An Evaluation of Clinicians with Subsequent Disciplinary Actions: Washington Medical Commission

The distressed chronic pain practitioner is nothing new. A minority of physicians have, throughout time, been willing to sell prescriptions for controlled substances without bothering to obtain a history and work up the patient’s complaint, perform a physical exam, arrive at a proper diagnosis, utilize testing or consultation, chose a rational treatment plan or properly monitor their patients. As a board investigator and private consultant, I have conducted more than 1,000 reviews of such dangerous practices.Many experts in the fields of drug diversion, addiction medicine and chronic pain medicine state the recent development and mass marketing of high-dosage “long acting” CII (schedule two) narcotics has created new exploitative opportunities for drug abusers and diverters. Because the majority of chronic pain practitioners are well educated, compassionate, conscientious and make substantial efforts to minimize drug abuse and diversion, the problem must lie elsewhere — and in reality, it does.Enter the distressed chronic pain practitioner. These are problematic physicians or other prescribing providers who, through errors of omission or commission, endanger patients or society. Many such errors are related to controlled substance prescribing, but many more are errors of a more fundamental nature.A number of common themes often surface when one studies the distressed chronic pain practitioner. In most situations, although the practitioners involved are self-declared experts in chronic pain medicine, they usually have no formal training in chronic pain medicine or any history of studying under a qualified mentor in a prolonged clinical fashion. Many distressed chronic pain practitioners lack any sort of comprehensive CME participation in recognized chronic pain educational programs, do not belong to professional pain treatment organizations and do not read recognized current textbooks or journals regarding chronic pain medicine. It appears that in a large number of cases, their main source of chronic pain diagnostic and treatment information is limited to what is supplied by pharmaceutical industry representatives and their patients. Another more common trait of those who have recently declared themselves to be chronic pain specialists is they frequently have failed to flourish in the specialty of medicine in which they were formally trained. Factors contributing to these failures may be related to professional incompetency, personality problems, ethical problems, organic cognitive impairment, poor business judgments, psychiatric issues or ongoing substance abuse.Twenty years ago, an otherwise failing physician could be kept afloat economically by “assisting” in a few major surgical procedures each week. Also, without competition from midlevel providers, there was more plentiful work for distressed physicians in underserved geographical regions, governmental positions and in group practices where their shortcomings were tolerated as long as they limited their practices to simple cases.The current economic outlook for a distressed physician is more bleak. Hospital privileges, insurance panels, liability companies and governmental positions now scrutinize providers to a degree that eliminates many distressed practitioners’ economic options. These economic bars to practice are still separate from those of medical regulatory boards and the Drug Enforcement Administration (DEA). In fact, it is this separation that enables many distressed practitioners to possess the two critical necessities for opening up a self-declared specialty practice in chronic pain medicine: a valid state, provincial or territorial license and a current DEA registration number.It is more common to encounter practitioners who have transformed themselves into self-declared chronic pain specialists who have been fired by an employer; lost their hospital privileges; been forced out of group practices; are not accepted to bill under Medicare, Medicaid or private insurance companies; been refused entry into the military or other government positions; or who cannot or will not purchase medical liability insurance. These poorly qualified pain specialists are frequently responsible for harm to their patients and society at large. The case presentation below is a typical example.A 55-year-old OB-GYN M.D. closed her practice and filed for bankruptcy after several serious medical malpractice cases were settled out of court. Two months later this physician moved to a remote rural town, opened a new practice and declared herself a “board-certified chronic pain specialist.” In fact, her only board certification was in OBGYN. She advertised in the local papers and soon developed a large chronic pain practice that attracted patients from well over 100 miles away. Within a few weeks of opening her practice, the gossip around town was the physician would collect $50 for each controlled substance