Ten ways to help state medical boards better protect patients
Although Doctors Behaving Badly tends to focus on exactly what you would expect, its mission is to make people aware of the many ways that patients are left unprotected.
There are nearly 1 million licensed, practicing physicians nationwide. Antidote has no ability to count how many are "behaving badly," but it is safe to say that only a slim minority are tainting the reputation of the medical community. Doctors who abuse, injure or kill patients are the surrogate markers for an illness in the physician discipline system. They are not the illness.
To treat the illness, Antidote offers these (mostly) simple steps for state boards, gleaned from the nationwide tour we concluded this week.
1. Talk to each other. There's no good reason for a doctor to lose his license for overprescribing dangerous drugs in Colorado but remain fully licensed in Minnesota. Boards clearly don't have a good way of communicating with each other. Doctors should not be allowed to testify to one state board about what actions another state board has taken. If Orange County sheriff deputies were following up a case that crossed into Los Angeles County, they would get on the phone and call deputies in LA. Instead, boards take it on faith that doctors are telling the truth on their applications or in board hearings. Also, boards in different states rarely talk to each other about doctors who are licensed multiple places. That's why Idaho can be so concerned about a doctor's lack of skills that it bans him from performing 46 specific cosmetic surgery procedures while Wyoming, next door, does nothing.
2. Use the National Practitioner Data Bank. Medical boards are not using the data bank to see if a doctor applying for a license has a disciplinary history. According to data reviewed by Antidote, the Michigan Board of Medicine and Michigan Board of Osteopathic Medicine and Surgery oversee a combined 43,849 doctors. Yet, these boards only made 21 queries to the NPDB from 2007 through 2009. That's 1 query for every 2,088 doctors. In contrast, the South Dakota Board of Medical and Osteopathic Examinersoversees about 1,300 doctors. It queried the data bank 1,331 times. There's no reason for these ratios to be so out of whack.
3. Widen the network. Boards need to start public awareness campaigns among the local, state and federal agencies that might come in contact with a physician or someone pretending to be one. Give them all magnets with the medical board's phone number. "Nabbed an MD on a DUI? Call 1-800-DOC-AHOL!" Or "Somebody's lying about being an MD? Call 1-800-NOT-A-DOC!" Hand them out to malpractice attorneys, courthouse clerks and, especially, nurses.
4. Follow practice guidelines. Reading board hearing transcripts can lead a consumer to believe that there are no standards for practicing medicine. The only standard is which expert is more persuasive: the one the board hires to review the doctor's record or the one the doctor hires to defend him. That's why you can have a board tying itself in knots to help a doctor explain why he would have a pregnant teen-ager touch her own cervix in front of him or why he would other pregnant women get up on all fours while he stood behind them to conduct an examination. But there are standards. As Dr. Doris Cope from the American Society of Anesthesiologists explained to Antidote, pain medicine is an area where guidelines have been ignored for too long. We have seen this all across the country, and we think that if more boards just looked at rules laid out by groups that certify physicians in their specialties, there would be less debate and more meaningful discipline.
5. Create three strikes rules where appropriate. For the 51 doctors highlighted in this tour, 18 had been disciplined once or not at all by the state in question.Another 19 had been disciplined twice. The other 16 had been disciplined three or more times. Of those, I wish I could say all had lost their licenses, but, in reality, only six had their licenses revoked or were forced to surrender them. There doesn't seem to be a good reason for a doctor to be allowed to go through the disciplinary process 12 times before losing his license, as happened in Montana. Let's go back to "by the state in question." Many of the doctors already had disciplinary histories in other states, so, even though a doctor may have been disciplined once in Alaska, he may also have been disciplined in New York or elsewhere. Boards should look at the totality of a doctor's history and see if there are three cases in all states combined that warrant a permanent revocation. Perhaps three cases of harming, abusing or killing patients would be sufficient.
6. Help doctors get help. Antidote has said this before, but doctors should not be left hanging when a state runs an unsuccessful treatment program for physicians. Medicine is a high-stress field with access to all kinds of drugs. A doctor who has had a problem with addiction may otherwise be a great clinician, but, from my vantage point, I don't see a lot of success stories of boards helping doctors get back on track. Instead, doctors bounce from treatment program to treatment program with little follow-up.
One question boards should ask is: how many physicians have been successfully rehabilitated through a particular inpatient or outpatient treatment program? If the track record is weak, the state should choose a different program. And, once doctors are again working under a restricted license, don't let them choose their own practice monitors. This type of buddy system leads to exactly what you would expect: one friend letting another cut corners. If the practice monitor is board-appointed and completely independent of the offending physician, there is likely to be more accountability and more pressure to make sure the physicians are following the rules.
