Abstract
Abstract
The accountabilities and operations of state medical boards can have significant implications for hospitals and health systems in terms of their efforts to ensure quality care and patient safety. This study examined the performance of state medical boards and the reasons for variability in board performance by identifying factors impacting the performance of state medical boards in terms of physician discipline and those variables most critical to medical board performance. The findings suggested that increasing staff support and appointing lay board members would lessen the degree of variability in the performance of state boards although there remained a significant amount of variance to be explained.
“Over the past 20 years, John F. Pholeric struggled on and off with cocaine addiction, cycled in and out of rehab and was convicted of a felony. During that time, he also practiced medicine” (CitationThompson 2005, A01). This physician acknowledged using cocaine 3–4 times a week in his office, stealing drugs from hospitals, and writing numerous false prescriptions. On several occasions the state medical board in the state that granted Pholeric his medical license met to review his case but never suspended his license to practice medicine. Also retaining their licenses in this country were an ophthalmologist who operated in surgery under the influence of drugs and a gastroenterologist who opted to inject himself with the pain medication ordered for his colonoscopy patients (CitationThompson 2005). Questions regarding the vigilance of state medical boards is not limited, however, to issues dealing with substance abuse problems, but it also involves a variety of behavioral issues (CitationGuglielmo 1999). The most frequent reasons for physician discipline by state medical boards from 1996–2003, in addition to substance abuse, were unprofessional conduct and fraud (CitationSteiger 2005).
State medical boards are the entities charged with accountability for ensuring that physicians provide competent care and for disciplining those physicians who fail to meet appropriate standards (CitationJost and Strasser 1993). A Washington Post series examining physician disciplinary actions indicated that the methods used to discipline incompetent doctors are seriously flawed and that there are “big variations in the operations of state medical boards” (CitationThompson 2005, A01). A consumer group monitoring the performance of the state medical boards, the Health Research Group (CitationHRG; 2006a), noted that state boards would be able to do a better job in disciplining physicians if there were adequate funding, adequate staffing and proactive investigations, with independence from undue physician influence as well as an appropriate legal basis for disciplining doctors.
State Medical Boards
Prior to the latter part of the 20th century, state medical boards focused primarily on licensure. The boards typically regulated the practice of medicine by ensuring that individuals desiring to hold themselves out to the public as physicians had graduated from an accredited medical school, passed the required medical examination, and completed anywhere from 1–7 years of advanced education in the form of a residency.
Following a critical report in 1963, which chastised the state medical boards’ oversight of physicians, laws were passed in several states that mandated public access to board proceedings. These laws prompted increased scrutiny of state board activities by public media and consumers (CitationAmeringer 1999). In response to this pressure, boards started to become more accountable for their oversight function in the 1960s and 1970s, resulting in increased caseloads and a more legalistic format for board procedures. The momentum for change was further encouraged during the 1990s with a report from the Pew Charitable Trust Health Professions Commission which focused on the regulation of healthcare providers by the licensing boards as a way of improving the quality of healthcare and patient safety (CitationFinocchio et al. 1995).
Even in this evolved state, however, most medical boards focus on disciplining physicians after unsatisfactory performance is reported to the board by patients, hospitals, malpractice carriers, or the public media. The executive director of the Virginia Board of Medicine noted that the “practice of medicine is on the honor system. Once you get your license… . the board assumes that you're out there taking good care of patients until we hear otherwise” (CitationThompson 2005, A01).
Physician Disciplinary Action Rates
One of the biggest challenges in reviewing the state of physician disciplinary actions in our country is the lack of certainty as to the extent and number of problem physicians. Extrapolation from a number of small studies, however, would indicate that the number of problem physicians is not insignificant (CitationGray and Zicklin 1992). That the extent of the problem is somewhat vague, however, has not hindered criticism of state medical boards.
