Psychiatrists in Trouble: Licensure Actions Involving ABPN Diplomates and Candidates

1. Psychiatrists in Trouble: Licensure Actions Involving ABPN Diplomates and Candidates Dorthea Juul, Ph.D. American Board of Psychiatry and Neurology, Inc. April 21, 2010

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

3. 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

4. Licensure and Certification

5. 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 state’s “Medical Practice Act.”

6. 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.

7. 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.

8. 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

9. 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.”

10. 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.”

11. 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.

12. 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

13. 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)

14. Certification, continued • Lifetime vs. time-limited certificates • Recertification (cyclical)  Maintenance of Certification (continuous)

15. Literature Review

16. 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

17. 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

18. 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

19. 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

20. Disciplinary Action by Medical Boards and Prior Behavior in Medical School Conclusions • Professionalism should have a central role in medical academics and throughout one’s medical career • Our study supports the importance of identifying students who display unprofessional behavior

21. 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%)

22. 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

23. 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

24. 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

25. 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 Canada’s 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Physicians Disciplined by a State Medical Board Results, continued Factor associated with decreased risk of disciplinary action: • Specialty board certification

32. 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

33. 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

34. 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

35. 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

36. Characteristics Associated with Physician Discipline Results, continued Compared to internal medicine, these specialties had an decreased risk of disciplinary action: • Pediatrics • Radiology

37. Characteristics Associated with Physician Discipline Conclusion • Certain physician characteristics and medical specialties are associated with an increased likelihood of discipline

38. 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

39. 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-gynecology, family practice, and general practice than in other specialties

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. ABPN Licensure Policy

48. 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.

49. 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.

50. ABPN Licensure Policy A diplomate who no longer meets the Board’s 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.