MDC Disciplinary Action by Medical Boards and Prior Behavior in Medical School Essay

Description

You are to read the Papadakis article, attached, and write a 1000 word reflective essay on the article.?T h e n e w e ng l a n d j o u r na l o f m e dic i n e
special article
Disciplinary Action by Medical Boards
and Prior Behavior in Medical School
Maxine A. Papadakis, M.D., Arianne Teherani, Ph.D., Mary A. Banach, Ph.D., M.P.H.,
Timothy R. Knettler, M.B.A., Susan L. Rattner, M.D., David T. Stern, M.D., Ph.D.,
J. Jon Veloski, M.S., and Carol S. Hodgson, Ph.D.
abstract
background
Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case–control study, we investigated the association
of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are
most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school.
methods
The study included 235 graduates of three medical schools who were disciplined by
one of 40 state medical boards between 1990 and 2003 (case physicians). The 469
control physicians were matched with the case physicians according to medical
school and graduation year. Predictor variables from medical school included the
presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an
overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe).
From the School of Medicine, University
of California, San Francisco, San Francisco (M.A.P., A.T., M.A.B.,); the San Francisco Veterans Affairs Medical Center,
San Francisco (M.A.P.); the Federation of
State Medical Boards, Dallas (T.R.K.); the
Jefferson Medical College of Thomas Jefferson University, Philadelphia (S.L.R.,
J.J.V.); the University of Michigan Medical
School, Veterans Affairs Ann Arbor
Healthcare System, Ann Arbor (D.T.S.);
and the University of Colorado at Denver
and Health Sciences Center, Denver
(C.S.H.). Address reprint requests to Dr.
Papadakis at the University of California,
San Francisco, S-245, Box 0454, San Francisco, CA 94143, or at papadakm@
medsch.ucsf.edu.
N Engl J Med 2005;353:2673-82.
Copyright © 2005 Massachusetts Medical Society.
results
Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval,
1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent.
The types of unprofessional behavior most strongly linked with disciplinary action
were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to
40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also
associated with low scores on the Medical College Admission Test and poor grades
in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong
than that with unprofessional behavior.
conclusions
In this case–control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school.
Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should
have a central role in medical academics and throughout one’s medical career.
n engl j med 353;25
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december 22, 2005
2673
T h e n e w e ng l a n d j o u r na l o f m e dic i n e
T
he importance of professionalism
in medical school is receiving renewed attention.1-6 A fundamental assumption in
medical education is that professional students
become professional physicians. However, the data
to support this assumption are limited.2
In a pilot study of physician graduates of the
University of California, San Francisco (UCSF),
we found that disciplinary action taken against
physicians by the Medical Board of California
was associated with prior unprofessional behavior when the physicians were students.7 We also
identified three types of unprofessional behavior
that were of particular concern: irresponsibility,
diminished capacity for self-improvement, and
poor initiative.8 We undertook this case–control
study, involving three medical schools, to determine whether these findings could be generalized
to all medical students and state medical boards.
adversely affect patients.13 Three persons, two of
whom were staff members at the Federation of
State Medical Boards, classified the disciplinary
actions of the state boards into three categories:
unprofessional behavior, incompetence, and violation with the category not determined.
selection of control physicians
In the analysis, each physician who was disciplined
was paired with two control physicians who had
graduated within one year of the disciplined physician and for whom no disciplinary actions were
recorded in the database of the Federation of State
Medical Boards. In the pilot study, the reports of
unprofessional behavior among the control physicians differed among medical specialties.7 To
control for specialty in this study, the specialty of
one of the two control physicians was matched to
that of the disciplined physician. Information regarding specialties was obtained from the American Medical Association masterfile14 and the
methods
database of the American Board of Medical Speselection of physicians who were disciplined cialties.
The physicians who had been disciplined were
graduates of three medical schools since 1970: measurements
the University of Michigan Medical School in Ann The graduates’ academic records from their medArbor, Jefferson Medical College of Thomas Jef- ical schools contained applications for admission,
ferson University in Philadelphia, and UCSF School course grades, evaluation narratives, scores from
of Medicine. These schools were chosen for rea- licensing examinations, administrative corresponsons of geographic diversity and to provide rep- dence, and the dean’s letter of recommendation to
resentation of both public and private institutions. a residency program. Research assistants and acaIn addition, complete records for their graduates demic investigators for this study gathered the
were available. The physicians from the University data from these records while blinded to the case
of Michigan and Jefferson Medical College includ- or control status of the physicians.
