In the Public Interest: Medical Licensing and the Disciplinary Process

Abstract

The body of scholarly literature devoted to the role and function of state medical boards is not especially deep. Accordingly, when a book appears adding to that body of literature scholars and the medical community cannot help but take note.This is particularly true with the publication of In the Public Interest: Medical Licensing and the Disciplinary Process by New York University sociology professor Ruth Horowitz.Having served on state medical boards in Delaware and New York, Horowitz is uniquely positioned to deliver thoughtful analyses of medical boards' collective functioning from multiple perspectives, including that of public board member, educator and sociologist.In the Public Interest contributes meaningful insight on all three counts.The book opens with Horowitz's contrasting experiences on state boards and introduces the concept of “deliberative democracy” in operation within these public agencies (an important concept she returns to later in more detail). The historical origin and mission of state boards are related in the early chapters from their 19th century market-driven, physician-centric focus on licensing standards to the important shift toward a consumer-oriented mission focusing on discipline beginning in the 1960s.Horowitz traces this steady, if fitful, evolution in boards' focus through several telling examples of sunset review and media scrutiny in several states as well as the change in boards' composition beginning in the 1960s with the inclusion of public members. Along the way, the book acknowledges the inherent tensions to modern medical boards' composition and mission, e.g., balancing the needs for public transparency against physician privacy; balancing physician rehabilitation versus public protection in state boards' mission.Horowitz excels in her treatment of board member deliberations and interactions in disciplinary matters as a form of discourse—a dialogue laden with implications for both individual board members and the medical board collectively as it seeks to carry out its mission. In examining the discourse seen in both formal public board hearings and the private investigative phase of boards' deliberations, she draws the readers' attention to the contrast of two differing types of discourse: medical/professional and legal/administrative.Horowitz asserts that the degree to which the former characterizes the discourse bears heavily upon tone and direction that physician members pursue in dealing with disciplinary matters. Having been “schooled” in grand rounds and peer review, physician members of boards may (un)consciously direct their board colleagues toward seeking an “understanding” of what occurred. This discourse inherently places the physician in the foreground and the patient offstage. Additionally, it often focuses on the character and intent of the physician before the board, all of which may foster feelings of empathy for a professional colleague caught up in a bad situation.Horowitz asserts that the extent to which medical-board discourse stays in the latter domain (legal/administrative) directly empowers boards' public members to fulfill their role on the board and to allow physician members to achieve a psychological distancing from professional interests or biases. In this discourse, the emphasis stays upon evidence, efficiency and legal soundness—and thus the patient—as opposed to the technical aspects of medicine that leave the public members often unsure of themselves and reluctant to question their physician colleagues on the board.Horowitz acknowledges that the inclusion of public members on state medical boards provides no panacea for mission-drift away from a patient-centered, public protection.In fact, her own experience and research lead her to assert that strong communication skills and adequate training are critical for public members if they are to bring this perspective to bear as the “social conscience” ascribed to them by one physician board member.The book's concluding chapter provides numerous recommendations for improving medical boards. These range from boards' selection processes and composition to establishing practices that foster transparency.While these are worthwhile and merit attention by medical board members and staff, perhaps the most important theme to derive from In the Public Interest is its assertion that the individual board member's critical ability to “take the role of the other” not only ensures the appropriate functioning of medical boards but fosters the deliberative democracy envisioned for modern state agencies blending public and professional interests with an overarching civic responsibility.