Sidney M. Wolfe, M.D.
Peter Lurie, M.D., M.P.H.
Based on state-by-state data released late yesterday by the Federation of State Medical Boards (FSMB) on the number of disciplinary actions taken against doctors in 2005, combined with data from 2003-2004, Public Citizen’s Health Research Group has calculated the rate of serious disciplinary actions (revocations, surrenders, suspensions and probation/restrictions) per 1,000 doctors in each state and compiled a national report ranking state boards by the rate of serious disciplinary actions per 1,000 doctors for the years 2003-5 (See Table 1).
Until two years ago, our ranking was based solely on the data from the most recent year. Because some small states do not have many physicians, an increase or decrease of one or two serious actions in a year can have a much greater effect on the rate of discipline in such states than it would in larger states. Therefore we now calculate the three-year average rate of discipline (for each year and the preceding two years) for all states and list them by rank for each three-year interval so that trends in rank over the past decade can more accurately be examined (see Table 2). Again, the newest ranking is based on the three-year average rate, not the rate for 2005 alone.
Our calculation of rates of serious disciplinary actions per 1,000 doctors by state is created by taking the number of such actions for each state (the first two categories of the FSMB data) and dividing it by the American Medical Association data on nonfederal M.D.s as of December 2004 in that state (adding to this the number of osteopathic physicians if the board is a combined medical/osteopathic board). We then multiply the result by 1,000 to get state disciplinary rates per 1,000 physicians. This rate calculation is done for each of the last three years (2003-2005), and the average rate for the three years is used as the basis for this year’s state board rankings.
There were 3,255 serious disciplinary actions taken by state medical boards in 2005, slightly down (1.2%) from the 3,296 serious actions taken in 2004. The three-year state disciplinary rates ranged from 1.62 serious actions per 1,000 physicians (Mississippi) to 9.08 actions per 1,000 physicians (Kentucky), a 5.6-fold difference between the best and worst states.
Worst States (those with the lowest three-year rate of serious disciplinary actions).
As can be seen in Table 1, the bottom 15 states, those with the lowest serious disciplinary action rates for 2003-2005 were, starting with the lowest: Mississippi (1.62 actions per 1,000 physicians), Delaware (1.63 per 1,000 physicians), Minnesota (1.65 per 1,000 physicians), Wisconsin (1.72 per 1000 physicians), Nevada (2.03 per 1,000 physicians), Maine (2.04 per 1000 physicians, South Carolina (2.06 per 1,000 physicians), Maryland (2.14 per 1000 physicians), South Dakota (2.18 per 1000 physicians), Hawaii (2.19 per 1000 physicians), Washington (2.22 per 1,000 physicians), Michigan (2.40 per 1,000 physicians), Rhode Island (2.49 per 1,000 physicians), Arkansas (2.49 per 1,000 physicians), and Connecticut (2.50 per 1,000 physicians).
Table 2 shows that four of these 15 states, (Wisconsin, Minnesota, Delaware, and Hawaii) have been among the bottom 15 states for the last 10 three-year periods. In addition, Maryland and Connecticut have been among the bottom 15 states for nine of the last 10 three-year periods; Washington, for seven of the last 10 three-year periods; South Carolina, for six of the last 10 three-year periods, and Rhode Island, for five of the last 10 three-year periods. Four states have experienced at least a 20 place drop in ranking between the 1999-2001 ranking to the current ranking: Arkansas went from 15th to 38th; Michigan went from 20th to 40th; Mississippi, from 9th to 51st ; Nevada, from 22nd to 47th.
These data raise serious questions about the extent to which patients in many of these states with poorer records of serious doctor discipline are being protected from physicians who would likely be barred from practice in states with boards that are doing a better job of disciplining physicians. It is quite possible that in states with poor doctor disciplinary records, patients are being injured or killed more often by doctors who should have been disciplined than patients in states with consistently high disciplinary performance.
Best States (those with the highest rates of serious disciplines).
The top 10 states are (in order): Kentucky (9.08 actions per 1,000 physicians), Alaska (8.49 per 1,000 physicians), Wyoming (8.19 serious actions per 1,000 physicians), Ohio (6.33 per 1,000 physicians), Arizona (6.20 per 1,000 physicians), Oklahoma (6.19 per 1,000 physicians), North Dakota (6.07 per 1,000 physicians), Colorado (5.75 per 1,000 physicians), West Virginia (5.45 per 1,000 physicians), and Missouri (5.34 per 1000 physicians). Nine of these 10 states were in the top 10 states in last year’s ranking. Last year Missouri was ranked 11th.
As can be seen in Table 2, three of these 10 states (Wyoming, Oklahoma and Alaska) have been in the top ten for all ten of the three-year average periods listed. Six more of these top 10 states have been in the top 10 for at least six of the last 10 three-year periods: Colorado (6), Arizona, Kentucky and West Virginia (7), North Dakota and Ohio (9).
It is clear that state-by-state performance is spotty. Only one of the nation’s 15 most populous states, Ohio, is represented among those 10 states with the highest disciplinary rates. Illinois and Pennsylvania, other states with large populations, have usually been near the bottom, although Illinois has improve more recently, ranking 18th. California and New Jersey have hovered around the middle.
What Makes a Difference?
Boards are likely to be able to do a better job in disciplining physicians if most, if not all, of the following conditions are met:
- Adequate funding (all money from license fees going to fund board activities instead of going into the state treasury for general purposes)
- Adequate staffing
- Proactive investigations rather than only following complaints
- The use of all available/reliable data from other sources such as Medicare and Medicaid sanctions, hospital sanctions and malpractice payouts
- Excellent leadership
- Independence from state medical societies and other parts of the state government
- A reasonable legal framework for disciplining doctors (“preponderance of the evidence” rather than “beyond reasonable doubt” or “clear and convincing evidence” as the legal standard for discipline).
Most states are not living up to their obligations to protect patients from doctors who are not practicing medicine in the best manner and are thus endangering the lives and health of residents. Serious attention must be given to finding out which of the above bulleted variables are deficient in each state. Action must then be taken, legislatively and through pressure on the medical boards, to increase the amount of discipline and, thus, the amount of patient protection. Without adequate legislative oversight, inadequate constructive criticism of medical boards will continue to allow inadequate boards to perform poorly.
 Physician Characteristics and Distribution in the U.S. American Medical Association, 2006 Edition.
 Fact Sheet: American Osteopathic Association. Statistics as of August, 2004, available at