The population of physicians grew by approximately 6% from 2004 to 2007 (CitationHRG 2008), whereas instances of serious disciplinary action, defined as revocation or surrender or suspension of licensure as well as physician probations or practice restrictions, dropped by 553 on a national basis (CitationHRG 2008). The HRG ranks individual state medical boards based on the rate of serious disciplinary actions per 1,000 physicians and for 2007 reported significant variation among the states with rates ranging between 8.33 discipline actions per 1,000 physicians for Alaska whereas South Carolina disciplined physicians at a rate of 1.18 per 1,000 physicians (CitationHRG 2008).
Sidney Wolfe, director of the HRG, indicated that this type of variation
raises serious questions about the extent to which patients in many of these states with poorer records of serious doctor discipline are being protected from physicians who might will be barred from practice in states with boards that are doing a better job of disciplining physicians” (CitationHRG 2006a, 1).
The umbrella organization for the state medical boards, the Federation of State Medical Boards of the United States, has acknowledged that there are some problems with the state medical boards and that “many are understaffed, overworked and poorly funded” (CitationRomano 2006, 32). It is often implied in the literature that various structural characteristics of the medical boards influence the disciplinary effectiveness of the different states (CitationAmeringer 1999; CitationBovbjerg, Aliaga, and Gittler 2006; CitationBrennan 1998; CitationFellmeth 2003; CitationHRG 2006a; CitationMiller 1997). The enablers of effective disciplinary processes are suggested to include higher funding levels, more public board members, increased staff support and reduced legal requirements in terms of the burden of proof standards (CitationBovbjerg, Aliaga, and Gittler 2006).
CitationYeon et al. (2006) attempted to give consideration to the variability in the performance of the state medical boards while also inferring that there were substantial differences in the states regarding the number of board members, the number of lay members on boards, board funding and the size of the board support staff. In addition it was noted that differences exist in terms of the legal standards of proof required and the specific licensing and reporting functions of the board.
Purpose of Study
State medical boards are deemed to be critical in helping to ensure the quality of medical care provided in the United States. Unfortunately, “the literature is long on opinions about Boards but short on documentation, and there is almost no analysis of disciplinary activities in practice” (CitationBovbjerg, Aliaga, and Gittler 2006, 2). It becomes important, therefore, to better appreciate the dynamics of the state boards and the reasons for variability of board performance in addressing the concerns of the nation's licensed physicians. In the present study, we make an effort to contribute to understanding board operations by considering board performance in relation to four independent variables deemed to be fundamental for operations. These variables include the level of support staff for the board, the legal burden of proof required for the board to take action, the amount of funding available, and the number of lay board members.
METHOD
The descriptive research involves a cross-sectional quantitative study of secondary data utilizing regression analysis as well as other basic statistical techniques to determine the degree of relationship between the dependent variable with consideration for the presence, direction, and strength of association to the independent variables. Using a regression analysis, we examined the relationship between each independent variable and the dependent variable. The basic regression formula in its general form is y = a + bx where y is the dependent variable and x is an independent variable with a as the y-intercept or the predict value of y when x is equal to zero, whereas b is the regression coefficient of the associated independent variable or partial regression coefficient. The analysis of this relationship is further expanded to consider the degree of association between the dependent variables and the independent variables in combination through multiple regression analysis. The multiple regression formula is stated as: y = a + b 1 x 1 + b 2 x 2 + b 3 x 3 …+ bkxk ; where y is the dependent variable and each x is an independent variable with a as the y-intercept or the predicted value of y with all the xs are equal to zero, bs are the regression coefficients of the associated independent variable or partial regression coefficients.
Although there is an inherent tendency with a regression-based model to assume cause and effect in terms of the dependent and independent variables, it is recognized that regression measurements only suggest rather than confirm causal relationships. The study population consists of state medical boards from the fifty states and the District of Columbia.
