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Nov 3 2014

A Medical Board of action: how the NCMB works to anticipate and address challenges in medicine

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Image for A Medical Board of action: how the NCMB works to anticipate and address challenges in medicine The work of the Medical Board falls in three main areas: discipline and remediation, licensing and, finally, policy. Our disciplinary work is complaint driven and, consequently, a mostly reactive process. The Board investigates complaints and reviews information about the cases to determine what action, if any, is needed. If the Board decides to take action in a case, it does so to protect the public by addressing areas of concern so that similar occurrences may be avoided in the future.

Licensing also involves the review of information submitted to the Board in the form a license application, but it is not a purely reactive process. In fact, in many ways it is a proactive way for the Board to protect patients. By maintaining high standards for licensure and a rigorous application review process, the Board protects patients by issuing licenses only to those applicants it
believes can practice safely.

The third main type of Medical Board work—policy—provides the most opportunity for the Board to be proactive, and the NCMB has become increasingly so in recent years. Nonetheless, some observers apparently look on the Medical Board as slow to act, a point that came up during a recent Board retreat. A consultant hired to assist with strategic planning interviewed groups and individuals to solicit comments and critiques of the NCMB. Some, it seems, think the Medical Board doesn’t act to address problems, but instead reacts as issues arise. I would like to correct the perception that the NCMB is unwilling or unable to anticipate challenges. I would like to correct that perception.

Transparency and inclusion
Over the past few years the Board has worked to become a far more open and transparent organization that routinely engages in dialogue with its constituencies. The NCMB is not content to consider only those issues it decides are important—the Board reaches out in numerous ways to ask stakeholders for their thoughts and ideas. For example, the NCMB now regularly conducts group policy discussions that include both Board Members and interested parties outside the NCMB before decisions are made. The Board conducts licensee surveys on important topics, invites—and answers—comments to online Forum articles and has become far more proactive about seeking out opportunities for Board Members to speak and present. We are also on Facebook and Twitter and engage with followers there.

Including stakeholders in policy discussions is perhaps the change that has had the most impact in how the NCMB does its policy work. This method of engaging with parties interested in and affected by the Board’s work is far more proactive than the traditional process of accepting oral and written comment via public hearings, which typically garner low or no attendance. Participants literally have a seat at the table and discuss the issues at hand with sitting members of the Board.

An early example of this is the special task force on physician scope of practice issues (aka “practice drift”) the Board convened in October 2010. This task force discussed the growing incidence of licensees practicing outside of the areas in which they completed formal postgraduate training and led the Board to adopt a position statement on this issue. The task force process was inclusive and the subject was forward thinking, enabling the Board to get in front of the issue of “practice drift.”

Since 2010, the Board has hosted numerous other policy discussions that follow the same basic model as the physician scope of practice task force. Issues examined by these Board-stakeholder groups include treatment of self and close family members, prescribing of controlled substances for the treatment of chronic pain, the collateral consequences of NCMB actions and, most recently, telemedicine.

In recent years, the Board has used this newsletter as a means of engaging in dialogue with licensees. Through the Forum, the Board has conducted multiple surveys that received an unprecedented response rate. Surveys on prescribing to self and family and on licensee use of opioids in their current practice setting each received more than 1,000 responses and hundreds of narrative comments. In both cases, these results were considered by the Board as part of major policy decisions.

Comments to the online version of Forum newsletter articles are another small way the Board can engage in two-way communication with licensees and other readers. For example, a reader of the Hepatitis C article that appeared in the Summer 2014 issue noted that it failed to discuss the cost of the new treatments examined in the piece. The Forum editor forwarded the comment to the article’s author, who provided a response that was then posted in answer to the reader comment (the response is also published in this issue of the newsletter, on p.3.)

More than just discipline
As noted earlier in this article, the Board’s disciplinary function is complaint driven and, by definition, reactive. Over time, however, as the NCMB reviews cases that involve different licensees but contain similar facts, opportunities for intervention and outreach become obvious.

Problems with opioid prescribing are a prime example. In recent years, excessive or otherwise inappropriate opioid prescribing has been a factor in approximately 20 percent of all public adverse actions for a given year. In response, the Board has found numerous was to address this problem outside the traditional disciplinary case review process.

I have mentioned the roundtable discussion on opioid prescribing. This group’s work informed the Board’s review and sweeping revision of its position statement on prescribing controlled substances for the treatment of chronic pain earlier this year. Based on feedback from roundtable participants and others, the Board took a different approach with the new position statement,
which was adopted in May. For the first time in a position statement, the Board provided detailed, specific clinical guidance to prescribers. The Board hopes that this new approach will be more effective at helping prescribers avoid problems with prescribing that have brought licensees to the Board’s attention in the past.

The NCMB has been busy on less obvious fronts to improve opioid prescribing as well. Last year, the Board cosponsored with the NC Medical Society and other organizations, a continuing medical education session on responsible opioid prescribing. It was the Board’s first time cosponsoring a CME event, but we hope to do more. This year, the Board secured a grant that will help cover the costs of a CME event on opioid prescribing at a meeting of the NC Academy of Family Physicians in December.

The NCMB has also collaborated with the state agency that administers the NC Controlled Substances Reporting System to make it easier to register for access. Licensed physicians and physician assistants can now register for access to the NCCSRS, the statewide database that tracks all controlled substances dispensed in outpatient settings, through the same NCMB portal they use to update their information. The Board hopes this effort will encourage more licensees to use the system.

Now, the Board’s continued collaboration with the NCCSRS is expanding to include regular reports on the state’s most prolific prescribers of controlled substances. The Board will review this information and investigate, as appropriate. This initiative will help the Board be truly proactive in its investigative work by enabling the NCMB to address prescribing issues before licensees come to the Board’s attention due to a death or adverse incident.

Other ways the Board is being proactive
Another effort that is worthy of mention is the Outreach Committee. I established this standing committee of the Board last fall as one of my first acts as Board president. The Outreach Committee works to improve relations with the professional and public constituencies by engaging them in dialogue about the Board’s policy and work. This dialogue is critical since it implie a two-way interchange. The Board does not want to make decisions regarding policy in isolation.

One major area of emphasis has been increasing the number of talks and presentations given by the Board to professional groups and associations, as well as other audiences such as medical students and residents. The Board believes informing licensees and prospective licensees about Board expectations, applicable laws, rules and other policies as early in their careers as possible will lead more licensees to make good professional decisions. We hope, over time, sustained outreach will result in fewer regulatory problems.

The Board also sees value in helping students, residents and licensees develop a productive relationship with their regulator. Our goal is for licensees to see the NCMB as a resource that wants them to be successful in practice.

These are just a few of the ways the Board has become more strategic and proactive in its efforts to protect patients and improve the quality of medical care provided in North Carolina. I’ve no doubt the NCMB will become even more active on this front in the years to come. Increasing outreach was one of a handful of major priorities identified during the NCMB’s recent retreat and the Board will soon discuss ways to make this happen.

As someone who, as of Nov. 1, will again be a rank-and-file licensee, I look forward to seeing what’s in store.

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