience) I feel entirely competent to handle most of my patients psychiatric needs.

By Alan A. Wartenberg, MD on Sep 03, 2010 at 2:42pm

Nice article. Good commentary !

Is is important to remember, however, that each educated and licensed physician should be given the latitude to intervene beyond his/her specialty if the medical need arises and the doctor has the ability to do the work. To be forced do call the infectious disease specialist to prescribe for acute herpes genitalis, or the ENT doc. to wash out ear wax is much too restrictive. Get my point ?

By seadoc37 on Sep 03, 2010 at 3:29pm

One has to be very careful about this and painting the world with a broad brush. All physicians are supposed to know the basics of medical practice and should be able to prescribe anxiolytics, pain meds, anti hypertensives, etc. The setting up of territorial pissing matches helps no one.

An incompetent doctor is an incompetent doctor regardless of the specialty they practice or where they extend the limits of their practice. As physicians we do not police our own. A grossly incompetent physician is often not taken to task as they are political insiders, or bring needed income to hospitals, or are likable people, whereas the highly competent physician may be constantly called on the carpet as they challenge the status quo. Until recent years every surgeon who learn laparoscopic surgery did so at “weekend seminars”.
There is no uniform criteria for evaluating physician performance, there is then clearly no uniform review of patients charts to insure quality of care.There is no system of helping physicians who fall below standard,or want to expand their areas of practice, or simply want to update clinical skills.There is no system of review for the surgeon who does a total thyroidectomy for a benign multinodular goiter, nor for the family doc who should have put the patient on thyroid hormone and never referred her to the surgeon.
If docs are incompetent or verging on being incompetent, they need correction and direction. They don’t need to be told they are operativing out of their speciality.

By Jan B Newman MD on Sep 03, 2010 at 4:22pm

Please do not set a precedent by making things more difficult for the Family Physician than they already are. “Drift” is relative. Allow us to practice safe and cost effective medicine. Otherwise we will have nothing more than scattered specialists and no real patient guidance.

By William J. DeMedio MD on Sep 03, 2010 at 11:17pm

I feel that both Drs Jablonski and Bowens are meddling around in areas which they fail to appreciate all of the complexities of.  In the case of Dr. Bowens, I must add that I don’t attempt to regulate psych meds where I can avoid doing so; but I haven’t found psychiatrists to be “rocket scientists” of neurochemistry in comparison to general int. med specialists or family practitioners.  It all depends upon the individual.  And no,the particular board certification doesn’t guarantee real knowledge in particular matters.  In fact, going back to my basic sciences background, I’d like to compare what I know of these meds and of neurochemisty/biochemistry compared to a great number of psychiatrists I run across.  It is not common for me to find patients managed by psychiatrists who place the patient on four or five SSRI’s, still not functioning well, and still not having their core psychiatric issue properly diagnosed or treated.  I also find psychiatrists crossing over into areas of management such as sleep disorders when it becomes pretty obvious that they don’t have a clue what they are doing.  But again, this isn’t a slam against psychiatrist, per se.  It is all about the individual practitioner.

This discussion of “drifting” scares me considerably.  So we now aren’t supposed to practice both medicine and surgery?  Dr. J, you speak against the entire premise of practicing in such fields as Emergency Medicine and Family Practice.  I think you are perhaps starting an unnecessary “witch hunt” which could end up displacing a lot of very qualified individuals from fields in which they are quite competent and passionate in practicing.  And just how much “drifting” actually constitutes really questionable practice?  Not easy to answer.

By Gregory Benbow on Sep 04, 2010 at 6:02am

Perhaps if compensations were adequate the pressure to seek additional services to offer would be minimized. It is unfortunate that primary care is in such a current sad state of affairs with cuts to the SGR impending every 6 months.

By Kristin Shealey M.D. on Sep 04, 2010 at 12:59pm

Regarding family physicians prescribing psych meds. I am a psychiatrist. There is a huge shortage of psychiatrists in the country, insurance and patient preference barriers exist to see a psychiatrist, and all the practices in my area routinely turn away large numbers of people because we are full. If family docs do not prescribe psych drugs, some of these patients would get no psych care at all.

By Farrel Klein on Sep 04, 2010 at 10:33pm

It is obviously undesirable for anyone to do any procedure or practice any medicine which they are not qualified to practice.  However, “qualifications” are not limited just to residency.  By these rules, nobody would ever be qualified to do cosmetic procedures, because no residency teaches them.  No new procedures would every be done because nobody would have done them in residency to be “qualified”.  So who is “qualified” to do a new procedure?  There is no difference between a Plastic Surgeon who gets additional training in Botox injections, or an ENT, or a Dermatologist, or an internist.  Most Botox injections are done by nurses or cosmetologists who never went to med school or did a residency.  Does that make them “unqualified”?  I would make the case that all of modern medicine is the result of “drift”  Somebody had to do the first craniotomy.  Somebody had to do the first laproscopic surgery.  Those people did not do them in residency, but went on to teach new residents how to do them.  This article presents a dangerous sentiment.  I am all for sanctioning incompetent physicians.  But revocation of licensure should be done because of demonstrated incompetence, not simply because the Board feels they have “drifted”.

By Shon Cook, MD on Sep 06, 2010 at 11:34am

I find myself managing schizophrenic pts not because I want - BUT because I can not find a psychiatrist willing to see many of the managed care pts   and I am stuck with these pts for many months up   until I get a consultant to see these pts. I had to learn many therpapies previously   used by psych.  alone.

By Jaco Fishenfeld on Sep 07, 2010 at 10:46pm

Where can you find a competent psychiatrist to refer to that take the most common insurances in AZ?  Whare can a true pain management specialist or psychiatrist be found?

“many, many internist and family care physicians practice extensively in the psychiatric area, mostly in prescribing. I am a psychiatrist and i see awful errors in polypharmacy and/or psychotropic cocktails. patients are harmed”—-I see patents that are harmed from not having there lithium levels monitored BY THE SPECIALISTS, WHO ALSO DO NOT MONITER BLOOD SUGAR LEVELS.

By WT MD on Sep 10, 2010 at 4:49am
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