THE FUTURE OF MEDICAL LICENSURE After your introduction, advance to next slide Martin Crane, M.D. , Chair Massachusetts Board of Registration in Medicine

BOARD MISSION STATEMENT To ensure that only qualified physicians are licensed to practice in the Commonwealth, and to support an environment that maximizes the high quality of health care in Massachusetts. It’s always nice to mention the mission statement, demonstrating what we think we’re about. You can also mention that in Massachusetts currently there are 605 active DOs (2%), and 28,525 MDs (98%).

Organization of Agency DPH Patient Safety Programs BRIEFLY describe the make-up of the Board (5 docs/2 public members, appointed by Gov to staggered 3-yr terms). BRIEFLY describe divisions of the agency. Consumer Protection Investigation Litigation Clinical Care General Counsel Physician Health Data Repository Patient Care Assessment Clinical Skills Analysis Liability Reform Initial Licenses Renewals Verifications Affiliation Agreements Public Information Web Site Call Center

PUBLIC INFORMATION WWW.MASSMEDBOARD.ORG Virtually anything a consumer or a physician might want to know is available on the Board’s website: WWW.MASSMEDBOARD.ORG Board Actions Licensing information Physician Change of Address Online Complaint Forms & Instructions Patient Care Assessment Alerts New Licensees Publications FAQs I think we always want to point out our website, and the kinds of information that can be found there. Ours is pretty good, so we should be proud of it.

THE FUTURE OF MEDICAL LICENSURE

CURRENT PATH OF LICENSURE Medical School Internship Residency (Limited License) COMLEX/USMLE Full License CME Credits Biennial Renewal Repeat Last 2 Steps as Necessary The traditional path to licensure (although as late as 20 years ago, some jurisdictions still did not require residency). COMLEX stands for Comprehensive Osteopathic Medical Licensing Examination

EVOLVING PATH OF LICENSURE Stronger education requirements More Comprehensive Evaluation Focus on Clinical Skills Emphasis on Patient Safety Licensure is a career-long process, not a single event Here’s the trend. So what do we mean by this? The following slides elaborate on each of these points.

STRONGER EDUCATION REQUIREMENTS Highlight Communication Skills Emphasize Working Within a Team Structure Teach Students to be Doctors, Not Just Scientists Incorporate Professionalism into the Curriculum – and Evaluation Research and experience suggest that communication and team work are absolutely critical to good health care and reducing medical errors. Professionalism (defined in upcoming slide) is another element the literature – and training programs – are focusing on.

MORE COMPREHENSIVE EVALUATION ACGME “Core Competencies”

CORE COMPETENCIES Patient Care Medical Knowledge Practice-Based Learning & Improvement Interpersonal Communication Skills Professionalism Systems-Based Practice

ACGME ELEMENTS of PROFESSIONALISM Honesty/Integrity Reliability/Responsibility Respect for Others Compassion/Empathy Self-Improvement/Knowledge of Limits Communication/Collaboration Altruism/Advocacy

FOCUS ON CLINICAL SKILLS Again – COMMUNICATION, First & Foremost On-Going Evaluation of Competency Staying Current with National Standards & Benchmarks

EMPHASIS ON PATIENT SAFETY Individual Responsibility vs Systems/Process Failure It’s all about who or what bears responsibility. When an error occurs, was it because of the action of a physician(s) or other medical staff? Or was it a systems failure, like poor prescription verification protocols that resulted in a patient being given the wrong drug. Health care facilities have to be open, honest and transparent about investigating – and reporting – what happened, because that’s the only way to avoid similar mistakes in the future.

LICENSURE IS A CAREER-LONG PROCESS On-Going Clinical Skills Evaluation Evaluation Will Be the Standard for Everyone, Not Just Those with Deficits Targeted CMEs Clinical skills evaluation is the watch word(s) of the day. No longer will physicians obtain their licenses and be free to practice forever without some sort of post-licensure demonstration of continuing clinical competence. Evaluations will be regular and routine, but they will also come in response to questions raised about a particular physician’s skill level.

“Baseball – of all things – was an example of how an unscientific culture responds, or fails to respond, to scientific methods.” Moneyball – Michael Lewis

PREDICTABILITY Baseball Expected Runs By Situation Bases Occupied   1 2 3 1,2 1,3 2,3 Full .46 .81 1.19 1.39 1.47 1.94 1.96 2.22 .24 .50 .67 .98 .94 1.12 1.56 1.64 .10 .22 .30 .36 .40 .53 .69 .82 Outs   *The sacrifice bunt *The stolen base *The intentional walk “The Numbers Game” Alan Schwartz

PREDICTABILITY Medicine Consumer/Other Complaints Hospital Discipline Professional Liability Payments Discipline by Medical Board/Behavior in Medical School From: “Disciplinary Action by Medical Boards & Prior Behavior in Medical School” – M.A. Papadakis

MEDICAL MALPRACTICE DATA So, other than it’s the right thinig

Massachusetts Medical Malpractice Data 1990-2003 5.40% of all physicians made a payment in 1990-1999 6.17% made a payment in 1994-2003 Agency has done 2 reports on medmal statistics – 1990-1999 & 1994-2003 – available on website! NOT including OB-only specialty – there’s only 23 of them, and statistics are meaningless with so few. This type of analysis (to benefit the profession) is one reason BORIM asks for so much info (# of suits, payments, specialty, etc.)

SIZE OF PAYMENTS Over the 10-year period 1994-2003 the average payment was $360,000 In 2001 the average payment in the U.S. was $300,000. In Massachusetts it was $388,841 The number of payments over $1,000,000 grew from 5.9% to 8.5% of all payments (a 50% increase) Growth in $1M+ payments tracks national data perfectly Drop in under-$100K payments possibly due to reluctance of contingency fee lawyers to pursue small awards Payments between $500,000 - $1,000,000 rose 19% Payments under $100,000 dropped 36.6%

TOTAL MALPRACTICE PAYMENTS 1994-2003 FOCUS ON FAR RIGHT COLUMN: Inflation-adjusted payments by year PEAKED in 2001 – we hope this is the start of a trend! Analysis of 2004 data will be done in the fall. If trend continues, entirely possible medmal insurance premiums could start to level off or fall – takes a few years, as payments made today are for suits filed years ago.

TOTAL MALPRACTICE PAYMENTS 1993-2004 Just a graphic representation of the previous slide. Red line shows statistical trend. We hope that line will begin to swing downward soon.

TYPES OF OB/GYN PATIENT COMPLAINTS 72 68 281 159

NUMBER OF COMPLAINTS PER OB/GYN 65 81 192

OUTLIERS 98 physicians had more than two paid claims 4.2% of the 2,307 physicians who made a payment. 1/4 of one percent of all physicians. These 98 physicians were responsible for 388 ( 13.5%) of all paid claims. $133,988,105 (12.9%) of all dollars paid.

98 OUTLIERS 48 NO LONGER IN PRACTICE 50 remain in active practice, of whom 9 have been disciplined by the Board. 48 NO LONGER IN PRACTICE 8 Revoked 2 SOA issued, overturned 9 Disciplinary Resignation 1 Letter of Concern 2 Suspended 4 Formal Discipline 4 Deceased 5 Formal Retirement (1 after Discipline) 13 Did Not Renew

Recommendations Better Communication of Performance/Quality Data Clinical Skills Assessment & Enhancement Comprehensive Training In Best Practices & New Technologies Targeted CME opportunities in Communication

BOARD OF REGISTRATION IN MEDICINE WEBSITE HTTP://WWW.MASSMEDBOARD.ORG Impress upon them that they can read the full medmal report, our annual report and others online.