The number of physician disciplinary actions per licensed physician practicing within the particular state provide the foundational basis for the dependent variable related to the performance of state medical boards. Board disciplinary actions were obtained from the FSMB (2006). The independent variables include the number of staff supporting the state board per licensed physician, size of the board's budget per licensed physician, number of nonphysicians on the board per licensed physician, and the legal standard of evidence in determining appropriateness of physician conduct. Data for the independent variables is based on survey information of state medical board structures and functions (FSMB 2003). These variables are factors most frequently mentioned in the general media and literature as potential reasons for performance variability and are factors common to all boards (CitationAmeringer 1999; CitationBovbjerg, Aliaga, and Gittler, 2006; CitationFellmeth 2003; CitationHRG 2006a; CitationRomano 2006; CitationThompson 2005; CitationYeon et al. 2006). The underlying hypotheses for the study are that these variables are predictive of a state board's performance on disciplining physicians and that there will be a positive association.
Dependent Variable
The effectiveness of state medical board performance is consistently defined throughout the literature as a function of the number of physician disciplinary actions enacted by a particular state medical board (CitationAmeringer 1999; CitationBovbjerg, Aliaga, and Gittler 2006; CitationGuglielmo 1999; CitationHRG 2006b; CitationThompson 2005; CitationYeon et al. 2006). The assumption explicit in the literature is that the higher the rate of physician disciplinary action, the better the performance of the state medical board. As the dependent variable in the analysis, the performance of the state medical boards is defined as the rate of total disciplinary actions which is the most widely utilized measure of board performance (CitationBovbjerg, Aliaga, and Gittler 2006).
Independent Variables
Staff
Lack of staffing is indicated as a probable cause of difficulties for both the timely review of complaints against physicians as well as the actual ability of the state medical boards to take disciplinary action (CitationBovbjerg, Aliaga, and Gittler 2006). The support staff count for the analysis includes both part- and full-time employees per licensed practicing physician in the state.
Legal burden
The two standards of proof utilized by the states are preponderance of evidence and clear and convincing evidence. Preponderance of evidence requires the state medical boards to demonstrate, prior to effecting a disciplinary action, that the physician did not exercise due care (CitationBlack 1951). If a state legislature wants to make the case for disciplinary action more difficult for the state medical board to prove, it can raise the standard of proof to one of clear and convincing evidence (CitationGray and Zicklin 1992). The hypothesis related to the legal burden is that board performance is positively associated with the lower standard of proof preponderance of evidence.
Budget
A lack of adequate funding is one of the most consistently mentioned probable causes for variation in the performance of state medical boards (CitationAmeringer 1999; CitationBovbjerg, Aliaga, and Gittler 2006; CitationBrennan 1998; CitationFellmeth 2003; CitationHRG 2006a; CitationMiller 1997; CitationRomano 2006; CitationYeon et al. 2006). The fiscal year state medical board budget figures are calculated based on budget dollar per licensed practicing physician in the state.
Lay board members
The effectiveness of physician self-regulation has increasingly been challenged and identified as a potential contributing factor to the ineffectiveness of state medical boards. “Among physicians, the efficacy of collegial control appears to be undermined by the ‘ethics’ of professional courtesy” (CitationScott 1982, 221). The appointment of lay members to state medical boards is purported to be the solution to this concern. We used the number of lay board members per licensed practicing physician as the lay board member variable for the state.
Limitations
With a study population comprising the 50 states and the District of Columbia, we recognize that an issue related to statistical power could arise in the analysis and that based on some guidelines, the number of participants are at the lower end of the range for definitive results (CitationMaxwell 2004). The relationship between statistical significance and statistical power were monitored, however, and the standards related to these statistical issues were utilized with appropriate judgment in arriving at study conclusions together with consideration for both positive and negative associations.
In addition, the secondary data utilized for both the dependent and independent variables were the most current available when the original study was completed. The discrepancy in the dates of the variables, however, should be acknowledged as a consideration. Although at this time more contemporary data is available for the dependent variables, the FSMB survey of state boards utilized as the data source for the independent variables has not been updated.
