From the Editor

As always, Benjamin Franklin was able to reduce a powerful concept to a simple truth — one that even children understand. The idea of heading off large problems later by taking small preventive steps now has long been a core principle of medicine — but in recent years it has been gaining particular traction among medical regulators. The idea is that by identifying health care providers who are at a higher risk of providing sub-standard care, we might be able to take steps to ward off problems before they occur. Is such an approach viable? In this edition of JMR we include a recent report from the Pan Canadian Physician Collaboration offering data in support of risk-based approaches to medical regulation. The analysis demonstrates patterns of dysfunction among physicians and has been proposed as the basis for proactive education of high-risk practitioners. The greatest risk factors that have been determined by this analysis are older age (a category I fit into), male gender, International Medical Graduates (IMGs), low scores on exams, isolated practice settings, and possibly lack of engagement. More scrutiny and the associated stress may lead to unintended consequences — more work for regulators with unclear benefits, as the incidence of dysfunction is low. Identification of areas of knowledge and skill, followed by education, may be more helpful than waiting for harm to patients significant enough to report to regulators…Our second article — a review of disciplinary actions related to the prescribing of controlled substances in Rhode Island — demonstrates that the incidence of such actions in that state peaked in 2013 and progressively decreased through 2017. In the course of the authors' study of the data, it became clear that prescribing issues were more common in physicians who were older and male — suggesting that potential preventive strategies could be aimed at this particular demographic group. The authors specify risk-stratified, preventive approaches, such as academic detailing and continuing medical education…These articles remind us that as regulators we spend enormous time and energy on those who fail, when perhaps we should be seeking to facilitate skills optimization modeled on highly functional practices. This could become important as we evolve into an era of team-based care with independent physician assistants (PAs) and advanced practice registered nurses (APRNs). Do PAs and APRNs stratify to the same risk categories as others? Is the future — “preventive medical regulation” — already here?

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