prescription she wrote. This doctor saw an average of 60 patients per day, Monday through Saturday. A concerned local E.R. physician complained to the medical board that the physician’s patients were presenting to the emergency room with life-threatening signs of drug overdose. The medical board had the case for approximately one year, but took no action. Finally, undercover law enforcement agents documented the physician was not taking histories, performing exams, ordering lab tests or other studies or consultations and was charging $75 per prescription. Shortly thereafter, the doctor’s practice was closed by law enforcement agents. Several patients died as a result of accidental drug overdoses prescribed by this physician, and charges were brought against her for trading prescriptions for sexual favors from patients. It should be noted this physician had no training or interest in learning about pain medicine. Estimates from law enforcement are she prescribed well in excess of 10,000 doses of CII controlled substances per day, six days a week. The amounts of CIII (schedule three) substances prescribed were even larger, but more difficult to estimate, as many of these were phone prescriptions with multiple refills to pharmacies in at least two other states.Interviews revealed this physician opened up a chronic pain medicine practice because she needed money quickly. She also admitted to having a deep need to “finally have a successful practice” and enjoyed working with “patients who really depended on me for help.” She repeatedly stated, “I have no responsibility for what my patients do with their pain medicines. I am not a cop.” She dismissed her lack of histories, exams, urine testing, other diagnostic procedures, any treatments other than controlled substances, informed consent, treatment contract, and specialty consultations as either completely irrelevant or as impossible to do because she had “way too many patients to see and help out each day.” After law enforcement raided and closed the doctor’s practice, the state medical board suspended her license pending further investigation. She has been officially charged with manslaughter, prescribing violations and sexual crimes against patients. Confidential interviews with the doctor’s local colleagues revealed that all of them knew she was running a “drug mill” and could not believe the medical board took so long to take action.Although I serve as a consultant in helping problem practitioners, the aforementioned physician is probably not a good candidate for many reasons. Her interest in and knowledge of general outpatient medicine, pharmacology and chronic pain medicine was minimal. She showed no desire to learn about how to properly diagnose, treat and monitor chronic pain patients. In addition, this physician’s track record is replete with poor medical judgments and even poorer ethical decisionmaking. It is highly unlikely she would respond favorably.Another new problem category is composed of midlevel providers, nurse practitioners and physician assistants who are usually employed by busy chronic pain practices. Again, many of these providers lack any formal training in chronic pain medicine and sometimes also lack appropriate physician supervision. Such poorly supervised midlevel chronic pain prescribing can lead to disastrous results.A new form of distressed chronic pain physicians has only begun to surface. This group is made up of physicians who perform invasive office-based procedures and whose only interventional training has been short CME courses on such procedures as nerve blocks. PowerPoint slide shows and brief cadaver labs do not an interventionist make.In many situations, practice remediation can be successful. During evaluation and practice remediation every effort is made to preserve the dignity and confidentiality of the doctor/patient relationship and to avoid embarrassment or negativity. Such practices need some degree of ongoing practice monitoring in order to prevent practitioner back-sliding into unsafe practices. With well-crafted board orders and written releases, the status of a physician’s post-remediation compliance can be regularly communicated to regulatory boards, hospitals, attorneys, partners, medical insurance companies, liability carriers and other governmental entities. Please see my article “Guidelines for Medical Board Investigators and Consultants Dealing with Distressed Pain Medicine Practices,” published in the Volume 91, Number 2, issue of the Journal, for more details on evaluation and remediation.The present situation is clear: Either physicians and other stakeholders need to seriously deal with prescription drug abuse and diversion, or the government will do it. The medical profession must better train and police itself in order to avoid being forced to take many giant steps backward into a setting where chronic pain patients were undertreated, ignored, shamed or labeled as hypochondriacs and malingerers. The time to act has come.

