JMR Journal medical regulationjmr.fsmb.org/Archive/2000s/An Assessment of USMLE Examinees...

Journal of medical

regulationJMR

A L S O I N T H I S I S S U E

Setting the Standard for Recovery: Physicians’ Health Programs

Recalling August Heckscher

An Assessment of USMLE Examinees Found to Have Engaged in Irregular Behavior

Evaluating the impact of infractions on licensing

C R I T I C A L T H I N K I N G O N I S S U E S

O F M E D I C A L L I C E N S U R E A N D D I S C I P L I N E

V O L U M E 9 5N U M B E R 42 0 0 9 / 2 0 1 0

Submit a manuscript to the Journal of Medical Regulation For more information about how to submit a manuscript, please see Information for Authors on page 47.

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A R E I N D I V I D UA L S W H O

HAVE ENGAGED IN IRREGULAR

B E H AV I O R W H E N TA K I N G

T H E U S M L E A B L E TO O B TA I N

L I C E N S U R E L AT E R ?

Journal of medical

regulation

VO L U M E 9 5 , N U M B E R 4 , 2 0 0 9 / 2 0 1 0 2 Publisher’s Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 Quoted | Notes from the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4 Message from the Chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8 Recalling August Heckscher, Philanthropist and Observer Humayun J. Chaudhry, D.O., FACP, President and CEO, Federation of State Medical Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 Setting the Standard for Recovery: Physicians’ Health Programs Robert L. DuPont, M.D. A. Thomas McLellan, Ph.D. William L. White, M.A. Lisa J. Merlo, Ph.D. Mark S. Gold, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26 An Assessment of USMLE Examinees Found to Have Engaged in Irregular Behavior, 1992–2006 David Alan Johnson, M.A., Vice President for Assessment Services Federation of State Medical Boards

36 International Briefs

40 State Member Board Briefs

43 Legal Briefs

47 Information for Authors

Editor-in-Chief William E. Wargo, J.D., M.S.W.

Editorial Committee

John W. Graves, J.D.

Michael K. Helmer

Ruth Horowitz, Ph.D.

Susan R. Johnson, M.D., M.S.

C. Grant La Farge, M.D., FACC, FACP, FAPS

Michael E. Norins, M.D., M.P.H., FACP

Sandra L. Osborn, M.D.

Sindy M. Paul, M.D., M.P.H., FACPM

Leticia J. San Diego, Ph.D.

Danny M. Takanishi Jr., M.D.

William A. Walker, M.D., FACS, FASCRS

Editor Emeritus Dale G Breaden

© Copyright 2010 The Federation of State Medical Boards of the United States Inc.

FSMB Officers

Chair: Martin Crane, M.D.

Chair-elect: Freda M. Bush, M.D.

Treasurer: James M. Andriole, D.O.

President/Chief Executive Officer: Humayun J. Chaudhry, D.O., M.S., FACP, FACOI

Immediate Past Chair: Regina M. Benjamin, M.D., M.B.A.

FSMB Board of Directors

Hedy L. Chang

Leslie A. Gallant

Galicano F. Inguito, Jr., M.D., M.B.A.

Ram R. Krishna, M.D.

Kim Edward LeBlanc, M.D., Ph.D.

Bruce W. McIntyre, J.D.

Tully C. Patrowicz, M.D.

Janelle A. Rhyne, M.D., FACP

Lance A. Talmage, M.D.

Jon V. Thomas, M.D., M.B.A.

Cheryl A. Vaught, J.D.

FSMB Executive Staff

President/Chief Executive Officer: Humayun J. Chaudhry, D.O., M.S., FACP, FACOI

The Journal of Medical Regulation (ISSN 1547-48IX, publication number 189-120) is published quarterly by the Federation of State Medical Boards of the United States Inc., 400 Fuller Wiser Rd., Suite 300, Euless, TX 76039

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Published Continuously Since 1915 | Volume 95, Number 4, 2009/2010All articles published, including editorials, letters and book reviews, represent the opinions of the authors and do not necessarily reflect the official policy of the Federation of State Medical Boards of the United States Inc. or the institutions or organizations with which the authors are affiliated unless clearly specified.

Journal of medical

regulation

JMR

A S PAT I E N T S we sometimes forget that our physicians are prone to all the

same illnesses and problems as we are—physicians, after all, are humans with frail-

ties and vulnerabilities. When physicians face illness, however, challenging ques-

tions are raised. What is the impact of physician health status on patients? What

can be done to ensure physician illness doesn’t impact patient care? What do we do

when the healers are sick themselves? In this issue of the Journal of Medical Regu-

lation, we highlight efforts by state medical boards to create programs that deal

specifically with physicians who have addictive disorders, such as drug and alcohol

abuse. It’s a particularly challenging problem, known to medical regulators for years,

and formally recognized by the American Medical Association more than 30 years

ago in a landmark policy paper titled “The Sick Physician: Impairment by Psychiatric

Disorders, Including Alcoholism and Drug Dependence.” Over time, the regulatory

community has tackled this issue—each state in its own way—and today all states

have some kind of physician-impairment program in place. The research study

begins on page 10.

You will notice that this issue of the Journal has a new format and design, intended

to enhance readability. We are interested in your opinions and welcome your input

and comments on our new look. Please send an e-mail to [email protected], letting

us know what you think.

Bill Wargo, Editor-in-Chief

A person who has not been sick cannot be a good doctor.

— Chinese Proverb

JOURNAL of MEDICAL REGULATION VO L 9 5 , N O 4 | 3

4 | JOURNAL of MEDICAL REGULATION VO L 9 5 , N O 4

I N B R I E F Dr. Crane summarizes his year in office as chair of the FSMB Board of Directors, noting that the organization must continue to exert leadership by focusing on several core capabilities and priorities

One year ago, at the beginning of my chairmanship, I wrote a message titled “It is Time to Lead.” I noted that, at its core, the Federation of State Medical Boards remained a membership organization with a primary role of supporting the state medical boards in their vital work and representing the needs, goals, successes and challenges of our member boards in national policy forums on health care regulation, patient safety, access to the highest quality care for all and health care reform. Patients rely on their state medical boards to protect them and this can only occur when those boards are well funded, have appropriate resources and are statutorily strong.

I observed that in order for us to continue to fulfill our responsibility to the public, we must focus on those aspects of our organization that are the core of our existence and those that provide the best opportunity to carry out our mission, remain viable, exercise leadership and collaborate with others in today’s ever-changing world of health care aware-ness and reform. This means being nimble and ready to react to change in a positive and determined manner. It means understanding and responding to significant challenges facing our organization and our member boards so that together we can successfully carry out our missions and also fulfill our roles as leaders and collaborators in developing solutions to improve the quality and safety of our country’s health care.

In May 2009, I suggested to the FSMB Board of Directors that we give priority to a list of initiatives designed to position and to strengthen the Federation’s ability to protect the public, improve health care quality, patient safety and physician practice and

therefore positively impact our nation’s health care. Our board and management responded with a collective determination. Included here are high-lights of our effort to fulfill those initiatives. More specific details on this year’s accomplishments can be found in “The Report of Our Strategic Plan,” presented during the FSMB Annual Meeting in Chicago April 22–24, 2010.

New management and leadership at the FSMBIn July 2009, our Board concluded a comprehensive search by appointing Humayun J. Chaudhry, D.O., FACP, as our new president and chief executive officer. He previously served as public health com-missioner of Suffolk County, New York. “Hank” has exceptional talent as an administrator, regulator and educator in health care, along with a passion for public protection. He has been evaluating the management and operational infrastructure of the FSMB and has been assembling an experienced and highly qualified senior management team to lead the Federation into the next decade. Hank chose Sandra Waters to be our new chief operating officer, and Todd Phillips, MBA, to be chief financial officer. A chief of information officer will soon be added. I believe that this is a necessary and brilliant move in positioning an organization whose “core busi-ness” is data collection and information management to meet its future potential. This strengthening of our internal management infrastructure is essential to carrying out our mission and preparing for the demands of an ever-changing regulatory and health care environment. This team is strong, vibrant, focused, creative and engaged in providing the FSMB with a “can do/can lead” culture and the effective tools and resources to meet new challenges. Consistent with these efforts, the board has also established new oversight procedures for itself and has enhanced the partici-pation of the Finance Committee in the budgetary process to assist in the alignment of our resources with our mission and current goals.

Message from the Chair We Stand Ready to ‘Astound’ Martin Crane, M.D., FACOGChair, Board of DirectorsFederation of State Medical Boards


National advocacy for state medical boardsAs extensive discussions on U.S. health care reform were held in Washington, D.C. throughout 2009, the FSMB broadened its national advocacy efforts on behalf of its member boards. In January 2010, we opened the new FSMB Washington, D.C., office, which will serve as the hub of our work with national legislators and policy-makers and as a focal point to raise awareness and understanding of the impor-tant mission of state medical boards in health care. The office, supervised by Lisa Robin, our senior vice president for Advocacy and Member Services, has already helped establish the FSMB as a robust, com-prehensive and sought-after informational resource for health care policy development and implemen-tation. There is a growing recognition that the FSMB’s physician databases, technology infrastructure and informational management systems—which we are enhancing and further developing—are second to none. As our nation begins to embrace issues and concepts such as telemedicine, electronic health records, effective and efficient responses to national emergencies, physician workforce needs, health care fraud and abuse and the expansion and access

of health care for all, we can and will demonstrate that the Federation and its member boards are fully capable and prepared to exercise leadership and partnership roles in such initiatives.

