According to the Federation of State Medical Boards of the

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1 Characteristics of physicians disciplined by the State Medical Board of Ohio Steven W. Clay, DO Robert R. Conatser, MS Although physicians have been disciplined for a variety of offenses by state medical boards across the United States, limited information is available about the characteristics of these physicians. To assess the characteristics of, offenses committed by, and resulting disciplinary actions taken against a consecutive series of disciplined physicians in the state of Ohio, the authors conducted a case-control study of all 308 physicians publicly disciplined by the State Medical Board of Ohio (SMBO) from January 1997 to June Subjects were matched with two groups of control physicians one matched by location only, and the second matched for location, gender, practice type, and self-designated specialty. The main outcomes measured were disciplinary actions, offenses leading to state medical board actions, and the characteristics of disciplined physicians. Of 340 physicians disciplined during these 30 months (approximately 0.37% per year), 308 committed 477 offenses requiring 409 actions by the SMBO. The most common offenses were impairment due to alcohol and/or drug use (21%), inappropriate prescribing or drug possession (14%), previous state actions (15%), negligence or incompetence (7%), and drug-related charges (7%). Although offenders were significantly less likely to be women (P.05; odds ratio [OR], 0.46; 95% confidence interval [CI], ), the authors found no difference in the severity of disciplinary action taken against offenders by gender (OR, 1.23; 95% CI, ) or by type of medical training, ie, between osteopathic physicians and allopathic physicians (OR, 0.70; 95% CI, ). Compared with controls matched for location, gender, practice type, and self-designated specialty, offenders were significantly less likely to be board certified (OR, 0.65; CI, ) and significantly more likely to have been in practice 20 or fewer years (OR, 1.51; 95% CI, ). Disciplinary actions in Ohio were more frequent, Dr Clay is an associate professor in the department of geriatric medicine and gerontology at the Ohio University College of Osteopathic Medicine, where Mr Conatser is a research associate in the department of biomedical sciences. Address correspondence to Steven W. Clay, DO, Department of Geriatric Medicine and Gerontology, Ohio University College of Osteopathic Medicine, 355 Grosvenor Hall, Athens, OH clay@exchange.oucom.ohiou.edu more severe, and more often in response to impairment due to alcohol and/or drug use and previous state actions than previously reported. No difference in the severity of disciplinary action was noted between men and women or between osteopathic and allopathic physicians. (Key words: Ohio, osteopathic physicians, physician intervention, severe disciplinary action, state medical board, State Medical Board of Ohio) According to the Federation of State Medical Boards of the United States, The primary responsibility and obligation of a state medical board is to protect consumers of health care through proper licensing and regulation of physicians... 1 In 1998, state medical boards across the United States disciplined physicians with 4520 actions, including prejudicial (ie, those involving revocation or suspension of license) and nonprejudicial actions.1 Prevention and early intervention by state medical boards may correct behavioral problems in physicians before the public is put at risk and before trained physicians lose the ability to and privilege of practicing medicine. However, prevention and early intervention require the identification of those physicians at risk for subsequent disciplinary action. Many studies have examined characteristics of physicians whose behavior most often leads to disciplinary actions by state medical boards, including impairment due to alcohol and/or drug use,2-6 inappropriate prescribing or drug possession,7,8 mental and/or physical impairment,9 sexual and/or inappropriate patient contact,10,11 fraud and misrepresentation of credentials,12,13 incompetence,14 and malpractice claims.15,16 However, the aforementioned studies did not include control subjects. In a Medline literature search from 1966 to October 1999, only one study was found that compares disciplined physician characteristics with nondisciplined physician control groups.17 In their study of physicians disciplined by the Medical Board of California, Morrison and Wickersham17 found that compared with controls, disciplined physicians were more likely to be: men; in medical practice more than 20 years; or in specialized practice for anesthesiology, psychiatry, or obstetrics and gynecology. JAOA Vol 103 No 2 February