Who to Believe? Consequences for Physicians and Nurses Who Spread Misinformation

Misconduct in clinical research jeopardizes the integrity of medical science. Physician researcher misconduct that produces flawed results has consequences, including the subsequent inability of other physicians who rely on erroneous data to provide informed consent and/or accurate assessment of pharmaceutical and medical device efficacy and safety. This deviation from acceptable medical practice can directly harm patients. How state medical boards address this clinical problem is uncertain. To examine this issue, we asked 51 U.S. medical boards to search their databases for disciplinary action in response to physician researcher misconduct (PRM) from 1996 thru early 2007. We compared their responses with data from federal agencies responsible for disciplinary actions against clinical researchers. Our results demonstrated: i) a high percentage (45 percent) of U.S. medical boards indicated that they did not have or could not provide access to data adequate to address whether or not disciplinary action for PRM had been levied in their states and ii) of respondents able to make relevant information available, we identified only 13 cases of physician disciplinary action for PRM. In contrast, several dozen examples of disciplinary action against physicians for serious clinical research misconduct could be readily documented in publicly accessible data from federal regulatory agencies.

At first glance, the lusterless title and grave-grey book jacket of this monograph tend to discourage one from ever starting a most thought-provoking, easy-reading, absorbing argument. Robert C. Derbyshire, a past president of the Federation of State Medical Boards and now secretary-treasurer of the New Mexico Board of Medical Examiners, has written a serious, somber work that warrants the attention of every physician. And although the facts offered are mostly morbid, there is, between the lines, a hope, plea, and directions for something better. This book is much more than a simple history of state medical licensing boards. It is more an account of the inadequacy of those medical boards and what little, if any, appropriate disciplinary action they have undertaken. History, for history's sake (along with background philosophy) is kept to the very minimum, other than to point out just how the past has led to the present turmoil

INTRODUCTION The passing of the 10th anniversary of Oregon’s unique Death with Dignity Act occurred unremarkably, with one notable exception: soon it may no longer stand alone. After several failed attempts, right-to-die advocates in the state of Washington are once again attempting to vault into the dispute; taking on religious groups, right-to-life organizations, and even the federal government to advance the right-to-die movement. Such legislation places medical providers unequivocally in the center of one of the most impassioned debates this nation has engaged in since Roe v Wade, and compels physician assistants (PAs) to evaluate their own attitudes and ethics when confronted with a terminally ill patient making the ultimate request. To place this in perspective, most PAs will be confronted during their careers with patients who are diagnosed with a terminal illness. Continuing involvement with that patient until the end is an obligation, especially where a pre-existing established relationship exists between the PA and the patient. Although providing it can sometimes be discomforting and unpleasant, patients need competent and informed care at this decisive juncture, and being competent entails comprehending all treatment alternatives, even those that cause moral distress. This is especially true in jurisdictions where a patient may query the PA on the rules of self-termination. However, solid foundation in this arena must begin with the fundamentals: at the PA program level. Then as states evolve legislation is this setting (and arguably they will), the PA profession will be a respected leader. Like Oregon’s, Washington’s proposal was advanced through the “public initiative” process, as opposed to through state congressional legislation. Washington, like approximately half the states in the nation, enjoys the option of pursuing legislation through public initiative. This method requires that signatures on petitions be obtained from representative portions of the state. In July 2008, Washingtonians garnered more than 300,000 signatures, far exceedThe Just Ethics feature is a forum for sharing insights, experiences, and literature on how we do and should teach ethics to our students. All who teach the subject of professional behavior and bioethics are invited to share their personal insights, experiences, and approaches to teaching this foundational and essential topic. Authors desiring to contribute to Just Ethics should forward submissions to:

The aim of the study was to determine the relationship between performance on the American Board of Physical Medicine and Rehabilitation primary certification examinations and the risk of subsequent disciplinary actions by state medical boards over a physician's career. The hypothesis is that physicians who do not pass either or both of the two initial specialty certification examinations are at higher risk of disciplinary action from a state medical licensing board. This is a retrospective cohort study that analyzed board certification examination data from all physicians who completed physical medicine and rehabilitation residency between 1968 and 2017. Matching examination and license data were available for 9889 physical medicine and rehabilitation physicians, who received a total of 547 disciplinary action reports through the Federation of State Medical Boards. The results showed a significant correlation between failing an American Board of Physical Medicine and Rehabilitation certification examination and the risk of subsequent disciplinary action by a state medical board. Failure to pass either the written (Part I) or oral (Part II) examination increased the risk of subsequent disciplinary action by 5.77-fold (P < 0.0001, 95% confidence interval = 4.07-8.18). Physicians in physical medicine and rehabilitation who do not pass initial certification examinations and become board certified are at higher risk of disciplinary action from a state medical licensing board throughout their careers.