ed all graduates disciplined by any state medical
Negative excerpts about professional behavboard in the United States between 1990 and 2003. ior were culled from reports of admission interThe physicians from UCSF included all graduates views, course evaluations (including check marks
disciplined by any state board other than the Med- in designated boxes on rating forms and narraical Board of California during the same period. tive comments), deans’ letters of recommendation
UCSF graduates disciplined by the Medical Board to residency programs, and any documents in
of California were excluded from this study, be- the students’ files dated before graduation. The
cause they had been described previously.7
course-evaluation forms contained items intended
All physicians were identified through a search to capture the entirety of professional behavior.
of public records maintained in databases by the
Federation of State Medical Boards. The disciplin- Overall Unprofessional Rating
ary actions taken against physicians are available The excerpts containing information about unto the public9-13 according to individual state laws. professional behavior were compiled and assigned
The disciplinary actions range from public repri- a severity rating for such behavior by at least two
mand to revocation of the medical license. Ac- investigators. The definition of unprofessional becording to the Federation of State Medical Boards, havior was based on our previously established
even behavior that results in the least severe dis- criteria.15,16 The rating scale for unprofessional
ciplinary action — public reprimand — may behavior included the five categories evaluated in
2674
n engl j med 353;25
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december 22, 2005
unprofessional behavior in medical school and disciplinary action
the UCSF pilot study: none, trace, concern, problem, and extreme.7 An a priori decision was made
that the ratings would be dichotomized, with the
categories of concern, problem, and extreme meeting the threshold of unprofessional behavior. The
investigators who assigned ratings could refer
back to the academic file to provide a context for
the excerpts. In the ratings of the negative excerpts, the interobserver agreement was 91 percent; the interobserver correlation was 95 percent
for severity ratings of none or trace as compared
with concern, problem, or extreme. Consensus was
reached on all discordant rankings.
Types of Unprofessional Behavior
An analysis of the content of the negative excerpts
was performed to characterize the types of behavior that were deemed unprofessional. The items
from the UCSF Professionalism Evaluation Form
and from our pilot study were used to develop a
set of software-related search terms (with the use
of QSR NVivo software, version 2.0) for eight
types of unprofessional behavior.8,15,16 Two of the
academic investigators reviewed all comments
coded by the software; search terms were either
added or removed by consensus. An NVivo listing
of the total number of search terms per type of
behavior per physician was uploaded into an SPSS
statistical program. The severity of unprofessional
behavior was ranked on the basis of the frequency
of the search terms (none = 0; one or two times =
moderate; three or more times = severe).
Other Predictor Variables
Other variables included age, sex, undergraduate
grade-point average (GPA) for science courses,
scores on the Medical College Admission Test
(MCAT), grades for medical school courses and
clerkships, and scores on the examination of the
National Board of Medical Examiners (NBME),
Part I, or on the U.S. Medical Licensing Examination (USMLE), Step 1.
The scaled scores that were based on different
versions of the MCAT were transformed to z scores
with the use of the means and standard deviations for each subtest of each version of the
MCAT. The mean z score of the subtests for each
student was used as the independent variable. For
students who repeated the MCAT, the mean of
the first two scores was used.17 The three medical schools used numerical, letter, and pass–fail
grades. To standardize these measures, we di-
n engl j med 353;25
chotomized the grades on the basis of the inability to pass a course on the first attempt (as indicated by a number grade below 70 points, a letter
grade of D or F, or a provisional nonpass or fail).
Raw scaled scores from NBME Part I and USMLE
Step 1 were changed to z scores with the use of
the mean and standard deviation for the year in
which the test was taken.
statistical analysis
The demographic characteristics of the disciplined and control physicians were analyzed with
the use of the chi-square test for proportions. The
associations of predictor variables with case and
control status were first examined with the use
of conditional logistic-regression models (SAS
software, version 8) that adjusted only for specialty, as required by the sampling design.18 We
then examined the association between the predictor variables and disciplinary action using unadjusted and adjusted conditional logistic-regression analyses. Variables in the multivariate model
included sex, MCAT z scores, the number of medical-school courses not passed on the first attempt,
the overall measure of unprofessional behavior,
and the specialties of the physicians (categorized
as internal medicine, family practice, obstetrics and
gynecology, pediatrics, or all other specialties).
We subsequently evaluated the eight types of
unprofessional behavior as predictors of disciplinary action using unadjusted conditional logisticregression analyses. These eight types of behavior
(each categorized as 0, 1, or 2) then competed
for inclusion in a conditional logistic-regression
model that predicted the risk of disciplinary action. The two types of behavior found to be significant in the logistic-regression analysis and a
third behavior that almost reached statistical significance replaced the variable for overall unprofessional behavior in a multivariate model that
adjusted for all the variables listed above. We
then repeated the multivariate conditional logistic-regression analysis and replaced the three
types of behavior with their scores for severity of
behavior (moderate or severe).