2 Further, when compared with controls, disciplined physicians were less likely to be: in internal medicine or pediatrics; or board certified in their specialty. The purpose of this project is to compare physicians disciplined by the SMBO with nondisciplined physician controls from the same state. This study contributes to a better understanding of the characteristics of disciplined physicians and allows comparison with data from the California study. Methods The methods used by Morrison and Wickersham17 in California were duplicated in this study and applied to Ohio physicians and disciplinary actions taken by the SMBO. Physicians disciplined in Ohio were identified in the Formal Action Mailing List, published monthly by the SMBO and also available on the SMBO Monthly Formal Actions Web page (see All formal disciplinary actions taken and recorded by the SMBO from January 1997 to June 1999 were used to obtain physicians identities, practice locations, disciplinary actions taken, and the reasons for SMBO action. Similarly, these records were used to determine whether the action was a result of a prior SMBO action or the prior action of a state medical board in a different state. Further characteristics of those disciplined, including self-designated specialty, length of time in practice, board certification, and demographics, were obtained for osteopathic physicians trained in osteopathic residency programs from the American Osteopathic Association s (AOA) Yearbook and Directory of Osteopathic Physicians, 1999,19 and for allopathic physicians and osteopathic physicians with allopathic residency training from the American Medical Association s (AMA) 1998 Directory of Physicians in the United States.20 To allow for better comparison of data, offenses that were reasons for disciplinary actions taken by the SMBO were recorded following the methods used in the California study, including (1) negligence or incompetence, (2) inappropriate prescribing or drug possession, (3) impairment due to alcohol and/or drug use, (4) legal crimes (eg, tax fraud, kickbacks and false worker s compensation claims, and Medicare or Medicaid fraud), (5) sexual and/or inappropriate patient contact, (6) mental and/or physical impairment, (7) other and/or miscellaneous (eg, child support default), (8) other crime (eg, unprofessional conduct), (9) probation violation of a previous action, (10) unlicensed assistant or poor supervision, (11) working for an unlicensed person or entity, and (12) misrepresenting credentials.17 In addition to these twelve offenses included in the California study, this study of physicians in Ohio includes two offense types that are original to it, drug charge and continuing medical education (CME) violation. The drug charge offense in this study differs from the original classification inappropriate prescribing or drug possession in that it represents an actual legal charge. The CME violation offense differs from the original classification for misrepresenting credentials in that it presents a specific, documented lack of required CME credits. Location controls were found through the AOA s Yearbook and Directory of Osteopathic Physicians, 1999, or the AMA s 1998 Directory of Physicians in the United States, and identical characteristics for each location were recorded. A second control group, also identified from the aforementioned directories, was matched for location, gender, practice type, and self-designated specialty. The above characteristics and demographics were also recorded for this control group. To compare data, statistical analyses were completed following the methods used in the California study.17 A multivariate analysis to identify factors associated with discipline was done, and variables were kept binary to increase power. Variables included type of medical school attended (osteopathic or allopathic), gender, country of graduation (United States or foreign), practice type (direct patient care or other), board certification (yes or no), time in practice ( 20 years or 20 years), and self-designated specialty. Two specialties included in the California study, dermatology and physical medicine, were not included in this study because of low numbers. The association between the type of offense and severity of disciplinary action was tested using the Cochran-Mantel- Haenszel method.21 Data analyses were done using the SPSS statistical analysis program (Version 9.0, SPSS Science, Chicago, Ill). The level of statistical significance was.05. Results In 1998, 648,535 physicians were practicing medicine in the United States. During this time, 26,818 (4.1%) physicians were practicing in the state of Ohio. According to Danielle Bickers and Suzanne Milam, disciplinary information assistants for the SMBO (written communication, October 1999), the approximately 36,460 physicians licensed by the SMBO in 1998 included approximately 4350 (12%) osteopathic physicians and 32,110 (88%) allopathic physicians. The SMBO receives on average 3000 complaints annually regarding physicians in the state. In 1995, the major sources of the 2959 complaints received included the public (38%), SMBO staff (35%), state