FINDINGS

Based on the Federation of State Medical Boards' (FSMB) data released annually on the number of disciplinary actions taken against doctors, Public Citizen calculated the rate of serious disciplinary actions per 1,000 doctors in each state and compiled a national report ranking state boards by the extent to which they are taking serious disciplinary actions against doctors in 1999 (See Table A).

Public Citizen has had and continues to have, two disputes with the FSMB over these data. First, we choose to look only at the most serious actions taken by state medical boards as a way of evaluating them, whereas the FSMB looks at "prejudicial" actions, a broader category which includes relative slaps on the wrist such as fines and reprimands as well as what we deem "serious" disciplinary actions. This category, in our view, should include only license revocations, suspensions or surrenders, plus probations, restrictions or other limitations on license (categories A & B in the FSMB data).

Second, the Federation states "it is virtually impossible to make sound comparisons of one medical board to another," and thereby avoids doing a ranking of state boards. We strongly disagree, and the Federation admits that the structure and funding of medical boards may have a direct impact on their effectiveness. Public Citizen believes that a valid uniform measure of board effectiveness is the rate of serious disciplinary actions per 1,000 doctors per year--a belief shared by Richard Kusserow, formerly Inspector General of the federal Department of Health and Human Services.

According to James R. Winn, M.D., the Federation's executive vice-president, "Boards that are independent or semi-autonomous, adopting their own budgets and allocating revenues to their operations, appear to perform their role of public protectors more effectively than those boards that are classified as subordinate or advisory." So, although the FSMB disagrees with the idea of our rankings based on their data, it admits to differences in structure and funding between boards which are amongst the probable causes of the differences in rates of serious disciplinary action.

Our calculation of rates of serious disciplinary actions per 1,000 doctors by state is created by taking the number of such actions (as defined above) and dividing it by the American Medical Association data on non-federal M.D.s, and then multiplying the result by 1,000 to get state disciplinary rates. Nationwide, there were 2,696 serious disciplinary actions in 1999 out of 770,320 nonfederal M.D.s, which is a rate of 3.50 serious disciplinary actions per 1,000 physicians. State rates ranged from 10.34 (Alaska) to 0.96 (Delaware).

Best States. The top 10 states, or those with the highest rate of serious disciplinary actions per 1,000 physicians are (in order): Alaska (10.34/1,000 physicians), North Dakota (8.77), Wyoming (8.15), Idaho (7.02), Oklahoma (5.95), Kentucky (5.92), Ohio (5.90), Mississippi (5.87), Vermont (5.34), and Colorado (5.24). Five of these 10 states (Alaska, Oklahoma, Mississippi, Wyoming, and Ohio) were also in the top 10 in 1997 and 1998 and two, (Mississippi and Alaska) have been in the top 10 for nine straight years. Oklahoma, 5th this year, has been in the top 10 states for eight of the last nine years. Wyoming, 3rd this year, has been in the top 10 for seven of the last nine years and Vermont, 9th this year and Ohio, 7th this year, have been in the top ten for five of the last nine years.

It is clear that state-by-state performance is spotty. Only one of the nation's 15 largest states, Ohio, is represented among those 10 states with the highest disciplinary rates, as it also was in 1996, 1997 and 1998. Other large states such as, New York, Michigan and California (14th, 19th and 20th respectively in 1999) have shown improvement from 40th, 49th and 37th in 1991. But other large states such as Texas, Pennsylvania, Massachusetts and Illinois (34th, 36th, 39th and 43rd in 1999) have not done very much doctor discipline for many of the last 10 years.

Worst States. The bottom 15 states, those with the lowest serious disciplinary rates in 1998, were, starting with the lowest: Delaware 0.96 per 1,000 physicians), Nebraska (1.23), Tennessee (1.25), Minnesota (1.58), Hawaii (1.69), Connecticut (1.78), Kansas (1.82), South Dakota (1.92), Illinois (2.05), Wisconsin (2.06), D.C. (2.18), Maryland (2.42), Massachusetts (2.43), Florida (2.49), and Washington (2.49). Massachusetts, Tennessee, Minnesota, Wisconsin, Kansas, Hawaii, and Delaware were also in the bottom 15 states in 1997 and 1998. In 1999, the bottom 20 states all had rates of serious disciplinary action that were one-half or less than the rate of all of the top five states.

Table B shows the ranking of state boards for the last nine years. It can be seen that there are some states which have consistently been among the highest-ranking ones, others which have stayed consistently toward the bottom and yet others which have gone from better to worse or vice versa.

