Psychiatrists in Trouble: Licensure Actions Involving ABPN Diplomates and Candidates

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Psychiatrists in Trouble Licensure Actions
Involving ABPN Diplomates and Candidates

• Dorthea Juul, Ph.D.
• American Board of Psychiatry and Neurology, Inc.
• April 21, 2010

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Acknowledgements

• Larry Faulkner, M.D., President and CEO
• Stephen Glick, Manager, Credentials

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Overview

• Licensure and Certification
• Literature Review
• Disciplinary Action Notification System (DANS)
  and ABPN Procedures
• ABPN Diplomates State Medical Board Actions and
  Basis for Actions
• Implications for Physician Education and Future
  Research

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Licensure and Certification
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Licensure

• Under the 10th Amendment of the U.S.
  Constitution, states have the authority to
  regulate activities that affect health, safety
  and welfare of their citizens.
• States provide laws and regulations that outline
  the practice of medicine and the responsibility
  of the medical board to regulate that practice in
  the states Medical Practice Act.

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Licensure, continued

• Each state Act is unique therefore, there are
  some significant variations among states in how
  they address the privilege of practicing
  medicine.
• The licensure process is designed to ensure that
  practicing physicians have appropriate education
  and training and that they abide by recognized
  standards of professional conduct in treating
  patients.
• Licensed physicians must periodically re-register
  with the board.

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Licensure, continued

• On its own initiative or upon receipt of
  information reported by others, the state medical
  board investigates any evidence that appears to
  indicate that a physician is or may be
  incompetent, guilty of unprofessional conduct, or
  mentally or physically unable to engage safely in
  the practice of medicine or that the Medical
  Practice Act or the rules and regulations of the
  board have been violated.

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Licensure

• FSMB Federation of State Medical Boards
• 70 member medical licensing and disciplinary
  boards
• During 2009, state medical boards took 5,721
  actions against physicians, an increase of 342
  actions over 2008

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Certification

• Rosemary Stevens, American Medicine and the
  Public Interest A History of Specialization
• Arguably, specialization is the fundamental
  theme for the organization of medicine in the
  20th century.

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Certification, continued

• Kenneth Ludmerer, Time to Heal
• Identifies specialty and subspecialty
  certification as one of the positive actions
  taken over the last century to assure that
  medical practice was conducted at the highest
  possible level.

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Certification, continued

• While a medical license is legally required in
  order to treat patients, board certification
  implies a higher level of clinical expertise in a
  particular specialty and/or subspecialty of
  medical practice.
• Board certification is often needed for a
  physician to obtain hospital privileges and to
  contract with insurance companies.

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Certification, continued

• ABMS American Board of Medical Specialties
• 24 member boards
• Currently, certification is offered in 147
  specialties and subspecialties
• About 85 of U.S. physicians are (or have been)
  certified by an ABMS member board

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Certification, continued

• Requirements
• Successful completion of ACGME-accredited
  training
• License to practice medicine in at least one
  state, territory or possession of the U.S.
• Successful performance on certification
  examination(s)

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Certification, continued

• Lifetime vs. time-limited certificates
• Recertification (cyclical) ? Maintenance of
  Certification (continuous)

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Literature Review
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Disciplinary Action by Medical Boards and Prior
Behavior in Medical School

• Papadakis et al. (NEJM, 2005)
• Case control study of 235 graduates of three
  medical schools who were disciplined by one of 40
  state medical boards between 1990-2003
• 469 control physicians matched with the case
  physicians according to medical school and
  graduation year

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Disciplinary Action by Medical Boards and Prior
Behavior in Medical School

• Medical school predictor variables
• Presence/absence of narratives describing
  unprofessional behavior
• Grades
• Standardized test scores
• Demographic characteristics

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Disciplinary Action by Medical Boards and Prior
Behavior in Medical School

• Results
• Disciplinary action by a medical board was
  strongly associated with prior unprofessional
  behavior in medical school
• The types of unprofessional behavior most
  strongly linked with disciplinary action were
  severe irresponsibility and severely diminished
  capacity for self-improvement

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Disciplinary Action by Medical Boards and Prior
Behavior in Medical School

• Results, continued
• Disciplinary action also associated with low MCAT
  scores and poor grades in the first two years of
  medical school
• The association with these variables was less
  strong than that with unprofessional behavior

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Disciplinary Action by Medical Boards and Prior
Behavior in Medical School

• Conclusions
• Professionalism should have a central role in
  medical academics and throughout ones medical
  career
• Our study supports the importance of identifying
  students who display unprofessional behavior

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Performance During Internal Medicine Residency
Training and Subsequent Disciplinary Action by
State Licensing Boards

