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Characteristics Associated With Physician Discipline: A Case-Control Study
Abstract
There has been increasing attention devoted to patient safety. However, the focus has been on system improvements rather than individual physician performance issues. The purpose of this study was to determine if there is an association between certain physician characteristics and the likelihood of medical board-imposed discipline.
Unmatched, case-control study of 890 physicians disciplined by the Medical Board of California between July 1, 1998, and June 30, 2001, compared with 2981 randomly selected, nondisciplined controls. Odds ratios (ORs) were calculated for physician discipline with respect to age, sex, board certification, international medical school education, and specialty.
Male sex (OR, 2.76; P<.001), lack of board certification (OR, 2.22; P<.001), increasing age (OR, 1.64; P<.001), and international medical school education (OR, 1.36; P<.001) were associated with an elevated risk for disciplinary action that included license revocation, practice suspension, probation, and public reprimand. The following specialties had an increased risk for discipline compared with internal medicine: family practice (OR, 1.68; P =.002); general practice (OR, 1.97, P =.001); obstetrics and gynecology (OR, 2.25; P<.001); and psychiatry (OR, 1.87; P<.001). Physicians in pediatrics (OR, 0.62; P =.001) and radiology (OR, 0.36; P<.001) were less likely to receive discipline compared with those in internal medicine.
Certain physician characteristics and medical specialties are associated with an increased likelihood of discipline.
... However, it should be noted that only a limited number of factors were universally validated in more than three studies. These included older age [1,2,7,8,26,31,44,45,47,51,56,60,65,70,90], male gender [1, 2, 7, 8, 11, 29, 34, 35, 43-45, 47, 51, 54-56, 60, 62, 64, 65, 67, 68, 71, 75, 81-83, 85, 87, 89, 90, 93, 94], poor performance in examinations [47,63,73], low scores [63,73,77,85], specific specialties (surgery [1,8,11,34,65,68,70,71,81,85,90,91], obstetricsgynaecology [1,7,8,47,60,62,65,70,81,90], and general practice [1,11,12,35,60,62,68,89,93]), the professions of family practitioners [47,60,62], longer practice time [27,32,34,47,48,52,59,62,64,66,78], one or more previous claims history [1,7,8,31,36,67,71,83,95], not being board certified [60][61][62], greater patient volume/clinical activity [31,32,49,50,52,67,71], working longer hours [47,81,82], and solo practice [35,47,64,68]. ...
... However, it should be noted that only a limited number of factors were universally validated in more than three studies. These included older age [1,2,7,8,26,31,44,45,47,51,56,60,65,70,90], male gender [1, 2, 7, 8, 11, 29, 34, 35, 43-45, 47, 51, 54-56, 60, 62, 64, 65, 67, 68, 71, 75, 81-83, 85, 87, 89, 90, 93, 94], poor performance in examinations [47,63,73], low scores [63,73,77,85], specific specialties (surgery [1,8,11,34,65,68,70,71,81,85,90,91], obstetricsgynaecology [1,7,8,47,60,62,65,70,81,90], and general practice [1,11,12,35,60,62,68,89,93]), the professions of family practitioners [47,60,62], longer practice time [27,32,34,47,48,52,59,62,64,66,78], one or more previous claims history [1,7,8,31,36,67,71,83,95], not being board certified [60][61][62], greater patient volume/clinical activity [31,32,49,50,52,67,71], working longer hours [47,81,82], and solo practice [35,47,64,68]. ...
... However, it should be noted that only a limited number of factors were universally validated in more than three studies. These included older age [1,2,7,8,26,31,44,45,47,51,56,60,65,70,90], male gender [1, 2, 7, 8, 11, 29, 34, 35, 43-45, 47, 51, 54-56, 60, 62, 64, 65, 67, 68, 71, 75, 81-83, 85, 87, 89, 90, 93, 94], poor performance in examinations [47,63,73], low scores [63,73,77,85], specific specialties (surgery [1,8,11,34,65,68,70,71,81,85,90,91], obstetricsgynaecology [1,7,8,47,60,62,65,70,81,90], and general practice [1,11,12,35,60,62,68,89,93]), the professions of family practitioners [47,60,62], longer practice time [27,32,34,47,48,52,59,62,64,66,78], one or more previous claims history [1,7,8,31,36,67,71,83,95], not being board certified [60][61][62], greater patient volume/clinical activity [31,32,49,50,52,67,71], working longer hours [47,81,82], and solo practice [35,47,64,68]. ...
Background
Identifying the risk and predicting complaints and misconduct against health practitioners are essential for healthcare regulators to implement early interventions and develop long-term prevention strategies to improve professional practice and enhance patient safety. This scoping review aims to map out existing literature on the risk identification and prediction of complaints and misconduct against health practitioners.
Methods
This scoping review followed Arksey & O'Malley's five-stage methodological framework. A comprehensive literature search was conducted on MEDLINE, EMBASE and CINAHL databases and finished on the same day (6 September 2021). Articles meeting the eligibility criteria were charted and descriptively analysed through a narrative analysis method.
Results
The initial search generated 5473 articles. After the identification, screening, and inclusion process, 81 eligible studies were included for data charting. Three key themes were reported: methods used for identifying risk factors and predictors of the complaints and misconduct, synthesis of identified risk factors and predictors in eligible studies, and predictive tools developed for complaints and misconduct against health practitioners.
Conclusion
Risk identification and prediction of complaints and misconduct are complex issues influenced by multiple factors, exhibiting non-linear patterns and being context-specific. Further efforts are needed to understand the characteristics and interactions of risk factors, develop systematic risk prediction tools, and facilitate the application in the regulatory environment.
... Evidence indicates that physicians who have been in practice for more than 20 years are at increased risk for disciplinary action. 20,21 We investigated whether this was true in our study sample by dichotomizing the disciplined physicians according to the year of graduation -before 1980 and 1980 or later. ...
... In previous studies, physicians practicing in the areas of obstetrics and gynecology, general practice, psychiatry and family medicine were more likely to receive disciplinary action, and those practicing in pediatrics and radiology were less likely to be disciplined. 20,21 The practices of internal medicine, surgery and anesthesiology were not predictive of disciplinary action. In our study, similar patterns of discipline according to specialty were seen in five of the seven largest specialties (internal medicine, family practice, pediatrics, surgery and obstetrics and gynecology); these patterns support the generalizability of our findings. ...
... In contrast to earlier studies, we did not find male sex to be a risk factor. 20,21 Our study design precluded a full assessment of age as a risk factor for disciplinary action. ...
Background
Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case–control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school.
Methods
The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe).
Results
Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (one percent and seven percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior.
Conclusions
In this case–control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one’s medical career.
... Dermatologists were underrepresented on the LEIE compared to the proportion in the general physician population, consistent with findings that physician discipline is not distributed equally by specialty. 2,3 Men and older physicians had higher representation on the LEIE compared to the national dermatologist workforce, which is also consistent with existing literature. [2][3][4] Differences in practice style, patient interaction, and propensity for precarious and/or aggressive behavior have been proposed as the basis of these sex and age discrepancies. 2 Additionally, the higher proportion of older disciplined physicians could be related to the accumulation of inappropriate habits and discipline. 2 The majority of disciplinary cases involved multiple infraction categories, indicating that unlawful behavior does not always occur in isolation. ...
... 2,3 Men and older physicians had higher representation on the LEIE compared to the national dermatologist workforce, which is also consistent with existing literature. [2][3][4] Differences in practice style, patient interaction, and propensity for precarious and/or aggressive behavior have been proposed as the basis of these sex and age discrepancies. 2 Additionally, the higher proportion of older disciplined physicians could be related to the accumulation of inappropriate habits and discipline. 2 The majority of disciplinary cases involved multiple infraction categories, indicating that unlawful behavior does not always occur in isolation. Although the counts and nature of these infractions vary, dermatologists on the LEIE demonstrated multiple and/or egregious offenses involving clear wrongdoing. ...
... [2][3][4] Differences in practice style, patient interaction, and propensity for precarious and/or aggressive behavior have been proposed as the basis of these sex and age discrepancies. 2 Additionally, the higher proportion of older disciplined physicians could be related to the accumulation of inappropriate habits and discipline. 2 The majority of disciplinary cases involved multiple infraction categories, indicating that unlawful behavior does not always occur in isolation. Although the counts and nature of these infractions vary, dermatologists on the LEIE demonstrated multiple and/or egregious offenses involving clear wrongdoing. ...
... There were attempts to categorise the types of unprofessional behaviours, although there is no universally accepted classification. (3)(4)(5) A summary of papers from Canada, Australia, New Zealand and the United States (US) showed a higher incidence of disciplinary actions involving family medicine, (6)(7)(8)(9) psychiatry, (6)(7)(8)(9) and obstetrics and gynaecology. (7)(8)(9) Among internal medicine physicians, unprofessional conduct was the commonest offence, (10) while among psychiatrists it was sexual misconduct (11,12) and among anaesthesiologists, standard of care issues. ...
... There were attempts to categorise the types of unprofessional behaviours, although there is no universally accepted classification. (3)(4)(5) A summary of papers from Canada, Australia, New Zealand and the United States (US) showed a higher incidence of disciplinary actions involving family medicine, (6)(7)(8)(9) psychiatry, (6)(7)(8)(9) and obstetrics and gynaecology. (7)(8)(9) Among internal medicine physicians, unprofessional conduct was the commonest offence, (10) while among psychiatrists it was sexual misconduct (11,12) and among anaesthesiologists, standard of care issues. ...
... (3)(4)(5) A summary of papers from Canada, Australia, New Zealand and the United States (US) showed a higher incidence of disciplinary actions involving family medicine, (6)(7)(8)(9) psychiatry, (6)(7)(8)(9) and obstetrics and gynaecology. (7)(8)(9) Among internal medicine physicians, unprofessional conduct was the commonest offence, (10) while among psychiatrists it was sexual misconduct (11,12) and among anaesthesiologists, standard of care issues. (13) Several papers in the literature discuss unprofessional behaviours among doctors in training. ...
Introduction:
This is a retrospective analysis of outcomes by Singapore Medical Council (SMC) disciplinary tribunals in cases involving junior doctors. We aimed to classify the types of unprofessional behaviour and consider appropriate measures for remediation and prevention.
