Morrison J, Wickersham P. Physicians Disciplined by a State Medical Board. JAMA. 1998;279(23):1889-1893. doi:10.1001/jama.279.23.1889
From the Department of Veterans Affairs Medical Center Coatesville, Coatesville, Pa (Dr Morrison); and the Department of Clinical Biostatistics, Wyeth-Ayerst Research, Radnor, Pa (Mr Wickersham).
Context.— State medical boards discipline several thousand physicians each year.
Although certain subgroups, such as those disciplined for malpractice, substance
use, or sexual abuse, have been studied, little is known about disciplined
physicians as a group.
Objective.— To assess the offenses, contributing factors, and type of discipline
of a consecutive series of disciplined physicians.
Design.— Case-control study on publicly available data matching 375 disciplined
physicians with 2 groups of control physicians, one matched solely by locale,
and a second matched for sex, type of practice, and locale.
Subjects.— All disciplined physicians publicly reported by the Medical Board of
California from October 1995 through April 1997.
Main Outcome Measures.— Characteristics of disciplined physicians, offenses leading to discipline,
and type of discipline.
Results.— A total of 375 physicians licensed by the Medical Board of California
(approximately 0.24% per year) were disciplined for 465 offenses. The most
frequent causes for discipline were negligence or incompetence (34%), abuse
of alcohol or other drugs (14%), inappropriate prescribing practices (11%),
inappropriate contact with patients (10%), and fraud (9%). Discipline imposed
was revocation of medical license (21%), actual suspension of license (13%),
stayed suspension of license (45%), and reprimand (21%). Type of offense was
significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians
with controls matched by locale, board discipline was significantly associated
with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval
[CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI,
1.75-3.75). In the regression model with additional matching criteria, disciplinary
action was negatively associated with specialty board certification (OR, 0.42;
95% CI, 0.29-0.60) and positively associated with being in practice more than
20 years (OR, 2.02; 95% CI, 1.39-2.92).
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.
IN 1996 in the United States, the regulatory bodies that investigate
and adjudicate alleged violations of law, ethics, or practice standards reported
3653 prejudicial disciplinary actions against physicians.1
The nature of these complaints varied widely from inadequate record keeping
to allegations of malpractice or criminal activity. Penalties ranged from
revocation or suspension of medical license to a public notice that the practitioner
had been found involved in wrongdoing.
The Federation of State Medical Boards (FSMB) compiles annual data on
physician discipline for all US jurisdictions. State medical boards publish
annual statistics on complaints received and how they are settled. Many medical
boards publish the names of disciplined physicians (DPs). Despite the apparent
magnitude of the problem and its implications for patient care, relatively
little has been published in the medical literature about the general characteristics
of these DPs.
Previous reports have focused on loss of insurance coverage,2 negligence or incompetence,3
malpractice (a legal term not synonymous with negligence or incompetence),4- 8
impairment by substance abuse or mental illness,9- 12
sexual misconduct with patients,13,14
misrepresentation of credentials,15 and inappropriate
prescribing practices.16,17 In
a description of actions taken against a series of physicians in New York
State during the 1980s, Post18 focused on the
disciplinary process to the near exclusion of data about the DPs themselves.
Donaldson19 described problematic behaviors
in a series of 49 British physicians from 1 hospital over a 5-year period.
A literature search from 1970 through November 1997 found no reports of a
controlled, consecutive series of physicians disciplined by a medical board.
Approximately 104000 physicians—about 15% of those licensed in
the United States—are licensed by the Medical Board of California (MBC).20 Each year the board investigates approximately 10000
complaints about physicians made by the public (approximately 63%), government
agencies (19%), insurers (14%), and other miscellaneous sources (4%).20 About 80% of these complaints are closed after initial
staff inquiry reveals lack of face validity; of the 20% assigned for investigation,
prosecution is recommended in about one fourth.20
Half of these—about 250 per year—ultimately result in disciplinary
Like many other states, California invokes the following 4 main levels
of discipline: (1) Reprimand is the mildest form of discipline and signals
behavior that, while cause for concern, does not warrant more substantial
punishment. (2) Probation, in which the physician's license is technically
suspended or revoked for up to 10 years. However, if that action is stayed,
the physician can continue to practice provided certain conditions (eg, additional
education, psychiatric examination) are observed. (3) Actual suspension of
license, which ranges from a few days to 6 months or longer and usually leads
to a longer period of probation. (4) Permanent revocation of license, which
the physician may either contest or accept by default.