Public awareness and public membersCoupled with our Washington, D.C., advocacy, the FSMB has begun an effort to raise public awareness of our member boards and their work. Using a media and public relations campaign, we are presenting the needs, goals and successes of our state member boards and the necessity to have adequate funding and resources for them to carry out their mission of public protection. In a related effort, the Federation and the FSMB Foundation are undertaking the development of educational modules to assist in the orientation of public members to the duties and responsibilities of board membership. This year, FSMB is providing a number of additional stipends dedicated to bring public members to our annual

meeting in Chicago. These efforts recognize that the public, whom we serve, is our most impor-tant constituency and that our public board members are unique and valuable contributors to our regulatory system.

Data and informational resources

Federation Credentials Verification Service, Uniform Application, and License Portability I believe that we are an information organization. FSMB is currently making a long-overdue and significant investment to enhance its overall technological capa-bilities—enabling it to provide the highest quality, most efficient, comprehensive and robust research, credentialing and licensure information to our member boards and to a wide array of other stake-holders. This is our core product and this year we have fast-tracked a major technology upgrade designed to significantly enhance our capabilities for verifying physician credentials through the Federation Credentials Verification Service (FCVS). FCVS is designed to streamline the credentialing process, making it more efficient for physicians who need their credentials primary-source verified and for institutions utilizing these credentials. The newly enhanced, robust FCVS will launch later this year. Also in 2009, many state medical boards implemented the Uniform Application for State Medical Licensure (UA). The application consists of one primary form common to all states with state-specific addendums, allowing each state to tailor the form to the needs of their jurisdiction while gaining the efficiencies associated with a standard electronic application. When a physician elects to use the UA in conjunction with FCVS credentialing services, further efficiencies are realized. The UA is populated with data from the FCVS application and the credentials verification process is effectively re-engaged when licensure is sought in additional states. We realized the necessity and urgency of these improvements and responded with synergism between the board and management that should make us all proud. These efforts will bring us closer to making the concept of license portability a reality in mainstream medicine. In March 2010, the FSMB received the welcome news that it has received a Licensure Portability Special Initiative grant under the American Recovery and Reinvestment Act of 2009 (ARRA). The two-year, $500,000 grant is designed to assist the FSMB and state medical boards continue all the initiatives described above. This grant affirms that the FSMB is being recognized as a significant contributor to health care solutions in the United States. As we continue this effort in

PATIENTS RELY ON THEIR STATE MEDICAL

BOARDS TO PROTECT THEM AND THIS CAN ONLY

OCCUR WHEN THOSE BOARDS ARE WELL

FUNDED, HAVE APPROPRIATE RESOURCES AND

ARE STATUTORILY STRONG.


the future, license portability will help to address some of the most significant health care issues we face, including the need to lower costs, provide care to under-served populations and facilitate telemedicine and other forms of medical technology that will bring quality healthcare to our patients.

Maintenance of Licensure (MOL)

Assuring the continued competence of licensed physiciansIn 2004, the FSMB adopted policy stating that state medical and osteopathic boards have an “obligation to the public to assure the continuing competence of physicians seeking license renewal.” During more than seven years of careful discussion and analysis, the FSMB’s MOL initiative has methodically and inclusively advanced and developed a framework by which such policy could be brought to a reality with the best interests of the public and the profession in mind. The FSMB MOL initiative has involved a broad spectrum of stakeholders across the entire medical profession, including the education, assessment, certification, accreditation, professional, and regula-tory sectors and, most importantly, the public. This collaborative effort produced several reports (Special Committee’s Report on Maintenance of Licensure, two Impact Analyses Reports and most recently an Advisory Group Report on the Continued Competence of Licensed Physicians). Through this important initiative, FSMB and its member boards are advancing a concept that will help strengthen our state medical boards’ responsibility for public protection while being sensitive to the needs of our member state medical boards and the medical profession. We have “talked the talk” and are now prepared to “walk the walk.” The Advisory Group report has concluded that the FSMB MOL framework is “feasible, reasonable.... and suitable for use by our state member boards in assuring the continued competence of licensed physicians and, furthermore that any challenges can be overcome through clear communication of a compelling rationale, leadership, and appropriate resources.” After lengthy study, a board report incorporating the Advisory Group’s recommendations for a policy framework for MOL will be sent to the FSMB House of Delegates in April 2010 for review and approval as official FSMB policy. To be prepared for this sentinel event for our regulatory system, we have charged an Implementation Workgroup with exploring a framework for a “starter plan” that state medical and osteopathic boards could consider in implementing an FSMB MOL policy. This will not be a revolutionary process but rather an evolutionary

one. We need to work carefully as we begin to focus on implementation and be prepared to make mid-course corrections as we work to get it right. Change is always more difficult than the status quo, but the concept of MOL is worth the effort and will make a tangible difference in improving the quality and safety of health care. I believe that successful implemen-tation of MOL will bolster the public’s confidence in our self-regulatory system and in the profession itself. So let’s “step it up” and finish the job we have all begun!

Response and readiness (emergency preparedness)The FSMB has the most comprehensive and robust physician database in our nation and is developing informational system capabilities to maximize the use of our data. As such, we can realize our potential as an integral part of a system to respond to national emergencies and disasters. The FSMB Readiness and Response Workgroup was re-established and charged with providing guidance to state medical boards as well as national and state agencies regard-ing emergency preparedness, disaster planning and the deployment of physician volunteers during a public health emergency or national disaster.

Through our Washington, D.C., office, we have con-nected with governmental agencies that see us as an important partner in emergency management and planning with respect to medical resources. The Readiness and Response Workgroup held its initial meeting on December 10, 2009, with a subsequent meeting held on January 26, 2010, in Washington, D.C. During that meeting, representatives from the medical profession, the U.S. departments of Home-land Security and Health and Human Services, and preparedness experts from the Chertoff Consulting Group participated in the Workgroup’s discussions.

Most recently, we have used our credentialing services and expertise to assist with physicians responding to the Haitian disaster, thereby demonstrating our significant capabilities.

Affiliation and partnership developmentThis year, we have continued our work in developing and strengthening our collaboration with other health care stakeholders since our nation’s health care future depends on our ability to work together across diverse sectors and communities as we seek new paths and solutions. To accomplish this goal, we continue to strive to be valuable, desirable and respected partners. We have reached out to all health care stakeholders and have been able to forge


new relationships and explore new collabo rative ven-tures. I am especially pleased to report our efforts to develop affiliations with all the U.S. Uniformed Health Services as we explore ways in which the FSMB could enhance and support their credentialing and regulatory needs and how, together, we are poised to positively impact our nation’s emergency and disaster responses.

We have continued to play a key role in the worldwide body of medical regulators—the International Asso-ciation of Medical Regulatory Authorities (IAMRA)— as its secretariat and as a sponsor of its Ninth Annual Conference in Philadelphia, September 26–29, 2010. As health care becomes more global and physi-cians more mobile, the FSMB will be an important resource and partner in regulatory best practices and inno vations to meet these future challenges.

Special Committee on Strategic PositioningFSMB’s Special Committee on Strategic Positioning was convened in December 2008 and charged with reviewing the FSMB’s current strategic plan and developing the strategic direction of the FSMB over the next five years. Specifically, the Committee was asked to identify possible areas of modification of our current strategic plan and to develop new strategic planning recommendations that will position the FSMB for the future, support the future needs of the medical regulatory community, and, position the FSMB as the leader in medical regulation.

Under the dedicated leadership of its chairman, Bill Martin, M.D., the Committee completed its task this year. The result of the committee’s work is a revised strategic plan that includes a clear vision statement that is more succinct, proactive and directed toward the future; a new mission statement that acknowledges the importance of state medical boards’ mission of public protection and FSMB’s role as “voice” and “resource,” while incorporating what is unique about FSMB and how it is distinguished from other organizations; a reworking of our core values; and six new strategic goals that are outcome-oriented. The report of this committee, which will provide a “roadmap” for the FSMB, will be presented during the 2010 FSMB Annual Meeting for approval.

FSMB FoundationAt last year’s FSMB Annual Meeting, the Federation announced the rejuvenation of its Research and Education Foundation—seeking to position it as a more effective and efficient vehicle by which

to deliver meaningful, practical and cost effective programs and services to our member boards.