Methods:
SMC's annual reports from 1979 to 2017 and published grounds of decision from 2008 to 2017 were examined using two screening levels to identify cases involving junior doctors. Cases were sorted into five outcome categories: (a) professional misconduct; (b) fraud and dishonesty; (c) defect in character; (d) disrepute to the profession; and (e) acquitted.
Results:
A total of 317 cases were identified, of which 13 (4.1%) involved junior doctors: 4 (30.8%) cases involved professional misconduct, 4 (30.8%) cases involved fraud and dishonesty, 3 (23.1%) cases saw an acquittal, and one case each involved defect in character and disrepute to the profession. The four cases of professional misconduct highlight the need to differentiate medical errors due to systems factors from those due to individual culpability, by applying analytical tools such as root cause analysis and Unsafe Act Algorithms. Disciplining the individual alone does not help prevent the recurrence of similar medical errors. We found that fraud and dishonesty was an important category of unprofessional behaviour among junior doctors.
Conclusion:
While the frequency of unprofessional behaviour among junior doctors, as determined by the SMC disciplinary tribunal, is low (4.1%), this study highlights that complaints against medical doctors often involve systems issues and individual factors. Unprofessional behaviours related to fraud and dishonesty need special attention in medical school.
... Recent reports on physician discipline indicate that more than 4,000 physicians are disciplined annually (Federation of State Medical Boards, 2018); most physicians are often sanctioned for negligence, practice under the influence, inappropriate prescribing, sexual misconduct, and fraud (Cardarelli & Licciardone, 2006;Clay & Conatser, 2003). Factors associated with physician sanctioning include maleness, increasing age, lack of board certification, international education, Black practitioners, poor medical school performance, and higher years of practice (Khaliq et al., 2005;Kohatsu et al., 2004;Papadakis et al., 2005). ...
... Maleness was predictive of revocation, and certified occupational therapy assistant professional designation was predictive of suspension; the former is congruent with existing literature (Khaliq et al., 2005;Kohatsu et al., 2004). Although associations between these attributes and severe sanctioning should be approached with caution given their BF10 outcomes, Bayesian THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY NOVEMBER/DECEMBER 2024, VOLUME 78, NUMBER 6 evidence regarding their overrepresentation in disciplinary cases compared with national practitioner distributions was decisively strong. ...
Importance: One primary function of occupational therapy state licensure boards (SLBs) is the discipline of ethical misconduct by licensed occupational therapy practitioners. However, SLB sanctioning is poorly understood by practitioners, regulators, and the public.
Objective: To identify predictors of occupational therapy practitioner sanctioning outcomes in the United States.
Design: Retrospective study; all public final consent orders and database entries provided online by SLBs were analyzed. Supervised gradient boosting machine learning, logistic regression, and contingency tables were used to generate odds ratios for variables associated with each sanctioning outcome. Multinomial testing was used to identify attribute overrepresentation among cases and national practitioner distributions.
Participants: A total of 2,400 cases were analyzed across 47 states and Washington, DC.
Intervention: None.
Outcomes and Measures: Numerous complaint and respondent attribute variables were collected from final consent orders and database entries.
Results: Complaint reason, practice setting, and complaint source had the highest influence on predicting sanction outcome; geographic region, number of complaints in a given case, and length of investigation in months were secondarily influential. Being male or a certified occupational therapy assistant was associated with higher odds of severe sanctioning outcomes.
Conclusions and Relevance: Disciplinary actions against occupational therapy practitioners were determined by numerous contextual factors; however, the most influential factors were complaint reason, practice setting, and complaint source. These results provide direction for exploring factors that predict sanctioning outcomes in the United States and also provide occupational therapy practitioners and SLBs a basis of applied outcomes that may improve implementation and education regarding clinical practice ethics.
Plain-Language Summary: Occupational therapy state licensure boards (SLBs) are responsible for disciplining licensed occupational therapy practitioners for ethical misconduct. SLB sanctioning is poorly understood by practitioners, regulators, and the public. In this study, we identify the factors that predict the sanctioning outcomes of occupational therapy practitioners. The results may help state regulators, educators, and national associations more effectively act in a way that protects the public faith in occupational therapy services by providing contextualized information on practitioner behaviors that result in specific sanctioning outcomes. The study findings also provide occupational therapy practitioners and SLBs a basis of applied outcomes that may improve the implementation of and education regarding clinical practice ethics.
... Misconduct was categorized into (1) inappropriate prescribing, (2) criminal conviction, (3) fraudulent behavior or prevarication, (4) misconduct secondary to mental illness, (5) self-use of drugs or alcohol, (6) sexual misconduct, (7) practice below standard of care, (8) unprofessional conduct, (9) unlicensed activity, (10) miscellaneous findings (ie, improper maintenance of medical records and confidentiality breaches), and (11) unclear. Punishments included (1) license revocation, (2) voluntary license surrender, (3) suspension, (4) license restriction, (5) mandated retraining, education or assessment, (6) mandated participation in psychological counseling or addiction rehabilitation, (7) formal reprimand, (8) fine or cost repayment, and (9) other [36][37][38][39][40][41][42]. ...
... RateMDs.com is a publicly accessible physician rating website founded in the United States in 2004. Since its launch in Canada (2005), it is the country's leading physician rating website and one of the most popular physician rating websites in North America [41,43]. As of 2013, RateMDs.com ...
Background
Physician rating websites are commonly used by the public, yet the relationship between web-based physician ratings and health care quality is not well understood.
Objective
The objective of our study was to use physician disciplinary convictions as an extreme marker for poor physician quality and to investigate whether disciplined physicians have lower ratings than nondisciplined matched controls.
Methods
This was a retrospective national observational study of all disciplined physicians in Canada (751 physicians, 2000 to 2013). We searched ratings (2005-2015) from the country’s leading online physician rating website for this group, and for 751 matched controls according to gender, specialty, practice years, and location. We compared overall ratings (out of a score of 5) as well as mean ratings by the type of misconduct. We also compared ratings for each type of misconduct and punishment.
Results
There were 62.7% (471/751) of convicted and disciplined physicians (cases) with web-based ratings and 64.6% (485/751) of nondisciplined physicians (controls) with ratings. Of 312 matched case-control pairs, disciplined physicians were rated lower than controls overall (3.62 vs 4.00; P<.001). Disciplined physicians had lower ratings for all types of misconduct and punishment—except for physicians disciplined for sexual offenses (n=90 pairs; 3.83 vs 3.86; P=.81). Sexual misconduct was the only category in which mean ratings for physicians were higher than those for other disciplined physicians (3.63 vs 3.35; P=.003)
Conclusions
Physicians convicted for disciplinary misconduct generally had lower web-based ratings. Physicians convicted of sexual misconduct did not have lower ratings and were rated higher than other disciplined physicians. These findings may have future implications for the identification of physicians providing poor-quality care.
... Relative to other health professionals, psychiatrists and psychologists have been shown to have high rates of complaints and disciplinary actions. [1][2][3][4][5] Prominent issues include sexual boundary violations, [6][7][8][9][10][11][12][13][14] concerns about practitioners' involvement in legal proceedings or reports, 11 15-17 and breaches of confidentiality. 9 17 However, existing studies have significant limitations. ...
... University of Wollongong School of Psychology, Wollongong, New South Wales, Australia5 Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia6 Sydney Local Health District, Sydney, New South Wales, Australia ...
Objectives
To understand complaint risk among mental health practitioners compared with physical health practitioners.
Design
Retrospective cohort study, using incidence rate ratios (IRRs) to analyse complaint risk and a multivariate regression model to identify predictors of complaints.
Setting
National study using complaints data from health regulators in Australia.
Participants
All psychiatrists and psychologists (‘mental health practitioners’) and all physicians, optometrists, physiotherapists, osteopaths and chiropractors (‘physical health practitioners’) registered to practice in Australia between 2011 and 2016.
Outcome measures
Incidence rates, source and nature of complaints to regulators.
Results
In total, 7903 complaints were lodged with regulators over the 6-year period. Most complaints were lodged by patients and their families. Mental health practitioners had a complaint rate that was more than twice that of physical health practitioners (complaints per 1000 practice years: psychiatrists 119.1 vs physicians 48.0, p<0.001; psychologists 21.9 vs other allied health 7.5, p<0.001). Their risk of complaints was especially high in relation to reports, records, confidentiality, interpersonal behaviour, sexual boundary breaches and the mental health of the practitioner. Among mental health practitioners, male practitioners (psychiatrists IRR: 1.61, 95% CI 1.39 to 1.85; psychologists IRR: 1.85, 95% CI 1.65 to 2.07) and older practitioners (≥65 years compared with 36–45 years: psychiatrists IRR 2.37, 95% CI 1.95 to 2.89; psychologists IRR 1.78, 95% CI 1.47 to 2.14) were at increased risk of complaints.
Conclusions
Mental health practitioners were more likely to be the subject of complaints than physical health practitioners. Areas of increased risk are related to professional ethics, communication skills and the health of mental health practitioners themselves. Further research could usefully explore whether addressing these risk factors through training, professional development and practitioner health initiatives may reduce the risk of complaints about mental health practitioners.
... In the United States (US), the majority of physicians committing sexual misconduct are male, and such misconduct is linked to the absence of a chaperone [7][8][9]. Despite recommendations from various medical societies, patients do not always require a chaperone's presence when the physician and patient are of the same gender. ...
Background
In the United States (US), most physicians who commit sexual misconduct are male, and such misconduct is associated with the absence of chaperones. Several organizations recommend a chaperone during all intimate examinations (breast, genital, and rectal exams). However, in Japan, guidelines are not clearly defined, and hospitals and medical societies have not established standardized protocols. At Chiba University Hospital’s Department of General Medicine, female nurses are requested to act as chaperones during female patients’ physical examinations. However, limited medical resources make this challenging. Thus, it is necessary to investigate the necessity of female chaperones for the examination area to prioritize their presence. This study surveyed physicians to determine which examination areas require the presence of female chaperones during the examination of female patients by male physicians. The necessity was stratified and compared by the physician’s sex and age.
Methods
This pilot cross-sectional study surveyed physicians in the Department of General Medicine at Chiba University Hospital. The study content was explained via email, and only those who consented to participate were asked to complete the questionnaire. Only physicians who had passed the Japanese medical licensing examination and had completed two years of residency were included. The primary factors were the physician’s sex and age. The necessity for female chaperones was measured using a five-point Likert scale for different examination areas and patient age groups. The Mann-Whitney U and Kruskal-Wallis tests were also employed.