All recipients of formal discipline are listed in Action Report, a quarterly publication mailed to every health care
professional licensed by California. The entries in Action
Report are prepared by a senior investigator working from a concise
abstract of charges used by the judge. These entries are checked for accuracy
and completeness by a different MBC staff member; before publication, the
work is reviewed by a third staff member. The published information includes
name, city and state of record, cause and severity of the discipline, and
whether disciplinary action was taken in response to the action of another
For this study, we reviewed and abstracted data for all DPs listed in Action Report issues from October 1995 through April 1997. Action Report data were augmented by information from the Directory of Physicians in the United States.21
This biennial publication lists more than 723000 physicians and reports medical
school and year of graduation, current address, date of first license in that
jurisdiction, self-designated specialties, type of practice (training, patient
care, administration/research, retired or otherwise inactive), specialty certification,
and possession of the Physician's Recognition Award. Any further data necessary
were obtained by request from the MBC.
We also selected 2 control groups of physicians for comparison with
the study group. The first control group comprised, for each DP, the next
physician listed in the Directory of Physicians in the United
States21 who matched for location (city
and state). The second control group was composed of an equal number of physicians,
matched with each DP for location, sex, and type of practice. The same data
as were obtained for DPs were recorded for physicians in each control group.
Reasons for imposing discipline were similar to those cited by Post,18 with "miscellaneous" reasons divided into other crimes,
misrepresentation of credentials, and employment of or working for an unlicensed
entity. When physicians were disciplined for multiple offenses, the principal
cause was usually clear from the Action Report documentation.
In the 14 cases for which the prinicipal cause was not evident, the principal
cause was assigned according to 2 rules: (1) Substance abuse and mental disorders
took precedence when mentioned because these offenses often induce abnormal
behaviors. (2) More serious charges (negligence or incompetence, sexual or
otherwise inappropriate patient contact, fraud and other illicit financial
dealings, other crimes) took precedence over behaviors that carry less potential
Multivariate logistic regression models were used to identify factors
associated with disciplinary action. Due to a lack of previous research in
this area, we attempted to keep explanatory variables binary, thus limiting
the number of parameters estimated in the model and preserving the overall
power of the models to detect significant differences. Given a sample size
of 375 pairs of cases and controls and assuming the estimated proportions
of disciplined physicians in the controls and cases to be 0.1 and 0.2, respectively,
odds ratios (ORs) of at least 1.79 could be detected with 80% power.22
Factors of interest were entered into regression models stepwise and
retained based on the residual score statistic.23
Physician sex and type of practice (direct patient care or other) were examined
in the control group matched for location. Time of practice (≤20 years
or >20 years), international medical education (domestic and/or foreign),
board certification (yes or no), Physician's Recognition Award (yes or no),
and specialty were included in the analysis of the control group matched for
location and for other characteristics. Association of the type of offense
and severity of punishment was tested using Cochran-Mantel-Haenszel methods.24 All tests were based on a significance level of .05
with a Bonferroni correction for multiple comparisons. Data were analyzed
using the SAS System (Version 6.12; SAS Institute, Inc, Cary, NC).
During the 18-month study period analyzed, 375 California physicians
(a rate of approximately 0.24% per year) were reported to have received some
form of disciplinary action by the state medical board. Of these, 103 (27%)
were currently living in another state or jurisdiction. During the same interval,
another 73 physicians voluntarily surrendered their licenses, thereby halting
the investigative process.
Of the 375 DPs, 32 (9%) were women, and 288 (77%) had been in practice
at least 20 years. A total of 327 (87%) were involved in direct patient care,
31 (8%) were retired or inactive, 11 (3%) were in academic administrative
practice, and 6 (2%) were resident physicians. Compared with controls matched
by location, DPs were less likely to be women (OR, 0.44; 95% confidence interval
[CI], 0.28-0.70) and were more likely to be involved in direct patient care
(OR, 2.56; 95% CI, 1.75-3.75).
Compared with controls matched by location, sex, and type of practice,
DPs were more likely to have been in practice more than 20 years and were
less likely to be board certified. Of the self-reported specialties with sufficient
numbers for meaningful comparison, only anesthesia and psychiatry appeared
overrepresented among DPs, although neither reached statistical significance
The 375 physicians had been disciplined for a total of 465 offenses(Table 2). Seventy-four physicians (19%)
had been disciplined for multiple offenses (58 for 2 offenses, 16 for 3) but
accounted for 29 unstayed revocations (36%), 13 actual suspensions from practice
(27%), 29 actions that were stayed (17%), and 3 letters of reprimand (4%).
Multiple offenders were more likely (OR, 3.18; 95% CI, 1.91-5.28) than single
offenders to receive severe discipline (unstayed revocation or actual days
Overall, 130 DPs (35%) received severe discipline (Table 3). These included 15 physicians (79%) who were cited principally
for mental or physical impairment, 7 (58%) who had violated probation, and
19 (54%) who had committed fraud. For all other categories, rates of severe
discipline ranged from 11% (working for an unlicensed entity) to 41% (sexual
or inappropriate conduct). Public reprimand most often resulted from the lesser
offenses in the "other" category, although 14 (33%) of the 42 actions for
drug prescriptions and dispensing were reprimands. Generalized Mantel methods
showed a significant association between type of offense and ordered severity
of punishment (P=.03). Women were more likely (OR,
2.65; 95% CI, 1.30-5.41) than men to be disciplined severely. Type of practice
did not significantly differentiate male from female physicians.