This year, the FSMB Board and the Education Com-mittee have made practical this synergistic relation-ship by working with the Foundation to assist us in focusing on the vital role of public members on our state medical boards during the 2010 FSMB Annual Meeting. The Foundation has developed needs assessment surveys and videos that target our pub-lic members and their role in building strong state medical boards. It will also develop an “instruction manual” that will provide both practical and thought-provoking materials for public members as well as a report highlighting important qualifications for public members to assist authorities as they vet potential candidates for appointment. We believe that this is a great start and look forward to further contribu-tions from our Foundation in the future.

Together, we have accomplished much this year but we are not finished as FSMB “aims at an end indisputably desirable” (Harpers Weekly, July 26, 1913). In this dynamic world of health care and impending reform, we must win the trust and confidence of both the public and the medical pro-fession—their “hearts and minds”—so we can do our job efficiently, effectively, responsibly and fairly. We ask all to join with us in this most worthy endeavor and work toward a common goal of access to the highest quality of health care for all our patients, practiced by the most competent and dedicated health care professionals.

It has been my privilege and an honor to serve as your chairman this year. I am proud to have been given this opportunity to work alongside our board members, our staff, our membership and our nation’s health care partners. I am proud to be part of an organization of such high purpose as it truly moves from “good to great” and realizes its full potential for both leadership and partnership in improving the future of the health care provided to all of our patients.

As Mark Twain said, “Do what is right and you’ll please some of the people and…astound the rest.”

The Federation of State Medical Boards and our member state medical boards stand ready to “astound.” Thank you for the opportunity to serve. ■


Recalling August Heckscher, Philanthropist and Observer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .By Humayun J. Chaudhry, D.O., FACP, President and CEO, Federation of State Medical Boards

I N B R I E F Dr. Chaudhry details the significance of August Heckscher’s rich career and contributions to the profession from a 21st century perspective. The impact and relevance of Dr. Heckscher’s unique approach is still strong.

“Every profession and every social institution,” wrote August Heckscher, “is the product of a particular time.” As Director of the Twentieth Century Fund (now The Century Foundation), a nonpartisan think tank founded in 1919 to promote progressive public policy, Heckscher knew what he was writing about. A multimillionaire capitalist and philanthropist, he was a German immigrant who began as a laborer in the coal mining industry, studied English at night, and worked his way up from wearing a blue collar to a white collar while amassing a small fortune. Realizing the American dream, he founded the Heckscher Children’s Fund and created several play-grounds and parks that bear his name in New York. Heckscher was also prescient, especially when he predicted, in a 1959 speech on Medicine and Society that was published in the New England Journal of Medicine, that “the prevailing structure of medical care—the doctor in solo practice dealing on a fee-for-service basis with the individual patient—is not part of the eternal order of things.”1

On the fiftieth anniversary of the publication of Heckscher’s presentation, as comprehensive health care reform in the United States begins to occur, it is worth reviewing his comments to remind those of us involved with medical regulation of how things were in medicine and society, of what the profession of medicine promised society and individuals, and of what challenges and pressures existed for the practicing physician before Medicare and Medicaid, to put the activities of today in their proper per spective. As Harvard philosopher George Santayana once famously declared, “Those who cannot remember the past are condemned to repeat it.” This review is also a reminder, albeit

implicitly, of the value of the work of state medical and osteopathic boards and the Federation of State Medical Boards (FSMB), then as now, to the com-munity and the public at large.

Not without some provocation, Heckscher begins his comments about health care by first postulating that the relationship between the doctor and the patient reflects the “nineteenth-century concept of ethics,” including “the prevailing ideas of indi-vidualism and commercialism,” namely, that “one man was expected to bear what he must, whereas another was expected to take what he could get.” He quickly cautions, however, that in practice these ideas were “softened and overlaid” by such concepts as charity and the growth of professional standards (championed, we would note, by state medical and osteopathic boards and organized medicine) that “put service above personal gain and made it possible for the doctor to attain at his best a genuinely disinterested attitude in treating his patient.”

Heckscher reminds us that in the “ethics of the nineteenth century,” reflected even in many circles in 1959, there was an assumption that “the cost of sickness was something that the patient bore alone, out of his own resources, and that whether or not he got well was up to himself entirely, with no inter-est of the community involved.” While communities were by then well aware of the role of contagion and the spread of disease in epidemics, Heckscher observes that individual illness “on the whole” was not considered a concern of the community. By con-trast, the American Public Health Association today is just one influential organization whose focus is on the assurance of community-based health promotion and disease prevention activities. To his credit, Heckscher recognizes the emerging value of the community to health care, stating “the individual cannot exist as a mature personality apart from the social context.” Reflecting on the lessons learned from World War II, in fact, Heckscher mentions that


“it was only when war became a matter involving the whole citizenry that it was apparent how much poor health could weaken the national effort” and that “it helped men to see that in peace, as well as in war, health may be vitally related to national well-being.”

From the point of view of the physician, Heckscher mentions a truism of the nineteenth century that we would consider quaint if not incongruous today, that “all that was known of the healing arts was capable of being embodied in one man.” (By the conventions of his day, Heckscher always refers to the physician as male.) The recognition in the mid-twentieth century of the value of more knowledge and information about disease and its treatment lead to, as Heckscher notes, the doctor “tending to refer more and more of his work to specialists.” What Heckscher leaves out, but could not possibly have considered in 1959, is the ability of today’s primary care physicians (internists, family practitioners and pediatricians) as well as specialists of every field to readily access at their fingertips the abundance of medical, if not patient, information available to them through desktop and laptop computers and hand-held, Internet-based electronic devices.

One comment he makes about health care refers something likely to have been apparent to many in 1959 but less obvious today: “how much the growth of (medical) group practices owes to the labor unions,” whose leaders and their search for “legitimate fringe benefits” for their workers “led them to explore ways of insuring their members” and which “led them to seek new forms of medical service.” To this list of “new experiments” and welcome additions he later adds the “quickening growth of hospital insurance” and “new arrangements for financing medical care.”

In commenting about the very nature of the practice of medicine, Heckscher writes, “I get the impression that the career of medicine is not quite what it once was—in dignity, in educational breadth, in personal service and in the satisfactions and rewards that it brings to the practitioner.” Putting in an unintended admonition in support of today’s concept of primary care medicine, Heckscher notes in 1959 that the graduates of medical school have had their minds “sharpened, but not broadened, and they go out with a very meager feeling for the things of the world that lie beyond their sphere of specialization.”

Of particular interest to the harried physician of today may be Heckscher’s sincere observation that “one of the aspects of the modern profession of medicine that has seemed incongruous and disturbing

is the average doctor’s lack of leisure.” Adding a caveat that he does not define leisure necessarily as the time to go fishing or to play golf, he writes instead of leisure as “the opportunity to think, to reflect imaginatively and to restore the batteries of creativity that constant toil drains low.” Specifically reaching out to state medical and osteopathic boards with an idea that has not taken hold even 50 years later but is worth musing about, Heckscher writes that he has sometimes “thought that licensing bodies should exact from the doctor the requirement that he take a regular sabbatical.” Were he alive today, one surmises Heckscher would wholly support the work-hour limits now in place for medical and surgical residents.

Finally, and most remarkably, anticipating by more than 40 years the focused discussions and analyses by the FSMB about a policy and process to promote the assurance of continued competency by actively licensed physicians, Heckscher alludes to the need for physicians to demonstrate continued learning and continued competency. “Surely there must also be provision,” he rhetorically asks, “for the doctor to absorb new knowledge as the times progress—to combine the career of practice with the career of learning, and at every stage along his way to have his assumptions checked by intimate associations with his peers, and his knowledge brought into line with the latest developments in various specialized fields.”

The FSMB’s current mission seeks “continual improve-ment in the quality, safety and integrity of health care through the development and promotion of high standards for physician licensure and practice.”2 In sharing with us the general thinking about health care from several eras gone by, Heckscher’s presen-tation reminds us today of the value of our increasingly proactive efforts to protect the public, to proactively enhance the education of physicians across the continuum of medical education and to proactively promote the continued delivery of quality health care. As Heckscher writes in his wish for the nation in 1959, and as we should wish for today, “May (there be) a great movement toward simplification of life, toward a restoration of conditions that seem at the same time closer to real happiness and to real health.” ■

References

1. Heckscher A. Medicine and Society. N Engl J Med. 1960; 262:(1): pp. 19-23.

2. Federation of State Medical Boards. FSMB Mission, Vision, Core Values and Goals. www.fsmb.org/mission.html. Accessed December 2, 2009.


A B S T R A C T : A sample of 904 physicians consecutively admitted to 16 state Physicians’ Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care manage-ment, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence. © 2009 Elsevier Inc. All rights reserved.