• Papadakis et al. (Ann Intern Med, 2008)
• Retrospective cohort study of 66,171 physicians
  who entered IM residency training in the U.S.
  from 1990-2000 and became ABIM diplomates
• No. of physicians with disciplinary actions 638
  (1)

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Performance During Internal Medicine Residency
Training and Subsequent Disciplinary Action by
State Licensing Boards

• Residency predictor variables
• Components of Residents Annual Evaluation
  Summary ratings
• ABIM certification examination scores

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Performance During Internal Medicine Residency
Training and Subsequent Disciplinary Action by
State Licensing Boards

• Results
• A low professionalism rating on the Residents
  Annual Evaluation Summary predicted increased
  risk for disciplinary action
• High performance on the ABIM certification
  examination predicted decreased risk for
  disciplinary action

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Performance During Internal Medicine Residency
Training and Subsequent Disciplinary Action by
State Licensing Boards

• Conclusion
• These findings support the ACGME standards for
  professionalism and cognitive performance and the
  development of best practices to remediate these
  deficiencies

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Physician Scores on a National Clinical Skills
Examination as Predictors of Complaints to
Medical Regulatory Authorities

• Tamblyn et al. (JAMA, 2007)
• Cohort study of 3,424 physicians (generalists and
  specialists) who took the Medical Council of
  Canadas clinical skills licensure examination
  between 1993 and 1996 and entered practice in
  Ontario and/or Quebec
• 17 subsequently had at least one retained
  patient complaint to provincial medical
  regulatory authorities

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Physician Scores on a National Clinical Skills
Examination as Predictors of Complaints to
Medical Regulatory Authorities

• Predictor variables
• Scores on clinical skills licensure examination
  (20 cases based on standardized patients with
  physician raters)
• Scores on written licensure examination

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Physician Scores on a National Clinical Skills
Examination as Predictors of Complaints to
Medical Regulatory Authorities

• Results
• Scores achieved in patient-physician
  communication and clinical decision making on a
  national licensing examination predicted
  complaints to medical regulatory authorities

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Physician Scores on a National Clinical Skills
Examination as Predictors of Complaints to
Medical Regulatory Authorities

• Conclusion
• Direct observation and assessment of patient
  communication skills may be useful in identifying
  trainees who are more likely to experience
  difficulties in practice

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Physicians Disciplined by a State Medical Board

• Morrison and Wickersham (JAMA, 1998)
• Case-control study of 375 physicians disciplined
  by the Medical Board of California from October
  1995-April 1997 two control groups one matched
  by locale, and a second matched for sex, type of
  practice, and locale

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Physicians Disciplined by a State Medical Board

• Results
• Factors associated with increased risk of
  disciplinary action
• Male gender
• Involvement in direct patient care
• Being in practice more than 20 years

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Physicians Disciplined by a State Medical Board

• Results, continued
• Factor associated with decreased risk of
  disciplinary action
• Specialty board certification

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Physicians Disciplined by a State Medical Board

• Conclusions
• 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

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Characteristics Associated with Physician
Discipline

• Kohatsu et al. (Arch Intern Med, 2004)
• Unmatched, case-control study of 890 physicians
  disciplined by the Medical Board of California
  between July 1, 1998, and June 30, 2001, compared
  with 2,981 randomly selected, nondisciplined
  controls

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Characteristics Associated with Physician
Discipline

• Results
• Factors associated with an elevated risk for
  disciplinary action
• Male gender
• Lack of board certification
• Increasing age
• International medical school education

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Characteristics Associated with Physician
Discipline

• Results, continued
• Compared to internal medicine, these specialties
  had an increased risk of disciplinary action
• Family medicine
• General practice
• Obstetrics and gynecology
• Psychiatry

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Characteristics Associated with Physician
Discipline

• Results, continued
• Compared to internal medicine, these specialties
  had an decreased risk of disciplinary action
• Pediatrics
• Radiology

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Characteristics Associated with Physician
Discipline

• Conclusion
• Certain physician characteristics and medical
  specialties are associated with an increased
  likelihood of discipline

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Physicians Disciplined for Sex-Related Offenses

• Dehlendorf and Wolfe (JAMA, 1998)
• Subjects were 761 physicians disciplined for
  sex-related offense from 1981-1996
• Predictor variables specialty, age, and board
  certification status

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Physicians Disciplined for Sex-Related Offenses

• Results
• Compared with all physicians, physicians
  disciplined for sex-related offenses were more
  likely to practice in the specialties of
  psychiatry, child psychiatry, obstetrics-gynecolog
  y, family practice, and general practice than in
  other specialties