The 73 physicians who had voluntarily relinquished their licenses had
graduated an average of 10 years earlier than DPs, although their areas of
specialty did not differ significantly (data not shown). Insofar as could
be deduced from available records, their alleged principal offenses were on
average more serious than those of the DP group—40 (65%) of 61 that
could be clearly ascertained were related to incompetence (n=27) or sexual
In our study of physicians disciplined by a state medical board, we
evaluated 375 principal offenses and 465 total offenses and found that no
single cause for action dominated these data. The largest component, accounting
for about one third of all cases, was negligence or incompetence. Kusserow
et al25 found that incompetence contributed
only minimally to the total of medical board actions and suggested that it
and sexual impropriety were difficult for medical boards to pursue. Post18 noted that negligence or incompetence was the most
common (28% of all actions) category in the spectrum of physician offenses
in New York State.
California law requires judgments against physicians to be reported
to MBC, which evaluates these cases and assigns an investigator whenever it
seems that negligence or incompetence, sexual misconduct, or unprofessional
conduct appears to be involved. With charges eventually filed in about 5%
of cases, MBC officials estimate that approximately 20% of disciplinary actions
stem from malpractice suits. Available data do not permit further characterization
of these physicians or comparison with the larger group of DPs. However, if
the percentage of actions related to negligence or incompetence is any guide,
MBC appears to be dealing with physician incompetence more successfully than
medical boards did a decade ago.
Comprising nearly one fifth of all causes for disciplinary action, issues
related to physicians' health were the next most common cause for action.
The 3:1 ratio of abuse of alcohol or other drugs to physical or other mental
disorders is similar to findings reported by Shore11,12
in a series of impaired physicians. Talbott et al26
reported that medical licensure had been affected in only about one third
of chemically impaired physicians, suggesting that there are more impaired
physicians practicing unsupervised than were identified by the California
board. However, during the study period, 43 additional chemically dependent
physicians were involved in the California state diversion program.20 These physicians were largely self-referred (only
a few entered the program in lieu of disciplinary action) and the total number
of these physicians is small. If included as DPs, they probably would have
only minimally reduced the average severity of discipline. Overall, the data
reaffirm the continuing importance of physician impairment as a cause of discipline,
although physical illness appears to be a less frequent source of physician
impairment than mental disorder and substance abuse.
Illegal activities and other inappropriate voluntary behaviors not associated
with mental disorders or substance abuse precipitated another strong minority
of actions. Sexual misconduct constituted the major offense for 10% of DPs,
although that proportion seems low considering reports that up to 9% of physicians
admit having sex with 1 or more patients.27
Post18 found that throughout the 1980s, 24%
of the DP cases in New York State resulted from fraud, which caused only 9%
of actions in our present data. These offenses included kickback schemes and
overt theft from patients, but the vast majority represented illegal billing
or Medicaid fraud. Misrepresenting credentials was a principal or secondary
offense of only 8 DPs (2%). This proportion also seems small compared with
similar problems reported by 2 other studies: misrepresentation by 5% of physicians
applying to 1 health care organization15 and
false claims of board certification by nearly 18% of 650 Veterans Administration
physicians.28 In aggregate, these factors suggest
that, despite a 50% increase in the percentage of MBC disciplinary actions
in 4 years,20 many actionable offenses may
go unreported or unaddressed.
Of all DPs, 12 (3%) were cited in part for violation of previous disciplinary
action, compared with only 1 probation violation (of 221) mentioned by Post.18 This discrepancy may reflect the recent increase
in disciplinary actions, which creates more physicians on probation who can
violate the stipulations of their probation. Bloom et al16
found more malpractice claims than expected among physicians who had been
investigated for prescribing practices, and Bovbjerg and Petronis5 reported that a history of malpractice payout predicted
Most offenses by DPs involve some aspect of patient care (negligence
or incompetence, inappropriate prescribing, sexual contact, Medicare fraud)
or tend to attract attention in the context of patient care, such as substance
abuse or mental impairment. Even the 11 physicians primarily involved in academics
and administration had offenses in the context of patient care: negligence
or incompetence in 6 cases, substance abuse in 3, and inappropriate sexual
contact with a patient in 1. Only 1 instance of research fraud related to
a physician's academic duties was reported. Marked underrepresentation of
physicians in training (ie, only 6 physicians in residency or fellowship were
disciplined) may reflect the close supervision residents receive and is in
agreement with speculation2 that it takes time
to develop a detectable pattern of discipline-prone behavior. The only previous
study with relevant data9 reported that more
than 65% of anesthesiologists who abused substances worked in an academic
setting, either as faculty or trainee, but selective referral patterns as
an explanation of the finding could not be ruled out.