Results
Responses were obtained from 17 of the 19 physicians (89%; 10 male and seven female). Regardless of sex, there was consensus on the necessity of female chaperones when examining intimate parts (chest, thighs (disrobed), breasts, inguinal region, perineum, and buttocks). Female physicians were more likely to consider chaperones necessary for additional areas, including the head/face (p=0.014), chest (clothed) (p=0.019), abdomen (clothed/disrobed) (p=0.003, 0.033), back (clothed) (p=0.001), buttocks (clothed) (p=0.023), shoulder-upper arm (clothed) (p=0.005), and thighs (clothed) (p=0.033). The necessity for chaperones decreased as the patient’s age increased.
Conclusion
Female physicians presented more cautious opinions, considering chaperones necessary for a broader range of examination areas beyond the traditionally defined intimate parts.
... The exact frequency of sham peer review is uncertain, but according to NPDB records, hospital disciplinary actions including perceived sham peer review average 2.5 per year per hospital. This number does not include the rate of false allegations made against physicians to coerce settlements without a NPDB report, which putatively occurs at a rate that is at least 4 times higher [2,3]. This correlates with a 5-figure number and it is common enough to have a real impact on the growing epidemic of resignations, burnout, and poor morale of physicians. ...
... Any adverse privilege action as the result of sham peer review is reported to the National Practitioner Databank (NPDB), which makes it very difficult for the physician to get privileges at any other hospital. 15 This is even further compounded by the fact that after being adjudicated by a state licensing board, hospitals don't have to remove their adverse action from the NPDB on the practitioner. 16 The exact frequency of sham peer review is uncertain, but according to NPDB records, hospital disciplinary actions including perceived sham peer review average 2.5 per year per hospital for 6100 US hospitals in total. ...
This commentary article highlights the need for an insurance product for hospital-employed physicians that provides coverage against sham peer review and a complete defense against wrongful hospital allegations of incompetent, whistleblowing, or disruptive behavior.
... In addition, the risk of being falsely accused has a chilling effect on the willingness of physicians to act as a whistleblower and speak up about safety problems. Evidence shows the main reason physicians are reluctant to participate in peer review committees is not from fear of lawsuits by an accused peer, but from lack of trust in the process, particularly when they learn of a peer falsely accused based on ulterior motives [7]. ...
... The exact frequency of sham peer review is uncertain, but according to NPDB records, hospital disciplinary actions including perceived sham peer review average 2.5 per year per hospital. This number does not include the rate of false allegations made against physicians in order to coerce settlements without a NPDB report, which putatively occurs at a rate that is at least 4 times higher [2,3]. This correlates with a 5-figure number and it is common enough to have a real impact on the growing epidemic of resignations, burnout, and poor morale of physicians. ...
A just, equitable, and credible peer review process is the cornerstone of a high quality and safe Health Care System. The importance of an unbiased and protected Peer Review System is codified in the Health Care Quality Improvement Act of 1986
... 24,25 Individual characteristics associated with physician discipline have also been identified, such as male. 26 Previously, there were no studies that evaluated the association between documented professionalism violations (DPV) or low academic performance during PA education and subsequent PGDA by state PA licensing boards, particularly studies that evaluate retrospective cohort data. ...
Purpose:
The purpose of this study was to evaluate associations between postgraduate disciplinary actions (PGDA) by state licensing boards and physician assistant (PA) school documented professionalism violations (DPV) and academic probation.
Methods:
This was a retrospective cohort study comprising PA graduates from 2001 to 2011 at 3 institutions (n = 1364) who were evaluated for the main outcome of PGDA and independent variable of DPV and academic probation. Random-effects multiple logistic regression and accelerated failure time parametric survival analysis were used to investigate the association of PGDA with DPV and academic probation.
Results:
Postgraduate disciplinary action was statistically significant and positively associated with DPV when unadjusted (odds ratio [OR] = 5.15; 95% CI: 1.62-16.31; P = .01) and when adjusting for age, sex, overall PA program GPA (GPA), and Physician Assistant National Certifying Exam Score (OR = 5.39; 95% CI: 1.54-18.85; P = .01) (fully adjusted). Academic probation increased odds to 8.43 times (95% CI: 2.85-24.92; P < .001) and 9.52 times (95% CI: 2.38-38.01; P < .001) when fully adjusted.
Conclusion:
Students with professionalism violation or academic probation while in the PA school had significant higher odds of receiving licensing board disciplinary action compared with those who did not. Academic probation had a greater magnitude of effect and could represent an intersection of professionalism and academic performance.
... The exact frequency of sham peer review is uncertain, but according to NPDB records, hospital disciplinary actions including perceived sham peer review average 2.5 per year per hospital. This number does not include the rate of false allegations made against physicians in order to coerce settlements without a NPDB report, which putatively occurs at a rate that is at least 4 times higher [2,3]. This correlates with a 5-figure number and it is common enough to have a real impact on the growing epidemic of resignations, burnout, and poor morale of physicians. ...
In 1986, the US Congress passed the Health Care Quality Improvement Act of 1986. (HCQIA) was designed to protect the health and safety of the public by 1) enhancing the Peer Review process through protection for peer review members from lawsuits, and 2) providing a national repository for reported information regarding medical malpractice payments and adverse actions involving physicians, which among other things, would monitor the movement of incompetent or unprofessional physicians. The framers of HCQIA did not foresee that in 2023, hospitals and employers will invariably deny employment and/or hospital privileges based on an NPDB report outlining loss of hospital privileges or relinquishment of hospital privileges under investigation. Such an adverse report by NPDB results in the inability of the physician to obtain employment or practice in a hospital. Therefore, in 2023, the unintended consequence of the reporting of adverse peer review actions by NPDB, an agency of the Federal Government, can violate the constitutional and civil rights of the said physicians.
... The exact frequency of sham peer review is uncertain, but according to NPDB records, hospital disciplinary actions including perceived sham peer review average 2.5 per year per hospital. This number does not include the rate of false allegations made against physicians in order to coerce settlements without a NPDB report, which putatively occurs at a rate that is at least 4 times higher [2,3] . This correlates with a 5-figure number and it is common enough to have a real impact on the growing epidemic of resignations, burnout, and poor morale of physicians. ...
A just, equitable, and credible peer review process is the cornerstone of a high quality and safe Health Care System. The importance of an unbiased and protected Peer Review System is codified in the Health Care Quality Improvement Act of 1986, HCQIA. However, the peer review process may go wrong when in the new landscape of healthcare which is dominated by large hospital organizations and the big business of medicine, the peer review system may be misused for reasons other than to ensure compliance to the highest standards of professionalism in the interest of the public and the profession. In those instances, due to the immunity protection, which is afforded by HCQIA, contrived allegations of incompetence or disruptive behavior may be used to retaliate against physicians. Most physicians are not familiar with these complex issues which can affect their careers. It is time for a comprehensive discourse among physicians and healthcare attorneys with the singular goal of preserving the legitimacy of Peer Review.
... Adverse outcome leads to disciplinary action and revoking the physician's hospital privileges. Any adverse privilege action is then reported to the National Practitioner Databank (NPDB), which makes it very difficult for the surgeon/physician to get privileges at any other hospital [1]. Surgeons of all subspecialities are more frequently affected by these punitive actions than non-operative physicians. ...
... On occasion, incompetence or disruptive behavior of a clinician is found to have caused patient harm. The peer review committee holds the defi cient physician accountable and the hospital uses their authority to impose swift corrective action ranging from remedial education, proctoring or the restriction or revocation of hospital privileges [1]. ...
An important responsibility of hospitals is to assure the quality of the medical care they provide. One of the key pillars of quality assurance is a committee of local peers to determine the professional competence of physicians. On occasion, incompetence or disruptive behavior of a clinician is found to have caused patient harm. The peer review committee holds the deficient physician accountable and the hospital uses their authority to impose swift corrective action ranging from remedial education, proctoring or the restriction or revocation of hospital privileges [1].
... 2,3 There is also wide variability in the severity of disciplinary actions, which might include an increase in oversight, mandated education, restrictions on practice, publishing disciplinary letters while allowing the physician to continue practicing, license revocation and fines. 3,[12][13][14][15][16] In particular, there is a 7.89-fold variation across SMBs in rates of severe disciplinary actions taken against physicians. 4 For example, in cases when a physician is found guilty of sexual abuse, many boards would revoke the physician's license, whereas other boards would not remove the physician from practice and, instead, enforce less severe punishments (e.g., boundary or ethics classes, mandated chaperones, limit clinical privileges) or permit the physician to resign, enabling them to obtain a license in another state. ...
Purpose
There is wide variability in the frequency and severity of disciplinary actions imposed by state medical boards (SMBs) against physicians who engage in egregious wrongdoing. We sought to identify cutting-edge and particularly effective practices, resources, and statutory provisions that SMBs can adopt to better protect patients from harmful physicians.
Main findings
Using a modified Delphi panel, expert consensus was reached for 51 recommendations that were rated as highly important for SMBs. Panelists included physicians, executive members, legal counsel, and public members from approximately 50% of the 71 SMBs that serve the United States and its territories.
Conclusion
The expert-informed list of recommendations can help support more effective and transparent actions and processes by SMBs when addressing suspected egregious wrongdoing. While some SMBs may be limited in what policies and provisions they can adopt without approval or assistance from state government, many of these recommendations can be autonomously adopted by SMBs without external support.
... On the other hand, it is not surprising that patients rate open communication as one of the most important aspects of their relationship with the physicians [12]. Research has shown that an effective, patient-centered communication is important to increase patient satisfaction [17,20,24,34,39,49,61]. It can have also beneficial effects on patient's health, improving physiologic measures as blood pressure and glucose levels [62], increasing understanding and adherence to therapy [36], and even creating a placebo effect in some cases [35]. ...
Effective communication is a crucial skill for healthcare providers since it leads to better patient health, satisfaction and avoids malpractice claims. In standard medical education, students’ communication skills are trained with role-playing and Standardized Patients (SPs), i.e., actors. However, SPs are difficult to standardize, and are very resource consuming. Virtual Patients (VPs) are interactive computer-based systems that represent a valuable alternative to SPs. VPs are capable of portraying patients in realistic clinical scenarios and engage learners in realistic conversations. Approaching medical communication skill training with VPs has been an active research area in the last ten years. As a result, the number of works in this field has grown significantly. The objective of this work is to survey the recent literature, assessing the state of the art of this technology with a specific focus on the instructional and technical design of VP simulations. After having classified and analysed the VPs selected for our research, we identified several areas that require further investigation, and we drafted practical recommendations for VP developers on design aspects that, based on our findings, are pivotal to create novel and effective VP simulations or improve existing ones.