Keywords: Addiction treatment; Substance use disorders; Physicians health programs

Setting the Standard for Recovery: Physicians’ Health Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Robert L. DuPont, (M.D.) Institute for Behavior and Health, Rockville, MD, USA

A. Thomas McLellan, (Ph.D.)* Treatment Research Institute, Phildelphia, PA, USA

William L. White, (M.A.) Chestnut Health Systems, Bloomington, IL, USA

Lisa J. Merlo, (Ph.D.), Mark S. Gold, (M.D.) Department of Psychiatry, University of Florida, Gainesville, FL, USA Received 22 October 2007; received in revised form 4 January 2008; accepted 8 January 2008

1. BackgroundOne of the major public health achievements of the past half century has been the creation of a system of specialty treatment programs for persons with alcohol- and other drug-related problems. Although the treatment efforts for those with substance use disorders (SUDs) in this country have deep historical roots, the replicable models upon which the modern treatment system was built all emerged between 1944 and 1970. These models included outpatient alcoholism clinic models pioneered in Connecticut (1944) and Georgia (1953); the short-term residential/inpatient “Minnesota Model” of alcoholism treatment developed at Pioneer House, Hazelden, and Willmar State Hospital (1948–1950), the long-term therapeutic community for the treatment of drug addiction (1958), and methadone maintenance (1964; see White, 1998, and Musto, 1999, for more details). With the exception of the alcoholism clinics and methadone maintenance,

treatments were delivered in hospital or residential settings and employed multiple, intensive group and individual counseling sessions often in marathon sessions, designed to break tenacious resistance to the admission of loss of control and to foster a willingness and commitment to sustained abstinence and broader behavioral change.

The movement to treat instead of simply punish addiction problems was strongest in the early 1970s, when the infrastructure of modern addiction treatment emerged, based predominantly on two events. The first was the return of a large number of Vietnam era veterans with addiction problems and the link of heroin to a rapid rise in serious crime. This produced a federal, state, and local partnership that provided the funds to plan, build, staff, operate, and evaluate community-based addiction treatment programs throughout the United States. The second event involved policy changes within insurance companies that provided reimbursement for alcoholism

R E P R I N T E D F RO M

T H E J O U R N A L O F

S U B S TA N C E A BU S E

T R E AT M E N T

3 6 ( 2 0 0 9 ) 1 5 9 – 1 7 1

*Corresponding author. E-mail address: [email protected] (A.T. McLellan).

0740-5472/08/$—see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2008.01.004


treatment under private health insurance—a shift that spawned the rapid spread of private, hospital-based, and free-standing alcoholism treatment programs (White, 1998). These changes marked a shift in the nation’s long-standing strategy of “supply reduction” (law enforcement) to a more balanced strategy that included “demand reduction” (primary prevention, early inter vention, and treatment). This policy shift was manifested in the creation of the National Institute on Alcohol Abuse and Alcoholism (1970), the White House Special Action Office for Drug Abuse Prevention (1971), and the National Institute on Drug Abuse (1973).

The shift to include a major investment in the treat-ment of addiction faced substantial skepticism from the beginning, not just from law enforcement but also from within the health care field. There was

skepticism about the value of this policy shift (e.g., treatment policies might signal permissiveness and spawn greater use), about the effectiveness of treatment (e.g., significant posttreatment relapse rates were widely perceived to indicate the failure of treatment), and about the wisdom of diverting scarce health care resources to these disorders (see Newcomb, 1992). Because of these still enduring questions, the addiction treatment field was pushed to produce evidence for the effectiveness of existing treatments for addiction and to develop new treat-ments. In turn, the science of addiction medicine, particularly over the past decade, has focused as never-before on “evidence-based” evaluations of both prevention and treatment and on the development of new evidence-based medications, therapies, and interventions (e.g., Van den Brink & Haasen, 2006).

After the rapid expansion of substance abuse treatment in the 1970s, and early 1980s, the mid-1980s brought managed care, and other cost-containment efforts produced shifted the design of addiction treatment from a predominantly hospital and residential treatment model to a predominantly outpatient system of care. This change occurred throughout health care but was most pronounced in the treatment of addictions (see Institute of Medicine [IOM], 2006; Mechanic et al., 1995). By

the beginning of the 21st century, the addiction treatment system was still using most of the same original group and individual therapy methods originated in the 1950s—but changes in national priori ties, cost consciousness throughout health care, and specific public dissatisfaction with addiction treatment left the nation’s substance abuse treat-ment system predominately outpatient (80%+), very short term (less than 1 month of care), with little clinical supervision for counselors and few objective checks on continued substance use (e.g., urine testing) and on the effectiveness of treatment (see IOM, 2006; McLellan et al., 2003). The early innovation and competition for excellence in addiction treatment was replaced by a largely neglected, underfunded, and poorly led treatment system that focused more on minimizing costs than supporting long-term recovery. The recent focus on recovery as a definition of success that goes beyond just drug abstinence has led to new questions on the old issue of the efficacy of treatment for SUDs (see Betty Ford Institute Consensus Panel, 2007). Just how good can the treat-ment of SUDs be, not just during treatment but over the course of extended periods? What is the highest standard of success in the promotion of recovery? What can be learned from those best practices that can enhance mainstream addiction treatment?

1.1. Treatment of addicted physiciansWithin this context, our small group decided to examine a relatively new form of care management that had demonstrated effectiveness with an espe-cially significant group of patients, namely, addicted physicians. This population attracted our interest for three important reasons. First, addicted physicians represent a critical population from both public health and public safety perspectives. Despite the fact that physicians commonly have more financial and personal supports than most other segments of the addicted population, their occupations place them at almost continual exposure to drugs of abuse and thus at an elevated risk for relapse. Further, substance abuse among physicians has been associated with suicide (Roy, 1985; Simon, 1986). As a result, this population may represent both a particularly difficult and a particularly important chal-lenge for addiction treatment. The second reason for our interest is that a distinctive form of treatment management has been developed for addicted physicians, in part because of the special importance and problems associated with this group. Specifi-cally, this approach appeared to combine many of the elements of effective care derived from research and delivered in a context of combined social

THE MOVEMENT TO TREAT INSTEAD OF

S IMPLY PUNISH ADDICTION PROBLEMS WAS

STRONGEST IN THE EARLY 1970 S, WHEN

THE INFRASTRUCTURE OF MODERN ADDICTION

TREATMENT EMERGED.


for addiction counselors (White, DuPont, & Skipper, 2007). In this article, we summarize some of our Phase II findings and speculate on the implications of these findings for the care of other patients with SUDs.

1.2. The PHP modelBefore describing our findings, it is important to understand what PHPs are and what they are not. Surprisingly, they are not addiction treatment programs. Instead, PHPs provide active care man-agement for, as well as monitoring and supervision of, physicians who have signed formal, binding contracts for PHP participation (generally extending for 5 years). The extended period of PHP care most often begins with intervention followed by evalu-ation and intensive residential and/or outpatient substance abuse treatment. Although time spent in formal treatment varies based on the individual’s evaluation and unique needs, throughout the entire period of PHP care, all participants receive active monitoring and care management from their PHP usually including care for comorbid medical and psychiatric disorders.

The PHP contracts offer support and, most often, a temporary safe haven for physicians who are typically in jeopardy or under pressure from others due to problems related to SUD. The PHPs work to develop and maintain a close working relationship with their state medical licensing boards. The boards often accept the care of the PHP in lieu of imposing disciplinary action for physicians, but with the stipulation that failure to adhere to the PHP’s treatment recom-mendations and/or return to the use of alcohol or other drugs will lead to referral of the physician back to the licensing board for disposition.

Importantly, the contracts typically stipulate intense and ongoing treatment accompanied by regular monitoring of their substance use and addiction-related behaviors through random drug testing as well as unscheduled work site visits or work site monitors for extended periods—typically 5 or more years. These physicians are also typically seen at weekly self-help Caduceus meetings. The treatment, super-vision, and monitoring plans for these physicians are individualized around a core approach that dominates the PHP model (Merlo & Gold, 2008a; Pomm & Harmon, 2004). Physicians who engage fully in treatment, comply with their contractual agreement, and provide negative drug tests indicating no alcohol or nonmedical drug use may depend upon these PHP records for support and even PHP advocacy with their licensure boards and other entities. On the other hand, physicians who refuse the terms

support for the addicted patient with vigorous con-tingency management characterized by meaningful consequences for failure to comply with the treatment (see below). This form of care management is con-ducted by state-level Physicians’ Health Programs (PHPs), a unique institution devoted to the twin goals of protecting the public and saving the careers and lives of addicted physicians. The final reason for our interest was the fact that favorable results had been reported for physicians treated and mon-itored within these PHPs. Specifically, addicted physicians treated within the PHP framework have the highest long-term recovery rates recorded in

the treatment outcome literature: between 70% and 96% (Domino et al., 2005; Gastfriend, 2005; Gold & Aronson, 2005; Smith & Smith, 1991; Talbott, Gallegos, Wilson, & Porter, 1987). For these reasons, the PHPs appeared to represent one of the most sensible and evidence-based approaches to addiction currently available. We reasoned that an examination of this novel care management approach might provide suggestions for optimally organized and delivered addiction treatment— real-world treatment at its best. If there were clear evidence of positive results from this form of care, the findings might provide guidance for improving mainstream treatment efforts.

