Sidney M. Wolfe M.D.
Based on the Federation of State Medical Boards (FSMB) data on the number of disciplinary actions taken in 1998 against doctors, Public Citizen 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 extent to which they are taking serious disciplinary actions against doctors (See Table 1).
Our calculation of rates of serious disciplinary actions (revocations, surrenders, suspensions and probations/restrictions) per 1,000 doctors by state is created by taking the number of such actions and dividing it by the American Medical Association data on non-federal M.D’s as of December, 1997 then multiplying the result by 1,000 to get state disciplinary rates. Nationwide, there were 2,731 serious disciplinary actions in 1998 out of 726,648 nonfederal M.D’s, which is a rate of 3.76 serious disciplinary actions per 1,000 physicians. This rate is slightly lower than the rate of 3.84 serious disciplinary actions per 1,000 physicians in 1997. As can be seen in Figure 1, the number of serious actions has more or less plateaued for the past five years despite the fact that the number of non-federal physicians has increased substantially. Thus, the rate of serious disciplinary actions per 1,000 physicians has fallen from 4.3 per 1,000 in 1994 to 3.76 in 1998 (see Figure 2), a statistically significant decrease of 12.6%
State rates ranged from 15.4 serious actions per 1,000 doctors (Alaska) to 0.85 per 1,000 physicians (Tennessee), an 18-fold difference between the best and worst states. If all the boards did as good a job as the top five boards, the lowest rate for #5, West Virginia, being 7.68 serious disciplinary actions per thousand physicians or .768%, this would amount to 5,580 (.768% of 726,648 non-federal doctors) serious actions a year, twice as many (2849 more actions) as the 2,731 that actually occurred in 1998.
Best States. (those with the highest rates of serious disciplines).
Table 1 lists each state’s ranking and rate in descending order. The top 10 states, or those with the highest rate of serious disciplinary actions per 1,000 physicians are (in order): Alaska (15.4/1,000 physicians), Oklahoma (9.23), Mississippi (8.92), Arkansas (8.32), West Virginia (7.68), Vermont (7.12), Wyoming (6.51), New Mexico (6.14), Maine (6.13), and Ohio (5.96). Five of these 10 states (Alaska, Oklahoma, Mississippi, Wyoming, and Ohio) were also in the top 10 in 1997 and two, (Mississippi and Alaska) have been in the top 10 for eight straight years. Oklahoma, 2nd this year, has been in the top 10 states for seven of the last eight years. West Virginia, 5th this year and Wyoming, 7th this year, have been in the top 10 for six of the last eight years and Vermont, 6th this year and Ohio, 10th this year, have been in the top ten for four of the last eight years. (See Table 2)
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 and 1997. Other large states such as Michigan, New York and California (13th, 16th and 27th respectively in 1998) have shown improvement from 40th, 49th and 37th in 1991.
Worst States. (those with the lowest rate of serious disciplines).
The bottom 10 states, those with the lowest serious disciplinary rates in 1998, were, starting with the lowest: Tennessee (0.85 per 1,000 physicians), Delaware (1.07), Florida (1.32), Missouri (2.06). Massachusetts (2.07), Wisconsin (2.24), Pennsylvania (2.29), Kansas (2.36), North Carolina (2.54), Minnesota (2.56), and Illinois (2.62). Massachusetts, Tennessee and Minnesota were also in the bottom 10 in 1996 and 1997. In 1998, the bottom 24 states all had rates of serious disciplinary action that were one-half or less than the rate of all of the top five states. States with large numbers of doctors such as Pennsylvania, Virginia, Massachusetts and Connecticut have been in the bottom half of all states for eight years in a row.
These data raise 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 that patients are being injured or killed more often in states with poor doctor disciplinary records than in states with consistent top 10 performances.
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 true:
- 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
- Excellent leadership
- Independence from state medical societies and other parts of the state government
- A reasonable statutory framework for disciplining doctors (preponderance of the evidence rather than beyond reasonable doubt or clear and convincing evidence).