... 13 In fact, previous literature has demonstrated an association between unprofessionalism among physicians and earlier professional misconduct during medical training. 14,15 Applicants to plastic surgery residency programs use several strategies to strengthen their applications such as preforming well on elective rotations, participating in research projects and other extracurricular activities, and many others. However, our study shows that falsifying publications on their CV is not a common strategy used. ...
Background
Physicians with history of unprofessional behaviour during their medical training are shown to be 3 times more likely to have board disciplinary action later in their career. One realm in which unprofessional behaviour takes place is the phenomenon of unverifiable publications or “ghost publications.” To that end, this study aims to assess the rate of ghost publications among a recent cohort of Canadian Plastic Surgery residency applicants to determine if this phenomenon is geographic in nature.
Methods
The current study was a retrospective, cross-sectional observational study; a review of all residency applications submitted to a single Canadian Plastic Surgery residency program from 2015 to 2018 was performed and all their listed publications were verified for accuracy. The review was conducted by a third party librarian and a research coordinator blinded to the authors identifying information. “Ghost publication” was defined as any publication listed as “published,” “accepted,” or “in-press” that did not exist in the literature.
Results
A total of 196 applications of 186 applicants were submitted over the span of 4 years. A total of 362 publications listed as peer-reviewed articles, belonging to 114 applications were extracted and reviewed. Among the 362 publications listed as peer-reviewed articles, 2 could not be found in the literature (0.55%). Additionally, 42 citations were found with 48 minor differences than what was cited.
Conclusions
The rate of ghost publications among recent applicants to a Plastic Surgery residency program is low (less than 1%). Future studies should investigate methods to further improve and instill the value of professionalism in our future plastic surgery trainees.
... On the other hand, it is not surprising that patients rate open communication as one of the most important aspects of their relationship with the physicians [12]. Research has shown that an effective, patient-centered communication is important to increase patient satisfaction [17,20,24,34,39,49,61]. It can have also beneficial effects on patient's health, improving physiologic measures as blood pressure and glucose levels [62], increasing understanding and adherence to therapy [36], and even creating a placebo effect in some cases [35]. ...
Effective communication is a crucial skill for healthcare providers since it leads to better patient health, satisfaction and avoids malpractice claims. In standard medical education, students' communication skills are trained with role-playing and Standardized Patients (SPs), i.e., actors. However, SPs are difficult to standardize, and are very resource consuming. Virtual Patients (VPs) are interactive computer-based systems that represent a valuable alternative to SPs. VPs are capable of portraying patients in realistic clinical scenarios and engage learners in realistic conversations. Approaching medical communication skill training with VPs has been an active research area in the last ten years. As a result, the number of works in this field has grown significantly. The objective of this work is to survey the recent literature, assessing the state of the art of this technology with a specific focus on the instructional and technical design of VP simulations. After having classified and analysed the VPs selected for our research, we identified several areas that require further investigation, and we drafted practical recommendations for VP developers on design aspects that, based on our findings, are pivotal to create novel and effective VP simulations or improve existing ones.
... A number of studies have considered the activities of state licensing and professional regulatory authorities and have tabulated and analyzed their experiences. [1][2][3][4][5] Studies of these agencies have been directed at assessing their ability to identify health care professionals who "may be incompetent, impaired, uncaring or may have criminal intent." The government licensing agencies and state medical boards appropriately resolve these issues. ...
Context
Although they have no legal authority, medical organizations are frequently asked to assess physician conduct. These organizations have established a variety of procedures to review grievances brought for their consideration.
Objective
This analysis was conducted to assess the nature and the disposition of the complaints considered by the Professional Standards Committee (Committee) of an urban medical society.
Design
All cases considered by the Committee (193 complaints) during a six-year period were arbitrarily sorted into categories and the nature of how the case was resolved was tabulated.
Results
Of all the cases considered 108 (56 percent) were categorized as related to quality of care and physician/staff behavior issues. Of these, 39 (20 percent) dealt with the characteristics of the care provided, 28 (15 percent) with physician and staff behavior, 23 (12 percent) with physician and staff communications and 18 (nine percent) with ethical issues. An additional 85 cases (44 percent) were related to administrative issues and office procedures. Of these, 50 (26 percent) were related to billing, fees and charges, 23 (12 percent) concerned medical records, 10 (five percent) dealt with office practices and procedures and two (one percent) were related to worker’s compensation. Of 141 cases in which a judgment could be made, 48.2 percent were decided in the complainant’s favor and corrective recommendations were made. The grievance appeared to be inappropriate in 51.8 percent of the cases and the reason for this decision was explained to the complainant. In the remaining 22 percent of the cases irreconcilable descriptions of the circumstances made it impossible for the Committee to make a decision or recommendation about the grievance.
Conclusion
The mechanism of review by the Professional Standards Committee of a medical society does appear to offer a procedure by which there can be some resolution of these complaints. In cases in which a judgment could be made the complaint was decided in favor of the complainant as frequently as in favor of the physician.
... On the other hand, it is not surprising that patients rate open communication as one of the most important aspects of their relationship with the physicians [12]. Research has shown that an effective, patient-centered communication is important to increase patient satisfaction [17,20,24,34,39,49,61]. It can have also beneficial effects on patient's health, improving physiologic measures as blood pressure and glucose levels [62], increasing understanding and adherence to therapy [36], and even creating a placebo effect in some cases [35]. ...
Effective communication is a crucial skill for healthcare providers since it leads to better patient health, satisfaction and avoids malpractice claims. In standard medical education, students' communication skills are trained with role-playing and Standardized Patients (SPs), i.e., actors. However, SPs are difficult to standardize, and are very resource consuming. Virtual Patients (VPs) are interactive computer-based systems that represent a valuable alternative to SPs. VPs are capable of portraying patients in realistic clinical scenarios and engage learners in realistic conversations. Approaching medical communication skill training with VPs has been an active research area in the last ten years. As a result, the number of works in this field has grown significantly. The objective of this work is to survey the recent literature, assessing the state of the art of this technology with a specific focus on the instructional and technical design of VP simulations. After having classified and analysed the VPs selected for our research, we identified several areas that require further investigation, and we drafted practical recommendations for VP developers on design aspects that, based on our findings, are pivotal to create novel and effective VP simulations or improve existing ones.
... Results noted with CPSA registration variables were largely expected (e.g., higher complaints are associated with older male physicians, trained abroad, etc.). 25 Of interest is that those physicians using EMRs had a higher rate of patient complaints. Previous studies have also highlighted this unintended consequence; that is, the doctor-patient relationship can be negatively impacted by the use of an EMR, presumably due to the attention placed on completing (3) Male physicians (33% more patients were prescribed 2+2) (4) Performing procedures requiring sedation/ anaesthesia (over twice the number of patients were prescribed 2+2) (5) Being an IMG (31% more patients were prescribed 2+2 than CMG) (6) Accepting new patients (26% more patients were prescribed 2+2) (7) Younger physicians (for each decrease in one year of age, 2% more patients were prescribed 2+2) (8) Not practicing exclusively as a locum (14 times more patients were prescribed 2+2) (9) Teaching with provision of medical services (5% more patients were prescribed 2+2) (10) Using an EMR (37% more patients were prescribed 2+2) ...
The purpose of this longitudinal study was to gather extrapolation evidence of validity by assessing whether performance on a national medical licensing exam, in addition to practice and socio-demographic variables, is predictive of future physician performance in practice. The study focused on a cohort of 3,404 physicians who were registered with the College of Physicians and Surgeons of Alberta (CPSA) and who completed the Medical Council of Canada Qualifying Examination (MCCQE) Parts I and II between 1992–2017. Separate multivariate quasi-Poisson regression models were run to assess the degree of relationship between first-time pass/fail status on the MCCQE I and II, and several CPSA socio-demographic variables and several CPSA socio-demographic variables, in addition to complaints/physician and various prescribing flags. Candidates who failed the MCCQE I on their first attempt had 27% more complaints lodged against them, compared to those who passed. Physicians who failed the MCCQE II on their first attempt prescribed 2+ benzodiazepines and 2+ opioids to 30% more patients than those who passed. Conclusions: Performance on the MCCQE Part I and II is an important predictor of physician performance. Combined with other critical variables, these measures provide important evidence to aid in risk modeling efforts and to guide educational interventions for physicians at an early stage of their careers.
... Women in surgery still represent a minority, although this appears to be increasing, with female surgeons accounting for 11% of consultants, but 30% of surgical trainees 13 . It has been noted that male doctors overall are far more likely to face disciplinary hearings and receive sanctions[14][15][16] . Previously postulated theories for this discrepancy have included differences in communication styles (suggesting that women communicate more effectively with patients), differences in the threshold of tolerance by the public and/or the regulatory body and differences in working patterns (fewer patient interactions as a result of higher rates of less than full time equivalent working among female doctors)17,18 . ...
Surgeons are commonly evaluated with respect to outcomes and adherence to rules and regulations, rather than a true holistic examination of the character of the surgeon in question. We sought to examine the character failings of surgeons who faced fitness to practice enquiries under the Medical Practitioner Tribunal Service in the UK. In particular, we examined the absence of virtue as perceived through the lens of Aristotelian ethics using thematic analysis of tribunal hearing transcripts from 2016 to 2020. We identified three overarching themes that are explored in depth: ‘the god complex’, ‘reputation over integrity’ and ‘wounded pride’. We hope to use this as the foundation for a re-examination of the place of phronesis in postgraduate surgical education, which we argue should be perceived as an exercise in character development and reformation rather than the simplistic teaching of skills to standardised outcomes.
... Prior analysis has shown specialty may be a risk for disciplinary actions. 7 This study did not demonstrate any significant difference by specialty, likely because of the relatively smaller sample size of 66 physicians disciplined in the period observed. ...
Disciplinary actions against physicians are uncommon, and loss of license is less common. This unmatched, case-control, and descriptive study reviews disciplinary actions involving physician loss-of-license cases from January 1, 2009, to December 31, 2019. There were 82 physician loss-of-license cases involving 66 physicians, which were categorized by age, sex, and specialty and were compared to 4,347 non-disciplined controls. In this study, males (OR 4.69, p<0.001) were associated with an increased risk of loss of license; age was a separate risk factor (OR 1.24, p<0.05). Preventive strategies are discussed to reduce future physician loss of license.