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Physicians Disciplined for Sex-Related Offenses

• Results, continued
• Physicians disciplined for sex-related offenses
  were also
• Older than the national physician population
• No different in board certification status

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Physicians Disciplined for Sex-Related Offenses

• Conclusion
• Discipline against physicians for sex-related
  offenses is increasing over time and is
  relatively severe, although few physicians are
  disciplined for sexual offenses each year

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Psychiatrists Disciplined by a State Medical Board

• Morrison and Morrison (AJP, 2001)
• Subjects were 584 physicians disciplined by the
  California Medical Board in a 30-month period
  compared with matched groups of nondisciplined
  physicians

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Psychiatrists Disciplined by a State Medical Board

• Results
• Compared to nonpsychiatrists, psychiatrists were
• Significantly more likely to be disciplined for
  sexual relationships with patients
• About as likely to be charged with negligence or
  incompetence

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Psychiatrists Disciplined by a State Medical Board

• Results, continued
• Disciplined and nondisciplined psychiatrists did
  not differ on
• Number of years since medical school graduation
• IMG status
• Board certification

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Psychiatrists Disciplined by a State Medical Board

• Conclusions
• 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

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Literature Summary

• Performance in medical school and residency and
  on licensure and certification examinations has
  been predictive of subsequent behavior in
  practice
• Risk factors for disciplinary action included
  psychiatry specialty, male gender, and increasing
  age
• Board certification was associated with a
  decreased risk in some studies

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ABPN Licensure Policy
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ABPN Licensure Policy

• ABPN candidates and diplomates must hold an
  active and unrestricted allopathic and/or
  osteopathic license to practice medicine in at
  least one state, commonwealth, territory, or
  possession of the United States or province of
  Canada.

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ABPN Licensure Policy

• If licenses are held in more than one
  jurisdiction, all licenses held by the physician
  must be full and unrestricted to meet this
  requirement.

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ABPN Licensure Policy

• A diplomate who no longer meets the Boards
  licensure requirements shall, without any action
  necessary by the Board or any right to a hearing,
  automatically lose his or her diplomate status in
  all specialties and subspecialties for which the
  individual has received a certificate from the
  Board, and all such certificates shall be invalid.

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Disciplinary Action Notification System (DANS)
and ABPN Procedures
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DANS

• DANS Disciplinary Action Notification System
• Beginning in 2004, the ABMS began receiving
  automated reports on licensure actions from the
  FSMB these reports are forwarded to member
  boards
• To date ABPN has received approximately 2600
  reports about candidates (active and inactive)
  and diplomates

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ABPN Procedures

• DANS report received
• Credentials staff review report and determine
  whether to obtain additional information from
  FSMB
• Based on FSMB report, additional information
  ordered from state medical board(s)

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ABPN Procedures, continued

• Credentials staff review all information and
  determine if a candidate does not qualify for
  examination or if a diplomates certificate(s)
  is/are invalid
• Courtesy notification sent to physician with 30
  days to respond
• Candidates application is denied and/or
  certificate has been invalid since licensure
  action

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ABPN Procedures, continued

• If no response in 30 days, physician is asked to
  return certificate(s)
• ABMS is notified about change in diplomate status

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ABPN Procedures, continued

• Reinstatement of Application
• Physician notifies Board in writing that all
  licenses are now full and unrestricted
• Credentials staff review documentation from
  applicable state licensing board(s)
• If approved, candidate may apply for examination

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ABPN Procedures, continued

• Reinstatement of ABPN Diplomate Status
• Physician notifies Board in writing that all
  licenses are now full and unrestricted
• Credentials staff review documentation from
  applicable state licensing board(s)
• If approved, diplomate is assigned a new
  certificate number and sent a new certificate
• All certificates will be 10-year, time-limited
  certificates, regardless of the certificate
  previously held

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Results for ABPN Diplomates
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Results for Three ABPN Cohorts

• This presentation will focus on three diplomate
  cohorts those certified in 1990, 1995, and 2000

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Results for Three ABPN Cohorts

• Across these three cohorts, DANS notifications
  were received for 115 psychiatrists, 38
  neurologists, and 3 child neurologists
• They represent about 4 of the psychiatrists, 3
  of the neurologists, and 2 of the child
  neurologists

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State Medical Board Actions
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State Medical Board Actions

• Loss of License or Licensed Privilege Includes
  revocation, suspension, surrender or mandatory
  retirement of license, or loss of privileges
  afforded by that license
• Restriction of License or Licensed Privilege
  Includes probation, limitation, or restriction of
  license, or licensed privileges

