Doctor, Judge Thyself - DOCTalk Sits Down With Former Texas Medical Board Member Dr. David E. Garza

• LAREDO

When you see a cop show on television, there is always a mysterious, if not sinister air attached to Internal Affairs--the police who watch after the police. While they are the modern bureaucratic answer to an old Latin question: Quis custodiet ipsos custodes? (‘Who watches the watchmen?’), they are also regarded with more than a little suspicion and resentment by the others.

There has been a similar aura around what was formerly known as the Texas State Board of Medical Examiners, now known as the Texas Medical Board. The motto of the board is, “Safeguarding the public through professional accountability.” But that mission brings them into conflict with some members of the profession from whom they were drawn.

Dr. David E. Garza is a well-regarded osteopathic physician from Laredo who has served his hometown community as a physician for thirteen years.  An almost off-hand comment elevated him into the ranks of the Texas Medical Board for seven years.

Here Dr. Garza sits down with DOCTalk to unveil some of the mystery around the TMB, among other topics.

DOCTalk: Doctor, where are you from originally?

Dr. David E. Garza: I’m from Laredo, a second-generation Laredoan.

So you went off to medical school, came back and decided that this is where you were going to practice?

I almost stayed in Fort Worth.  I had an offer there. But I did a residency in Corpus Christi instead. I almost stayed in Corpus.  But then Doctors Hospital called and asked if I was going to be coming back and the rest is history.  I came back home. My wife, Linda Kazen Garza, is from Laredo, too.

Your specialty is family practice, yes? How do you find the challenges of that these days?

I think that it’s extremely challenging because you have to stay up-to-date in a lot of areas. It’s not just ear, nose and throat.  It’s not just hearts. If you want to be good at it, and do the best for your patients, you’ve got to stay current. Though I don’t deliver babies anymore, for those of us who still do, we’ve got to keep up in that area, too.

What about your reimbursements?

We are close to the bottom of the heap when it comes to reimbursements. We simply see patients for a living—we do some procedures, maybe some EKGs, and small things that are meaningful, but it’s not heart surgery. So, we have to see more people to generate the income required to pay the bills.

How long have you been in private practice?

I’ve been in private practice since 1993.

If you were back in medical school, and you came to that fork in the road, would you choose the same line?

Sometimes I think I should have gone into radiology or anesthesia, specialties that have a better quality of life.

But I think I chose family medicine because it appealed to me. I met my first family physicians when I was a kid myself – but perhaps that didn’t impress me as much as when I went to the Baylor Collage of Medicine for a summer and got to hang out with the family practitioners there. I liked who they were, what they did--I liked their personalities. It sounded like something I would like to do, and it just kind of happened after that.

As difficult as a lifestyle as this is, there are many things about it that are quite good. I see patients from 8 to 5, and have an hour-and-a-half off for lunch. I have occasional hospital work. I almost never have to go to the emergency room, so actually it’s not bad. It’s just that I have to see a lot of patients, whereas some specialists might see ten or fifteen a day, which makes things a bit easier.

I understand you spent seven years on what is now called the Texas Medical Board. How did that come about?

In 1998, I was on a CME trip with some friends, including Terry Boucher, who was then Executive Director of the Texas Osteopathic Medical Association. I casually mentioned to him that I had been looking at the Web site, because I had recognized someone from one of the bulletins. I just said that it would be nice to serve on one day, not really thinking that it could happen.

As it turned out, a position opened up a few months later for an osteopathic position--they had nine MDs and three DOs--and I got a call from Terry, who said, ‘What do you think about serving on the medical board?’ I thought he was just joking, but he said “There’s an opening, and you are being considered.”  Then I knew he was serious.

A little later, I got a call later that day from the governor’s appointments office, and they confirmed that I was being considered. I interviewed very well, and soon thereafter, I was confirmed. I was appointed by then-governor George Bush, and served for six years.

Last year, when my term was up in April, Governor Perry’s office asked me to reconsider and take another six-year term. My ego said yes, but after about six months of that new term, I realized – being so active in so many other activities aside from my practice and my family – that it was really taking a toll. I added up all the things that I did, and they still did not equal all the time I spent in Austin, which is about twenty to thirty days out of the office per year.

I also realized that there was an economic impact I was having a hard time overcoming, and that just cemented the decision to leave. But I enjoyed it—I thought it was a wonderful experience.

There have been a lot of changes at the medical board. It used to be perceived as a good ole boy network.  Has that changed?