... En respuesta, se generó el movimiento por la seguridad del paciente promovido por la Organización Mundial de la Salud, que constituyo la Alianza Mundial por la Seguridad del Paciente [2] , organización dedicada a estimular y apoyar en cada país el desarrollo de estrategias integrales orientadas a prevenir los eventos adversos y el error médico; uno de los componentes claves es el mejorar el desempeño del factor humano en la gestión del riesgo en salud. En relación con el factor humano, diversos estudios [3][4][5][6][7][8][9] resaltan que las quejas y denuncias (éticas o legales) contra médicos y otros profesionales de la salud no son pocas y se asocian a diversos factores (estructurales y de proceso), indicativos de problemas en la atención de salud; por lo que la comprensión de su dinámica y características permitiría mejorar la calidad y seguridad de la atención sanitaria. ...
Objetivo. Describir la frecuencia y características de los procesos ético-disciplinarios derivados de actos médicos resueltos por el Consejo Nacional del Colegio Médico del Perú, así como las características de los médicos implicados. Material y métodos. Se analizaron las resoluciones emitidas por el Consejo Nacional del Colegio en procesos ético-disciplinarios instaurados por denuncias de pacientes en el periodo 1991-2015. Resultados. Los procesos ético-disciplinarios instaurados por denuncias de pacientes aumentaron 4,3 veces entre 1991-2000 y 2006-2015; la mayoría (87%) provino de Lima y Callao. La tasa de incidencia de médicos involucrados en los procesos éticos fluctuó entre 1,5/1000-3,36/1000 en el periodo de estudio. La demanda más frecuente fue por mala atención (55%) seguida de certificado médico irregular (12%), delitos (11%) y no obtener consentimiento informado (9%). Fue sancionada casi la mitad de los 448 médicos implicados (49%) y en este grupo ser varón, médico general y ejercer fuera de Lima y Callao se asoció significativamente (p< 0,05) con severidad de la falta ética. Conclusión. Hubo crecimiento exponencial en procesos ético-disciplinarios derivados de actos médicos en el periodo de estudio y el motivo más frecuente fue la mala atención.
There is scarce information about the institutional mechanisms creating the demographic portrait of sanctioned doctors published in the U.S. Office of Inspector General's (OIG) List of Excluded Individuals and Entities (LEIE). The current study examines the demographic characteristics of 1,289 physicians who appeared in the LEIE during a five-year period from 2008 to 2013. The results of a multivariate logistic regression found that sex, country of medical school training, and medical specialty were associated with being excluded by the OIG for a quality of care matter. Findings suggest the demographic portrait of doctors in the LEIE reflects the interplay between the doctors' behaviors and the actions of various agencies. A demographic portrait of physician violators,if one considers the mechanisms generating the list, can be useful for public policy recommendations and action.
One of the most important responsibilities of hospital administrators is to assure the quality of the medical care they provide. A key pillar of quality assurance has been the use of a committee of local peers to determine professional physician competence.
Purpose
To evaluate the likelihood of disciplinary actions against medical licenses of ophthalmologists who maintained board certification through successful completion of the American Board of Ophthalmology Maintenance of Certification program compared with ophthalmologists who did not maintain certification.
Methods
The study was a retrospective cohort study of ophthalmologists certified by the American Board of Ophthalmology from 1992 to 2012 with time-limited certificates. Rates and severity of disciplinary actions against medical licenses were analyzed amongst ophthalmologists who did and did not maintain certification.
Results
Of 9,111 ophthalmologists who earned initial board certification between 1992 and 2012, 8.073 (88.6%) maintained their certification and 1,038 (11.4%) did not maintain their certification. A total of 234 license actions were identified in the study group. Among ophthalmologists who did not maintain board certification, the risk of a license action was more than two times that of those who maintained board certification (HR 2.34, 95% CI, 1.73-3.18). License actions were significantly higher in men than in women (HR 2.02, 95% CI 1.43-2.86). Ophthalmologists who had a lapse in their certification had a higher severity of disciplinary actions (χ² = 9.21, p < .01) than ophthalmologists who maintained their certification.
Conclusions
This study supports prior literature in other specialties demonstrating a higher risk of disciplinary licensure actions in physicians who did not maintain board certification as compared with those who did. Physicians who did not maintain certification were also more likely to have actions against their license reflecting a higher severity violation.
This chapter examines the lessons learned from 30 years of experience with a large cohort of medical professionals referred to continuing medical education (CME) courses for unprofessional behavior. The courses offered are aimed at (1) maintaining proper boundaries, (2) prescribing controlled drugs, and (3) addressing unprofessional behaviors that compromise safety in clinical practice (aka the distressed physician course). These courses provide skills and training to remediate lapses in professional behavior for physicians who engage in mid-level lapses of professionalism. While a small subset of physicians are unfit to practice medicine, most physicians are able to return to practice with enhanced knowledge and skills.KeywordsUnprofessional behaviorSexual boundary violationsMisprescribingDisruptive physician behaviorContinuing medical education
Internationally, efforts promoting greater transparency and improved management strategies for conflicts of interest (COI) have gained traction in healthcare settings. This particularly pertains to the development and use of clinical practice guidelines (CPG). Mounting evidence indicates that pharmaceutical industry payments to GPG authors and developers influence clinical recommendations, including drug selection, often to benefit commercial interests and at the expense of patients. To prevent undue influence of COI and develop trustworthy CPG, authors and developing organizations should establish strict COI management policies, including full disclosure. Such policies should include details about the monetary values and funding sources of all payments and gifts from pharmaceutical companies. Authors and developers should refuse any payments or gifts while drafting CPG. CPG developers should establish clear and comprehensive COI definitions and create monitoring committees that implement COI policies, promote external review, and track COI declared by CPG authors using existing payment databases.
The spread of misinformation and disinformation related to science and technology has impeded public and policy efforts to mitigate threats such as COVID-19 and anthropogenic climate change. In the digital age, such so-called fake science can propagate faster and capture the public imagination to a greater extent than accurate science. Therefore, ensuring the most reliable science reaches and is accepted by audiences now entails understanding the origins of fake science so that effective measures can be operationalized to recognize misinformation and inhibit its spread. In this chapter, we review the potential weaknesses of science publishing and assessment as an origin of misinformation; the interplay between science, the media, and society; and the limitations of literacy as an inoculation against misinformation; and we offer guidance on the most effective ways to frame science to engage non-expert audiences. We conclude by offering avenues for future science communication research.
Background:
American Board of Plastic Surgery (ABPS) Diplomates complete training in aesthetic surgery through an ACGME-accredited program. American Board of Cosmetic Surgery (ABCS) diplomates complete residency training in a "related" specialty, some historically non-surgical, followed by an American Association of Cosmetic Surgery (AACS) fellowship. Unlike the ABPS, the ABCS is not recognized by the American Board of Medical Specialties (ABMS) as an equivalent certifying board. This study evaluated differences in the rates of punitive action against Diplomates of the ABPS and the ABCS.
Methods:
Diplomats were accessed from their respective society's websites (ABCS&ABPS). Punitive action data were obtained by search of publicly available state medical board databases. A comparative analysis was performed between ABPS and ABCS.
Results:
One thousand two-hundred and eight physicians were identified for comparative analysis. Two hundred and sixty-six (22%) were members of the ASPS, 549 (49%) were members of the TAS. ABCS Diplomates had significantly higher rates of disciplinary administrative action by their respective state medical boards [31 (9.0%)] when compared with ABPS members [TAS: 26 (4.4%) and ASPS: 8 (3.1%); p=0.003] with a higher; proportion of repeat offenders. In addition, ABCS Diplomates had more public letters of reprimand [ABCS:12 (3.5%) vs. TAS: 6 (1.2%) and ASPS: 2 (0.8%); p=0.015].
Conclusions:
ABCS Diplomates have significantly higher rates of punitive actions than ABPS Diplomates. Although the reasons for this discrepancy warrant further investigation, punitive data should be transparently and publicly available to aid patients in informed decision-making.
Purpose:
As the last examination in the United States Medical Licensing Examination (USMLE) sequence, Step 3 provides a safeguard before physicians enter into unsupervised practice. There is, however, little validity research focusing on Step 3 scores beyond examining its associations with other educational and professional assessments thought to cover similar content. This study examines the associations between Step 3 scores and subsequent receipt of disciplinary action taken by state medical boards for problematic behavior in practice. It analyzes Step 3 total, Step 3 computer-based case simulation (CCS), and Step 3 multiple-choice question (MCQ) scores.
Method:
The final sample included 275,392 board-certified physicians who graduated from MD-granting medical schools and who passed Step 3 between 2000 and 2017. Cross-classified multilevel logistic regression models were used to examine the effects of Step 3 scores on the likelihood of receiving a disciplinary action, controlling for other USMLE scores and accounting for jurisdiction and specialty.
Results:
Results showed that physicians with higher Step 3 total, CCS, and MCQ scores tended to have lower chances of receiving a disciplinary action, after accounting for other USMLE scores. Specifically, a 1-standard-deviation increase in Step 3 total, CCS, and MCQ score was associated with a 23%, 11%, and 17% decrease in the odds of receiving a disciplinary action, respectively. The effect of Step 2 CK score on the likelihood of receiving a disciplinary action was statistically significant, while the effect of Step 1 score became statistically nonsignificant when other Step scores were included in the analysis.
Conclusions:
Physicians who perform better on Step 3 are less likely to receive a disciplinary action from a state medical board for problematic behavior in practice. These findings provide some validity evidence for the use of Step 3 scores when making medical licensure decisions in the United States.
