Leaders in Medical Education

Chair of the Federation of State Medical Boards (FSMB), Dr. Jon V Thomas

Osmosis Team
Published on May 1, 2014. Updated on Invalid date.

Most medical students are familiar with the National Board of Medical Examiners (NBME) because of the USMLE Step 1 examination, but they may not be aware of another critical governing body in medicine known as the Federation of State Medical Boards (FSMB). In addition to sponsoring the USMLE with the NBME, the FSMB also works with state medical boards to set policy on issues such as telemedicine and physician licensing.

Osmosis had the opportunity to speak with the Chair of the Federation of State Medical Boards, Dr. Jon V Thomas, MD, MBA, about his background in medicine and policy as well as advice he has for medical students.

How did you get into the business side of medicine?
I trained at Mayo Clinic for medical school and residency. Mayo is a phenomenal institution for any trainee because it’s completely focused on helping you learn. There are no extraneous or unnecessary activities because you are pretty much inundated with educational opportunities there. In that environment I was insulated from the “ugly” side of how physicians actually get paid; that is, how overhead, reimbursement, and all those other thorny issues work.After completing my training I joined a small private practice group in St. Paul. Though we offered great care, we were floundering financially because my partners and I were not as well prepared to handle the business aspects of healthcare. It was during that time that I decided to get an MBA, so I could understand more about the system. I am one of those people who feels the strong need to understand something from the fundamental level all the way to the 30,000-foot view. So I enrolled in a 10-week introductory certificate course in healthcare, which I loved so I decided to do the full two-year MBA program that was focused on medical group management.

That’s impressive that you were able to go back to school after entering private practice. How did you manage that?
The short answer: I have a very supporting wife. She is a tenured professor at Macalester College in St. Paul, Minnesota, where she teaches American Studies. We are no strangers to higher education (she has a JD and PhD), and found ourselves trading off work and school experiences. When I went back to get my MBA while working full time, she was also working and did some of the heavy lifting with family, and I returned the favor when she went back to complete her JD.Between you and your wife, it doesn’t seem like there is a degree missing! So after the MBA how did you find yourself working on regulatory issues through medical practice boards?

The MBA opened my eyes to a lot of aspects of medicine and as a result I became more interested in the financial and legal aspects of the healthcare system. I got involved in organized medicine from the start. Early on in my first year of practice I went to a meeting of my county’s medical society, which was sponsoring a debate between two mayoral candidates. I wasn’t particularly looking to get involved, but during that meeting a colleague nominated me to serve on the “Nominating Committee.” I kindly asked him later why he did that when I didn’t know anybody, and he replied, “Jon, you’re young and it’ll be a good experience. Plus it won’t take too much of your time, as you’ll only meet once.” So somewhat serendipitously I got plugged into the county society and before I knew it I was serving on and chairing a number of additional committees at the county and state level.

After completing my MBA, one of my senior partners recommended that I get involved with the Minnesota Board of Medical Practice, on which he served. I followed his advice and found it to be an incredibly rewarding experience. One thing a lot of people don’t realize is that most physicians on medical boards are practicing physicians. It’s typically a Gubernatorial appointment and from the beginning you realize that you have an incredibly important mission: to protect the public. You have to have a little idealism in you because the pay is incredibly low, so the motivation truly is that you’re giving back to your community. I’ve never met a physician who worked on the Board who didn’t find the experience rewarding.

Given your medical, business, and legal perspectives on healthcare, if you could change one thing about the system what would it be?
If I could only choose one thing to tackle, it would be transparency. I strongly believe that all stakeholders - payers, providers, pharma, device manufacturers, everyone - should disclose their prices. Everyone professes to speak on behalf of, or in the best interest of, the patient. However, the elephant in the room is always the money piece. Here’s a quick example of what I mean by transparency. A colleague’s wife had a sprained ankle and went to a specialist orthopedic center for a walk-in evaluation. The colleague is an emergency physician so was pretty sure it was just a sprained ankle, but decided that he didn’t want to treat a family member. The first thing that the center wanted to do was an MRI scan. No choices or discussion of costs and benefits. That’s crazy, and certainly not high-value, cost-effective medicine. It’s just one anecdote, but clearly we’ve seen a conflict-of-interest problem when centers like that have in-house MRI scanners. Patients need to know the prices of the tests that are being ordered on them. This wealth of data should be out in the public. Another simple mind-blowing example of transparency: as an ENT I often do surgeries to remove head and neck cancers. I can’t tell you how many I have done, nor could I easily, (easily being the operative word) find that out because that data is siloed in different electronic health record systems that are in different hospitals. A quick start to improving transparency would be to simply provide the numbers, not even the outcomes. A simple question: how many surgeries has Dr. Thomas done? There are many really simple numbers that can be made public without much effort needed to analyze or scrub the data. A company as large and complex as Apple could tell you exactly how many of its products are sold in every location in the world. We should be able to do the same.