Well, let’s go back a little bit. It used to be that the medical board--which has been around for a little over a hundred years--simply did the licensing and perhaps some discipline.

As recently as the 1970s, a lot of the disciplinary action in the medical profession happened at the local level, with the county medical societies. Whether it was for alcoholism, or bad medicine, or whatever--you really were at the mercy of your colleagues.

Perhaps because of litigation, or a simple reluctance to take action, or render an opinion on your fellow physician, that responsibility slowly became the purview of the medical boards. While medical societies can still get involved and take action, for the most part, those issues are taken up by the medical board. That’s one major shift that’s occurred in the last twenty-five to thirty years.

As far as the good ole boy network is concerned, in the seven years I was there, I never saw that. The nice thing about working with the medical board is that it was government--it was not a club or a society. We answered only to the governor.

What I’m speaking of is the public perception that a lot of physicians were not disciplined after it seemed clear that it should have been otherwise.

The medical board did come under fire after a series of articles in the Dallas Morning News, starting back about four years ago. Doug Swanson, the writer in that case, discovered something that I, as a brand-new board member, did not know: We had boxes of files that had not been closed; there were some investigations that were still pending.

Perhaps as a result of that, disciplinary action was not being doled out quickly enough to the right people. Perhaps some of that was due to overload, perhaps some due to lack of coordinated efforts at the medical board – I don’t know for sure, I cannot say.

Lack of funding, maybe?

Lack of funding was a huge, huge issue. The medical board in California gets to keep 100 percent of the fees they collect; in Texas, we keep 20 percent. The rest goes to roads, bridges and prisons.

Why is that?

That’s just the way it is, it goes to the general fund. Whether you are a lawyer, or chiropractor, or podiatrist, a certain percentage of your license fee goes to the general fund. That’s just the way it is.

Now we have had to ask for special funding from the governor’s office and the Legislature, and that has helped. But trying to manage 50,000 licensees with a budget of $5 million and a staff of about 110 – while reimbursing board members for their travel and gas – gets to be pretty tight. I personally believe that funding was the major issue.

With the passage of Prop. 12 a few years ago, was there added pressure on the medical board to be stricter and more diligent?

Yes. One of the beneficial spin-offs of Prop. 12 was an agreement that was made, that “if we are going to do this for the physicians, let’s also make the medical board stronger.” More effective, more efficient and better funded.

I was witness to that. I saw the money come in and the staff get what they needed. There was also a significant reorganization from the top-down. That was the work of Dr. Donald Patrick, the executive director of the medical board. He did a fabulous job.

Haven’t you seen a big increase in the number of the disciplinary actions since Prop. 12?

Yes, we have, but we have also seen an increase in the number of complaints to the board. We don’t know for sure, but we think that it might be a result of plaintiffs not being as successful at finding a lawyer to take their case. They may be told to complain about the physician to the board and get at them that way if they think there is an issue.

It also seems to me that some complaints may be taken to the board just to see if the board will bite, to see if they will do anything about it, and if they do, then the plaintiff and their lawyer will take it to court and try to use the board’s decision as a basis for successful litigation.  That’s just my personal feeling, but there are a lot of other people who have had that same feeling.

The reality is the vast majority of Texas physicians are good physicians who practice good medicine. But, as with any other group of human beings, there are going to be some outliers, some physicians with substance abuse problems, who have personality issues. Some who don’t keep up with current medicine and don’t know that they are not up-to-date.

There are a variety of issues that basically fall under standard-of-care issues--how good a doctor you are--and non-standard-of-care issues--are you an alcoholic or sleeping with your patients, other ethical things.

We get anywhere between 8,000 and 10,000 complaints per year, but only 300 to 400 of those will result in formal action by the board, which is called a board order. So, you can do the math.

That’s what I tell my friends at TOMA and TMA when they corner me about the board, or at least when they used to. Some of them still do, or think I’m still there. I still say “we” – after seven years it’s hard to break the habit. I tell them to do the math – if you think we’re so bad and mean, just out for a body count to get numbers in our column, you’re wrong. If we get a complaint about you to the board, chances are it will get dismissed. You may not even know about it – it may be dismissed before you even get a letter from an investigator.

From the world we know of from TV, police view their internal affairs people very negatively, in a very different light than other cops. Do other doctors view physicians on the board in a similar light?

Yes. When I first got nominated and confirmed, people were a little reluctant to say things around me, for fear that it would affect them negatively. Once they realized that I was not a traffic cop, but more of a judge over the proceedings in Austin, then they relaxed a little bit.