Thus, beginning in 2005, researchers from the Institute for Behavior and Health (DuPont) and the Treatment Research Institute (McLellan) initiated collaboration with the Federation of State Physician Health Programs (FSPHP; Skipper and Carr) to study the PHP supervised treatment of addicted physicians. The study, funded by the Robert Wood Johnson Foundation, was the first national study of these distinctive programs. It had two phases. The first investigated the structure and function of the PHPs, and the second phase studied the outcomes over 5 or more years of 904 physicians drawn from 16 state PHP programs. Findings from Phase I have been presented at the 2006 and 2007 meetings of the American Society of Addiction Medicine and at the 2007 meeting of the FSPHP, as well as being the focus of a publication

Setting the standard for recovery: Physicians’ Health Programs from the J O U R N A L O F S U B S TA N C E A BU S E T R E AT M E N T 3 6 ( 2 0 0 9 ) 1 5 9 – 1 7 1

THE SHIFT TO INCLUDE A MAJOR INVESTMENT

IN THE TREATMENT OF ADDICTION FACED

SUBSTANTIAL SKEPTICISM FROM THE BEGINNING,

NOT JUST FROM LAW ENFORCEMENT BUT

ALSO FROM WITHIN THE HEALTH CARE FIELD.


of the contract and/or are found to continue sub-stance use risk report to their boards, which may result in loss of their licenses.

Following the signing of a PHP contract and after a full evaluation, most physicians engage in formal addiction substance abuse treatment. All PHPs share a complete abstinence approach to the treat-ment of addiction. Physician participants must agree to total abstinence as a treatment goal, and as will be seen, adherence to this goal is assessed repeatedly throughout the ensuing prolonged monitoring. Most PHPs operate under the principles espoused by Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and other 12-step programs, and virtually all physicians are expected to attend AA, NA, or other 12-step meetings. The physician is responsible for the costs of treatment, urine monitoring, and aftercare conditions such as seeing a therapist or a psychiatrist.

The first phase of PHP care typically begins with 3 months of residential or intensive outpatient care in a specialty treatment program. Commonly, physicians withdraw from medical practice during this initial period of addiction treatment. Participating physicians are given a choice of treatment providers, but generally, the choices are limited to a few specific addiction treatment programs with which the PHP has had extensive, successful experiences over many years. The fact that the PHPs have an arm’s length relationship with the treatment providers appears to be important. The PHP selects treatment programs and other service providers (e.g., organizations that provide urine monitoring the physicians) that the PHP trusts to provide excellent services. If there is evidence of slippage in the performance of a particular treatment program or other service provider, it can be removed from the list of approved providers. Even the hint of such a “delisting” by a PHP can motivate providers to make meaningful improvements in their care.

The second phase of formal treatment is continued, less intensive outpatient addiction treatment (often two to three meetings per month) for 3 to 12 months, and for many, additional personal therapy for comorbid medical or mental health problems, although the treatment experience varies somewhat among PHPs and is tailored to the individual physi-cian patient’s needs. Families are encouraged to be actively involved in this care. Families are coached on how to support recovery as well as how to manage their own codependency and associated recovery. Physicians often resume practice during this phase of care under close supervision by the PHP.

Indeed, it is following treatment that PHPs exercise one of their more distinctive functions—intensive random drug and alcohol testing coupled with compli-ance monitoring and support. The usual pattern of testing of observed urine specimens, analyzed for an extended panel of 20 drugs or more, including alcohol. Usually, participating physicians call a telephone number each morning of the work-week to see if they are to be tested that day. The yes-or-no decision is made by random computer assignment over the course of 5 years or longer. The frequency of testing generally is greater at the beginning of the contract period (weekly or twice weekly) and lesser at the end of PHP monitoring (20/year), unless there is evidence of noncompliance or relapse, in which case the frequency of drug testing is increased. Monitoring over the 5 years of the typical PHP contract is not confined to drug testing but typically also involves assessment of the physicians’ work environ-ments and compliance with their specific monitoring contract plan.

The management of relapses, and even the definition of relapse, bears careful attention. “Relapse” certainly includes any use of alcohol or other drugs used nonmedically, but it also includes failure to attend treatment sessions and other signs of non-compliance or even lying about some aspect of care or recovery. It is important and controversial that initial relapses generally do not lead to termination from PHP care and do not always result in reporting to the medical licensing board. This is because of the expansive definition of relapse and the many

circumstances under which it may occur. A relapse may be failure to attend an AA meeting, failure to report promptly for a drug test, or evidence that the participant has been lying about participation in treatment. Even frank substance use may be drinking a glass of wine at a wedding or a beer following golf. Although all of these are considered clinically important, these particular behaviors do not place patients in jeopardy. However, if there is evidence of relapse under patient care conditions (or even during an on-call period), there often is a report to the boards. Regardless of the level of the relapse episode, these typically lead to an additional evaluation

…IN GENERAL, PHYSICIANS WHO UNDERWENT

TREATMENT FOR A SUD UNDER THE

SUPERVISION OF THESE 16 STATE PHPS HAD

GOOD OUTCOMES.


and usually to intensified treatment and monitoring. In other words, PHPs set a high standard of expecta-tion, and instead of casting out the participants who relapse, the PHPs pull them in closer to give them more care and more monitoring to ensure the relapse or relapse behavior is in remission.

It is obvious that the case management provided by the PHP is very different from the typical, managed care, cost containment approach to case manage-ment. The PHPs are not involved in the financial aspects of addiction treatment. This separation rein-forces the two standards the PHPs uphold when making decisions about the care of participating physicians: first, they are patient-safety focused, and second, they promote lifelong recovery for the physician. Neither of these standards is compromised by financial or other conflicts of interest for the PHP.

A case management system similar to the PHP model has been used for other specific and limited work-related populations, including commercial airline pilots and lawyers, as well as other health care professionals, including nurses, dentists, and veterinarians—many of whom are also monitored by the PHP. However, the largest population subject to this model of care is physicians, who were also one of the first groups to use this approach. Within PHPs, this model of care management is no longer limited to those with SUDs. Many PHPs now apply similar approaches to the management of other disorders that threaten the physician’s health and practice, including physical and mental health problems and a variety of other behavioral problems and disorders. However, the one condition for which all PHPs manage care is addiction, and the one population they all serve is physicians.

2. Selected resultsOur study was a minimum 5-year, retrospective, intent-to-treat analysis of all physician participants admitted to 16 PHPs that participated in the national survey evaluation (Audrey, cite Phase I article here). All physicians admitted to these programs from September 1, 1995, through September 1, 2001, were followed through inspection of available lab oratory and chart records throughout the duration of this episode of PHP care management, typically a 5-year or longer period. The design of the study and all data collection and patient protection procedures were reviewed and approved by the Institutional Review Board of the Treatment Research Institute. Thus, our sample was composed of consecutively admitted physicians who had entered into a PHP con-tract at least 5 years prior to the onset of the study.

2.1. Physician characteristicsThe 904 physician participants enrolled in the 16 participating PHPs were predominantly male (86%). The average participant was 44 years old and married (63%).

Five medical specialties each represented more than 5% of the total number of physician patients: family medicine (20%), internal medicine (13%), anesthesiology (11%), emergency medicine (7%), and psychiatry (7%). The primary drugs of choice reported by these physicians were alcohol (50%), opiates (33%), stimulants (8%), or another sub-stance (9%). Fifty percent reported abusing more than one substance, and 14% reported a history of intravenous drug use. Seventeen percent had been arrested for an alcohol or drug-related offense, and 9% had been convicted on those charges. Thirty-nine percent had a prior experience in addiction treatment, and 14% had experienced disciplinary action by their licensing agency prior to this episode of care.

2.2. PHP enrollmentFifty-five percent of enrolled physicians were formally mandated to enter the PHP by a licensing board, hospital, malpractice insurance company, or other agency. It is likely that the remaining 45% of enrollees were also mandated— but informally—by families, colleagues, employers, or a combination, as self-referral to addiction treatment is as uncommon among physicians as it is in the general population. All physicians were monitored as a standard part of their contract. Most physicians (88%) met diagnostic criteria for substance dependence, and most of these had a minimum monitoring period of 5 years. The small proportion of physicians (10%) diagnosed with alcohol or substance abuse usually received shorter-term contracts (6 months– 5 years) with the stip ulation that a positive drug test result would prompt further evaluation often leading to formal treatment and monitoring. The remaining physicians in the sample (2%) included those who had voluntarily re-signed a continuing monitoring agreement following successful completion of an earlier PHP contract.

2.3. Formal treatmentEighty-one percent of the physicians received formal addiction treatment after signing monitoring contracts and thus had treatment results recorded in their PHP charts. The remaining 19% included transfers from other PHPs, contract renewals, and physicians who had received formal treatment prior to the index enrollment; thus, treatment informa-tion was not available from their charts. Of the 734



physicians whose treatment was documented in PHP records, 78% had participated in formal residential or outpatient day treatment, usually at the beginning of their contracted period. These more intensive forms of standard addiction treatment often lasted 30 to 90 days (average = 72 days) and were usually followed by less-intensive outpatient treatment (one to four nights per week) for 2 to 12 additional months Regardless of setting or duration, essentially all treatment provided to these physi-cians (95%) was 12-step oriented, with a goal of total abstinence from any use of alcohol and other drugs of abuse and included the expectation of continued participation in AA or other 12-step oriented post-treatment support. Ninety four percent of the physicians referred to formal treatment successfully completed that part of their contracted obligation to the satisfaction of the monitoring PHP.