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State Medical Board Actions, continued

• Other Prejudicial Actions Modification of a
  physicians license, or the privileges granted by
  that license, that results in a penalty or
  reprimand, etc., to the physician
• Non-Prejudicial Actions An action that does not
  result in modification or termination of a
  license or licensing privileges and is frequently
  administrative in nature, such as a reinstatement
  following disciplinary action

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State Medical Board Actions
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Basis for Disciplinary Action
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Basis for Disciplinary Action

• The basis for disciplinary action taken by the
  state medical board is detailed in the following
  slides
• Many of the physicians had multiple bases/actions
• Different states may code infractions
  differently

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Basis for Disciplinary Actions Taken by State
Medical Board
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Basis for Disciplinary Actions Taken by State
Medical Board, cont.
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Basis for Disciplinary Actions Taken by State
Medical Board, cont.
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Basis for Disciplinary Actions Taken by State
Medical Board, cont.
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Basis for Disciplinary Actions Taken by State
Medical Board, cont.
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Basis for Disciplinary Actions Taken by State
Medical Board, cont.
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Examples
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Case 1

• A psychiatrist saw a patient for treatment of
  depression. In the course of treatment the
  psychiatrist and patient engaged in a romantic
  and sexual relationship. Over time they met at
  various places such as restaurants, parks, and
  outdoor recreation areas where they engaged in
  sex. They talked on the phone and sent text
  messages and cards to one another. The
  relationship ended when the doctor sent a text
  message of a personal nature that was apparently
  meant for another woman. The patient attempted
  suicide.

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Case 1, continued

• State medical board action(s)
• Indefinite suspension of medical license
• ABPN action
• ABPN certificate invalid

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Case 2

• A psychiatrist was convicted of felony Medicaid
  fraud and larceny for overbilling Medicaid by
  about 250,000. He also had a history of
  chemical dependency. He attended a Physician
  Health Program for several years.

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Case 2, continued

• State medical board action(s)
• License revoked in State 1
• License surrendered to avoid adverse action in
  State 2, based on State 1 action
• License revoked in State 3 based on conviction
  for felony
• State 4 granted licensure with restrictions and
  conditions, then removed conditions, and then
  reinstated conditions
• Currently has a license with conditions in State
  4 other licenses are revoked (State 3) or
  surrendered (State 2), and one expired on
  probation (State 1)

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Case 2, continued

• ABPN action
• ABPN certificate invalid

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Case 3

• A psychiatrist was evaluated and diagnosed with
  substance use disorder and was required to
  complete treatment. She initially complied then
  left and returned to treatment several times and
  suffered relapses.

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Case 3, continued

• State medical board action(s)
• License indefinitely suspended
• ABPN action
• ABPN certificate invalid

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Case 4

• A psychiatrist has bipolar disorder and admitted
  engaging in bizarre behavior. He is being
  monitored by a Physician Health Plan and must
  meet with a psychiatrist and a psychotherapist
  and abstain from alcohol and other mood-altering
  substances unless prescribed by his primary
  health care practitioner.

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Case 4, continued

• State medical board action(s)
• License suspended in three states
• License reinstated with conditions in one state
• ABPN action
• ABPN certificate invalid

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Case 5

• A psychiatrist failed to disclose on his license
  renewal form that he had been denied licensure in
  another state. The licensure denial was for
  unprofessional conduct, practicing without a
  license, and not being physically present during
  billed for time.

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Case 5, continued

• State medical board action(s)
• License restricted in state 1
• License denied in state 2
• Licenses expired in 18 other states
• ABPN action
• ABPN certificate invalid

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Conclusions
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Conclusions

• Small, but consistent, numbers of psychiatry
  diplomates of the ABPN have action taken against
  them by state medical boards
• Psychiatrists may be at somewhat greater risk for
  such action than neurologists/child neurologists

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Conclusions, continued

• The most common bases for these actions are
  professional/ethical misconduct, substance
  use/abuse, and violation of boundaries, including
  sexual misconduct

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Implications for Physician Education

• Research indicates that those who display
  problematic behavior during medical school and
  residency are at greater risk for licensure
  actions later in their careers
• Hence, it is important to emphasize competence
  AND professionalism-related issues during
  training and to address deficiencies and
  problematic behaviors

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Implications for Physician Education

• Hauer et al. (Academic Medicine, 2009)
• There is surprisingly little evidence to guide
  best practices of remediation in medical
  education at all levels.

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Implications for Future Research

• Further explore the relationship between
  performance on certification examinations and
  licensure actions
• Further explore the relationship between
  licensure actions and participation in MOC

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Questions?