Some states take prevention tactic on doctor discipline

Disciplinary actions against doctors increased last year, but some medical boards are turning to education and practice guidelines to keep physicians out of trouble.

By Damon Adams, amednews staff. May 7, 2001.

Before Maryland physicians renew their license for the first time, they must watch a video that outlines potential barriers to a healthy physician-patient relationship. By educating doctors now about pitfalls ranging from lying for patients to making sexual advances, the state hopes to keep them from getting into trouble later.

"Our board was concerned about the number of sex cases it was seeing. It decided it should do more than discipline in this area," said Margaret Anzalone, deputy director of the Maryland Board of Physician Quality Assurance.

More state medical boards are using educational programs and practice guidelines to limit physician misconduct and other problems, according to the Federation of State Medical Boards.

About 50 of the federation's 69 member boards have adopted pain management guidelines that include showing licensees how to document treatments with patients. The Texas State Board of Medical Examiners established a policy warning against improperly prescribing drugs.

"[State boards] are working harder today at educating their licensees how to stay out of trouble," said Dale Austin, the federation's interim chief executive officer.

Yet some doctors still cause problems.

Disciplinary actions against physicians rose slightly to 4,617 actions in 2000, up from 4,569 in 1999, according to the federation's annual summary of board actions, released in April. An increase in doctors -- about 34,000 more than 1999 -- may have contributed to the increase, officials said.

Although non-prejudicial actions decreased, punitive actions -- license revocation, suspensions, probations and other restrictions -- climbed 3%. Accounting for most punitive actions were substance abuse, unprofessional conduct, prescribing violations and negligence.

"Clearly, boards are continuing to do a very good job of disciplining physicians," Austin said.

Group wants more oversight

A Washington, D.C.-based nonprofit consumer advocacy organization disagrees.

Public Citizen used the federation's data and calculated that the rate of serious disciplinary actions remained the same the past two years. Public Citizen's Health Research Group said there were 3.5 serious disciplinary actions per 1,000 physicians in 2000.

The group said state-by-state performance is spotty, and noted that only two of the country's 15 largest states -- Ohio and New York -- are among the 10 states with the highest disciplinary rates. It said boards would do a better job of protecting the public if they had, in part, adequate funding and staffing and were conducting proactive investigations.

Austin said state boards already were being proactive by offering education and guidelines to keep doctors out of trouble.

Preventive measures

The Maryland board, for example, in April 1999 began requiring doctors applying for the first renewal of their state license to attend a new physician orientation program. The three-hour orientation covers state regulations, responsibilities to patients and the state board's policies and procedures.

Participants watch two videos: "Crossing the Line," which discusses boundary violations such as lying for patients or sleeping with them, and "Sense of Balance," which covers prescribing controlled drugs, overprescribing, addicted physicians and identifying drug-seeking patients.

"It's aimed at new physicians, but we show it from time to time to hospital groups and credentialing organizations," Anzalone said.

Washington and Louisiana boards are interested in using parts of the videos, she said. A Maryland board member will present the program to Virginia's board in June.

In February, New York approved new clinical guidelines for surgery in office-based settings. If problems arise, a doctor who fails to adhere to the standards could face misconduct charges by the state's disciplinary board. "The expectation is that these guidelines will provide clear direction for doctors," said Kristine Smith of the New York State Board for Professional Medical Conduct.

In 1998, the Texas board set standards for integrative and complementary medicine, discussing documentation and treatment. The following year, it created a policy regarding Internet prescribing.

That policy said it was unprofessional for a doctor to prescribe drugs without forming a physician-patient relationship. An evaluation online or by telephone is inadequate.

The policy allows the board to discipline doctors but also spells out a proper doctor-patient relationship when prescribing drugs. That includes establishing a diagnosis through accepted medical practices and verifying the identification of the person requesting medication.

Education up front is a good way to keep doctors from facing discipline later, Texas officials said.

"We'll still have some people who will get in trouble and only respond to harsh measures," said F.M. "Skip" Langley, MD, executive director of the Texas board. "In the long run, [education] is a better use of the state's dollars. Just being punitive alone belongs in the last century."