The independent variables were identified based not only on the review of previous research but also on the assumptions being put forth in the public media and within an advocacy framework. It is acknowledged, however, that there are numerous other variables that offer the potential to help predict the performance of state medical boards, including range of the sanctions available to boards, number of input sources regarding problem physicians, board statutory limitations, high costs of legal investigations, access to medical expertise, the litigation climate of the state available to aggrieved physicians, and board member compensation, among others (CitationBovbjerg, Aliaga, and Gittler 2006). This study, therefore, should be considered only explorative in nature.
RESULTS
Descriptive Statistics of Independent and Dependent Variables
Nationally, the number of total disciplinary actions averaged 0.0080 per practicing physician with a standard deviation of 0.004653. There is a significant variation among the states with a range from a minimum of 0.00275 per practicing physician to the most prolific state in terms of disciplining physicians, which has a rate of 0.0275. The frequency shows, however, that 86% of the data points are within ± 1 standard deviation of the mean (see ).
Table 1 Descriptive Statistics of Dependent and Independent Variables
Table 2 Regression—Support Staff
With the exception of the legal standard, this variability among the states is consistently demonstrated with the remaining variables as well as the tendency for the states to be clustered around the mean. The state medical boards average 0.0036 staff per practicing physician ranging from a minimum of 0.0001 to a maximum of 0.0119, whereas the average of the states reporting budgets for their state medical boards is $307 per practicing physician, with states ranging from $4 per practicing physician to $866 per practicing physician. Although such a wide range may itself suggest something important, it also raises a possible estimation issue. In an effort to address this concern and stabilize the variance, the budget dollar values were transformed into their natural logarithmic form for purposes of the study. Although the overall rate of states appointing lay members to state medical boards is fairly minimal with an average of 0.00097 per practicing physician and a standard deviation of 0.001184, results are skewed to the right of the mean, showing a tendency of some states to more fully adopt the concept of lay representation than others.
However, the states already utilize the preponderance of evidence as their standard of proof for purposes of disciplining physicians; 76% of the boards have preponderance of evidence as their standard, whereas only 24% are required to work within the parameters of the higher standard, clear and convincing.
Regression and Correlation Statistics
With the exception of the legal standard and budget considerations there is support for the contention that the support staff and lay board member variables used in the study are positively associated with state board performance in disciplining physicians although the variables explain only a small portion of the variance in state disciplinary action rates.
The coefficient of 0.736 shown in demonstrates a relationship between the number of medical board support staff and the rate of disciplinary actions indicative of a strong level of association. With a positive coefficient, an increase in the number of support staff would increase the rate of disciplinary actions in the state. The calculated R 2 indicates that the number of medical board support staff explains 13.8% of the variation in the rate of total disciplinary actions.
Using the natural logarithmic form of the budget dollars, indicates that the correlation between the budget for state medical boards and the rate of total disciplinary action per licensed practicing physician in the state was not significant. Some caution should be exercised, however, when considering this analysis as the wide range of reported budgets may be as much a function of variances in state accounting and allocation procedures as the absolute dollar resources available to state medical boards.
Table 3 Regression—Budget
Table 4 Regression—Lay Board Members
The analysis contained in shows a positive association between the total disciplinary action rate per licensed practicing physician and the number of lay board members, although the number of lay board members accounted for only 8.4% of the variation. The coefficient of 1.123 is significantly greater than zero.
A binary variable scale with a minimal 0–1 coding scheme was used for the evidence standard, with the preponderance of evidence standard set at 0 and clear and convincing coded as 1. Spearman's ρ correlation () was used to measure the relationship of the evidence standard and the other variables. The correlations for the standard of proof criteria utilized by the state medical board were not significant at the p = .05 level (two-tailed).
Model of All Independent Variables
After reviewing the relationship for total disciplinary actions in regards to medical board staff support, legal standards, medical board budget, and the number of lay members on the medical board, the level of association was further investigated by conducting a multiple regression analysis of all the independent variables. There was no value added, however, in developing this total model utilizing all of the variables. The model was not significant at the p = .05 level.