The proportion of disciplinary action that was
attributable to a variable was calculated with the
use of population attributable risk19 according to
the following equation (with PAR denoting population attributable risk, Pd the proportion of the
exposure in the cases and RR the adjusted relative risk): PAR = [Pd × (RR−1)] ÷ RR. Continuous
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T h e n e w e ng l a n d j o u r na l o f m e dic i n e
variables (e.g., MCAT z scores) were dichotomized
(as the proportion of cases in the bottom quartile vs. others). The frequency distribution of
specialties represented by the physicians who
had been disciplined was compared with that of
the specialties of all graduates of the three
medical schools, to determine whether the specialties were similarly distributed.
Evidence indicates that physicians who have
been in practice for more than 20 years are at
increased risk for disciplinary action.20,21 We investigated whether this was true in our study
sample by dichotomizing the disciplined physicians according to the year of graduation — before 1980 and 1980 or later.
The institutional review boards of UCSF, the
University of Michigan, and Jefferson Medical
College approved this study, and none required
informed consent from the graduates. The Federation of State Medical Boards approved and
collaborated with the investigators of this study.
To protect confidentiality, we did not list the number of disciplined physicians according to medical school, year of graduation, or state in which
disciplinary actions occurred.
overall unprofessional behavior
Twice as high a proportion of disciplined physicians as of control physicians demonstrated unprofessional behavior in medical school (Table 3).
In unadjusted analyses, disciplined physicians were
more likely than control physicians to display the
following types of unprofessional behavior while
in medical school: irresponsibility, diminished capacity for self-improvement, poor initiative, impaired relationships with students, residents, and
faculty, impaired relationships with nurses, and
unprofessional behavior associated with being
anxious, insecure, or nervous.
The multivariate analysis revealed three variables with regard to medical school that independently predicted disciplinary action. Unprofessional
behavior was associated with an increase, by a factor of three, in the risk of subsequent disciplinary
action, and it accounted for the largest population
attributable risk (26 percent) (Table 4). Low MCAT
scores and low grades in the first two years of
medical school were also significant predictors,
with a population attributable risk of disciplinary
action of 1 percent and 7 percent, respectively.
types of unprofessional behavior
results
Records for 235 of the 243 physicians who were
disciplined and 469 of the 486 control physicians
were available. Each of these 704 physicians graduated from one of the three medical schools between 1970 and 1999. One or more of 40 state
medical boards disciplined the case physicians;
unprofessional behavior was the basis for at least
74 percent of the violations (Table 1). Most physicians who were disciplined committed multiple
violations; for 94 percent of those who were disciplined, one or more violations involved unprofessional behavior.
The disciplined physicians had a slightly lower
mean undergraduate science GPA than did the
control physicians (Table 2). MCAT scores were
also slightly lower among the disciplined physicians, as were NBME Part I scores and USMLE
Step 1 scores. There was no difference in the findings for physicians who took the MCAT twice.
Disciplined physicians were roughly twice as
likely as control physicians not to have passed at
least one course on the first attempt in both the
preclinical and clinical years of medical school.
2676
n engl j med 353;25
We evaluated the types of unprofessional behavior
and the frequency of their occurrence during medical school (Table 3). Examples of irresponsibility
were unreliable attendance at clinic and not following up on activities related to patient care.
Examples of diminished capacity for self-improvement were failure to accept constructive criticism,
argumentativeness, and display of a poor attitude.
Poor initiative was characterized by a lack of motivation or enthusiasm or by passivity.
Two types of unprofessional behavior independently predicted disciplinary action: irresponsibility and diminished capacity for self-improvement.
The odds of receiving disciplinary action increased
as the frequency of unprofessional behavior increased; students who were severely irresponsible
(as indicated by three or more search terms) or
who were described as severely unable to improve
their behavior had odds ratios of 8.5 (95 percent
confidence interval, 1.8 to 40.1) and 3.1 (95 percent confidence interval, 1.2 to 8.2), respectively,
for subsequent disciplinary action. Unprofessional
behavior associated with being anxious, insecure,
or nervous (three or more search terms) approached
statistical significance (P = 0.06).