2.4. PharmacotherapyUse of pharmacotherapy as a component of treatment for SUDs or comorbid psychiatric conditions was uncommon. Only 1 of the 904 physicians studied was placed on methadone for an opiate-dependence problem. Naltrexone was prescribed for 46 physicians (5%) as an adjunct to treatment. About a third (32%) were prescribed an antidepressant for comorbid depression or anxiety disorders.

2.5. Supportive servicesSupportive services used by these recovering physicians included AA or NA 12-step groups (92%), aftercare groups from their formal treatment programs (61%), and follow-up from the PHP monitors (53%).

2.6. Alcohol and drug testing A key component of PHP agreements was random drug testing—typically conducted throughout the PHP contract period—with various contingen cies specified in the physician’s contract for failure to remain abstinent from any use of alcohol and other drugs of abuse. In this study, urine was tested in 99.2% of cases, with rare use of hair (0.2%), saliva (0.1%), or breath (0.6%) testing. About 75% of all urine sample collections were directly observed by collection personnel. In most other cases, dry room collection procedures were used. A typical drug-testing panel included more than 20 substances, such as amphetamines, barbiturates, benzodiaz-epines, opioids, cocaine, cannabinoids, ethyl alcohol, and often ethyl glucuronide, which has demon-strated improved sensitivity (Skipper et al., 2004). Also available was a more expanded panel that

included the following: other stimulants (pseudoephed-rine, ephedrine, methylphenidate, and so forth), zolpidem (Ambien), other narcotics (fentanyl and congeners, methadone, pentazocine, and so forth), ketamine, and antihistamines.

Physicians were tested on average twice a month, usually with more frequent testing at the start of the agreement period and reduced testing following periods of stable negative drug test results. For physicians with substance dependence, the average period of testing was 47 months. Physicians with substance abuse were tested on average for 29 months. About 22% of physicians had active monitoring contracts beyond^ the typical 5-year contract period—initiated either voluntarily or as required following a relapse. All of the monitored physicians were subject to random testing for alcohol and drug use each workday throughout their extended monitoring periods, regardless of the frequency of the testing.

2.7. PHP actions in response to positive tests or noncompliance Across programs, the PHPs took a variety of actions in response to a positive drug test result. In part, this was due to different circumstances of the substance use. For example, drinking a glass of champagne at a wedding, while defined as a relapse and a serious occurrence, is quite different from a patient safety standpoint than intoxication while on medical duty. For the first positive test, almost all PHPs reacted clinically, with combinations of the following activities: reevaluation (54%), increased monitoring (43%), and further addiction treatment (42%). Forty-two percent of PHPs also reported such first positive tests the physician’s licensing agency, hospital, or other entity, and an additional 16% initiated confidential actions, such as a non-public probationary period without referral to the licensing board or other agency. For those individuals who had more than one positive drug test, the same type of clinical and administrative actions were usually taken but with an increasing likelihood that the testing frequency would be increased and that the physician would be reported to the state medical licensing agency.

3. Outcomes

3.1. PHP contract completion Of the 904 physicians in our intent-to-treat sample, 448 (50%) completed their contracted period of monitoring and were no longer monitored by the PHP at follow-up (Completers). Another 199 physicians


(22%) either had their contracts extended beyond the original monitoring period or had signed voluntary new contracts with the PHP and were still being mon-itored (Continuers). Of these, 110 were mandated to continue in the program and 89 remained voluntarily. The remaining 257 physicians in the sample (28%) had not completed their contracts and were no longer monitored (Noncompleters). Among the Non-completers, 85 had withdrawn from the program, often simultaneously retiring from medicine and/or surrendering their licenses; 69 had transferred to a PHP in another state; 48 had been removed from the program, usually with a revoked license; 33 had moved and were lost to follow-up; and 22 died while in monitoring. Two of the deaths during monitoring were substance related, and six were suicides. The PHP records revealed that another 10 physicians died after monitoring was completed, meaning that as of study completion, a total of 32 of the physicians (4% of the total sample) had died.

3.2. Alcohol and other drug use during monitoring Table 1 summarizes the drug testing results for the three completion groups. Although the groups did not differ greatly in the length of the initial contract signed with the PHP (52–58 months on average), they varied in predictable ways on the length of time they were tested and the average number of tests per physician. Noncompleters were tested on average for about 24 months before leaving the program. During this period, they averaged 2.3 tests per month with 30% of them having at least one verified positive test for alcohol, an illicit drug, or a nonprescribed abused medication. Among the 76 Noncompleters who tested positively, about half (49%) were detected

using drugs or alcohol on more than one occasion. In contrast, nearly 90% of the Completers had no positive drug test results during an average of 48 months of testing at a cumulative rate of 1.7 tests per month. Only 8 of the 45 Completers who had a positive test (18%) also failed a subsequent test.

Continuers, whose 64-month average testing period exceeded their average length of contract by 6 months, were the most likely to have had at least one posi-tive test (37%). However, within this group, there were several significant differences between those who voluntarily extended their monitoring and those mandated to do so. During 64 months of testing, the Mandatory Continuers on average were tested more frequently (2.1 times per month vs. 1.7 for the Voluntaries); were much more likely to have at least one positive test (52% vs. 17%); and, among those with an initial positive test, were nearly twice as likely to have a subsequent positive (38% vs. 20%). In summary, the Voluntary Continuers had drug testing results that were similar to, if not quite as good as, those of the Completers; whereas, it appears that state licensing boards acted prudently in mandating continued monitoring for certain physicians.

3.3. Relapses affecting patient safety Apart from recording the incidence of substance use, chart reviewers were also asked to record the conditions under which drug or alcohol use occurred. In total, 261 physicians (29%) had at least one recorded use of substances, 14 (2% of total sample) had a relapse that was documented in the context of drunken driving, and 55 (6% of total sample) had relapse episodes that “occurred in the context of


Table 1:Drug testing results

Variables Completers (n = 448)

Continuers (n = 199)

Noncompleters (n = 257)

Total sample (n = 904)

Contract duration (mean months)

52 58 55 54

Drug testing period (mean months)

48 64 24 45

Mean no. of drug tests

81.8 120.7 54.3 82.6

Mean no. of tests/month

1.7 1.9 2.3 1.8

Percent with at least one positive

10.3 36.7 29.6 21.7

Percent of tests that were positive

0.30 (108/36,230) 0.55 (129/23,544) 1.18 (160/13,508) 0.54 (397/73,282)


medical practice.” These relapses could include being under the influence at work or while on call and therefore had the potential to adversely affect patient care.

Within these more serious relapses, we asked chart reviewers to record any mention of actual patient harm. Only one identified episode of patient harm (i.e., overprescribing) was noted. Although few frank episodes of actual or potential harm were recorded, it was not possible from these chart reviews to adequately capture other important negative conse-quences of the physicians’ substance use, such as exacerbation of mood disorders, professional relationship difficulties, or family problems.

3.4. Sanctions on physicians during PHP monitoringCumulatively, 180 physicians (20% of total) were formally reported to their board and/or oversight body, at some time during their monitoring period, for sub-stance use or other forms of noncompliance. Some physicians were reported more than once and had more than one disciplinary action taken against them. Actions taken by these agencies included limitations on practice (129 physicians), probationary agreements (130 physicians), suspension of license (94 physicians), and revocation of medical license (32 physicians). Sometimes additional agencies also became involved as an indirect result of actions taken by the state board. These actions included being reported to the National Practitioner Data Bank (121 physicians) and restriction of or loss of Drug Enforce-ment Administration (DEA) license (56 physicians).

3.5. PHP contract outcomes For one of the non-mandatory chart review items, 14 of the 16 PHPs provided summary judgments of the physicians’ overall outcomes for the contracts reviewed. This information was provided for 827 cases (91% of the total sample). Table 2 summarizes these outcomes by completion group type.

Nearly all of the Completers (98%) were judged to have been “fully successful” in completing this episode of care, although about 6% of this group succeeded only after experiencing some significant problems during monitoring. Only 19% of the Noncompleters were judged as having fully succeeded in the program, most of whom were physicians who transferred in good standing to another PHP. Nearly a third of Noncompleters (32%) were rated as having failed in the program without gaining benefit from their participation. However, the overall program outcome for many of the Noncompleter physicians (21%) could not be determined from the records because they had moved, died, transferred, or were other wise lost to follow-up.