Speaking about transparency, what do you think about the Medicare numbers being released this month?
It is a start. As a tax payer I think it is important to see how governments spends our money. Next we need to see similar reports for diagnostic services, pharma, devices and durable goods. We are spending a great deal of time and effort developing all sorts of quality metrics and measures. The thought is that patients need this information to make rational decisions and then will choose wisely and somehow through their choices drive out the waste and subsequently drive down the cost of medicine. It turns out that even when patients have access to data they don’t use it to make decisions about choosing a healthcare provider or service. Give them a substantially higher copay or deductible and suddenly they are interested in how much a test or procedure is going to cost and eventually will get around to asking the question, “Doc, do I really need this test?” Until patients are directly responsible and intimately involved with the cost piece I would not expect to see any substantial change in healthcare consumption.

How does your position at the FSMB influence your own private practice?
If I see something that bothers me it spurs me to want to change the system. As a physician on the front line, I’m supremely frustrated with the current state of healthcare and could spend hours talking about it. My change platform, both as a provider and as chair of the FSMB, is through participation and engagement. I have a unique perspective in that I sit at the table when policy decisions are being made that influence private practice in ways that I actually have to live with at the front line. I believe that every leader who sits at a table and makes policy decisions needs to experience what the consequences look like on the ground. There is definitely a difference between theory and practice; many ideas sound great on paper, but problems only become clear when you view how they impact practices up-close and on the ground. I’ll give you an example: The idea that you’re going to pay-for-value using patient satisfaction surveys. Satisfaction is incredibly subjective; for example, a colleague of mine has a practice in which a large percentage of his patients are refugees, poor and not fluent in English so the patient satisfaction surveys are almost meaningless, especially when you throw in cultural expectations. There was an interesting commentary in JAMA last year suggesting that patient satisfaction and cost-of-care correlate because, the reasoning goes, that providers who decline to prescribe unnecessary or non-evidence-based tests score lower on patient satisfaction due to their seeming lack-of-care.

At the WEDI conference where we met I was intrigued by your views on technology as it related to telemedicine and patient engagement. Can you discuss further?
Though I’m a provider of health care, I’m also a consumer. Personally, I only want to go to the doctor when I have to and if I am lucky, NEVER. I have seen farmers in their 90’s, who have never been to the doctor. Many find that to be irresponsible. I find it inspiring. Personally I would want an app, or a suite of apps, that reminds me to take care of my health. We need to harness technology to empower the individual. At the FSMB level I espoused this view by realizing that the telemedicine policy we had was outdated. The standard of care today for a patient-physician interaction requires that we physically be in the presence of a patient, and have to touch them to start a physician-patient relationship. Once that happens, then you can call that person a “patient.” Until you have had that physical encounter you cannot have a telemedicine encounter. I found that to be a little outdated. While the physical exam is of course useful, digital technologies are making it possible to provide objective information remotely without physically touching. For example, given the choice between physically palpating someone’s abdomen or having a trained person at the other end of a telemedicine encounter streaming sonography data to me, I’d take the latter. If I’m relying on digital information to make a decision, why do I necessarily need to be in the same room as the patient? Even in medical school, back in the 80’s, several of the cardiologists who taught me used to laugh at the stethoscope, instead opting to rely on ultrasound data at that time because they could actually see and measure what was going on with the patient’s heart.

Recently I was speaking with a businessman who had an interesting observation about healthcare. He said, “You know what the problem is with medicine? You’ve got a product that no one wants, and that no one wants to pay for.” In my opinion, if we have every person going to the doctor for an annual physical exam at their medical home, we’ve failed. The system should empower patients to take control of their own health and go to the appropriate clinicians only when the situation warrants. I view wellness, screening exams, acute care and chronic disease management as separate issues requiring different expertise and infrastructure. We’re trying to shoehorn all of this into what has traditionally been acute care clinics. My goal would be to separate the different systems. I think technology can help us achieve that.

Do you have any advice for current medical students? 
I think medical students are very idealistic, which is good. Part of the issues I see with medical school training is that it can be soul-crushing. You come out of medical school optimistic and then are put into situations that are very tough both psychology and physically. I find the debt burden to be unconscionable, even unethical. The leadership to fix this will have to come from students and their generation because I see the current generation as wanting their Medicare, which if not controlled will bankrupt us all. So it is important that students get involved politically. A lot of the problems are systemic, and not necessarily the faults of individuals, but at the end of the day we receive payment from the Federal government and insurance companies and their influence is tremendous. Today patients are not directly involved in the interaction and I think that’s another opportunity for improvement, especially with new technologies. Students should be active in their own education, particularly when it comes to understanding the financing and the need to incorporate technology into their practices.

I would also say that if you’re going into medicine, you should strongly consider a joint degree like an MD/MBA, MD/JD, or MD/MPH. Future physicians will need to have more tools at their disposal if they want to have an impact on the system. Because of all of the changes coming with the Affordable Care and HITECH Acts, small group practices may not be able to survive the upcoming reporting requirements. Many clinicians are consolidating their practices into large integrated systems and becoming cogs in a system. If the large integrated healthcare delivery system has a structure with little input from physician leadership at the top, those employed physicians will be unhappy. I think you need to have enlightened systems that will have joint leadership models with physician leadership at the top who isn’t disconnected from the realities of day-to-day practice.