While psychiatrists are much less likely to face a malpractice action than the majority of physicians practicing in other medical specialties, the principal foundations that underlie a malpractice lawsuit are the same, regardless of specialty. The basic tenets of a negligence suit involve establishing and proving four distinct elements: (1) a physician owed the patient a duty to treat him or her, (2) the physician’s treatment fell below an acceptable standard of care in the profession which constituted a dereliction of duty, (3) the patient suffered damages, and (4) there was direct causation (i.e., if it were not for the actions or inactions of the physician, the patient would not have suffered damages). In addition to these four basic elements, this chapter reviews the theory and limitations of malpractice litigation, the frequency of malpractice claims and medical board complaints against psychiatrists, and the specific allegations of negligence that are most commonly encountered in psychiatric malpractice cases. Finally, basic recommendations regarding liability prevention will be presented.KeywordsPsychiatric malpracticeLiabilityNegligenceDutyStandard of careDamagesCausationDocumentation
Medical practice acts (MPAs) govern the practice of medicine in all 50 American states and authorize state medical boards (SMBs) to license, regulate, discipline, and, at times, facilitate rehabilitation of physicians and other medical professionals. A critical mission of the SMB is to protect the public from unprofessional, unlawful, and incompetent conduct by physicians and to ensure the integrity and safety of healthcare in the state. This chapter will cover the structure and function of SMBs, including the typical investigative and disciplinary process following a complaint. Although the literature is limited, known patterns and data regarding which physicians are disciplined and for what reasons are discussed. Finally, general recommendations for physicians facing a medical board complaint are presented.KeywordsState medical boardsBoard complaintDisciplinary actionMedical practice actPhysician disciplineFederation of State Medical Boards
What research has been done to characterize the outcomes of disciplinary action or fitness-to-practice cases for regulated health professionals?
To answer this research question, relevant publications were identified in PubMed, Ovid EMBASE, CINAHL via EBSCOhost, and Scopus. Included papers focused on reviews of regulatory body disciplinary action for regulated health professionals.
Of 108 papers that were included, 84 studied reasons for discipline, 68 studied penalties applied, and 89 studied characteristics/predictors of discipline. Most were observational studies that used administrative data such as regulatory body discipline cases. Studies were published between 1990–2020, with two-thirds published from 2010–2020. Most research has focused on physicians (64%), nurses (10%), multiple health professionals (8.3%), dentists (6.5%) and pharmacists (5.5%). Most research has originated from the United States (53%), United Kingdom (16%), Australia (9.2%), and Canada (6.5%). Characteristics that were reviewed included: gender, age, years in practice, practice specialty, license type/profession, previous disciplinary action, board certification, and performance on licensing examinations.
As most research has focused on physicians and has originated from the United States, more research on other professions and jurisdictions is needed. Lack of standardization in disciplinary processes and definitions used to categorize reasons for discipline is a barrier to comparison across jurisdictions and professions. Future research on characteristics and predictors should be used to improve equity, support practitioners, and decrease disciplinary action.
Despite efforts to improve healthcare delivery and ensure patient safety, medicolegal claims in Saudi Arabia remain a concerning issue. This study investigated medical violation claims referred to the medical violation committee in the Eastern Province in Saudi Arabia. A retrospective study was conducted on medical violation claims from 2016 to 2019. Binary logistic regression was performed to examine the association between issued verdicts and a set of defendant, plaintiff and healthcare institution variables. During the study's period, the medical violation committee reached final verdicts against 1242 healthcare professional in which 69% of them were found guilty. The majority of the defendants worked in private healthcare institutions (66%), were physicians (30%), male (53%), and non-Saudi (64%). Working at pharmacies, other healthcare settings, and the private sector were significantly associated with receiving a guilty verdict. Male healthcare professionals as well as pharmacists were found to have a higher likelihood to receive a guilty verdict than their respective counterparts. Medical violation claims filled by the Ministry of Health were more likely to receive guilty verdicts than those filled by patients or healthcare professionals. Findings of the study extend the literature on medicolegal claims and introduces implications for healthcare professionals and policymakers at institutional and national levels.
Using physician licensing data from 1972–2015 obtained from Indiana, we examine the performance of the disciplinary process in enforcing minimum performance standards. Only 1.2 percent of the physicians in our dataset were disciplined. Drug diversion, substance abuse, and sexual misconduct account for 60 percent of all disciplinary actions. Male physicians are at higher risk for disciplinary action for sexual misconduct and drug diversion, but not for other types of misconduct. Graduates of U.S. and non‐U.S. medical schools have the same overall risk of disciplinary action—but for non‐U.S. educated physicians, this is the result of averaging a significantly lower risk of discipline for drug and alcohol abuse and drug diversion with a significantly higher risk of discipline for negligence and sexual misconduct. Physicians who attended medical school in the Caribbean have a significantly higher risk of discipline for negligence/incompetence, but not for other causes.
Purpose:
Disciplinary action imposed on physicians indicates their fitness to practice medicine is impaired and patient safety is potentially at risk. This national retrospective cohort study sought to examine whether there was an association between academic attainment or performance on a situational judgment test (SJT) in medical school and the risk of receiving disciplinary action within the first 5 years of professional practice in the United Kingdom.
Method:
The authors included data from the UK Medical Education Database for 34,865 physicians from 33 U.K. medical schools that started the UK Foundation Programme (similar to internship) between 2014 and 2018. They analyzed data from 2 undergraduate medical assessments used in the United Kingdom: the Educational Performance Measure (EPM), which is based on academic attainment, and SJT, which is an assessment of professional attributes. The authors calculated hazard ratios (HRs) for EPM and SJT scores.
Results:
The overall rate of disciplinary action was low (65/34,865, 0.19%) and the mean time to discipline was 810 days (standard deviation [SD] = 440). None of the physicians with fitness to practice concerns identified as students went on to receive disciplinary action after they qualified as physicians. The multivariate survival analysis demonstrated that a score increase of 1 SD (approximately 7.6 percentage points) on the EPM reduced the hazard of disciplinary action by approximately 50% (HR = 0.51; 95% confidence interval [CI]: 0.38, 0.69; P < .001). There was not a statistically significant association between the SJT score and the hazard of disciplinary action (HR = 0.84; 95% CI: 0.62, 1.13; P = .24).
Conclusions:
An increase in EPM score was significantly associated with a reduced hazard of disciplinary action, whereas performance on the SJT was not. Early identification of increased risk of disciplinary action may provide an opportunity for remediation and avoidance of patient harm.
Background
Fitness to practice (FtP) investigations by the General Medical Council (GMC) safeguard patients and maintain the integrity of the medical profession. The likelihood of FtP sanctions is influenced by specialty and socio-demographic factors and can be predicted by performance at postgraduate examinations. This is the first study to characterise the prevalence of FtP sanctions in early-career surgeons and to examine the association with performance at the Membership of the Royal College of Surgeons (MRCS) examination.
Methods
All UK graduates who attempted MRCS between September 2007–January 2020 were matched to the GMC list of registered medical practitioners. Clinicians who had active FtP sanctions between 28th August 2018 and 28th August 2020 were identified. Data were anonymised by RCS England prior to analysis.
Results
Of 11,660 candidates who attempted MRCS within the study period, only 31 (0.3%) had FtP sanctions between 2018 and 2020. Of these, 12 had active conditions on registration, seven had undertakings and 14 had warnings. There was no statistically significant difference in MRCS performance in either Parts A or B of the examination for those with and those free from FtP sanctions (P > 0.05).
Conclusions
In this, the largest study of MRCS candidates to date, the prevalence of active FtP sanctions in early-career surgeons was 0.3%, significantly lower than the prevalence of sanctions across more experienced UK surgeons (0.9%). These data highlight early-career surgeons as a low-risk group for disciplinary action and should reassure patients and medical professionals of the rarity of FtP sanctions.
We study the overlap between the medical malpractice (med mal) and medical disciplinary systems using the records of almost 90,000 Illinois physicians who held an active license at any point from 1990–2016. We quantify the specialty‐specific risk of having a paid med mal claim or a disciplinary action; how many physicians have both; and the extent to which physicians with two or more paid claims or two or more disciplinary actions account for a disproportionate share of the activity of both systems. We also examine which factors are associated with paid claims and disciplinary actions, and whether physicians with multiple paid claims or disciplinary actions are concentrated at particular hospitals. Physicians with two or more paid claims account for only 2.37 percent of all licensed physicians, but they account for 53 percent of paid claims and payouts. Physicians with two or more disciplinary actions account for only 0.47 percent of physicians but 28 percent of all disciplinary actions. The risk of paid claims and disciplinary actions varies greatly by specialty. Physicians who attended non‐U.S. medical schools are more likely to have paid claims but (except for high‐disciplinary‐risk specialties) are not more likely to be subject to disciplinary action. Physicians with prior paid claims are more likely to be the target of disciplinary action—but not vice versa. A small number of Illinois hospitals are staffed by physicians with unusually high numbers of paid med mal claims, disciplinary actions, or both.
The practice of medicine is stressful and demanding and does not exclude physicians from having to cope with the usual stressors of life outside of medicine. Medicine’s current practice environment, dwindling resources, diminished compensation, litigious practice climate, and increasing limits on physician autonomy have led to increased stress, decreased professional satisfaction and in some, disruptive behavior. Doctors are vulnerable to the same diseases, imperfections and flaws as everyone else. External demands and pressures combined with internalized high expectations have made today’s physicians especially susceptible to burnout, depression, anxiety, fatigue, cardiovascular disease, substance abuse and dependence, disability, fractured interpersonal relationships and suicide. The self-policing nature of the medical profession requires that all physicians are ethically obligated to report an impaired physician. The creation of Physicians’ Health Programs (PHPs) in all 50 states is a confidential resource for physicians to self-refer or for colleagues or healthcare facilities to refer one about whom they have concern.
Background:
Non-board-certified plastic surgeons performing cosmetic procedures and advertising as plastic surgeons may have an adverse effect on a patient's understanding of their practitioner's medical training and patient safety. The authors aim to assess (1) the impact of city size and locations and (2) the impact of health care transparency acts on the ratio of board-certified and non-American Board of Plastic Surgeons physicians.
Methods:
The authors performed a systematic Google search for the term "plastic surgeon [city name]" to simulate a patient search of online providers. Comparisons of board certification status between the top hits for each city were made. Data gathered included city population, regional location, practice setting, and states with the passage of truth-in-advertising laws.
Results:
One thousand six hundred seventy-seven unique practitioners were extracted. Of these, 1289 practitioners (76.9 percent) were American Board of Plastic Surgery-certified plastic surgeons. When comparing states with truth-in-advertising laws and states without such laws, the authors found no significant differences in board-certification rates among "plastic surgery" practitioners (88.9 percent versus 92.0 percent; p = 0.170). There was a significant difference between board-certified "plastic surgeons" versus out-of-scope practitioners on Google search between large, medium, and small cities (100 percent versus 92.9 percent versus 86.5; p < 0.001).