Among the Continuers group, most of the 76 Voluntary Continuers (78%) were judged to have completed the original contract successfully, either without problem (71%) or after some problems (7%). Outcomes for the 94 Mandatory Continuers were rated as one of the following: Still in Monitoring/ Can’t Yet Judge (51%), Benefited/Not Completed (27%), and either Successful/No Major Problems

Table 2:Five- to seven-year outcomes

Outcome rated as Completers (n = 418)

Continuers (n = 170


Total of rated cases (n = 827)

Successful, no major problems (%)

92.8 39.4 14.2 59.1

Successful, significant problems (%)

5.5 7.1 4.6 5.6

Benefited, did not complete (%)

0.0 16.5 28.9 12.1

Failed program, did not benefit (%)

0.0 0.6 31.8 9.3

Still being monitored (%)

0.0 36.5 0.0 8.1

Moved/ transferred (%)

0.0 0.0 10.9 3.1

Other (unknown, died, etc.) (%)

1.7 0.0 9.6 2.7


(14%) or Successful/ Significant Problems (7%). Of note, only one Mandatory Continuer was judged to have failed without benefit.

3.6. Continued medical practice At last contact with the PHPs, 651 of the 904 physi-cians in the sample (72%) were licensed without restriction and actively practicing medicine. As shown in Table 3, this percentage varied depending on the physician’s program completion status. Fully 91% of the Completers were practicing medicine, compared to just 28% of the Noncompleters. Among the Con-tinuers, there was not as big a difference between Voluntary and Mandatory Continuers as was found for other outcomes. Eighty-seven percent of the 89 Voluntary Continuers were in medical practice, compared to 78% of the 110 Mandatory Continuers.

The data in Table 3 provide evidence that PHPs, working in collaboration with the state licensing agen-cies, are effective in helping most of the physicians in their care with SUDs remain in medical practice as long as they participate in required treatment and monitoring, remain abstinent, and utilize supportive programs. In addition, it appears that this collaboration provides an effective method for removing physicians from the medical workforce who do not maintain contract compliance and remission from the use of alcohol and drugs of abuse. About half of the Non-completers (49%) were not practicing medicine at last contact either because they had retired, left, or sus-pended practice; voluntarily surrendered their license; or they had their license revoked or suspended.

4. Implications Results of the current intent-to-treat study demon-strated that, in general, physicians who underwent

treatment for a SUD under the supervision of these 16 state PHPs had good outcomes. Specifically, of the 904 physicians followed, 72% were still licensed and practicing with no indications of substance abuse or malpractice, 5 to 7 years after signing their contracts. In contrast, the PHP process appears to have moved approximately 18% of these physicians out of the practice of medicine through loss of license or pressure to stop practice. Of the 904, 180 (19%) had a relapse episode (see broad defini-tion) and were reported to their licensing boards. However, only 22% of these had any evidence of a second relapse—generally indicating that the intensified treatment and monitoring were successful in maintaining remission.

These results are similar to those described in previous research with physicians (Domino et al., 2005; Flaherty & Richman, 1993; Gallegos et al., 1992; Talbott et al., 1987). These replications heighten confidence in the strength of this conclusion. At the same time, the earlier reports have focused upon smaller samples of physicians and much shorter evaluation periods. The current findings come from the largest sample of addicted physicians ever followed and over the longest period.

The findings did not differ by the physician’s drug of choice. Rather, physicians with alcohol use disorders displayed similar outcomes to those presenting with opioid, crack cocaine, and benzo di-azepine use disorders. Physicians who used these drugs intraveneously did as well as other physicians.

These results are similar to those described in previous research (Domino et al., 2005; Flaherty & Richman, 1993; Gallegos et al., 1992; Talbott et al., 1987) and provide support for the use of a


Table 3:Status of medical practice

Medical status (last known)

Completers (n = 448)

Continuers (n = 199)


Total sample (n = 904)

Working in medicine (%)

91.1 81.9 27.6 72.0

Licensed/not practicing (%)

2.9 6.0 10.1 5.6

Not licensed/ suspended license (%)

2.2 6.5 31.5 11.5

Retired/left practice (%)

1.8 2.5 7.4 3.5

Died (%) 0.7 0.0 11.3 3.5

Unknown (%) 1.3 3.0 12.1 4.8


single category of “SUD,” rather than differentiating among patients based on their primary drug of choice. Further support for this idea is provided by frequency with which many individuals with SUDs use multiple substances or change their drug of choice across time. For example, in this sample, 50% of the physicians reported abusing more than one substance prior to their PHP care.

In general, physicians share some characteristics that differentiate them from the general public. However, their self-reported rates and types of substance use are similar to those of non physicians (although somewhat greater use of benzodiazepines by physicians; Conrad et al., 1988; Hughes et al., 1992). Although many theories have been sug-gested to explain the relatively high rates of addiction among physicians, the clinical reality is that this is a high-risk population for SUDs.

Physicians generally have higher incomes than the general population, making high-quality private substance abuse treatment more affordable for them. Yet, compared to the number of physicians who would benefit from a substance use interven-tion, they, like other populations, are generally underevaluated and undertreated (Gold & Aronson, 2004). Physicians have greater access to drugs of abuse, at least when these substances are pre-scription controlled substances. A significant number of practicing and resident physicians admit to self-prescribing medications (Bennet & O’Donnovan, 2001; Chambers & Belcher, 1992; Christie, Rosen, & Bellini, 1998), and this likely includes substances of abuse. Because physicians do not need to go through a “supplier” to support their non medical drug use, they may be more difficult to identify. In addition, physicians may be better able to hide their substance use than many other occupational groups (Domino et al., 2005). They know the common signs of abuse/dependence and are often able to maintain their alcohol and drug use without displaying these symptoms (e.g., visible injection sites, etc.). Physicians also typically develop sophisticated denial strategies, which support their SUDs. Finally, physicians are often hesitant to report suspected SUDs among their colleagues. In part, this is due to concerns about the perceived negative consequences of doing so (Farber et al., 2005). Beyond that, physicians receive little training in the identification and treatment of addictive illness and often view these illness as personal weaknesses rather than as treatable illnesses.

These characteristics put physicians at increased risk of SUDs compared to many other populations. In addition, these characteristics may delay the identi-fication of an SUD among physicians, allowing the severity of the problem to increase over time. Indeed, physicians being referred for treatment now may be more impaired than those referred for treatment in the past (Angres et al., 2003). Most physicians with SUDs display moderate to severe problems at the time of treatment (McGovern, Angres, & Leon 1998).

Whatever the differences from other populations experiencing SUDs, it is likely that the successful treatment of physicians with SUDs has important implications for SUD treatment in general. For

example, if physicians were found to have significantly better outcomes than other groups when treated for diabetes or coronary artery disease, this would be of great public health interest. Recognizing that SUDs are biological disorders with major behavioral components (just like diabetes and coronary artery disease), the relatively high level of success exhibited by physicians whose care is managed by PHP is important with respect to the potential for success in addiction treatment generally. Indeed, the observed rate of success among physicians directly con-tradicts the common misperception that relapse is both inevitable and common, if not universal, among patients recovering from SUDs.

In particular, we were struck by the exceptionally low rate of positive drug test results in this large sample of individuals who had experienced uniquely intensive drug testing over uniquely long periods. Within the entire sample, there were an average of 83 drug tests done over a mean period of 54 months of PHP monitoring. Among this sample of 904 physicians participating in a PHP program, 78% of the physician participants did not have a single positive test result for either alcohol or drugs of abuse during their prolonged period of monitoring. Overall, the positive drug testing rate was 0.54%, meaning that an average of about 1 in 200 samples was positive, even with the extended

…THE NEXT STEP IN IMPROVING SUD

TREATMENT FOR ALL IS TO DECONSTRUCT THE

PHP TREATMENT PACKAGE AND IDENTIFY

THE ESSENTIAL INGREDIENTS TO LONG-TERM

RECOVERY MAINTENANCE.


screens and the random testing used for this moni toring. These objective results are especially remarkable given the severity of the problems that the physician participants experienced with SUDs. The observed rate of positive test results was lower than that found in the U.S. Military (Bruins, Okano, Lyons, & Lukey, 2002) and far lower than found in random tests in general workplace populations (Osterloh & Becker, 1990). Further, it was completely different from what would be expected based on the rates of positive tests for nonmedical use of controlled substances typically found in patients experiencing chronic pain (Manchikanti et al., 2006) or patients with SUD (see Koenig, Denmead, Nguyen, Harrison, & Harwood, 1997). Indeed, rather than being a defining characteristic of addiction, the “inevitable

relapse” may be a defining characteristic of the acute care model of biopsychosocial stabilization, which offers an opportunity for recovery initiation but lacks the essential ingredients to achieve recovery maintenance. If the key ingredients of the PHPs—particularly ongoing monitoring for this chronic illness linked to meaningful con sequences—were universally available, we might find that relapse was far from inevitable and that active addiction careers could be significantly shortened and stable recovery careers extended.