Physicians, Patients, Sex and Chaperones: Rethinking Medical Regulation

As a result of recently passed legislation in Idaho, the Idaho State Board of Medicine is now housed within the Idaho Division of Occupational and Professional Licensing (IDOPL). The Division is responsible for administering licenses to dozens of professions and businesses in Idaho, working from three sections: Building, Construction and Real Estate; Occupational Licenses; and Health Professions. The Board of Medicine is in the Health Professions section, along with the state’s boards of Dentistry, Nursing, Pharmacy, Veterinary Medicine, Optometry and Podiatry, among others.During the state’s 2020 legislative session, Idaho House Bill 318 changed the Idaho Bureau of Occupational Licensing to IDOPL. Last June, Governor Brad Little issued Executive Order 2020– 10, shrinking the size of state government by consolidating 11 separate agencies into IDOPL.According to the Board of Medicine, the move will create efficiencies, with a central office, the consolidation of information technology (IT), and enhanced collaboration among licensing teams, medical investigators and administrative staff.All of the state’s licensing boards will be moved to one location during the Summer of 2021 to enhance customer service, streamline operations and create consistency among agencies.Source: The Report, Idaho State Board of Medicine, Fall 2020Prescribers in Idaho are now required to check the state’s Prescription Drug Monitoring Program (PDMP). During the 2020 Legislative Session, Idaho Senate Bill 1348 was passed, requiring all prescribers to review the previous 12 months of a patient’s history in the PDMP prior to issuing a prescription for an opioid analgesic or benzodiazepine listed in schedules II–IV for outpatient use.The Idaho Board of Pharmacy has initiated statewide integration to create PDMP access in electronic health records. According to the Idaho State Board of Medicine, “providers and health care facilities have expressed satisfaction with the ease and convenience of being able to access the PDMP in this way.” There is no charge to providers or facilities to connect with the PDMP.Source: The Report, Idaho State Board of Medicine, Fall 2020On October 28, 2020, Louisiana Governor John Edwards signed into law Senate Bill 27, authorizing the state to become the 32nd jurisdiction to join the Interstate Medical Licensure Compact.The Compact, launched in 2015, now includes 30 states, the District of Columbia and the Territory of Guam as member jurisdictions. Legislation is currently pending in New York, New Jersey and Ohio.The Compact, established to streamline licensure for physicians who want to practice in multiple states, reached a major milestone last year when the 10,000th medical license was issued using its process.Source: IMLCC news release, October 30, 2020The North Carolina Medical Board (NCMB) has created several new resources to help patients understand what to expect during a physical examination and learn to recognize red flags and signs of possible sexual misconduct by a medical professional.Provided online in the form of downloadable PDF documents, the three resources include: The Power of Touch, which explains the four main hands-on techniques physicians and other medical providers use when conducting physical examinations.Undergoing a Physical Examination: Your Rights, which covers what to expect during a physical examination, including the patient’s right to dress and undress privately and to request that a chaperone be present during the exam.Know the Signs of Sexual Misconduct, which is intended to help patients recognize behaviors that are inappropriate and unacceptable, or that could signal a provider is “grooming” a patient for possible sexual contact.To view the documents, please visit www.ncmedboard.org.Source: North Carolina Medical Board website announcement, October 29, 2021The State Medical Board of Ohio is warning its licensees that they should be on alert for a scam that has resurfaced, targeting Ohio prescribers. Scammers have been calling and faxing prescribers, stating they have been investigated for drug trafficking by the U.S. Department of Justice and their licenses have been suspended effective immediately.During one reported incident, the scammers called a physician’s office, faxed the physician a fraudulent document using the State Medical Board of Ohio’s logo, and used spoofing technology so it appeared they were legitimately calling from the Board’s office.The Board had posted information at its website helping licensees know how to identify a legitimate investigation, how to verify if the caller is from the Board and how to file a complaint if they are contacted by a scammer.The State of Ohio Board of Pharmacy has also reported an email “phishing” scam that has been sent to its licensees. The sender of the email claims to represent the Board of Pharmacy and utilizes a website that mimics the Board’s site in an additional step to deceive licensees.Source: State Medical Board of Ohio eNews, December 2020The Oregon Medical Board (OMB) is undertaking a rulemaking to implement cultural competency training for health care professionals that was recently mandated by the Oregon Legislature.Oregon’s HB 2011 legislation stipulates that, beginning July 1, 2021, OMB licensees must complete cultural competency continuing education as a condition of licensure.All Oregon physicians, physician assistants, and acupuncturists whose license is at a practicing status must meet the new requirement. Licensees must complete an average of at least one hour of cultural competency education per year during an audit period, which OMB estimates will be every four years for most licensees. Required hours will be based on the number of years licensed during the audit period: For example, a licensee who has been licensed for 3.5 years during the audit period will be required to obtain four hours of cultural competency education. Hours may be obtained at any time during the audit period, meaning that a licensee needing to fulfill four hours of CME could opt for one four-hour experience, or four one-hour courses — as long as they were completed within the prescribed period.A wide array of courses or educational experiences will be allowed, including courses delivered in-person or electronically, experiential or service learning, cultural or linguistic immersion, volunteering in a rural clinic, completing an employer’s cultural competency training, attending an event with members of an underserved community to discuss health care access issues, or courses approved by the Oregon Health Authority.Source: Oregon Medical Board Report, Fall 2020