Conclusions:
Non-board-certified providers tend to localize to smaller cities. Truth-in-advertising laws have not yet had an impact on the way a number of non-American Board of Plastic Surgery-certified practitioners market themselves. There may be room to expand the scope of truth-in-advertising laws to the online world and to smaller cities.
Objective
The aim of this study was to determine the types of medical misconduct, the practitioner, specialities and jurisdictions at risk, patient outcomes and the sanctions imposed.Methods
This study was a retrospective case series of 822 adverse medical tribunal determinations in Australia, New Zealand, Canada (Ontario, Alberta), Pennsylvania (USA), Singapore and Hong Kong in 2013-17.ResultsInappropriate medical care and illegal or unethical prescribing were the most common types of misconduct. Misconduct varied with practitioner sex, international medical graduate status, speciality and jurisdiction (P<0.05). Cases of inappropriate medical care were more common in Singapore (46.7% of all Singapore cases; 95% confidence interval (CI) 31.9-62.0) and among surgeons (47.6% of all surgeon cases; 95% CI 36.5-58.8). Illegal or unethical prescribing was more common in Australia (31.1%; 95% CI 24.8-38.2) and among general or family practitioners (26.9%; 95% CI 20.0-35.0). Misconduct not related to patients was more common in Pennsylvania (30.3%; 95% CI 25.2-36.0) and among local graduates (20.5%; 95% CI 17.1-24.5). Sexual misconduct was more common in Australia (29.6%; 95% CI 23.4-36.6) and among males (19.6%, 95% CI 16.7-22.8). Healthcare dishonesty was more common in Hong Kong (21.8%; 95% CI 14.0-32.2) and among surgeons (13.4%; 95% CI 7.2-23.2). The most common patient outcomes were patient risk (40.6%; 95% CI 36.1-45.4) and death and actual physical harm combined (31.2%; 95% CI 26.9-35.7). Sanctions were most commonly suspension or deregistration. Deregistration was most common in cases of sexual misconduct.Conclusion
Medical misconduct varies widely. Risk factors for particular misconduct types are apparent among jurisdictions and practitioner characteristics. The nature of patient harm varied by type of misconduct, with illegal unethical prescribing commonly leading to drug dependency and sexual misconduct leading to psychiatric injury.What is known about the topic?Medical misconduct is a continuing problem. Tribunals and medical boards sanction misconduct to protect patient safety and public trust.What does this paper add?Tribunals and boards differ in misconduct reporting and permitting public access to determinations. Types of misconduct vary between international jurisdictions, practitioner sex, international graduate status and speciality. Risk and physical injury (including death) are the most common patient outcomes. The nature of patient harm varied by type of misconduct, with illegal unethical prescribing commonly leading to drug dependency and sexual misconduct leading to psychiatric injury.What are the implications for practitioners?Medical colleges should tailor trainee programs to address the common types of misconduct within their specialities. Standardisation of misconduct reporting, and report access, across jurisdictions would facilitate ongoing surveillance and intervention evaluation.
The vast majority of ophthalmologists excluded from federally funded medical programs were male and older than 50. Ophthalmologists with international medical degrees were also overrepresented. The most common infraction resulting in exclusion was financial misconduct.
Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice.
To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment.
We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents.
We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations.
Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs.
We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes.
In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.
This study determined the risk of discipline by a medical board for psychiatrists relative to other physicians and assessed the contributions to such risk.
Physicians disciplined by the California Medical Board in a 30-month period were compared with matched groups of nondisciplined physicians.
Among 584 disciplined physicians, there were 75 (12.8%) psychiatrists, nearly twice the number of psychiatrists among nondisciplined physicians. Female psychiatrists were underrepresented in the disciplined group. Psychiatrists were significantly more likely than nonpsychiatrist physicians to be disciplined for sexual relationships with patients and about as likely to be charged with negligence or incompetence. The disciplined and nondisciplined psychiatrists did not differ significantly from a group of 75 nondisciplined psychiatrists on years since medical school graduation, international medical graduate status, or board certification. The disciplined group included significantly more psychiatrists who claimed child psychiatry as their first or second specialty and significantly fewer psychoanalysts.
Organized psychiatry has an obligation to address sexual contact with patients and other causes for medical board discipline. This obligation may be addressable through enhanced residency training, recertification exams, and other means of education.
Attention has recently been focused on medical errors as a cause of morbidity and mortality in clinical practice. Although much has been written regarding the cognitive aspects of decision making and the importance of systems management as an approach to medical error reduction, little consideration has been given to the emotional impact of errors on the practitioner. Evidence exists that errors are common in clinical practice and that physicians often deal with them in dysfunctional ways. However, there is no general acknowledgment within the profession of the inevitability of medical errors or of the need for practitioners to be trained in their management. This article focuses on the affective aspects of physician errors and presents a strategy for coping with them.
To determine whether patterns of differences in performance exist between United States Medical Graduate and Foreign Medical Graduate attending Physicians, two types of inpatient hospital audits (Payne Process Audit and the Joint Committee on Accreditation of Hospitals' Performance Evaluation Program-P.E.P. Audit) were conducted in 22 Maryland and Pennsylvania non-federal, short-term hospitals. A total of 6,980 medical records were abstracted from eight diagnostic categories for 1,321 attending physicians; 985 of which were USMGs and 331 were FMGs. The results from both audits indicate that while there is evidence of a strong hospital-type of physician interaction for many of the diagnoses, there was no significant overall difference in performance between USMG and FMG attending physicians. The largest and most consistent differences in physician performance were associated with hospital characteristics, not physician characteristics.
This study was undertaken to clarify which, if any, physician demographic characteristics are associated with an increased rate of medical malpractice claims.
We analyzed the malpractice experience of 9,250 physicians insured for at least 2 years from 1977 to 1987 in the state of New Jersey. After adjusting for years at risk, physician claims per year was categorized into low, medium, and high.
Male physicians were three times as likely to be in the high-claims group as female physicians, even after adjusting for other demographic variables (relative risk, 3.1; 99% confidence interval, 2.2 to 4.4). Specialty was strongly associated with claims rate, with neurosurgery, orthopedics, and obstetrics/gynecology having 7 to 12 times the number of claims per year as psychiatry, the specialty with the fewest claims. The rate of claims varied with age (p < 0.001) and peaked at approximately age 40. No association was evident between claims rate and a physician's site of training or type of degree.
Male physicians are three times as likely to be in a high-claims category as female physicians. We suspect that the most likely explanation for this finding is that women interact more effectively with patients. Understanding the reasons for the variation in claim rates between physicians may lead to the development of methods to reduce the overall rate of malpractice claims.
This review examines the current medical disciplinary process in New York State and assesses whether it protects the public and is fair to respondent physicians. Clearly there is urgent need for reform. Results of 1,036 disciplinary actions over the years 1982-1989 have been reviewed, with special attention to the 878 cases during 1985-89. The types of misconduct and their incidences among these physicians represent but a small segment of the more than 40,000 licensed practising physicians in this state. Extrapolations concerning their incidence should not be made from these limited data to the general population of physicians. The many flaws in the present system have been noted. A brief review of the process in 32 other states, Ontario, and Great Britain has shown that New York's is the most cumbersome and lengthy. Changes are suggested to modify the present system preserving some features of the current process but eliminating others. Licensing and disciplinary processes should be included in a single agency within the Health Department and this must be kept independent.
As part of a quality-assurance program, we reviewed the clinical credentials listed on applications from 773 physicians applying for clinical positions in the Humana MedFirst national ambulatory care program between March 1 and December 31, 1986. In 39 applications (5.0 percent), physicians presented false clinical credentials: 27 physicians (3.5 percent) gave false information about their residency, 10 (1.3 percent) falsely reported board certification, and 2 (0.3 percent) provided false information about both residency and board certification. There was no significant difference between the falsification rates among graduates of U.S. medical schools and those among graduates of foreign medical schools, or among those in the various medical specialties. Falsification was more common among physicians recruited locally than among those recruited nationally, and was significantly more common among applicants who graduated before 1970. Because of this sample included only applicants for ambulatory privileges within a single organization, the findings may be of uncertain generalizability to groups of physicians applying for other classes of privileges in other institutions. We conclude that in applying for some clinical privileges, physicians present inaccurate clinical credentials more frequently than might be expected.
Several earlier studies compared performance differences between USMGs and FMGs in inpatient care settings, mainly hospitals. This study compares performance differences between USMGs and FMGs in ambulatory care settings. The sample consisted of 14,203 patient episodes treated by 1,156 physicians (pediatricians, obstetricians/gynecologists, internists, and other specialty physicians). The study setting was a midwestern state. Little evidence was found to support the hypothesis that the medical school origin (U.S. and foreign) had influenced physicians' technical quality in practice. Mean differences between the USMGs and FMGs were either not significant or contrary to the general assumption. The FMGs provided equal care to the USMGs, and sometimes the FMGs provided even marginally better care than the USMGs.
In the study reported here, the authors, using data from two American Medical Association surveys, examine the impact of board certification on selected physician practice characteristics. The results indicate that board certification is more prevalent for certain specialties, ages, types of practice, and locations of practice. Board certification has a substantial impact on the gross income of most major specialties, but these differences decline significantly for net incomes. Finally, comparisons of the hours worked per week and weeks worked per year show only small differences between board-certified and nonboard-certified physicians.
To design and implement an individualized program of evaluation and education to provide remedial experiences to physicians.
An evaluation and educational program for physicians practicing in New York State.
Physicians referred for evaluation and possible remedial educational experiences from the New York State Office of Professional Medical Conduct, from the New York State Committee on Physicians' Health, or self-referred.
Educational programs designed to meet the individually identified educational needs of physicians and placement of physicians in educational settings that facilitate their meeting the program goals and issues raised by the Office of Professional Medical Conduct.
Of the 28 physicians who have undergone evaluation activities, at the time of this report, five (18%) had completed their educational programs, five (18%) were participating in directed educational programs, five (18%) had approved educational programs and were awaiting placement, and 10 (36%) were awaiting acceptance of their program by the Office of Professional Medical Conduct.
A comprehensive evaluation program can identify areas amenable to education and target individualized remedial educational experiences that may enable physicians to become contributing members of the medical community.
To investigate the validity of the certification process of the American Board of Anesthesiology. Specifically, does board certification in anesthesiology identify physicians judged to be clinically superior by evaluators who are not part of the certification process?