Although the Bonferroni correction precludes definite conclusions, 2
specialties—anesthesiology and psychiatry—appeared somewhat overrepresented
among DPs. Previous studies reported special risk for malpractice, addiction,
sexual misconduct, or other disciplinary problems among anesthesiologists8,19,26 or psychiatrists.13,19,29 However, several
studies have reported that psychiatrists are at especially low risk for malpractice-related
contradictory findings suggest the need for further evaluation of the possibility
that some specialties carry extra risk for behaviors (eg, substance abuse
or sexual relationships with patients) that can lead to physician discipline.
Kusserow et al25 reported a consensus
of medical boards that educational quality of international medical graduates
was a premier problem facing American medicine. Our data do not support this
assertion, as we found that international medical graduates were not overrepresented
as receiving discipline. Schwartz and Mendelson2
found no excess of international medical graduates among physicians who had
lost their malpractice insurance.
In our study, DPs were more likely than controls to lack specialty certification,
which nearly all relevant prior studies have found to be inversely correlated
with disciplinary actions. Adamson et al4 reported
that surgeons terminated from a trust for having a high malpractice claim
rate were less likely to have completed a fellowship or to be board certified.
Caulford et al3 found that board certification
was an independent predictor of competence for family practicioners.
Underrepresentation of women among DPs also has been a consistent finding.
Galanter et al30 noted that only 7 of 100 impaired
physicians were women, and Gallegos et al9
found that females composed only 5% of impaired physicians (at that time)
but 15% of all physicians nationally. These data are not especially surprising,
given that women generally have a lower incidence of substance abuse. Taragin
et al8 reported that male physicians were 3
times more likely than female physicians to be at high risk for malpractice.
They suggested that female physicians may interact more effectively with patients,
reducing the likelihood of complaint. Levinson et al31
have recently demonstrated that effective communication reduces malpractice
risk. Although the small number of female DPs in our study does not allow
meaningful statistical comparison, the current data suggest that, when women
are disciplined, it is for the same spectrum of offenses as men, including
inappropriate personal relationships with patients.
However, female DPs in our study appeared to be disciplined more severely
than male physicians. This finding may reflect the fact that women were less
likely than men to surrender their licenses voluntarily (1 woman in 73) before
board action could be completed. Voluntary resignation of additional female
(or fewer male) physicians who received severe discipline would have reduced
the apparent sex discrepancy. Two other possible explanations, that female
physicians are only referred for board scrutiny when the offense is particularly
egregious, or once referred, women are held to a higher standard of conduct,
are unsupported by available evidence. Indeed, female physicians with substance
abuse problems may be less likely than male physicians with substance abuse
problems to have actions taken against their licenses.32
More study of sex differences, including voluntary surrender of license, among
DPs is necessary.
Several factors address the generalizability of a study based on the
actions of a single medical board. First, as the most populous state, California
has under license approximately 15% of all physicians registered in the United
States. Second, discipline reported by other jurisdictions prompted 27% of
the California board actions. Third, the FSMB's composite action index1 is the arithmetic mean of the 4 possible pairings
of total actions or total prejudicial actions with total licensed or total
practicing physicians within a state. Although published with a statistical
caveat about using this hybrid score to compare state boards, for 1996 the
composite action index ranks California near the median (23 of 52) of major
reporting jurisdictions. We believe that available data place California well
within the mainstream of medical board experiences. Nonetheless, because this
is the only controlled study to survey a consecutive sample of DPs, these
findings must be confirmed by reports from other jurisdictions. Also, because
our analyses were exploratory in nature with the purpose of promoting further
study, our results should be viewed with caution.
In the face of increasing consumer complaints,33
our data suggest that medical boards may have increased their ability (and
resolve) to deal with physicians who commit offenses that require discipline.
Despite these efforts, definitive national data about the number of physicians
disciplined per year are lacking. In 1996, the FSMB reported1
that more than 3200 physicians received discipline nationally, but this figure
makes no allowance for the fact that many actions are taken by reciprocity
with other medical boards and do not represent additional physicians or even
new offenses. The apparent increase in disciplined physicians could be partly
an artifact of improved reporting. If FSMB created a national unduplicated
count of DPs, monitoring and analysis of physician disciplinary actions would
be enhanced. If the California data reflect national experience and 75% of
those reported represent unduplicated data, approximately 2400 physicians
nationally are disciplined each year. Further study of DP populations may
help identify in advance those individuals likely to violate 1 or more standards
of practice. Efforts to identify these physicians represent an important aspect
of the medical profession's struggle to protect patients and to ensure the
delivery of quality care.