Objectives. To evaluate changes in monthly buprenorphine dispensation associated with federal prescribing policies in Washington State from 2012 to 2022. Methods. We conducted an interrupted time series analysis comparing monthly buprenorphine prescriptions dispensed per 1000 population after the Comprehensive Addiction and Recovery Act (CARA), Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), and new prescribing rules during the COVID-19 pandemic. Buprenorphine formulated for opioid use disorder was included from the Washington State Prescription Monitoring Program. A log-linear autoregressive model measured linear trend changes. Results. Physician prescribing increased by 1.63% (95% confidence interval [CI] = 1.41%, 1.85%) per month after CARA with sustained declines after SUPPORT. Nurse practitioner (NP) prescribing increased by 19.48% (95% CI = 18.8%, 20.16%) per month after CARA with physician assistants (PAs) showing similar trends. Following the implementation of SUPPORT, NP and PA trends continued to increase at a reduced growth rate of 3.96% (95% CI = 2.01%, 5.94%) and 1.87% (95% CI = 0.56%, 3.19%), respectively. No prescribers experienced increases during the COVID-19 pandemic. Conclusions. CARA nearly tripled the buprenorphine prescribing rate. The SUPPORT Act initiated sustained declines for physician prescribing, and the COVID-19 period reversed gains for PAs and NPs. The current opioid crisis requires expanded efforts in Washington State. (Am J Public Health. 2024;114(7):696-704. https://doi.org/10.2105/AJPH.2024.307649).

Physicians Look to Disrupt Longtime Regulatory Tradition for APRNs

Studies have found unprofessional behavior in medical school was associated with disciplinary action by state medical boards. For medical schools, promotions committees are responsible for identifying which students do not demonstrate academic performance and professional behavior acceptable for promotion and graduation. The objective of this study was to determine if student identification by promotions committees during medical school was associated with disciplinary actions by state medical boards later in practice. We reviewed 20 years of promotions committees' records from a single institution and noted students identified by promotions committees for performance or behavioral issues. These were compared with disciplinary action reports from the Federation of State Medical Boards (FSMB) for graduates. Over the two decades, 2,131 students matriculated and 2,078 of these graduated. The promotions committees identified 140 students for poor academic performance or behavioral problems (140/2,078, 6.7 %). Of these, 108 students graduated. FSMB records showed 29 of the 2,078 graduates had sanctions by state boards (29/2,078, 1.4 %). Only four students that had actions by state medical boards were among the 108 graduated students identified by medical school promotions committees (4/108, 3.7 %). Of the students not identified by promotions committees, 25 eventually had disciplinary actions (25/1,970, 1.3 %). The odds of having state medical board action if identified by promotions committees was 3.0 (CI 1.02-8.8, p < 0.05). In conclusion, identification of students by medical school promotions committees was later associated with state medical board actions. However, most graduates with state medical board actions were not identified by medical school promotions committees.

Women in rural areas are highly dependent on public clinics for family planning services, yet little information has been collected on rural family planning providers, especially on their funding and operation. All 31 family planning clinic sites in rural Washington State were surveyed about their sponsorship, staffing, service provision and population coverage. Clinic sites were located in 25 of the 53 discrete rural health service areas of Washington State. While the three wealthiest areas had clinics, eight of the poorest areas had no clinics. Eight clinics were Planned Parenthood affiliates, eight were private freestanding clinics and 15 were local health department sites. Clinic sites were small (with the equivalent of 2.4 full-time staff members, on average) and offered a mean of 18 of 43 potential reproductive and women's health care services; general primary care services were rarely provided. Only one clinic offered abortions. Family planning clinics in rural Washington State offer an important but limited number of services. Many rural areas have no local family planning clinic. Given these clinics' reliance on federal and state funding, decreased public support might seriously impair family planning provision in rural areas.

Time to Make a Call? The Ethics of Mandatory Reporting

To determine if medical students who demonstrate unprofessional behavior in medical school are more likely to have subsequent state board disciplinary action. A case-control study was conducted of all University of California, San Francisco, School of Medicine graduates disciplined by the Medical Board of California from 1990-2000 (68). Control graduates (196) were matched by medical school graduation year and specialty choice. Predictor variables were male gender, undergraduate grade point average, Medical College Admission Test scores, medical school grades, National Board of Medical Examiner Part 1 scores, and negative excerpts describing unprofessional behavior from course evaluation forms, dean's letter of recommendation for residencies, and administrative correspondence. Negative excerpts were scored for severity (Good/Trace versus Concern/Problem/Extreme). The outcome variable was state board disciplinary action. The alumni graduated between 1943 and 1989. Ninety-five percent of the disciplinary actions were for deficiencies in professionalism. The prevalence of Concern/Problem/Extreme excerpts in the cases was 38% and 19% in controls. Logistic regression analysis showed that disciplined physicians were more likely to have Concern/Problem/Extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15-4.02; p =.02). The remaining variables were not associated with disciplinary action. Problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school.

Disciplinary Action by Medical Boards and Prior Behavior in Medical School