Table 5 Correlation Analysis (Spearman rho)—Legal Evidence
DISCUSSION
The role of the medical boards in the United States is recognized by many individuals as being fundamental to providing quality medical care. Licensed physicians not only determine the quality of care provided to their individual patients but also play a major role in the quality efforts of hospitals, long-term care facilities, and ambulatory care centers.
Variability Among State Medical Boards
The variability of the disciplinary actions offers a particular concern in regard to ensuring the appropriate performance of state medical boards. The research results verify that there is indeed a great deal of variability among the states in terms of the rate of total disciplinary actions enacted by the medical boards. With the exception of the burden of proof standard, the differences among the state medical boards is further evidenced by significant variability in the number of support staff provided to a board by a state, the size of the budget allocated to a medical board by a state, and the number of lay members appointed to serve on the medical board. Although this study supports much of the contention that relates to the variability of the different factors associated with state medical boards and demonstrates that there were some significant variations among the states, the research also shows that for each of the factors studied there were large numbers of states clustered around the mean. A significant majority of the states were within ± 1 standard deviation of the mean and, indeed, for the evidence standard, 76% of the states utilized the lower burden of proof criteria.
The issue of variability among the different state medical boards may prove to be exceedingly difficult to address without some form of comprehensive national effort. The issue of variability among the different states as well as the overall effectiveness of the licensure process must give rise to alternative considerations in order to ensure quality medical care (CitationGross 1986; CitationRoberts et al. 2006; CitationSvorny 2008).
The assurance of quality medical care at least within the confines of healthcare institutions, therefore, must ultimately come to reside with the hospital or health system governing board and not on state medical boards. A call to responsibility was issued by the National Quality Forum to hospital governing boards to assume their accountability for quality medical care and challenged hospital boards to no longer delegate this responsibility to a quality committee or the medical staff of their organizations (CitationKurtzman and Page-Lopez 2004).
To address the concern with physician competencies, CitationLeape and Fromson (2006) suggested a voluntary collaboration among the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), the FSMB, and the American Board of Medical Specialties (ABMS). Recent developments are moving in this general direction, with the establishment of various physician competencies by the Joint Commission, the Council for Graduate Medical Education, and the ABMS, which are now being utilized within the Medical Staff standard for the purpose of accrediting hospitals and health systems by the Joint Commission (CitationJoint Commission 2009). The Joint Commission has also issued a leadership standard for accredited organizations, which requires hospitals and health systems to implement new policies to address unprofessional physician conduct (CitationErickson and Sederstrom 2009). These policies include establishing a code of conduct identifying inappropriate behaviors and a process for managing such behaviors. To make these standards effective, hospitals and health systems need to give consideration to establishing reporting procedures for inappropriate behaviors as well as guidelines to prevent retaliation for reporting concerns. The standards may also give rise to numerous related issues associated with the medical staff review process and protecting the rights of physicians throughout any judicial review.
State Medical Board Performance
The statistical analysis demonstrates that for the identified variables, level of staff support and the number of nonphysician board members, there is a positive correlation with the performance of the state medical boards as defined by the rate of total disciplinary actions imposed by the medical boards. There is no association with the rate of disciplinary actions and the lower evidence standard, preponderance of evidence or with the reported budgets of state medical boards.
These basic findings appear to lend credence to those advocating that by increasing the number of staff supporting the functions of a state medical board or in the appointment of nonphysicians to the medical board, a state can increase the rate that licensed physicians are disciplined. The positive correlations identified in the findings for the independent variables, however, help to explain only a small portion of the variance in the rate of total disciplinary actions per licensed physician. The low coefficient of determination for the different variables suggests there are additional factors that may impact the performance of the state medical boards. This study should temper the degree of confidence that may be applied to improving state medical board performance exclusively on the basis of providing increased support staff or the appointment of lay board members.