medical boards in different states (8%), pharmacists (4%), and physicians (3%).22 During the 30 months from January 1997 to June 1999, the SMBO received approximately 7500 complaints. After SMBO investigation, the exclusion of nondisciplinary actions, and follow-up reports on previous SMBO actions, court actions, and disciplinary actions, 340 complaints against physicians remained for these 30 months. This figure represents an annual discipline rate of approximately 0.37%. After the exclusion of complaints with missing data and those without controls, 409 actions taken against 308 disciplined physicians were recorded for this study. The initial 340 disciplined physicians and the remaining 308 subjects after exclusions were nearly identical in type of medical school attended (80.9% osteopathic physicians vs. 81.2% allopathic physicians), gender (90.9% men vs. 82 JAOA Vol 103 No 2 February 2003

3 Table 1 Demographic Characteristics of Physicians Disciplined by the State Medical Board of Ohio, January 1997 to June 1999 Characteristic All disciplined physicians, No. (%) (N = 340) Disciplined physicians with controls, No. (%) (N = 308) Osteopathic (DO) 65 (19) 58 (19) Allopathic (MD) 275 (81) 250 (81) Male 305 (90) 280 (91) Female 35 (10) 28 (9) US medical graduate 275 (81) 246 (80) International medical graduate 65 (19) 62 (20) Direct patient care 276 (81) 243 (79) 89.7% women), country of graduation (79.9% United States vs. 80.9% foreign), and practice type (78.9% direct patient care vs. 81.2% other) (Table 1). Of those disciplined, only 28 (9.1%) were women, 9 (2.9%) were in training, 62 (20.1%) were international medical graduates, 250 (81.2%) were graduates of allopathic medical schools, 157 (51.0%) were specialty board certified, 243 (78.9%) were in direct patient care, 130 (42.2%) were in practice for 20 or more years, and 64 (20.8%) had moved to another state or locality. Compared with location controls, disciplined physicians were significantly less likely (P.05) to be women (odds ratio [OR], 0.46; 95% confidence interval [CI], ), but not significantly more likely to be in direct patient care (OR, 1.05; CI, ). Compared with controls matched for location, gender, practice type, and self-designated specialty, disciplined physicians were significantly less likely to be board certified (OR, 0.65; CI, ) and significantly more likely to be in practice fewer than 20 years (OR, 1.51; 95% CI, ). Of the specialties self-reported by these physicians, anesthesia, psychiatry, and surgery appeared to be overrepresented among disciplined physicians, but due to low numbers in the study population, this comparison did not reach statistical significance (Table 2). The 308 physicians were disciplined for a total of 477 offenses: 165 (54%) with one offense, 117 (38%) with two offenses, and 26 (8%) with three offenses (Table 3). The most common individual offenses included the following: 100 (21%) with impairment due to alcohol and/or drug use, 66 (14%) with inappropriate prescribing or drug possession, 48 (10%) with previous actions by state medical boards in different states, 34 (7%) with negligence or incompetence, 33 (7%) with drug charges, 27 (6%) with CME violations (ie, deficits), 24 (5%) with other crimes, 24 (5%) with license renewal issues, 23 (5%) with violation of previous SMBO probation, 21 (4%) with mental and/or physical impairment, 18 (4%) with fraud or kickbacks, 17 (4%) with sexual and/or inappropriate patient contact, and 15 (3%) with unprofessional conduct or office management issues. When offenses are grouped by general category rather than more specific offense type, their prevalence is as follows: 121 (25%) health-related offenses (ie, impairment due to alcohol and/or drug use, mental and/or physical impairment); 99 (21%) drug or prescribing related crimes (ie, inappropriate prescribing or drug possession, drug charge); 71 (15%) previous state actions (ie, actions taken by state medical board in different states and SMBO actions); 59 (12%) personal and professional conduct offenses; 42 (9%) instances of fraud and other crimes, 34 (7%) negligence or incompetence issues; 26 (5%) credential issues; 17 (44%) sexual and/or inappropriate patient contact; and 8 (2%) miscellaneous offenses. Of the 308 disciplined physicians, 277 (90%) were disciplined once, 24 (8%) were disciplined twice, and 7 (2%) were disciplined three or more times. Disciplinary actions included license revocation (12%), suspension (24%), summary and automatic suspension (4%), probation and limitation (12%), stayed revocation (3%), stayed suspension (1%), consent agreement (19%), license surrender or forced retirement (8%), license denial (3%), proposed license denial before hearing (9%), and reprimand (5%). When disciplinary actions are grouped as severe (ie, resulting in actual loss of practice time) and not severe, 64% of disciplined physicians received severe disciplinary action by the SMBO (Table 4). No significant difference in severity of disciplinary action was seen between osteopathic and allopathic offenders (OR, 0.70; 95% CI, ), male and female offenders (OR, 1.23; 95% CI, ), or single and multiple offenders (OR, 1.52; 95% CI, ). Although some disciplined physicians in this study had multiple offenses, severe disciplinary action was most often associated with drug charges (88%), JAOA Vol 103 No 2 February

