Medical boards feel pressure, get tougher

Internet prescribing also comes into play.

By Damon Adams, amednews staff. April 21, 2003.

During the past 10 years, state medical boards have steadily increased disciplinary actions against doctors.

One explanation is a growing physician population. But there is more at work than demographics.

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Public awareness of medical errors has prompted increased scrutiny of medical boards and, in turn, boards have stepped up their scrutiny of physicians. Board reforms, frequently driven by state legislation, often result in stepped-up enforcement, as has a crackdown on substandard care. And some boards are taking a tough stance on Internet prescribing.

Medical board actions rose from 3,707 in 1993 to 4,875 in 2002 -- a 32% climb, according to annual summaries of board actions compiled by the Federation of State Medical Boards.

During those 10 years, punitive actions -- license suspensions, revocations, probations and other restrictions -- increased 35% (3,081 to 4,169 actions). Rising 13% (626 to 706) were non-prejudicial actions such as license denials due to lack of qualification and reinstatement following disciplinary action.

"Boards are working harder and harder at identifying and bringing to action physicians who are not behaving appropriately or have quality issues," said James Thompson, MD, chief executive officer of the Texas-based FSMB.

IOM report, Internet are key factors

For several years, the main reasons for physician disciplinary actions have been substance abuse, unprofessional conduct and prescribing violations.

But technology also has broadened the spectrum of behaviors for which physicians can face discipline. Since 1998, 27 of the 70 medical boards nationwide have disciplined doctors for improperly prescribing drugs online, according to the FSMB.

Punitive actions by medical boards increased 35% from 1993 to 2002.

Increased board scrutiny also has been fueled by reports and public debate about medical errors. A public uproar sent lawmakers, physicians and medical boards scrambling after a 1999 Institute of Medicine report said up to 98,000 Americans die each year from medical errors in hospitals.

"There's much greater attention to quality of care issues. Consumers are more willing to question and are more alert than they ever were before," said Dale Breaden, North Carolina Medical Board spokesman.

Legislators and board problems have forged changes as well.

After bad reviews four years ago for its performance, the Arizona Medical Board welcomed change. Laws were revised to improve enforcement, and an increase in investigators and medical consultants bolstered efforts and decreased investigation times.

"Our goal is to be a very proactive board. It gives [patients] confidence that we are in fact doing something," said Barry Cassidy, PhD, the Arizona Medical Board's executive director.

More disciplinary actions are expected in Virginia after a measure passed in March changed the disciplinary standard from "gross negligence" to a simpler "intentional or negligent conduct" that injures or is likely to injure a patient.

More physicians, a focus on medical errors and Internet prescribing have led to more actions.

Earlier this month, criticism of Maryland's Board of Physician Quality Assurance led to compromise legislation between lawmakers and the state's medical society that calls for using stricter disciplinary standards in some but not all cases.

"We have had a horrible board that was not disciplining doctors for the most part," said State Sen. Paula Hollinger, who had pushed for even tougher standards.

The Maryland State Medical Society disagreed with Hollinger's assessment but is OK with the measure passed by legislators.

"There were a small number of issues on which there was disagreement, but 'clear and convincing' evidence remains [the standard of proof] for cases involving alleged substandard care," said T. Michael Preston, society executive director.

Public Citizen remains unhappy

Meanwhile, Public Citizen continues to criticize some state boards for not doing enough.

Each year, the Washington, D.C.-based group uses the federation's data to calculate the rate of serious disciplinary actions per 1,000 doctors. It said the national rate increased from 3.36 actions per 1,000 doctors in 2001 to 3.56 actions in 2002.

For 2002, the group ranked the best states as those with the highest rate of serious disciplinary actions: Wyoming (11.87 actions per 1,000 physicians), North Dakota (8.76), Alaska (8.57), Kentucky (7.58) and Oklahoma (7.56). The worst states: Hawaii (1.07 actions per 1,000 physicians), Delaware (1.35), Wisconsin (1.4), Tennessee (1.47) and South Carolina (1.77).

Sidney Wolfe, MD, director of Public Citizen's Health Research Group, said the figures raised questions about how well some boards protect patients. The national rate for serious disciplinary actions, as calculated by his group, has increased slightly during the past 10 years, Dr. Wolfe said. But he said boards still need to do more, adding that doctors should lobby for board reforms the way they do for medical liability reforms.

"There's no question that one explanation in the amount of discipline is there are more doctors to discipline," Dr. Wolfe said. "But we do not hear them marching on state capitols to talk about more staffing for state medical boards."

Medical board officials agree that sheer numbers play a role in the increasing discipline rates. The number of medical doctors increased from 670,336 in 1993 to 836,156 in 2002, according to the AMA.

But some board officials discount Public Citizen's report, faulting the way that the rankings are determined and saying not all board actions are considered.

"We're not going to talk about Sidney's figures because they are Sidney's figures," Breaden said.

Physician leaders said doctors who follow the rules and practice good medicine should not worry about changes to medical boards. Only bad doctors have cause for concern.

"The overwhelming number of doctors are safe and good and credible," said James C. Martin, MD, president of the American Academy of Family Physicians. "A very small number are bad."