Factors Associated With High-Severity Disciplinary Action by a State Medical Board: A Texas Study of Medical License Revocation
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《美国整骨期刊》
the Departments of Family Medicine (Cardarelli) and Osteopathic Manipulative Medicine (Licciardone) at the University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine.
Context: There has been an increase in research evaluating factors associated with disciplinary action of physicians by state medical boards. However, factors related to the severity of disciplinary action are lacking. By investigating these factors while controlling for the type of violation, the authors sought to determine whether physician characteristics influenced the process of disciplinary action by state medical boards.
Methods: Physicians disciplined by the Texas Medical Board between January 1, 1989, and December 31, 1998, were included in this case-controlled study (N=1129). Multivariate logistic regression analysis was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with license revocation, the most severe disciplinary action, compared with all other forms of disciplinary action combined.
Results: Anesthesiologists (OR, 2.45; 95% CI, 1.05–5.74), general practitioners (OR, 1.80; 95% CI, 1.01–3.19), and psychiatrists (OR, 2.68; 95% CI, 1.41–5.13), as well as those with multiple disciplinary actions (OR, 1.91; 95% CI, 1.29–2.83) were most susceptible to license revocation. The more years a disciplined physician was in practice, the greater risk he or she had of license revocation (OR, 1.05; 95% CI, 1.04–1.07).
Conclusions: Factors associated with a greater likelihood of license revocation for physicians are: primary medical specialty, number of years in practice, and a history of multiple disciplinary actions.
In the United States, the steady rise in disciplinary actions throughout the 1990s by state medical boards against physicians have led researchers to evaluate factors associated with this occurrence.1–5 However, there is little information related to the severity of disciplinary actions taken. State medical boards have the responsibility to uphold the medical practice act in their jurisdiction by investigating patient and peer complaints, holding hearings, and imposing disciplinary action when appropriate. When physicians are formally disciplined by state medical boards, the severity of disciplinary actions can vary greatly, from written reprimands or probation to license suspension or revocation. In the state of Texas, the Texas Medical Board is responsible for upholding Title 3 of the state's Occupations Code, which contains regulations for the health professions.7
The most common physician violations cited by state medical boards include medical negligence, inappropriate prescription practices, and substance abuse.1 The relationship between violation type and the severity of the disciplinary action taken remains unclear. State medical boards may determine the severity of the punishment based on the type of violation (eg, substance abuse compared with medical negligence). In addition, it is unknown whether physician characteristics, such as gender or medical specialty, may place them at higher risk for more severe types of disciplinary action.
The purpose of our study is to evaluate factors potentially associated with the most severe disciplinary action available to a state medical board when taking disciplinary action against a physician: license revocation.
Methods
All procedures for this retrospective analysis were reviewed and approved by the institutional review board at the University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine.
Data on physician sex, race, medical degree, primary specialty, method of licensure, years in practice, type of violation, and the type and number of disciplinary actions taken were obtained from the Texas Medical Board (TMB; formerly called the Texas Board of Medical Examiners). This study included physicians disciplined by the TMB between January 1, 1989, and December 31, 1998. Only the most recent instance of disciplinary action was analyzed for physicians with a history of multiple violations (ie, 1 vs 2). Exclusion criteria for TMB physician records were those with missing data and those documenting out-of-state violations.
Multivariate logistic regression analysis was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with physician license revocation, the most severe disciplinary action, compared with all other forms of disciplinary action combined. Hypotheses were tested at the .05 level of statistical significance using SYSTAT software (SPSS Inc, Chicago, Ill).7
Results
Most physicians in this retrospective review (N=1129) were men, white, graduates of allopathic medical schools in the United States, and specified primary care as their primary specialty (Table 1). Number of years in practice was positively associated with license revocation compared with all other types of disciplinary action combined (Table 2). In addition, the odds of license revocation were greater among anesthesiologists, general practitioners, and psychiatrists compared with family physicians. A history of multiple disciplinary actions (ie, 2 disciplinary actions) was also associated with license revocation.
Comments
Our study found several factors associated with the severity of disciplinary action taken by the TMB. Although previous researchers have analyzed physician characteristics as factors that placed physicians at risk of disciplinary action by state medical boards,1–4 those studies did not review the decision-making process of the boards themselves. Therefore, to study the process of disciplinary action in the TMB, we chose to analyze factors associated with high-severity disciplinary action while controlling for the type of violation.