This analysis raises serious questions about the extent to which patients in many states with poorer records of serious doctor discipline are being protected from physicians who might well be barred from practice in states with boards that are doing a better job of disciplining physicians. It is likely, if not certain that patients are being injured or killed more often in states with poor doctor disciplinary records than in states with consistent top 10 performances. It is not unreasonable to estimate that at least 1 percent of doctors in this country deserve some serious disciplinary action each year, a number comparable to Alaska's rate of 10.32 actions per 1,000 doctors or 1.032 percent. In fact, each year one or more states achieves a rate of serious disciplinary actions of approximately 10 per 10,000 doctors. This would amount to 7,703 (1% of 770,320 non-federal doctors) serious actions a year, which cover only a small fraction of the 98,000 patient deaths thought to occur each year in American hospitals as a result of errors, almost all of it involving physicians. The current overall national rate of serious disciplinary actions, 3.50 per 1,000 or .350 percent is far short of the rate of 1.034 percent in Alaska. If the rate of serious disciplinary actions had been 10 per 1,000 (1 percent), the national total would have been 7,703 actions or 5,007 more actions in 1999 (2.8 times more) than the 2,696 that actually occurred in 1999.

Considering what is known about substandard doctoring, not even Alaska's disciplinary rate seems adequate. Most states have a long way to go before they even begin to offer serious protection for citizens from doctors who are incompetent, who sexually abuse patients or who otherwise have serious problems that interfere with delivery of high-quality medical care in a compassionate way. All states, even those with best records, need to strengthen the structure and functions of their licensing boards. The statement by the Federation that you cannot compare the disciplinary rates of boards with each other because they are set-up, structured and funded differently is preposterous.

Disciplinary Actions from Public Citizen's Database

As shown in Table C, of the 38,589 disciplinary actions reported by state boards or the federal government to Public Citizen (representing actions against 20,125 doctors), the majority (32,868 or 85.2%) of these were imposed by state medical boards. A description and statistical breakdown of the actions provided to Public Citizen by each state is provided in the "State by State Listings" section. These counts represent the two most serious disciplinary actions for each sanction reported. Some sanctions included more than two actions against the doctors. These less serious actions are not included in these counts.

Please note that the period of years covered in the database varies from state to state. However, of the 50 states and the District of Columbia, for 44 of these jurisdictions, (86%), we have 10 years of data, from the beginning of 1990 through 1999. For the remaining 7 states, we have between 6 and 3/4 years of data (Arkansas) and 9 and 1/2 years of disciplinary data (Florida).

The federal agencies account for the remaining 5721 disciplinary actions imposed; 6.4% (2,462) were DEA sanctions in contested and uncontested cases, 8.3% (3,234) were fines and exclusions from the Medicare program, and 25 were restrictions placed on a physician's eligibility to participate as investigators in FDA experiments or to work for FDA-regulated companies.

An analysis of the 2,366 doctors who were the subject of DEA disciplinary actions revealed that hundreds were not the subject of any state disciplinary action even though their federal narcotics license had been revoked, surrendered, or restricted.

Similarly, of the 3,232 Medicare doctors who were the subjects of the 3,234 Medicare disciplinary actions, hundreds were not disciplined by their state boards even though most had involved exclusion from Medicare.

Thus, many states are not acting promptly, if at all, against physicians about whom a federal agency has already compiled sufficient information to discipline them for very serious offenses.

Types of Disciplinary Actions and Offenses

The following tables provide a statistical national look at the types of disciplinary actions and the offenses for which they were taken.

Table D, Types of Disciplinary Actions Reported to Public Citizen shows that the most common type of state disciplinary action of those submitted to us was probation. States imposed probation 19.3% of the times (7,431 times) when practitioners were disciplined. They revoked licenses 7.9% of the time (3,045 times), suspended licenses 9.6% of the time (3,704 times), and accepted a doctor's surrender of his or her license 7.9% of the time (3,063 times). Cumulatively, only 9,812 or 25.4% of the actions against doctors listed in this report were ones which resulted in at least a temporary loss of ability to practice medicine (revocation, suspension and surrender). Most of the doctors who are listed in this book never had to stop practicing medicine and many more who had suspensions may once again be practicing. It is not likely that many of their patients are aware of these actions. A total of 20,125 different physicians were the subject of the 38,589 disciplinary actions taken by state and federal agencies.

Table E, Offenses for which Disciplinary Action was Taken. The reason an action was taken--the offense--was provided by state and federal authorities for 24,042 of the records in our database. For a number of offenses, more than one action was taken. In 7,132 cases, the stated reason for the listed actions was "disciplinary action taken by another state agency," leaving 16,910 offenses with specific details as to the nature of the offense. For 15,310 of these offenses or 90.6% of them, the offense was one of the five discussed previoiusly--substandard care, incompetence or negligence, criminal conviction, substance abuse, misprescribing or over prescribing of drugs or sex-related offenses--or another serious offense such as providing false information, loss of hospital privileges or fraud. Among those 16,910 actions for which specific reasons other than discipline by another state or agency were reported, the five most serious offenses were as follows.

Sexual abuse of or sexual misconduct with a patient accounted for 3.2% of the total known offenses for which doctors were disciplined. A total of 547 different doctors were disciplined for these offenses.

