A patient undergoes surgery to have a brain tumor removed. Although the surgeon believes the tumor was successfully excised he did not, in fact, remove it. The surgeon does not review post-operative imaging studies that show that the tumor is intact. Months later the patient returns to her primary care doctor with worsening headaches, blurred vision and other symptoms. A scan reveals the tumor the patient thought had been removed. The patient files a complaint with the Medical Board, which investigates the case and takes public action against the surgeon.

Now imagine that the patient is the spouse of a soldier on active military duty and that the surgery and followup care took place in a military hospital. It might go something like this:

The patient files a complaint with the Medical Board. The Board contacts the surgeon and the military hospital where he is employed to request the patient’s records, as well as an account of the surgeon’s handling of the case. The surgeon provides his account of the patient encounter. The military hospital, however, declines to release the records to the Board, citing federal law. The Board is unable to proceed with an investigation.

North Carolina law authorizes the Medical Board to regulate medicine and surgery for the benefit and protection of North Carolinians. It seems to me that the protections afforded by the law ought to apply to everyone in our great state. But in point of fact, this isn’t the case. The Board is often unable to proceed with investigations related to physicians and physician assistants who are licensed in NC but employed by federal facilities or the US military. When the Board receives complaints about these professionals, its investigators and legal staff always try to obtain the records and other information needed to proceed with an investigation of the alleged misconduct. The Board has a skilled staff and is sometimes successful, with considerable effort, at obtaining medical records from federal institutions. More often than not, however, the records are out of reach.

Why does this matter? First and foremost, it means that NC licensed physicians and PAs who work in federal institutions are not subject to the same rigorous standards and processes that all non-federal physicians and PAs are held to by the NCMB. From the licensee perspective, it’s a question of fairness: shouldn’t all licensees be accountable for their actions, regardless of where they happen to work? Second, but certainly no less important, it shortchanges patients who are treated in federal institutions because they do not have access to the same protections as North Carolinians treated in non-federal settings.

Another situation the Board is sometimes faced with involves privileging actions taken against NC licensed physicians or PAs working in federal institutions. When a federal institution revokes or suspends a NC licensee’s clinical privileges, the institution sometimes reports the action to the Medical Board. The Board has an obligation to investigate the actions, since the conduct that led to the privilege suspension or revocation may represent a threat to patient safety. In these situations, we face the same problems obtaining medical records and are usually unable to complete an investigation.

Situations in which a licensee of the Board has lost privileges at a federal institution are especially troubling. Where do these clinicians go when they can no longer practice in the federal system? They set up in private practice in North Carolina or get a job at the local urgent care. Meanwhile, the Board is limited in its ability to assess whether that licensee is competent and safe to practice.

This isn’t just a North Carolina issue, by the way. You may or may not know that clinicians working in federal institutions are required to hold a state medical license to practice in a federal facility, but the license does not necessarily have to be issued from the state in which they are working. Many, if not most, clinicians working in federal facilities in NC do, in fact, hold NC medical licenses. Some hold licenses in other states, in which case those state boards would have an interest in investigating alleged misconduct.

The difficulties the Board has had getting medical records from federal institutions has always troubled me. In my six years on the Board, I’ve helped to review complaint cases that involved serious allegations of substandard practice or misconduct on the part of federal medical practitioners (military, Veterans Administration, federal prison). It is a hard pill to swallow when it becomes clear that, despite our best efforts, the Board will be unable to conduct an appropriate investigation to resolve what appears to be a legitimate allegation of misconduct or substandard care. The national Federation of State Medical Boards has intervened on state boards’ behalf to persuade federal health care facilities to be more forthcoming, with little success.

I have worked in the VA system. I have friends and colleagues who still work in federal institutions and I know them to be competent and caring practitioners. I certainly don’t wish to malign the professionals who choose to practice in federal facilities or suggest that their care is categorically inferior. Indeed, they perform an essential and often thankless service.

As a former fulltime member of a VA facility’s medical staff, however, I feel strongly that the federal government’s process for holding its clinicians accountable is inferior to the process the NCMB guarantees to North Carolina patients. When patients file a complaint, the Medical Board investigates and comes to a decision, after a careful, multistep review of the facts, on how to resolve it. Patients and family members who file complaints aren’t always satisfied with their outcomes. I am confident, nonetheless, that their concerns get a fair and thorough review. I am proud of the Board’s high standard for transparency.

The NCMB informs the complainant, in writing, of the outcome of his or her case, whether no formal action is taken, private action is taken or some type of public action is taken. Cases that are resolved with public actions are publicly available in a variety of formats. Public documents are posted in their entirety on the information page of the licensee receiving the action. In addition, public actions are listed chronologically on the Board’s website and are published quarterly in the NCMB’s newsletter.

I acknowledge that I’m not fully informed about the federal government’s means of investigating and ad-dressing patient complaints. I do know that some of the patients who have filed complaints with the Board indicate that they have not been advised whether their concerns were seriously considered by the federal institution or told what action, if any, was taken. I also know I’d feel a lot more comfortable if the Medical Board were able to do its job when it receives complaints aboutlicensees working in federal settings.

The Board could do this if federal law and policies were amended to require the federal government to release the relevant medical records to the relevant state medical boards. That’s what I think needs to happen.