Presented October 2013

1. Presented October 2013 North Carolina Medical Board: Addressing ‘practice drift’ William A. Walker, MD Board President

2. What is ‘practice drift’? • All practice ‘drifts’ over time as medical practice evolves to include new techniques and modalities • Trained professionals expected to engage in continuing education to keep skills sharp, learn the new • NCMB generally not concerned with this type of drift, provided licensee is clinically competent

3. Drift that is concerning to the Board involves: • Physicians who have moved into an area of practice firmly outside their areas of specialty training • Example: Surgeons drifting into nonsurgical practice such as urgent care or family medicine; Non-surgeons drifting into procedures-based practice, including cosmetic surgery • Training that is cursory (hours or days)

4. Physicians who qualify for licensure in NC are granted a generalized, undifferentiated license to practice medicine and surgery • NOT licensed by specialty • Licensees are on their honor to practice only in areas where competent • ‘Drifting’ into an area in which licensee has not trained is not unlawful; it may be unethical and unprofessional (grounds for NCMB action)

5. NCMB believes the vast majority of licensees practice within their specialty area of training • Growing number of licensees are drifting into areas for which they did not train. WHY? Money – ‘drift’ into cash-based services including cosmetic surgery Burnout – leaving ER/OR-based practice for “easier” primary care Past history – Obstacles to practicing in area of training

6. NCMB’s mission and mandate is to protect the people of North Carolina by: 1. Ensuring that it licenses only those professionals with the competence and character to practice safely 2. Intervening when it determines that a licensee is practicing in a manner that does not meet accepted standards

7. NCMB regulates ‘drift’ as it regulates any quality of care case – does care meet at least minimum accepted standards of care? • If no, NCMB may take action (conditions/limitations, license suspension) • NCMB does NOT target or proactively search for licensees who are ‘drifting’ – cases come to the Board through regular channels

8. NCMB adopted a Position Statement on Physician Scope of Practice to make clear its position on ‘drift’ in 2011 • Position states that licensees who have ‘drifted’ will be held to the standard of care in that area of practice, regardless of training (e.g. family medicine doc doing cosmetic surgery held to same SOC as ABMS-boarded plastic surgeon)

9. ‘Drift’ case study • ENT surgeon in major NC metropolitan area builds plastic surgery practice • Numerous patients report bad outcomes to NCMB • Independent expert medical reviews find care in these cases below standard • Board investigation finds evidence that licensee has medical/neurological problems and has engaged in self-treatment and self-prescribing. Board action: indefinite suspension of medical license

10. ‘Drift’ case study • Family medicine physician completes weekend course in select cosmetic surgery procedures • MD begins offering cosmetic procedures to patients. • MD performed cosmetic surgeries on family members and engaged in an intimate relationship with a person who was previously a patient • MD self-prescribed weight-loss medications Board action: Four-month suspension, served retrospectively; Must not practice cosmetic surgery

11. ‘Drift’ case study • ENT surgeon built cosmetic surgery practice specializing in facial plastic surgery • Multiple patients who underwent face lifts filed complaints with the Board • Independent expert medical reviews found care below standard • MD charged in spring 2013; pending hearing

12. Historically, NCMB has sought to prohibit/end substandard practice when it occurs in the context of practice drift, not remediate the licensee • NCMB sees little role, if any, for assessment centers, personalized physician education organizations in addressing drift

13. Questions?