7. Make searching idiot-proof. Every board should add a Google-style search window to their site. Too many boards force consumers to pick from a menu of more than 100 different licensed professionals and to know a doctor's exact first name and last name. A last name like Levi-D'Ancona can turn up nothing because its hyphen and apostrophe throw off the board's antiquated database. And patients may know a doctor by "Dr. Greg" while the doctor's full name is Kevin Gregory Smith.
Boards, too, should find a way to work together to create a database where patients can search for profiles on every doctor in the country. Administrators In Medicine does this for about half the medical boards, but imperfectly. Medicare just unveiled its own doctor database, but, as I will explain next week, the site is difficult to use and short on details.
8. Remove time limits. Boards should not be dropping records off their websites every year. They should be building user friendly profiles that include all the disciplinary history records for a physician. Let patients decide whether something that happened in 1986 and then again in 1997 is relevant in 2010. This is what the Minnesota Board of Medical Practice and the Wisconsin Medical Examining Board have done. While the Medical Board of California, which has one of the most intuitive websites of any board, only keeps records active for 10 years.
9. Ask for volunteers. The boards that have told Antidote they are trying to build a larger online archive of physician records all complain about the same thing: time. Scanning records can be tedious and eat up valuable staff hours. Antidote made a suggestion at the Consumers Union Safe Patient Summit in Austin earlier this year: Why don't boards allow patient safety advocates and other volunteers to scan records for them? If state boards said they would allow volunteers to sign up one day a week for the next 52 weeks, I bet volunteers could scan the entire misbehaving doctor back-catalog. I'm going to make a small effort to kick-start this volunteer project by scanning some of the records I have obtained over the past year and sending them to the boards with the request that they be donated to the public good by being provided online for free. Why not? I've already paid for someone at the board to copy them and mail them to me. Shouldn't others benefit, too?
10. Give patients more opportunities to share their stories. After many of the posts that I have written, I have received emails from patients saying, "The same thing happened to me." These include patients who have been lured into destructive relationships with physicians, patients who have been hooked on addictive drugs and people who have lost a family member at the hands of an unskilled doctor. I always ask, "Did you complain to the medical board?" Rarely do they say that they have. Boards spend most of their public outreach efforts on reaching the physicians they oversee, but they have to, at a minimum, leverage their oversight role by requiring physicians and hospitals to make consumers aware of the board's. This could be as simple as the "How's My Driving?" approach. Just have doctors put signs up in their offices or provide patients with notices about how to contact the board. This is something California started requiring this year. And patients need to be persistent. As Antidote reported in writing about a Rhode Island physician who had a pattern of fondling patients, a patient had accused an anesthesiologist of sexual abuse only to see the case go nowhere. When she saw the same doctor accused again in the media, she came forward, and her testimony helped persuade the board to take the doctor's license away.
Health writers can help boards improve by writing about these cases where boards are ignoring their public protection missions. Of the 51 disciplinary cases covered in this tour of state medical boards, only 13 had been written about by other media outlets before Antidote covered the case. One of the cases that was missed by the media was a doctor whose license was finally revoked after attempting to buy military-grade weapons in order to export them to Iran. Many other doctors written about by Antidote had been featured in news stories as experts. Either their disciplinary histories were ignored at the time or, when they ended up in trouble later, there was no follow-up. More writers need to follow the lead of Marilynn Marchione at the Associated Press and look more closely at the doctors they quote, even if it takes them a few months to set the record straight.
In writing about these doctors, health writers need to look for ways to place blame judiciously and name names. The fact that the Oklahoma medical board has allowed a doctor with repeated drug addiction problems to continue practicing after four suspensions and two revocations in 20 years should make news, as should the fact that the Lyle R. Kelsey, theboard's chief executive, worked for 18 years for the Oklahoma State Medical Association, the state's lobbying group for physicians. Help these boards improve by being specific about what has gone wrong. Call out inconsistencies in discipline, roadblocks to providing important public information and other trends that put patients at risk. The St. Louis Post-Dispatch, the Orange County Register, the Wisconsin State Journal, andCalifornia Watch all have done a great job pointing out specific weaknesses in the way states fulfill their patient protection missions.
The truth is, there are hundreds of thousands of doctors saving lives, improving health and treating patients with dignity every day. Finding a better way to weed out the dangerous minority of physicians (and fake physicians) who are unskilled, addicted or unprincipled will allow the truly great doctors to do their jobs better, too.
I'd be remiss if I did not thank Jenn Harris for all of her digging and document chasing this year. She found about half of the doctors that I profiled. And thanks go, too, to Barbara Feder Ostrov for her thoughtful and careful editing this year and to Michelle Levander for making Reporting On Health a thriving, creative community.
Thanks go to you, too, for sticking with me. It's a bit much to expect readers to hang with a series once and often twice a week for a year. Your suggestions have made the posts stronger and kept me going when I was losing steam. If you have any more thoughts, please write email@example.com.