The same thing would happen when I would go to conventions and alumni meetings – folks would be a little stand-offish. Once they realized that I was okay and that I could actually help them, things turned around.

I get a lot of calls from people who want to get their license, and sometimes we have to intervene so they can get their license. I also get a lot of phone calls, emails and letters that are like, “Hey, there’s this guy I know and I think he’s in trouble because of X, Y and Z.” And I tell them, “It’s not my job to report. Here’s where you need to go.” And sometimes they would report it, and sometimes they wouldn’t.

Reporting is anonymous, but people are still reluctant, unless it’s a really egregious case. And even then sometimes they don’t. I could tell you some stories.

On the one hand, some doctors felt I was sort of a threat to them. But on the other hand, they would turn around and ask for assistance. I still get calls, and I do what I can.

But yes, it does put you in a different light.

Has the passage of Prop. 12 added more pressure to the licensing part of it as well?

Oh, yes. Normally, we would issue about 2,400 licenses per year. During my last meeting, however, I think the estimate may have been 4,000. So again, we’ve got the same funding, more applicants, the same number of licensees, but more work doing licensure. That slows the process down.

Another thing that slows the process down is that we have had to spend a lot more of our resources on defending ourselves at the State Office of Administrative Hearings, what they call SOAH. Say, for example, that a physician gets a complaint. The panel agrees that there is a problem and recommends a board order. However, the physician decides not to sign the order – they have the option to fight it, and take the matter up to the State Office of Administrative Hearings.

Which is like court, but more costly – it’s much more costly for the medical board. And there seems to be an upward trend in the number of physicians looking at a board order who prefer to pay their lawyer to take it up to SOAH. That drains the resources of the medical board, and things slow down. I saw that before I left this year – but it’s the right of the respondent, and it’s our right to defend it passionately at the state office. We have excellent attorneys, and we put the best ones in charge of that, but that means they can’t spend time doing other things.

In the years that you were there, what was the relationship like between the medical board and TMA?

Strained, although it’s much better now. It was strained at first – the medical board was caught between two divergent opinions. One is the opinion of the consumer, John Q. Public, that we don’t do enough, that we don’t smack enough doctors around and that we look the other way. The other opinion, from organized medicine, is the opposite of that - TMA, TOMA, etc., who for years thought that we did too much.

How do you reconcile that? How do you satisfy both? Well, you can’t and you never will. It’s never going to be enough for the consumers and it’s always going to be too much for organized medicine. And we serve organized medicine in the sense that we have tweleve physicians there who speak on behalf of the medical profession.

We also have seven public board members, and they represent the consumers. We all worked together very well, there were excellent people picked for the board.

But the relationship has improved.

It’s improved substantially. And I think that part of that is as a result of the Prop. 12 discussions, when they realized how important it was to have a strong medical board.

I think it’s also good right now because of the scope-of-practice issues on the horizon. The medical board is a firm believer in defending the practice of medicine and making sure that the practice of medicine is something that can be regulated by the appropriate board.

Now, there are non-physicians who practice as well, and you can call it medicine – and they have their regulatory agencies – but every time you turn around, you’ve got another non-physician who wants to skip medical school and go straight to practicing medicine. The medical board is very conservative in that regard, and stands shoulder-to-shoulder with organized medicine in the belief that the public needs to be protected and that those who want to perform medical procedures – diagnostic procedures, surgical procedures, what have you – need to be held accountable. They need to be held to the same high set of standards. The public deserves no less.

And you expect that to be a big issue in the upcoming session?

Yes.

As you look back at your years on the board, what would you say were the best of times? What did you enjoy the most?

What I enjoyed was serving the profession--doing something that was important to the regulation of the practice of medicine – but that didn’t require me to run for office, or require me to pay – though I did take time away from my office. It was something that was a really nice way of complimenting my career as a physician.

It made me a better doctor and it made me a better citizen. It changed my life forever, and I’m a greater resource to the community of physicians because of my experience. They may not like my opinion, but they are going to respect it.

Any regrets?

My greatest regret is that I spent a lot of time away from home. The practice wasn’t making the kind of money that I would have liked to have made in that period of my life, but that’s really not all that important.

The important thing was that I spent a lot of time away from my kids. We have two wonderful sons, and my youngest one was four years old when I started, and now he’s eleven. I missed a lot of basketball games, I missed several birthdays and other important things, and my wife had to fill in for me quite a bit.

Missing out on my family was the worst, but now I’m making up for lost time.   • DT