In our analysis, the personal characteristics of disciplined physicians did not influence the TMB's decisions to take high-severity disciplinary action against them. This result suggests that TMB decisions during the study period were based on the specifics of the cases reviewed, substantiating the board's primary responsibility to protect patients in the state of Texas.
However, we found evidence that the TMB was more likely to revoke the license of physicians who had a history of disciplinary actions from the board (ie, 2 or more disciplinary actions). Unfortunately, the characteristics of physicians' practices, such as patient volume, staff, clinic location, and environmental factors, which may confound our findings, cannot be accounted for. In a similar study based in Ohio that was published in JAOA—The Journal of the American Osteopathic Association,4 researchers did not find an association between high-severity disciplinary action and multiple physician offenses.
A longer time in medical practice was also associated with an increased probability of medical license revocation. This factor has not been reported in similar studies. We suggest that the longer a physician practices medicine, the greater the number of patient encounters (ie, higher levels of patient "exposure"), resulting in greater potential for violations and subsequent disciplinary actions by state medical boards.
In the Ohio study,4 physician gender is not associated with high-severity disciplinary action. Although women are less likely to be disciplined by state medical boards than their male counterparts,1–4 once disciplinary action is taken, physician gender is not associated with high-severity disciplinary action.
Our results concur with those of the Ohio study4 in that the TMB did not impose high-severity penalties disproportionately between allopathically or osteopathically trained physicians. In addition, there seems to be no relationship between high-severity disciplinary action for allopathic physicians as trained in the United States or abroad.
Although family and general practitioners, obstetrician-gynecologists, and psychiatrists are at increased risk for disciplinary action,1,3 we found only anesthesiologists, general practitioners, and psychiatrists at increased risk for license revocation once disciplined.
The effect of board certification was not directly measured in our study. However, our study design categorized family medicine and general practice separately, and we believe that we can use these data as a proxy for board certification. Although not proven, one potential hypothesis is that because general practitioners lack formal specialized medical training, they may be prone to committing mistakes with more severe outcomes. However, we cannot exclude the possibility that state medical boards may punish more severely physicians who lack board certification.
Anesthesiology is a specialty at increased risk for disciplinary action in some studies,2 but not in others.1,3,4 Based on our findings, once an anesthesiologist is found to be at fault, the severity of disciplinary action by TMB is harsh.
Psychiatrists were most likely to have their licenses revoked. Additional studies are needed to confirm this finding, however, and to further evaluate factors that may be associated with this outcome.
Contrary to the results of the Ohio study,4 we found no increased risk of license revocation among physicians with substance abuse and prescription misuse violations. There was no increased risk for license revocation among the types of violations, except for "Other." In our study, however, criminal charges were included in the "Other" category, which most likely explains our statistically significant finding. Additional violation categories may have also contributed to the statistically significant finding in "Other," but the small number of such violators precluded a more stratified analysis.
There are several limitations to our study. The details of physician violations were not available in the TMB records that were provided to us. Because these data were unavailable, we were not able to determine the degree and severity of the violations themselves. For example, physician use of alcohol may affect professional conduct to the extent that there is a fatal patient outcome. Alternatively, another physician may suffer from alcohol dependence yet never commit a medical error. It is unknown whether the severity of TMB disciplinary actions was determined by the severity or outcome of the violation cited.
Another limitation that researchers using data gathered from state medical boards must confront is the temporal realities of state medical boards. Members serving on state medical boards serve several-year terms, possibly resulting in a fluctuation of the decision-making processes on these boards.
Conclusion
Although the findings of our study cannot be generalized nationally because medical boards and physician characteristics differ somewhat across the nation,4 it is our hope that they will create an impetus for further research on the importance of physician specialty, lack of board certification, and multiple disciplinary actions as predictors of license revocation. In addition, further studies are needed to evaluate the decision-making processes of state medical boards to ensure that there are no age, specialty, or degree biases. Programs aimed at addressing these factors and providing appropriate physician education or early intervention may be useful in mitigating the toll of license revocation on physicians and their patients.
References
1. Cardarelli R, Licciardone JC, Ramirez G. Predicting risk for disciplinary action by a state medical board. Tex Med.2004; 100:84 –90.
2. Morrision J, Wickersham P. Physicians disciplined by a state medical board. JAMA.1998; 279:1889 –1893.
3. Kohatsu ND, Gould D, Ross LK, Fox PJ. Characteristics associated with physician discipline: a case-control study. Arch Intern Med. 2004;164:653 –658.
5. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med.2004; 79:244 –249.