Substandard care, incompetence or negligence: The most common single reason for which states disciplined doctors was for offenses involving substandard care, incompetence or negligence. which accounted for 18.8% of all the 16,910 actions for which a specific offense was stated. A total of 3,215 different doctors were disciplined for this offense.

Criminal conviction, the second largest category, accounted for 17.2% of known offenses other than those listed as disciplinary action by another state. A total of 2,963 different doctors were disciplined for criminal conviction (plea of guilty or nolo contendere--no contest).

Disciplinary actions taken because of misprescribing or overprescribing drugs accounted for an additional 7.7% of known offenses. A total of 1,318 different doctors were disciplined for these offenses.

Substance abuse accounted for an additional 10.0% of known offenses for which doctors were disciplined. A total of 1,715 different doctors were disciplined for these offenses.

The five offenses listed above, all extremely serious, accounted for 56.9% or more than half of all of those disciplinary actions in which a specific offense other than discipline by another state or agency was listed.

* Frequencies and types of violations cited by states or federal government for disciplinary actions. Includes only those actions for which an offense was reported and for which we had a corresponding term in our database. This table does not include the 5,371 cases in which the stated reason was action by another state.

Table F, Disciplinary Actions Taken Against Doctors Cited for Sexual Abuse of or Sexual Misconduct with a Patient, below, shows that of the 547 different doctors who were disciplined for sexual abuse of or sexual misconduct with a patient, there were 302 actions (81 revocations, 46 surrenders, 130 suspensions plus 45 emergency suspensions) which required those doctors, at least temporarily, to stop practicing medicine. Switching from actions to doctors, there were 286 doctors (52.3%) who were, at least temporarily, removed from practice by license suspension, surrender or revocation. But this means that at least 47.7% of doctors (261 doctors) were allowed to continue practicing, their behavior probably unknown to most if not all of their patients. It is likely that other doctors, especially those whose licenses were only suspended temporarily, are once again practicing medicine.

Table G, Disciplinary Actions Taken Against Doctors Cited for Substandard Care, Incompetence or Negligence, below, shows that of the 3,215 different doctors who were disciplined for substandard care, incompetence or negligence, there were 987 actions (315 revocations, 244 surrenders, 338 suspensions plus 90 emergency suspensions) which required those doctors, at least temporarily, to stop practicing medicine. Switching from actions to doctors, there were 942 doctors (29.3%) who were, at least temporarily, removed from practice by license suspension, surrender or revocation. But this means that at least 70.7% of doctors (2,273 doctors) were allowed to continue practicing, their behavior probably unknown to most if not all of their patients. It is likely that other doctors, especially those whose licenses were only suspended temporarily, are once again practicing medicine.

Table H, Disciplinary Actions Taken Against Doctors Cited for Criminal Convictions, below, shows that of the 2,963 different doctors who were disciplined because of a criminal conviction, there were 1,363 actions (563 revocations, 159 surrenders, 491 suspensions plus 150 emergency suspensions) which required those doctors, at least temporarily, to stop practicing medicine. Switching from actions to doctors, there were 1,162 doctors (39.2%) who were, at least temporarily, removed from practice by license suspension, surrender or revocation. But this means that at least 60.8% of doctors (1,801 doctors) were allowed to continue practicing, their behavior probably unknown to most if not all of their patients. It is likely that other doctors, especially those whose licenses were only suspended temporarily, are once again practicing medicine.

Table I, Disciplinary Actions Taken Against Doctors Cited for Misprescribing or Overprescribing Drugs, below, shows that of the 1,318 different doctors who were disciplined because of misprescribing or overprescribing drugs, there were 378 actions (96 revocations, 85 surrenders, 155 suspensions plus 42 emergency suspensions) which required those doctors, at least temporarily, to stop practicing medicine. Switching from actions to doctors, there were 368 doctors (27.9%) who were, at least temporarily, removed from practice by license suspension, surrender or revocation. But this means that at least 72.1% of doctors (950 doctors) were allowed to continue practicing, their behavior probably unknown to most if not all of their patients. It is likely that other doctors, especially those whose licenses were only suspended temporarily, are once again practicing medicine.

Table J, Disciplinary Actions Taken Against Doctors Cited for Substance Abuse, below, shows that of the 1,715 differentable doctors who were disciplined because of substance abuse, there were 611 actions (71 revocations, 111 surrenders, 293 suspensions plus 136 emergency suspensions) which required those doctors, at least temporarily, to stop practicing medicine. Switching from actions to doctors, there were 556 doctors (32.4%) who were, at least temporarily, removed from practice by license suspension, surrender or revocation. But this means that at least 67.6% of doctors (1,159 doctors) were allowed to continue practicing, their behavior probably unknown to most if not all of their patients. It is likely that other doctors, especially those whose licenses were only suspended temporarily, are once again practicing medicine.