There is no basis to indicate that a medical board's performance could be improved by having a state's legislature enact the preponderance of evidence standard. Admittedly, this finding is impacted by the fact that an overwhelming number of states already utilize the lower burden of proof requirement for disciplining physicians. State medical board budgets also do not indicate a relationship with physician disciplinary action rates, although this finding may be less than definitive due to possible concerns with the different allocation and accounting methodologies utilized by the states.
Conclusions
This research supports some of the contentions espoused in the media and literature that increasing the staff support for state medical boards and appointing lay board members may help to lessen the degree of variability in the performance of state medical boards and increase the rates at which licensed physicians are disciplined. It is also evident by the study, however, that reliance upon these factors, despite being the more frequently promoted solutions to the issue of variability among the state boards, is misplaced. There remains a significant amount of variation left to be explained in terms of state medical board performance. This variance may be exceedingly difficult to address without requiring the individual state medical boards to adhere to a set of uniform national standards. A continued focus on the issue of variability among the states, however, in regard to their disciplinary action rates may be misplaced.
Although the rate of physician disciplinary actions by state medical boards has been promoted as a quality indicator for medical care in the various states, to date such an association has not been identified as being definitive (CitationRoberts et al. 2006). Indeed if there is not a documentable relationship between medical quality and physician disciplinary action rates, then the variability of such rates among the states becomes of lesser consequence and the focus at least in the immediate future may more appropriately move to the role of the governing boards in helping to the ensure the provision of quality medical care within their hospitals and healthcare systems.
| Variable | M | SD | Minimum | Maximum | Mode | Median |
|---|---|---|---|---|---|---|
| Dependent variables | ||||||
| Total actions per practicing physician | 0.00808 | 0.004623 | .00275 | 0.02570 | 0.00670 | 0.00670 |
| Independent variables | ||||||
| Board staff per practicing physician | 0.0036 | 0.002335 | .0001 | 0.0119 | 0.0030 | |
| Budget per practicing physician | ||||||
| Reported budgets ($) | 307 | 172 | 4 | 866 | 333 | 321 |
| Natural logarithmic | 5.5348 | 0.93595 | 1.31 | 6.76 | 1.31 | 5.7637 |
| Lay board members per practicing physician | 0.00097 | 0.001184 | 0 | 0.004751 | 0.0001 | 0.000455 |
| Note. For evidence standard, the average response was 76% and 24% for preponderance of evidence and clear and convincing, respectively. The mode for evidence standard was preponderance of evidence. | ||||||
| Model | B | SE | β | t (df 1, 45) | p |
|---|---|---|---|---|---|
| Constant | .005 | .001 | 4.648 | .000 | |
| Board staff per physician | .736 | .274 | .371 | 2.681 | .010 |
| Note. The dependent variable was total actions per practicing physician. | |||||
| Model | B | SE | β | t (df 1, 32) | p |
|---|---|---|---|---|---|
| Constant | .002 | .005 | .359 | .722 | |
| Budget per physician | .001 | .001 | .228 | 1.323 | .195 |
| Note. The dependent variable was total actions per practicing physician. | |||||
| Model | B | SE | β | t (df 1, 40) | p |
|---|---|---|---|---|---|
| Constant | .007 | .001 | 8.676 | .000 | |
| Lay board members per physician | 1.123 | .525 | .290 | 2.140 | .037 |
| Note. The dependent variable was total actions per practicing physician. | |||||
| Spearman's rho Evidence standard | Correlation Coefficient | Sig. (2-tailed) | N |
|---|---|---|---|
| Board staff per Practicing Physician | .137 | .359 | 47 |
| Evidence Standard | 1 | — | 52 |
| Budget per Practicing Physician | .010 | .954 | 34 |
| Lay Board Members per Practicing Physician | .105 | .459 | 52 |
| Total Actions | .058 | .685 | 52 |
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