1. 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. 2 Acknowledgements Larry Faulkner, M.D., President and CEO Stephen Glick, Manager, Credentials

3. 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. 4 Licensure and Certification

5. 5 Licensure Under the 10 th 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. 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. 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. 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. 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 20 th century.”

10. 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. 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. 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. 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. 14 Certification, continued Lifetime vs. time-limited certificates Recertification (cyclical)  Maintenance of Certification (continuous)

15. 15 Literature Review

16. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 31 Physicians Disciplined by a State Medical Board Results, continued Factor associated with decreased risk of disciplinary action: Specialty board certification

32. 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. 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. 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. 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. 36 Characteristics Associated with Physician Discipline Results, continued Compared to internal medicine, these specialties had an decreased risk of disciplinary action: Pediatrics Radiology

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

38. 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. 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. 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. 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. 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. 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. 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. 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. 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. 47 ABPN Licensure Policy

48. 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. 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. 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.

51. 51 Disciplinary Action Notification System (DANS) and ABPN Procedures

52. 52 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

53. 53 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)

54. 54 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

55. 55 ABPN Procedures, continued If no response in 30 days, physician is asked to return certificate(s) ABMS is notified about change in diplomate status

56. 56 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

57. 57 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

58. 58 Results for ABPN Diplomates

59. 59 Results for Three ABPN Cohorts This presentation will focus on three diplomate cohorts: those certified in 1990, 1995, and 2000

60. 60 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 (%) Cohort199019952000 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%)

61. 61 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

62. 62 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%-----

63. 63 State Medical Board Actions

64. 64 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

65. 65 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

66. 66 State Medical Board Actions 1990, 1995, 2000 Psychiatry Cohorts (n = 115) ActionsNumber (%) Loss of license or license privileges 59 (51%) Restriction of license or license privileges 57 (50%) Other prejudicial action80 (70%) Non-prejudicial action48 (42%)

67. 67 Basis for Disciplinary Action

68. 68 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

69. 69 Basis for Disciplinary Actions Taken by State Medical Board CategoryNumber (%) Professional/ethical misconduct 63 (55%) Substance use/abuse34 (30%) Boundary issues (includes sexual misconduct) 26 (23%) Mental/Physical Impairment21 (18%) Inappropriate prescribing16 (14%) Convicted of crime14 (12%)

70. 70 Basis for Disciplinary Actions Taken by State Medical Board, cont. CategoryNumber (%) Failure to conform to standards of practice 12 (10%) Inadequate medical records12 (10%) Negligence11 (10%)

71. 71 Basis for Disciplinary Actions Taken by State Medical Board, cont. CategoryNumber (%) Committed fraud6 (5%) Immediate danger to the public health, safety, or welfare 4 (3%) Failure to comply with CME requirements 4 (3%) Moral turpitude/unfitness3 (3%)

72. 72 Basis for Disciplinary Actions Taken by State Medical Board, cont. CategoryNumber (%) Loan default2 (2%) Inadequate supervision of staff 2 (2%) Practicing without a license1 (1%)

73. 73 Basis for Disciplinary Actions Taken by State Medical Board, cont. CategoryNumber (%) Action taken by another board/agency 35 (30%) Failure to comply with state board requirements after action has been taken 27 (23%)

74. 74 Basis for Disciplinary Actions Taken by State Medical Board, cont. CategoryNumber (%) Falsification of licensure application 4 (3%) Failure to notify board of address change 2 (2%) Time lapse since active practice 1 (1%)

75. 75 Examples

76. 76 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.

77. 77 Case #1, continued State medical board action(s): Indefinite suspension of medical license ABPN action: ABPN certificate invalid

78. 78 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.

79. 79 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)

80. 80 Case #2, continued ABPN action: ABPN certificate invalid

81. 81 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.

82. 82 Case #3, continued State medical board action(s): License indefinitely suspended ABPN action: ABPN certificate invalid

83. 83 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.

84. 84 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

85. 85 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.

86. 86 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

87. 87 Conclusions

88. 88 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

89. 89 Conclusions, continued The most common bases for these actions are professional/ethical misconduct, substance use/abuse, and violation of boundaries, including sexual misconduct

90. 90 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

91. 91 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.”

92. 92 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

93. 93 Questions?