Psychiatrists in Trouble: Licensure
Actions Involving ABPN
Diplomates and Candidates
Dorthea Juul, Ph.D.
American Board of Psychiatry and
Neurology, Inc.
April 21, 2010
1
Acknowledgements
• Larry Faulkner, M.D., President and CEO
• Stephen Glick, Manager, Credentials
2
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
3
Licensure and Certification
4
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.”
5
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.
6
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.
7
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
8
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.”
9
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.”
10
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.
11
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
12
Certification, continued
Requirements
• Successful completion of ACGMEaccredited training
• License to practice medicine in at least one
state, territory or possession of the U.S.
• Successful performance on certification
examination(s)
13
Certification, continued
• Lifetime vs. time-limited certificates
• Recertification (cyclical)  Maintenance of
Certification (continuous)
14
Literature Review
15
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
16
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
17
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
18
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
19
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
20
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%)
21
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
22
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
23
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
24
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
25
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
26
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
27
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
28
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
29
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
30
Physicians Disciplined by a State
Medical Board
Results, continued
Factor associated with decreased risk of
disciplinary action:
• Specialty board certification
31
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
32
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
33
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
34
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
35
Characteristics Associated with
Physician Discipline
Results, continued
Compared to internal medicine, these
specialties had an decreased risk of
disciplinary action:
• Pediatrics
• Radiology
36
Characteristics Associated with
Physician Discipline
Conclusion
• Certain physician characteristics and
medical specialties are associated with an
increased likelihood of discipline
37
Physicians Disciplined for SexRelated 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
38
Physicians Disciplined for SexRelated Offenses
Results
• Compared with all physicians, physicians
disciplined for sex-related offenses were
more likely to practice in the specialties of
psychiatry, child psychiatry, obstetricsgynecology, family practice, and general
practice than in other specialties
39
Physicians Disciplined for SexRelated Offenses
Results, continued
Physicians disciplined for sex-related offenses
were also:
• Older than the national physician population
• No different in board certification status
40
Physicians Disciplined for SexRelated 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
41
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
42
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
43
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
44
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
45
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
46
ABPN Licensure Policy
47
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.
48
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.
49
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.
50
Disciplinary Action Notification
System (DANS) and ABPN
Procedures
51
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
52
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)
53
ABPN Procedures, continued
• Credentials staff review all information and
determine if a candidate does not qualify for
examination or if a diplomate’s
certificate(s) is/are invalid
• Courtesy notification* sent to physician
with 30 days to respond
* Candidate’s application is denied and/or certificate has been
invalid since licensure action
54
ABPN Procedures, continued
• If no response in 30 days, physician is asked
to return certificate(s)
• ABMS is notified about change in
diplomate status
55
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
56
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
57
Results for ABPN Diplomates
58
Results for Three ABPN Cohorts
This presentation will focus on three
diplomate cohorts: those certified in 1990,
1995, and 2000
59
ABPN Diplomates with DANS Actions:
1990, 1995, 2000
No. with DANS
Actions/
No. Certified
(%)
No. with DANS
Actions/
No. Certified
(%)
No. with DANS
Actions/
No. Certified
(%)
1990
1995
2000
Psychiatry
Total = 115
41/967 (4%)
40/1066 (4%)
34/1097 (3%)
Neurology
Total = 38
18/357 (5%)
13/367 (4%)
7/422 (2%)
Child
Neurology
Total = 3
1/45 (2%)
0/28 (0%)
2/51 (4%)
Cohort
60
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
61
ABPN Psychiatry Diplomates with DANS Actions:
1990, 1995, 2000
Passed Part I
on First
Attempt
Passed Part II
on First
Attempt
Certified in a
Subspecialty
Psychiatry
Total = 115
95/115
83%
75/115
65%
31/115
27%
All New
Candidates
1998-2002
75%
61%
-----
62
State Medical Board Actions
63
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
64
State Medical Board Actions,
continued
• Other Prejudicial Actions: Modification of a
physician’s 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
65
State Medical Board Actions
1990, 1995, 2000 Psychiatry Cohorts (n = 115)
Actions
Number (%)
Loss of license or license
59 (51%)
privileges
Restriction of license or
license privileges
57 (50%)
Other prejudicial action
80 (70%)
Non-prejudicial action
48 (42%)
66
Basis for Disciplinary Action
67
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
68
Basis for Disciplinary Actions Taken
by State Medical Board
Category
Number (%)
Professional/ethical
misconduct
63 (55%)
Substance use/abuse
34 (30%)
Boundary issues (includes
sexual misconduct)
26 (23%)
Mental/Physical Impairment
21 (18%)
Inappropriate prescribing
16 (14%)
Convicted of crime
14 (12%)
69
Basis for Disciplinary Actions Taken
by State Medical Board, cont.
Category
Number (%)
Failure to conform to
standards of practice
12 (10%)
Inadequate medical records
12 (10%)
Negligence
11 (10%)
70
Basis for Disciplinary Actions Taken
by State Medical Board, cont.
Category
Number (%)
Committed fraud
6 (5%)
Immediate danger to the
public health, safety, or
welfare
Failure to comply with CME
requirements
Moral turpitude/unfitness
4 (3%)
4 (3%)
3 (3%)
71
Basis for Disciplinary Actions Taken
by State Medical Board, cont.
Category
Number (%)
Loan default
2 (2%)
Inadequate supervision of
staff
Practicing without a license
2 (2%)
1 (1%)
72
Basis for Disciplinary Actions Taken
by State Medical Board, cont.
Category
Number (%)
Action taken by another
board/agency
35 (30%)
Failure to comply with state
board requirements after
action has been taken
27 (23%)
73
Basis for Disciplinary Actions Taken
by State Medical Board, cont.
Category
Number (%)
Falsification of licensure
application
4 (3%)
Failure to notify board of
address change
Time lapse since active
practice
2 (2%)
1 (1%)
74
Examples
75
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.
76
Case #1, continued
State medical board action(s):
• Indefinite suspension of medical license
ABPN action:
• ABPN certificate invalid
77
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.
78
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)
79
Case #2, continued
ABPN action:
• ABPN certificate invalid
80
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.
81
Case #3, continued
State medical board action(s):
• License indefinitely suspended
ABPN action:
• ABPN certificate invalid
82
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 moodaltering substances unless prescribed by his
primary health care practitioner.
83
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
84
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.
85
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
86
Conclusions
87
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
88
Conclusions, continued
• The most common bases for these actions
are professional/ethical misconduct,
substance use/abuse, and violation of
boundaries, including sexual misconduct
89
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
90
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.”
91
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
92
Questions?
93