6. Tex Occup Code ch 164. Available at: http://www.tmb.state.tx.us/rules/codes/chapter164.php#164001. Accessed March 1, 2006.(Roberto Cardarelli, DO, M)
Context: There has been an increase in research evaluating factors associated with disciplinary action of physicians by state medical boards. However, factors related to the severity of disciplinary action are lacking. By investigating these factors while controlling for the type of violation, the authors sought to determine whether physician characteristics influenced the process of disciplinary action by state medical boards.
Methods: Physicians disciplined by the Texas Medical Board between January 1, 1989, and December 31, 1998, were included in this case-controlled study (N=1129). Multivariate logistic regression analysis was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with license revocation, the most severe disciplinary action, compared with all other forms of disciplinary action combined.
Results: Anesthesiologists (OR, 2.45; 95% CI, 1.05–5.74), general practitioners (OR, 1.80; 95% CI, 1.01–3.19), and psychiatrists (OR, 2.68; 95% CI, 1.41–5.13), as well as those with multiple disciplinary actions (OR, 1.91; 95% CI, 1.29–2.83) were most susceptible to license revocation. The more years a disciplined physician was in practice, the greater risk he or she had of license revocation (OR, 1.05; 95% CI, 1.04–1.07).
Conclusions: Factors associated with a greater likelihood of license revocation for physicians are: primary medical specialty, number of years in practice, and a history of multiple disciplinary actions.
In the United States, the steady rise in disciplinary actions throughout the 1990s by state medical boards against physicians have led researchers to evaluate factors associated with this occurrence.1–5 However, there is little information related to the severity of disciplinary actions taken. State medical boards have the responsibility to uphold the medical practice act in their jurisdiction by investigating patient and peer complaints, holding hearings, and imposing disciplinary action when appropriate. When physicians are formally disciplined by state medical boards, the severity of disciplinary actions can vary greatly, from written reprimands or probation to license suspension or revocation. In the state of Texas, the Texas Medical Board is responsible for upholding Title 3 of the state's Occupations Code, which contains regulations for the health professions.7
The most common physician violations cited by state medical boards include medical negligence, inappropriate prescription practices, and substance abuse.1 The relationship between violation type and the severity of the disciplinary action taken remains unclear. State medical boards may determine the severity of the punishment based on the type of violation (eg, substance abuse compared with medical negligence). In addition, it is unknown whether physician characteristics, such as gender or medical specialty, may place them at higher risk for more severe types of disciplinary action.
The purpose of our study is to evaluate factors potentially associated with the most severe disciplinary action available to a state medical board when taking disciplinary action against a physician: license revocation.
Methods
All procedures for this retrospective analysis were reviewed and approved by the institutional review board at the University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine.
Data on physician sex, race, medical degree, primary specialty, method of licensure, years in practice, type of violation, and the type and number of disciplinary actions taken were obtained from the Texas Medical Board (TMB; formerly called the Texas Board of Medical Examiners). This study included physicians disciplined by the TMB between January 1, 1989, and December 31, 1998. Only the most recent instance of disciplinary action was analyzed for physicians with a history of multiple violations (ie, 1 vs 2). Exclusion criteria for TMB physician records were those with missing data and those documenting out-of-state violations.
Multivariate logistic regression analysis was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with physician license revocation, the most severe disciplinary action, compared with all other forms of disciplinary action combined. Hypotheses were tested at the .05 level of statistical significance using SYSTAT software (SPSS Inc, Chicago, Ill).7
Results
Most physicians in this retrospective review (N=1129) were men, white, graduates of allopathic medical schools in the United States, and specified primary care as their primary specialty (Table 1). Number of years in practice was positively associated with license revocation compared with all other types of disciplinary action combined (Table 2). In addition, the odds of license revocation were greater among anesthesiologists, general practitioners, and psychiatrists compared with family physicians. A history of multiple disciplinary actions (ie, 2 disciplinary actions) was also associated with license revocation.
Comments
Our study found several factors associated with the severity of disciplinary action taken by the TMB. Although previous researchers have analyzed physician characteristics as factors that placed physicians at risk of disciplinary action by state medical boards,1–4 those studies did not review the decision-making process of the boards themselves. Therefore, to study the process of disciplinary action in the TMB, we chose to analyze factors associated with high-severity disciplinary action while controlling for the type of violation.
In our analysis, the personal characteristics of disciplined physicians did not influence the TMB's decisions to take high-severity disciplinary action against them. This result suggests that TMB decisions during the study period were based on the specifics of the cases reviewed, substantiating the board's primary responsibility to protect patients in the state of Texas.