All 154 U.S. anesthesiology program directors (or faculty members they chose to represent them), unaware of the study's intent, were asked whether they would permit each of their residents completing training in 1991 to administer three increasingly complex anesthetic regimens to the directors themselves. This clinical skills rating was compared with the residents' performances in the certification process in 1992. A list of personal characteristics was also provided to the directors so they could identify reasons for less-than-optimal clinical skills ratings. A total of 1,310 residents participated in the certification process in 1992.
A total of 146 programs responded. The directors would have accepted anesthetic care for all three increasingly complex operations from 828 (63.2%) of their own residents; for only the two less complex procedures, from 262 (20%); and for only the least complex procedure, from 127 (9.7%). In addition, 93 residents (7.1%) would not have been accepted to administer anesthesia to their directors for any of these operations. Certification success rates for these groups were 74.6%, 53.8%, 44.9%, and 49%, respectively (p < .00001). The personal characteristics believed important to the practice of anesthesiology were strongly linked to the clinical skills ratings; these included motivation, adaptability, clinical judgment, manual dexterity, several work habits, response to criticism, and handling of stressful situations.
These data support validity for certification in anesthesiology and identify characteristics considered necessary for high-quality practice of the specialty.
This article has no abstract; the first 100 words appear below.
In this era of physician accountability, many organizations are searching for ways to evaluate physicians' performance. The principal method of the past — namely, the requirement of graduation from a training program and subsequent time-unlimited state licensure — seems naive in the context of the recent enthusiasm for assessing actual performance. Given that modern organizations, especially managed-care plans, still have little more than these criteria to go on when hiring new physicians, many use certification by 1 of the 24 member boards of the American Board of Medical Specialties (ABMS) as a major criterion for hiring.¹–³ In fact, many . . .
Jerome P. Kassirer, M.D.
Individualized educational programs based upon structured comprehensive evaluations have the highest opportunity for success in addressing the needs of physicians with lapsed skills. The purpose of this article is to describe the Physician Prescribed Educational Program (PPEP), an integrated series of programs that incorporate a formalized, structured evaluation strategy.
The PPEP is structured to determine: 1) The presence of deficits which are amenable to educational remediation, 2) The likelihood that an appropriate educational program can be developed, and 3) The structure of such a program.
Of 300 referrals, 100 have received evaluations thus far. A wide range of deficits were addressable, although there were specific exclusions to participation.
Administrators and others who wish to undertake these efforts should avail themselves of educational and other resources but should not expect rapid results. With careful planning and execution, these programs can provide appropriate and successful experiences for participants.
State medical boards discipline several thousand physicians each year. Although certain subgroups, such as those disciplined for malpractice, substance use, or sexual abuse, have been studied, little is known about disciplined physicians as a group.
To assess the offenses, contributing factors, and type of discipline of a consecutive series of disciplined physicians.
Case-control study on publicly available data matching 375 disciplined physicians with 2 groups of control physicians, one matched solely by locale, and a second matched for sex, type of practice, and locale.
All disciplined physicians publicly reported by the Medical Board of California from October 1995 through April 1997.
Characteristics of disciplined physicians, offenses leading to discipline, and type of discipline.
A total of 375 physicians licensed by the Medical Board of California (approximately 0.24% per year) were disciplined for 465 offenses. The most frequent causes for discipline were negligence or incompetence (34%), abuse of alcohol or other drugs (14%), inappropriate prescribing practices (11%), inappropriate contact with patients (10%), and fraud (9%). Discipline imposed was revocation of medical license (21%), actual suspension of license (13%), stayed suspension of license (45%), and reprimand (21%). Type of offense was significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians with controls matched by locale, board discipline was significantly associated with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval [CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI, 1.75-3.75). In the regression model with additional matching criteria, disciplinary action was negatively associated with specialty board certification (OR, 0.42; 95% CI, 0.29-0.60) and positively associated with being in practice more than 20 years (OR, 2.02; 95% CI, 1.39-2.92).
A small but substantial proportion of physicians is disciplined each year for a variety of offenses. Further study of disciplined physicians is necessary to identify physicians at high risk for offenses leading to disciplinary action and to develop effective interventions to prevent these offenses.
Noticing that moderately to severely incompetent physicians (as measured by a standardized assessment of physician competence) did not improve after traditional remedial continuing medical education (CME), the authors investigated the effects of a polyvalent, intensive, prolonged educational intervention on five physicians' competence.
The five physicians participated in a CME program that lasted three years and consisted of individualized review, ongoing small-group and evidence-based discussions, simulated patients and role playing, formal chart review, and peer review. At the end of the program, the physicians were reassessed.
Only one physician improved; another remained the same, and three deteriorated.
Successful remediation of severely incompetent physicians is uncertain at best, even with prolonged, intensive CME that incorporates modalities thought to be effective in changing physicians' behaviors. Alternative educational techniques may need to be developed for this select population. Conversely, there may be reasons that preclude improvement even with optimal techniques.
The recent Institute of Medicine (IOM) report on the quality of care, entitled “To Err Is Human,” has awakened much of the health care system to the challenge of reducing the number of adverse events in hospitals.1 The Agency for Healthcare Research and Quality is supporting research on methods of preventing injuries, and private industry is insisting on accountability. Many hospitals and their medical staffs are developing task forces to address the prevention of errors. Insurers and hospital associations are launching similar initiatives.2 Physicians and hospital leaders should welcome all these efforts; for too long we have been complacent about . . .
In recent years, professionalism in medicine has gained increasing attention. Many have called for a return to medical professionalism as a way to respond to the corporate transformation of the U.S. health care system. Yet there is no common understanding of what is meant by the word professionalism. To encourage dialog and to arrive eventually at some consensus, one needs a normative definition. The author proposes such a definition and asserts that the concept of medical professionalism must be grounded both in the nature of a profession and in the nature of physicians' work. Attributes of medical professionalism reflect societal expectations as they relate to physicians' responsibilities, not only to individual patients but to wider communities as well. The author identifies nine behaviors that constitute medical professionalism and that physicians must exhibit if they are to meet their obligations to their patients, their communities, and their profession. (For example, "Physicians subordinate their own interests to the interests of others.") He argues that physicians must fully comprehend what medical professionalism entails. Serious negative consequences will ensue if physicians cease to exemplify the behaviors that constitute medical professionalism and hence abrogate their responsibilities both to their patients and to their chosen calling.
Internal medicine residency training is demanding and residents can experience a wide variety of professional and personal difficulties. A problem resident is defined by the American Board of Internal Medicine as "a trainee who demonstrates a significant enough problem that requires intervention by someone of authority." Data are sparse regarding identification and management of such residents.
To gain more understanding of the prevalence, identification, management, and prevention of problem residents within US internal medicine residency programs.
Mailed survey of all 404 internal medicine residency program directors in the United States in October 1999, of whom 298 (74%) responded.
Prevalence of problem residents; type of problems encountered; factors associated with identification and management of problem residents.
The mean point prevalence of problem residents during academic year 1998-1999 was 6.9% (SD, 5.7%; range, 0%-39%), and 94% of programs had problem residents. The most frequently reported difficulties of problem residents were insufficient medical knowledge (48%), poor clinical judgment (44%), and inefficient use of time (44%). Stressors and depression were the most frequently identified underlying problems (42% and 24%, respectively). The most frequent processes by which problem residents were discovered included direct observation (82%) and critical incidents (59%). Chief residents and attending physicians most frequently identified problem residents (84% and 76%, respectively); problem residents rarely identified themselves (2%). Many program directors believed that residents who are from an underrepresented minority, are international medical graduates, or are older than 35 years are at increased risk of being identified as a problem resident (P<.05). Program directors believed that frequent feedback sessions (65%) and an assigned mentor for structured supervision (53%) were the most helpful interventions.
Nearly all internal medicine residency programs in this sample had problem residents, whose presenting characteristics and underlying issues were diverse and complex. JAMA. 2000;284:1099-1104
Since 1995, the University of California, San Francisco, School of Medicine has monitored students' professional behaviors in their third and fourth years. The authors recognized that several students with professionalism deficiencies during their clerkships had manifested problematic behaviors earlier in medical school. They also observed behaviors of concern--such as inappropriate behavior in small groups--in some first- and second-year students who could have been helped by early remediation. The authors describe the modifications to the evaluation system to bring professionalism issues to a student's attention in a new, earlier, and heightened way. In this new system for first- and second-year students, the course director of a student who has professionalism deficiencies submits a Physicianship Evaluation Form to the associate dean for student affairs, who then meets with the student to identify the problematic issues, to counsel, and to remediate. The student's behavior is monitored throughout the academic years. If the student receives two or more forms during the first two years and a subsequent form in the third or fourth year, this indicates a persistent pattern of inappropriate behavior. Then the physicianship problem is described in the dean's letter of recommendation for residency and the student is placed on academic probation. The student may be eligible for academic dismissal from school even if he or she has passing grades in all courses. The authors describe their experience with this system, discuss lessons learned, and review future plans to expand the system to deal with residents' mistreatment of students.
Board certification is often used as a surrogate indicator of provider competence, although few outcome studies have demonstrated its validity. The aim of this study was to compare the outcomes of patients who underwent surgical procedures under the care of an anesthesiologist with or without board certification.
Medicare claims records for 144,883 patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991 and 1994 were used to determine provider-specific outcome rates adjusted to account for patient severity and case mix, and hospital characteristics. Outcomes of 8,894 cases involving midcareer anesthesiologists, 11-25 yr from medical school graduation, who lacked board certification were compared with all other cases. Midcareer anesthesiologist cases were studied because this group had sufficient time to become certified during an era when obtaining certification was already considered important, and consequently had the highest rate of board certification. Mortality within 30 days of admission and the failure-to-rescue rate (defined as the rate of death after an in-hospital complication) were the two primary outcome measures.
Adjusted odds ratios for death and failure to rescue were greater when care was delivered by noncertified midcareer anesthesiologists (death = 1.13 [95% confidence interval, 1.00, 1.26], P < 0.04; failure to rescue = 1.13 [95% confidence interval, 1.01, 1.27], P < 0.04). Adjusting for international medical school graduates did not change these results.
When anesthesiology board certification is very common, as in midcareer practitioners, the lack of board certification is associated with worse outcomes. However, the poor outcomes associated with noncertified providers may be a result of the hospitals at which they practice and not necessarily their manner of practice.