George Orwell’s Animal Farm remains a powerful parable about how systems created with good intentions can gradually lose their way when power concentrates and accountability weakens. The animals overthrow an exploitative farmer with dreams of equality, only to see new leaders adopt the very behaviors they once opposed. Medical regulation offers a real-world parallel, not a complete betrayal, but a system that sometimes drifts from its original balance between patient protection and support for clinicians.

State medical boards were established to safeguard patients through professional self-regulation. In most states, including California, they operate primarily on revenue from physician licensing and renewal fees rather than general taxpayer funds. This model promotes independence but also ties operations closely to fee collection and enforcement volume.

In California, the Medical Board of California relies heavily on renewal fees and supplemental assessments, such as the CURES fee for prescription monitoring. While this structure has enabled self-sufficiency, it has also coincided with periodic budget pressures and high caseloads. Studies and reports note that many boards face challenges balancing thorough investigations with timely resolutions, sometimes leading to prolonged proceedings that affect physician well-being even when cases are ultimately dismissed.

Public Citizen’s disciplinary rankings consistently show interstate variation. Lower rates in some jurisdictions raise questions about enforcement of serious misconduct, while physicians frequently report disproportionate attention to documentation or lower-harm issues that carry significant professional consequences. Evidence links such regulatory stress to increased burnout, moral injury, and suicide risk. A 2019 study in the Journal of General Internal Medicine found state medical board investigations associated with measurable physician distress. Similar patterns appear in research on moral injury in health care.

These pressures contribute to broader challenges. Pain medicine fellowships have seen notable declines in applications, with reports of roughly 45 percent reductions in some periods, driven partly by the regulatory climate and litigation risk. Patient access suffers as a result, with longer wait times and reduced availability of specialized care. Overly restrictive policies have also coincided with declining legitimate opioid prescriptions while illicit overdose deaths rose, highlighting complex unintended consequences documented in multiple analyses. California’s health care debates, including perspectives from leaders like Becerra and Hilton, further highlight the tension between access, safety, and sustainability.

Recent discussions have thoughtfully explored what medical regulation might gain from restorative justice principles. Rather than purely adversarial processes that can leave lasting professional scars, restorative approaches focus on repairing harm, acknowledging accountability, and addressing root causes while supporting rehabilitation where appropriate. This framework aligns closely with the original mission of medical boards: protecting patients without unnecessarily undermining the workforce that delivers care.

As federal and state policymakers consider investments in health care oversight and regulatory infrastructure, one targeted idea merits serious consideration as part of medical board modernization: allocate a dedicated portion of new or restructured funds toward restorative justice mechanisms and reasonable compensation for physicians who were wrongfully or disproportionately investigated.

Evidence-based support for this approach includes:

• Studies showing that prolonged or ultimately dismissed investigations correlate with significant psychological and financial harm, even without formal discipline.
• Research on burnout and workforce attrition demonstrating that supportive interventions can improve retention and reduce defensive medicine practices.
• Successful restorative justice pilots in other professional and legal contexts that improved stakeholder satisfaction and reduced recidivism-like conflicts without compromising safety.

In practice, this could fund:

• Reimbursement for reasonable legal and administrative defense costs in cases that are dismissed or significantly reduced.
• Structured wellness, mentoring, or practice recovery support for affected clinicians.
• Pilot restorative justice processes for appropriate lower-risk matters, emphasizing collaborative resolution.

Such measures would strengthen patient protections by enhancing perceived fairness, reducing unnecessary physician exodus from high-need states like California, and reinforcing public trust that the system values both safety and justice.

A novel written by Alan Moore and Dave Gibbons, Watchmen powerfully explores the question “Who watches the watchmen?” a reminder that those entrusted with protecting society, the masked heroes in the story, must themselves be subject to oversight to prevent overreach or detachment from those they serve. In the context of medical regulation, state medical boards serve as essential watchmen safeguarding patient safety and professional standards. To keep them honest, effective, and accountable, we need thoughtful mechanisms for independent review and balanced governance. This could include enhanced transparency measures, periodic external audits, diverse stakeholder input including practicing physicians and patient advocates, and structured feedback loops that evaluate both patient outcomes and impacts on the clinician workforce. Such layered accountability strengthens the system constructively, ensuring the watchmen remain aligned with their protective mission while avoiding unintended drift.

Regulation, like any human institution, benefits from ongoing reflection and adaptation. By thoughtfully incorporating restorative justice principles, targeted relief mechanisms, and layered accountability inspired by the enduring question of who watches the watchmen, medical boards can better fulfill their protective role while supporting the dedicated professionals who provide care daily. This represents a positive evolution, one that honors the original vision of medical self-regulation and helps prevent the kind of gradual drift warned about in Animal Farm.

California and the nation have an opportunity to lead by building a regulatory framework that is both rigorous in protecting patients and humane in supporting clinicians. The result would be healthier physicians, better access to care, and stronger public confidence.

Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.

Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.

Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.