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december 22, 2005
unprofessional behavior in medical school and disciplinary action
other analyses
The major predictor variable, overall unprofessional
rating, remained significantly associated with disciplinary action when it was analyzed within subgroups. Disciplined physicians were compared with
control physicians matched by specialty (odds ratio, 3.1; 95 percent confidence interval, 1.8 to 5.3)
and with control physicians not matched by specialty (odds ratio, 3.1; 95 percent confidence interval, 1.7 to 5.8), as well as physicians stratified
according to year of graduation — 1970 to 1979
(odds ratio, 2.9; 95 percent confidence interval,
1.6 to 5.2) and 1980 to 1999 (odds ratio, 3.5; 95
percent confidence interval, 1.6 to 7.7). Two variables (undergraduate science GPA and z scores on
NBME Part I and USMLE Step 1) were deleted from
the final model because these variables were missing for nearly 30 percent of the study subjects. Had
the two variables remained in the final model,
they would not have been associated with disciplinary action (odds ratio for undergraduate science GPA, 0.8; 95 percent confidence interval, 0.4
to 1.5; odds ratio for z scores on the NBME Part I
and USMLE Step 1 board tests, 0.9; 95 percent
confidence interval, 0.6 to 1.3). However, the association of the overall unprofessional rating
Table 1. Description of the 740 Violations among 235 Physicians That Led to Disciplinary Action on the Part of 40 State
Medical Boards.
Type of Violation
No. (%)
Unprofessional behavior
Use of drugs or alcohol*
108 (15)
Unprofessional conduct
82 (11)
Conviction for a crime
46 (6)
Negligence
42 (6)
Inappropriate prescribing or acquisition of controlled substances
39 (5)
Violation of a law or order of the board, of a consent or rehabilitation order, or of probation
32 (4)
Failure to conform to minimal standards of acceptable medical practice
31 (4)
Sexual misconduct
29 (4)
Failure to meet requirements for continuing medical education or other requirements
26 (4)
Fraud or inappropriate billing practices (e.g., Medicare billing irregularities)
20 (3)
Failure to maintain adequate medical records
19 (3)
Failure to report adverse actions against oneself in accordance with rules of the board
10 (1)
Conduct that might defraud or harm the public
10 (1)
Other (less than 1% of any single category)
57 (8)
Total
551 (74)
Incompetence
Health-related problems, incompetence, or impairment
44 (6)
Unknown†
Violation imposed by another board or agency
87 (12)
License revocation or suspension
28 (4)
Inappropriate treatment or diagnosis of patients or malpractice
7 (1)
Other or not available (less than 1% of any single category)
23 (3)
Total
145 (20)
* The decision to categorize the use of drugs or alcohol as unprofessional behavior was based on the customary practice
of medical boards to discipline physicians for such use if they commit acts that endanger patients. Physicians who have
used drugs or alcohol but have not endangered patients may be referred to the diversion programs of medical boards
and generally do not face disciplinary action.
† The category of unknown violations includes those that could not be ascribed to unprofessional behavior or to incompetence.
n engl j med 353;25
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T h e n e w e ng l a n d j o u r na l o f m e dic i n e
Table 2. Demographic Characteristics and Measures of Academic Performance for the 704 Physicians from the Three
Medical Schools.*
Variable
Disciplined
Physicians
(N = 235)
Control
Physicians
(N = 469)
1970–1979
130 (55.3)
262 (55.9)
1980–1989
78 (33.2)
147 (31.3)
1990–1999
28 (11.9)
60 (12.8)
Internal medicine
47 (20.0)
112 (23.9)
Family practice
44 (18.7)
61 (13.0)
Pediatrics
7 (3.0)
18 (3.8)
Surgery
18 (7.6)
41 (8.7)
Psychiatry
10 (4.2)
19 (4.1)
Obstetrics and gynecology
21 (8.9)
33 (7.0)
Anesthesia
18 (7.7)
35 (7.5)
Emergency medicine
12 (5.1)
29 (6.2)
Radiology
7 (3.0)
17 (3.6)
Orthopedic surgery
9 (3.8)
21 (4.5)
Urology
7 (3.0)
10 (2.1)
Ophthalmology
7 (3.0)
15 (3.2)
P Value
Demographic characteristics
Graduation year — no. (%)
0.87
Specialty — no. (%)
Otolaryngology
6 (2.5)
7 (1.5)
Other†
22 (9.3)
51 (10.9)
Age at discipline — yr
44.1±6.9
Predictor variables
Male sex — no. (%)
123 (52.3)
242 (51.6)
0.83
Undergraduate science GPA
3.3±0.5
3.5±0.5
0.002
MCAT z score
0.6±0.6
0.8±0.6

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