4 Table 2 Characteristics of Physicians Disciplined by the State Medical Board of Ohio, January 1997 to June 1999* Characteristic Disciplined group, No. (%) (N = 308) Control group, No. (%) (N = 308) Odds ratio (95% CI) Board certified 157 (51) 191 (62) 0.65 ( ) Years of practice ( 20 y) 187 (61) 159 (52) 1.51 ( ) International medical graduate 62 (20) 59 (19) 1.04 ( ) Self-designated specialty Family and general practice 79 (26) 65 (21) Surgery 29 (9) 16 (5) 0.57 ( ) Internal medicine 52 (17) 55 (18) 1.31 ( ) Psychiatry 21 (7) 13 (4) 0.73 ( ) Obstetrics and gynecology 18 (6) 28 (9) 1.77 ( ) Pediatrics 7 (2) 14 (5) Anesthesia 25 (8) 17 (6) 0.81 ( ) Ophthalmology 1 (0.3) 13 (4) Radiology 9 (3) 14 (5) Emergency medicine 16 (5) 13 (4) Pathology 5 (2) 11 (4) Neurology 8 (3) 2 (0.6) Orthopedics 15 (5) 13 (4) Other 20 (7) 24 (8) * Controls matched for location (city and state), sex, and self-designated specialty. CI indicates confidence interval; dashes, data are not applicable. P.05 This list of specialties does not include two specialties that were included in the 1998 California study, dermatology and physical medicine. violations of previous SMBO actions (83%), inappropriate prescribing or drug possession, CME violation (80%), office mismanagement (80%), unprofessional conduct (80%), sexual and/or inappropriate patient contact (76%), impairment due to alcohol and/or drug use (74%), mental and/or physical impairment (67%), other crime (67%), fraud or kickbacks (66%), other offense (60%), and negligence or incompetence (50%). Of the 165 disciplined physicians with only one offense, 22% had SMBO action taken for impairment due to alcohol and/or drug use (55% severe action); 20% for inappropriate prescribing or drug possession (73% severe action); 10% for CME violations (43% severe action); 7% for child support default (100% severe action); 6% each for drug charges (86% severe action) and negligence or incompetence (43% severe action); and 4% each for mental and/or physical impairment (57% severe action), fraud (50% severe action), and sexual and/or inappropriate patient contact (80% severe action) (Table 3). Comment During the 30 months from January 1997 to June 1999, the SMBO took disciplinary actions against 340 physicians. Complete data on 409 actions regarding 477 offenses by 308 disciplined physicians allowed comparison to one control group matched only by location, and another control group matched for location, gender, practice type, and self-designated specialty. The SMBO s approximate rate of disciplinary action was 0.37% in contrast to the rate of 0.24% per year in California. Female physicians represented 9% of those disciplined in Ohio, identical to the percentage found in the California study.17 However, in contrast with the California study data that suggest more severe actions taken against female offenders,17 no significant difference in type of offense or severity of SMBO action was found among Ohio disciplined physicians based on gender. Consistent with the California study, lack of specialty certification was more likely in disciplined physicians than in control subjects.17 Although many studies discuss physician specialty and subsequent disciplinary actions, actual certification has not been explored.4, JAOA Vol 103 No 2 February 2003

5 Table 3 Principal Physician Offenses Leading to Disciplinary Action by the State Medical Board of Ohio* and the Medical Board of California Offense Ohio study, No. (%) (N = 477) California study, No. (%) (N = 465) Alcohol and/or other drug use, impairment 100 (21) 56 (12) Inappropriate prescribing, drug possession 66 (14) 62 (13) Previous state action 71 (15) 18 (4) Negligence or incompetence 34 (7) 145 (31) Drug charge 33 (7) Continuing medical education (CME) violation 27 (6) Misrepresenting credentials 26 (5) 9 (2) Other crime 24 (5) 19 (4) Mental and/or physical impairment 21 (4) 21 (5) Fraud or kickback 18 (4) 48 (10) Sexual and/or inappropriate patient contact 17 (4) 40 (9) Other and/or miscellaneous 40 (8) 47 (10) * Based on the authors case-control study of all 308 physicians publicly disciplined by the State Medical Board of Ohio from January 1997 to June Source: Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279: This list of offenses does not include two items that were included in the 1998 California study, Unlicensed assistant, poor supervision and Worked for unlicensed person or entity. Data for this type of offense were gathered in the Ohio study only. This is the first case-controlled study to report on disciplined physicians and include the type of medical training received (ie, osteopathic and allopathic). Although no significant differences in offense type or severity of disciplinary action were seen between osteopathic and allopathic physicians, osteopathic physicians represented 19% of physicians disciplined but only 12% of physicians licensed by Ohio, according to Danielle Bickers and Suzanne Milam, disciplinary information assistants for the SMBO (written communication, October 1999). The reason for this overrepresentation is unknown but may involve differences in reporting rates. Enborn and Thomas10 noted that osteopathic physicians in Oregon were overreported for allegations of sexual misconduct, but they did not report an overrepresentation of osteopathic physicians in disciplinary actions taken by the Oregon Board of Medical Examiners. However, Taragin et al16 reported no difference in malpractice claim rates between osteopathic and allopathic physicians from New Jersey during 10 years, and Bohigian et al23 reported no overrepresentation of osteopathic physicians in the Missouri Physicians Health Program. Differences in specialty may also be a factor as osteopathictrained physicians (about 12% of the total workforce of Ohio physicians) represent 27% of Ohio family physicians.24 Shore4 found that although 21% of Oregon allopathic physicians were in family medicine, they represented 35% of those impaired. Furthermore, Stratas25 found general practitioners and family physicians to be overrepresented in actions by the North Carolina Medical Board. In this study, general practitioners and family physicians in Ohio represented 26% of disciplined physicians and 21% of controls. International medical graduates were significantly less likely to be disciplined compared with controls matched for location, gender, practice type, and self-designated specialty. This result is consistent with the California study, which found international medical graduates to be underrepresented in their subject group.17 In Ohio, physician health issues were the largest causes of disciplinary action (25%), and impairment due to alcohol and/or drug use was the single most frequently cited offense (21%), whereas these offenses represented 17% and 12% of such actions, respectively, in the California study.17 In a study of 300 complaints to the Oregon Board of Medical Examiners, Kofoed et al7 found 13% to be drug- and alcohol-related. Furthermore, a ratio of nearly 5:1 of impairment due to alcohol JAOA Vol 103 No 2 February

6 Table 4 Offenses Committed by Physicians Receiving Severe Disciplinary Action by the State Medical Board of Ohio, January 1997 to June 1999 Offense All offenders, No. (%) (N = 308) Individual offenders, No. (%) (N = 165) Health-related issues 88 (73) 25 (55) Drug- or prescribing-related crimes 82 (83) 25 (76) Previous state action 40 (56) 3 (75) Personal and professional conduct 22 (69) 10 (67) Fraud and other crimes 26 (64) 10 (55) Negligence or incompetence 17 (50) 6 (43) Credential issues 23 (59) 11 (42) Sexual and/or inappropriate patient contact 13 (76) 4 (80) Miscellaneous 3 (38) 2 (40) Total 315* (66) 96 (58) * The total number of offenses committed is greater than 308 because multiple offenses were committed by individual offenders. and/or drug use to mental and/or physical impairment in Ohio was much higher than the approximate 2:1 reported elsewhere.4,17 One possible explanation for these differences is that public concern about drug and alcohol abuse in physicians may be more significant in the Midwest than on the West Coast, where the aforementioned studies were done. Similar rates of physical and mental causes of disciplinary actions were found in Ohio (4%) and California (5%), implying consistency among state medical board actions in the United States.17 Further study is needed to confirm this hypothesis. One fifth (21%) of disciplinary actions in Ohio occurred as a result of drug-related offenses, including either a drug charge (7%) or inappropriate prescribing or drug possession (14%), which compares with the 13% rate of inappropriate prescribing or drug possession found in the California study.17 Kofoed et al7 found that 51% of complaints to the Oregon Board of Medical Examiners related to inappropriate prescribing, of which only 50 of the 130 physicians involved went on to receive board action. Of the Oregon physicians investigated for this offense, 53% were in family practice or general practice. The third most frequent group of offenses (15%) was a violation of a previous action by a state medical board in a different state (10%) or by the SMBO (5%). In the California study, only 3% of disciplinary actions were the result of this type of violation.17 Similarly, Post26 found the number of such offenses in New York to be less than 0.5%. One explanation for this difference is that the SMBO may closely monitor physicians for violations of previous actions taken by state medical boards in different states due to a local concern about disciplined physicians moving from state to