However, we found evidence that the TMB was more likely to revoke the license of physicians who had a history of disciplinary actions from the board (ie, 2 or more disciplinary actions). Unfortunately, the characteristics of physicians' practices, such as patient volume, staff, clinic location, and environmental factors, which may confound our findings, cannot be accounted for. In a similar study based in Ohio that was published in JAOA—The Journal of the American Osteopathic Association,4 researchers did not find an association between high-severity disciplinary action and multiple physician offenses.
A longer time in medical practice was also associated with an increased probability of medical license revocation. This factor has not been reported in similar studies. We suggest that the longer a physician practices medicine, the greater the number of patient encounters (ie, higher levels of patient "exposure"), resulting in greater potential for violations and subsequent disciplinary actions by state medical boards.
In the Ohio study,4 physician gender is not associated with high-severity disciplinary action. Although women are less likely to be disciplined by state medical boards than their male counterparts,1–4 once disciplinary action is taken, physician gender is not associated with high-severity disciplinary action.
Our results concur with those of the Ohio study4 in that the TMB did not impose high-severity penalties disproportionately between allopathically or osteopathically trained physicians. In addition, there seems to be no relationship between high-severity disciplinary action for allopathic physicians as trained in the United States or abroad.
Although family and general practitioners, obstetrician-gynecologists, and psychiatrists are at increased risk for disciplinary action,1,3 we found only anesthesiologists, general practitioners, and psychiatrists at increased risk for license revocation once disciplined.
The effect of board certification was not directly measured in our study. However, our study design categorized family medicine and general practice separately, and we believe that we can use these data as a proxy for board certification. Although not proven, one potential hypothesis is that because general practitioners lack formal specialized medical training, they may be prone to committing mistakes with more severe outcomes. However, we cannot exclude the possibility that state medical boards may punish more severely physicians who lack board certification.
Anesthesiology is a specialty at increased risk for disciplinary action in some studies,2 but not in others.1,3,4 Based on our findings, once an anesthesiologist is found to be at fault, the severity of disciplinary action by TMB is harsh.
Psychiatrists were most likely to have their licenses revoked. Additional studies are needed to confirm this finding, however, and to further evaluate factors that may be associated with this outcome.
Contrary to the results of the Ohio study,4 we found no increased risk of license revocation among physicians with substance abuse and prescription misuse violations. There was no increased risk for license revocation among the types of violations, except for "Other." In our study, however, criminal charges were included in the "Other" category, which most likely explains our statistically significant finding. Additional violation categories may have also contributed to the statistically significant finding in "Other," but the small number of such violators precluded a more stratified analysis.
There are several limitations to our study. The details of physician violations were not available in the TMB records that were provided to us. Because these data were unavailable, we were not able to determine the degree and severity of the violations themselves. For example, physician use of alcohol may affect professional conduct to the extent that there is a fatal patient outcome. Alternatively, another physician may suffer from alcohol dependence yet never commit a medical error. It is unknown whether the severity of TMB disciplinary actions was determined by the severity or outcome of the violation cited.
Another limitation that researchers using data gathered from state medical boards must confront is the temporal realities of state medical boards. Members serving on state medical boards serve several-year terms, possibly resulting in a fluctuation of the decision-making processes on these boards.
Conclusion
Although the findings of our study cannot be generalized nationally because medical boards and physician characteristics differ somewhat across the nation,4 it is our hope that they will create an impetus for further research on the importance of physician specialty, lack of board certification, and multiple disciplinary actions as predictors of license revocation. In addition, further studies are needed to evaluate the decision-making processes of state medical boards to ensure that there are no age, specialty, or degree biases. Programs aimed at addressing these factors and providing appropriate physician education or early intervention may be useful in mitigating the toll of license revocation on physicians and their patients.
References
1. Cardarelli R, Licciardone JC, Ramirez G. Predicting risk for disciplinary action by a state medical board. Tex Med.2004; 100:84 –90.
2. Morrision J, Wickersham P. Physicians disciplined by a state medical board. JAMA.1998; 279:1889 –1893.
3. Kohatsu ND, Gould D, Ross LK, Fox PJ. Characteristics associated with physician discipline: a case-control study. Arch Intern Med. 2004;164:653 –658.
5. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med.2004; 79:244 –249.
6. Tex Occup Code ch 164. Available at: http://www.tmb.state.tx.us/rules/codes/chapter164.php#164001. Accessed March 1, 2006.(Roberto Cardarelli, DO, M)