state to avoid the consequences of past behavior. Negligence and incompetence represented only 7% of the causes for Ohio actions, whereas these offenses were reported at 31% in the California study.17 Kusserow et al27found only a minimal contribution of this to state medical board actions nationally, and Post26 found it represented 28% of the actions by the New York State Board for Professional Medical Conduct. These striking differences are difficult to explain but may result from differences in the definitions used by state medical boards, or by multiple types of offenses classified under the more general term incompetence. Legal crimes, another cause for disciplinary actions in Ohio, represented 9% of offenses, including fraud or kickbacks (4%) and other crimes (5%). The California study17 found a similar number of other crimes (4%) but more than twice the percentage of disciplinary actions as a result of fraud or kickbacks (10%). Post26 found that 24% of actions taken by the New York State Board for Professional Medical Conduct involved fraud. An actual decline in physician-related fraud since the 1980s or variations in state medical boards working definitions for these types of offenses might explain the large variations found in recorded disciplinary actions. Further study is needed to establish the cause of such wide variations in the reporting of legal crimes. Violations of CME requirements were the cause for 6% of 86 JAOA Vol 103 No 2 February 2003

7 SMBO disciplinary actions. Although the California study17 did not include a category for this type of offense, Stratas25 found this cause to represent less than 1% of disciplinary actions taken by the North Carolina Medical Board. Offenses related to misrepresenting credentials, license renewal violations, and failure to report reportable offenses contributed to 5% of SMBO actions, whereas credentialing issues represented only 2% of actions in the California study.17 In 1988, Schaffer et al28 found no difference in falsification of clinical credentials between US and international medical graduates, also finding that no single medical specialty predominated in this type of offense. Sexual and/or inappropriate patient contact represented only 4% of Ohio offenses and 9% of California offenses.17 According to data collected by the Public Citizen s Health Research Group,11 sex-related offenses represented between 2.1% and 5.2 % of disciplinary orders between 1989 and 1994 in the United States. Other offenses cited by the SMBO for which data in California are not available included unprofessional office conduct or poor supervision (5%) and child support default (1%). We are not aware of any other state medical board in the United States that disciplines physicians for child support default. Severe disciplinary action comprised 64% of SMBO actions, affecting 196 physicians, whereas in the California study, 35% of these physicians received severe disciplinary action. Severe action occurred in 88% of disciplined physicians with a drug charge and 80% of physicians with inappropriate prescribing or drug possession, whereas these offenses were reported at a rate of less than 41% in the California study.17 Offenses that were the result of mental and/or physical impairment led to severe disciplinary action in 79% of SMBO actions and 67% of California actions. Fraud or kickbacks and sexual and/or inappropriate patient contact offenses led to severe action in 66% and 76% of physicians disciplined in Ohio but only 54% and 42% of those disciplined in California, respectively.17 In Ohio, severe disciplinary action was ordered in 56% of probation violations, 44% of disciplined physicians with previous state disciplinary actions, and 83% of disciplined physicians with violations of previous SMBO actions. Similarly, the Medical Board of California took severe action against 58% of disciplined physicians with probation violations.17 Of disciplined physicians with negligence or incompetence offenses, 50% received severe action by the SMBO, while less than 41% of those disciplined for the same type of offense in California received severe action.17 Ohio physicians disciplined for health-related problems received severe disciplinary action for offenses that resulted from mental and/or physical impairment (67%) and impairment due to alcohol and/or drug use (74%). In contrast, 76% of SMBO-disciplined physicians but only 41% of California-disciplined physicians received severe disciplinary action for sexual and/or inappropriate patient contact.17 In Ohio, 44% of disciplined physicians with a CME requirement offense received severe action in the form of short suspensions (Table 4). Overall, the SMBO appeared to be evenhanded in disciplinary actions taken against osteopathic and allopathic physicians, men and women, and direct patient care and nonpatient care physicians. Disciplinary actions taken by the SMBO were more frequent and more severe than those taken by the Medical Board of California, and they were in response to more health-related impairment offenses due to alcohol and/or drug use and previous state medical board actions. Disciplined physicians in Ohio were younger than those in the California study, suggesting earlier intervention. Further, the specialties of anesthesiology, psychiatry, and surgery, though not statistically significant, may have been overrepresented. Women were clearly underrepresented, and physicians without board certification were overrepresented. International medical graduates were not overrepresented. Osteopathic physicians may have been overrepresented, but further study is needed to confirm this impression. Irvine notes that the public expects the medical profession to...show its determination to confront poor practice and end the secrecy that surrounds it...[and]...be tough on serious misconduct As the medical profession learns more about those physicians who require disciplinary action due to misconduct, incompetence, or impairment, we may be better able to meet the public s expectations and intervene earlier to conserve the valuable resource of trained physicians. Acknowledgments The authors thank Danielle Bickers and Suzanne Milam of the State Medical Board of Ohio for their assistance in data collection for the preparation of this study. References 1. Federation of State Medical Boards of the United States. Summary of 1998 Board Actions. Euless, Tex: Federation of State Medical Boards; O Connor, PG, Spickard A Jr. Physician impairment by substance abuse [review]. Med Clin North Am. 1997;81: Bissell L, Skorina JK. One hundred alcoholic women in medicine. An interview study. JAMA. 1987;257: Shore JH. The Oregon experience with impaired physicians on probation: An eight-year follow-up. JAMA. 1987;257: McAuliffe WE, Rohman M, Santangelo S, Feldman B, Magnuson E, Sobol A, Weissman J. Psychoactive drug use among practicing physicians and medical students. N Engl J Med. 1986;315: Brooke D. Impairment in the medical and legal professions. J Psychosom Res. 1997;43: Kofoed L, Bloom JD, Williams MH, Rhyne C, Resnick M. Physicians investigated for inappropriate prescribing by the Oregon Board of Medical Examiners. West J Med. 1989;150: Bloom JD, Williams MH, Kofoed L, Rhyne C, Resnick M. The malpractice claims experience of physicians investigated for inappropriate prescribing. West J Med. 1989;151: JAOA Vol 103 No 2 February

8 9. Wainapel SF. The physically disabled physician. JAMA. 1987;257: Enbom JA, Thomas CD. Evaluation of sexual misconduct complaints: The Oregon Board of Medical Examiners, 1991 to Am J Obstet Gynecol. 1997;176: ; discussion Dehlendorf CE, Wolfe SM. Physicians disciplined for sex-related offenses. JAMA. 1998;279: Jesilow P, Geis G, Pontell H. Fraud by physicians against Medicaid. JAMA. 1991;266: Schaffer WA, Rollo FD, Holt CA. Falsification of clinical credentials by physicians applying for ambulatory-staff privileges. N Engl J Med. 1988;318: Davis DA, Norman GR, Painvin A, Lindsay E, Ragbeer MS, Rath D. Attempting to ensure physician competence. JAMA.1990;263: Schwartz WB, Mendelson DN. Physicians who have lost their malpractice insurance. Their demographic characteristics and the surplus-lines companies that insure them. JAMA. 1989;262: Taragin MI, Wilczek AP, Karns ME, Trout R, Carson JL. Physician demographics and the risk of medical malpractice. Am J Med. 1992;93: Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279: State Medical Board of Ohio. Monthly Formal Actions. Columbus, Ohio: State Medical Board of Ohio; Available at: us/med/mfal/mfal.htm. Accessed January 15, American Medical Association. Directory of Physicians in the United States. 36th ed. Chicago, Ill: American Medical Association; Agresti A. Categorical Data Analysis. New York, NY: John Wiley & Sons; Bumgarner RQ. Physician discipline in the United States. Paper presented at: Second International Conference on Medical Registration; October 28, 1996; Melbourne, Australia. 23. Bohigian GM, Croughan JL, Sanders K, Evans ML, Bondurant R, Platt C. Substance abuse and dependence in physicians: the Missouri Physicians Health Program. South Med J. 1996;89: Williams PT. Twenty-year trends in the Ohio generalist physician workforce. J Fam Pract. 1998;47: Stratas NE. The contrast between physicians seen by the medical board and those seen in private practice. N C Med J. 1996;57: Post J. Medical discipline and licensing in the State of New York: a critical review [review]. Bull N Y Acad Med. 1991;67: Kusserow RP, Handley EA, Yessian MR. An overview of state medical discipline. JAMA. 1987;257: Schaffer WA, Rollo FD, Holt CA. Falsification of clinical credentials by physicians applying for ambulatory-staff privileges. N Engl J Med. 1988;318: Irvine D. The performance of doctors: the new professionalism [review]. Lancet. 1999;353: American Osteopathic Association. Yearbook and Directory of Osteopathic Physicians, th ed. Chicago, Ill: American Osteopathic Association; JAOA Vol 103 No 2 February 2003