Thus, the next step in improving SUD treatment for all is to deconstruct the PHP treatment package and identify the “essential ingredients” to long- term recovery maintenance. The individual elements that comprise the PHP model are potentially important for improving treatment for other patient popu lations; in addition, it is possible that they could be adapted to bring benefits to many other treatment populations. With this in mind, we single out five key elements as worthy of con-sideration for wider dissemination in substance abuse treatment:

1. Contingency management aspects of PHP care management. For physicians enrolled in a PHP program, there are both significant positive (continued ability to practice medicine; reduction of pending charges against them) and significant negative consequences (loss of license, professional disgrace) to non compliance with PHP treatment and monitoring requirements. There is a robust and rapidly growing body of knowledge supporting the view that addiction treatment programs that use “socially sanctioned coercion mechanisms” (Nace et al., 2007), by providing consequences for early termination of treatment or positive drug tests results, strongly improve the outcome in addiction treatment (e.g., Festinger et al., 2002; Fowlie, 2005; Monahan, 2003; Simpson & Joe, 1993).

Supporting the significant role of positive and negative behavioral contingencies is the example of Drug Courts (see Belenko, DeMatteo, & Patapis, 2007; Marlowe & Wong, 2007). In these courts, offenders charged with drug-related offenses may have those charges expunged if they complete a year of supervised addiction treatment accompanied by regular, random drug testing under the supervi-sion of the court—but face immediate, incarceration or other sanctions for failing to abide by the stipulations of the treatment and the monitoring. Although there are few similarities in background, social supports, or social status between addicted physicians super-vised by PHPs and drug-related criminal offenders supervised by drug court judges, both have significant positive and negative contingencies applied to their behaviors, and both have outcomes that are far better than general addicted pop ulations treated without these contingencies in standard addiction treatment programs (Kliner, Spicer, & Barnett, 1980). The PHP model provides far more meaningful and sustained consequences than any other model of contingency management.

2. Frequent random drug testing. Drug testing is seldom used in substance abuse follow-up for the general population (see Koenig et al., 1997; McLellan et al., 2003). When drug testing is used, the test results are seldom linked to meaningful consequences and drug testing is, to our knowledge, never used for such long periods or with the intensity that typifies PHP case management. Recovering physicians frequently report that knowing they are subject to drug screening linked to meaningful consequences is a powerful motivator to avoid using substances of abuse. In fact, it has been suggested that random urine screening actually serves as a


THERE I S A ROBUST AND RAP IDLY GROWING

BODY OF KNOWLEDGE SUPPORTING THE V IEW

THAT ADDICT ION TREATMENT PROGRAMS

THAT USE ‘ SOCIALLY SANCTIONED COERCION

MECHANISMS ’ . . . STRONGLY IMPROVE THE

OUTCOME IN ADDICT ION TREATMENT.


behavioral intervention for the recovering physicians, reminding them of the potential consequences of substance use (Jacobs, Repetto, Vinson, Pomm, & Gold, 2004) and may be the most effective com ponent of treatment. In the State of Florida, the physician in early recovery calls an 800 number every day during the initial phase of his or her contract and is randomized to drug test or no test. Thus, evidence of relapse is kept current. Failure to call in for randomization is a prognostic indicator of impending relapse (Jacobs et al., 2004). Such a calling system may be a form of telehealth therapy at no cost to the state. In addition, research has demonstrated that the addition of drug-testing to recovery monitoring can improve outcomes, with 96% of physicians who were tested maintaining sobriety, compared to only 64% of physicians who were not routinely tested (Shore, 1987).

3. Tight linkage with the 12-step programs and with the abstinence standard espoused by these fellowships. The PHP programs are abstinence-based, meaning that they require abstinence from alcohol and all nonmedical use of mood-altering drugs, not just the physician’s drug(s) of choice. For example, physicians in PHP care for opioid abuse are required to remain abstinent from all mood-altering substances, including alcohol, for the duration of their extended contracts. Research has repeatedly demonstrated the efficacy of the 12-step approach for physicians with SUDs (Galanter et al., 1990; Gallegos et al., 1992; Lloyd, 2002; Moos & Moos, 2005) and participation in a 12-step group, such as AA, is associated with improved self-efficacy for abstinence (Bogenschutz, Tonigan, & Miller, 2006). Combining AA and professionally directed addiction treatment has also been found to generate better recovery outcomes than is found in participating only in AA or only in treatment (Fiorentine & Hillhouse, 2000).

4. Active management of relapses by inten sified treatment and monitoring. Relapses do not typically lead to discharge from PHP care, at least not initially. They do routinely lead to intensive reevaluations of the treatment plans and to the implementation of additional care. For example, in this sample, most physicians who provided a urine specimen positive for drug use were reevaluated. In addition, almost half of these physicians were required to undergo additional treatment, more frequent drug testing, or a combination of the two. Other research has shown that physicians who

experience a relapse are generally able to reenter recovery with booster treatments (Lloyd, 2002).

5. A continuing care approach. Treatment, support, and monitoring in traditional addiction programs lasts 30 to 90 days. This is rarely accompanied by involvement of family or significant others. The

formal treatment is typically followed by passive referral to AA meetings but no continued aftercare, support, or monitoring. It is significant in this regard that although 1-year posttreatment relapse rates are typically 50% to 60%, more than 80% of those who relapse within a year do so within the first 2 to 3 months following discharge from formal treatment (Hubbard, Flynn, Craddock, & Fletcher, 2001). Our data support the conclusion that SUDs are chronic illnesses that are best managed with ongoing care just as are other serious, chronic ill-nesses. Specifically, acute care-oriented, short-term approaches have little evidence of long-term success in the treatment of SUDs. There are many novel ways of extending formal care with telephone-based or Internet- based monitoring and support (Betty Ford Center in the News, 2006; Hazelden, 2007; McKay, Lynch, Shephard, & Pettinati, 2005) and regular home visits (Dennis, Scott, & Funk, 2003) that have been shown to reduce relapse rates and enhance long-term recovery rates. The PHPs have formalized this element of sustained continuity of care and focused much of their professional resources on sustaining therapeutic contact over 5 years or longer.

6. Focus on lifelong recovery. Mere abstinence from the use of alcohol and drugs of abuse is seldom sufficient for PHP care. Rather, the physi-cians are supported and encouraged to significantly improve the quality of their lifestyles, both in their personal lives and in their practice of medicine. This support and encouragement are considered an important aspect of PHP care. Thus, care management for physicians with SUDs generally includes comprehensive assessment (including cooccurring medical and psychiatric conditions) and a wide spectrum of services including educational lectures, individual therapy, group therapy, and family therapy, as well as a performance-based assess-ment of competency to return to work and participation

MERE ABSTINENCE FROM THE USE OF ALCOHOL

AND DRUGS OF ABUSE IS SELDOM SUFFICIENT

FOR PHP CARE.


in continuing medical education as necessary (Merlo & Gold, 2008b). Lifestyle and practice modifications resulting from PHP participation can also include a change in medical specialty, prescribing restrictions, external monitoring of prescribing practices, or a change in institutional affiliation or work schedule.

Each of these six elements of PHP care management has potentially wide applicability within mainstream addiction treatment. However, one of the challenges in implementing this new evidence regarding potential improvements to recovery monitoring is finding ways to integrate these elements into other treatment models with other patient populations. Taken as a whole, these elements insure a compre-hensive assessment, promote development of a comprehensive treatment plan, enhance engagement and long-term retention in treatment, increase the initial dose of treatment services, extend the duration and increase the intensity of post-treatment monitoring and support, provide assertive linkage to recovery communities and esteem-enhancing recovery role models (e.g., other physicians in recovery via Caduceus Meetings and International Doctors in Alcoholics Anonymous [IDAA]), and enhance the quality of life of physicians in recovery. In the face of potential alcohol or other drug use, PHPs also provide a mechanism for reintervention that prevents an escalation in problem severity and preserves the recovery capital that has been developed through earlier participation in the PHP. The early intervention mechanism promotes long-term personal recovery and also serves as a safety net for the protection of public safety.

Most mainstream addiction treatment centers do not have physician administrators in charge of the programs, and many programs operate inde pendently, involving little or no collaboration/ communication with other programs. The treatment programs are generally not stable or well structured, and few treatment programs appear to have the capacity for innovation and change, even over long periods. On the other hand, the PHP programs are mostly headed by hands-on physicians who meet together with heads of the other PHP programs on a regular basis. This unique physician leadership com munity ensures both a high level of collaboration and also a spirited competition to improve the care of their physician patients.

The treatment programs and other service providers (including laboratories that conduct drug tests) that are used by the PHPs are an elite group chosen

for the excellence of their care and services. The leaders of the PHPs communicate with each other about best practices, and their own experiences with providers over many years shape their choices. Treatment programs seek to be selected by PHPs because this is recognized as a mark of distinction within the treatment field.

The PHP programs continue to actively innovate as they seek to improve their performances. For example, the PHP programs included in this study are increasingly using intensive out patient treatment rather than relying exclusively on residential treatment for the initial treatment experience. Based on recent research (e.g., Kintz, Villain, Dumestre, & Cirimele, 2005), they are also experimenting with the use of hair and oral fluids testing, as well as ethyl glucuronide (EtG) testing

(Skipper et al., 2004) for recent exposure to alcohol, to extend the more traditional role of urine drug testing. Similarly, the PHPs seldom use the very narrow panel of abused drugs that is typical of most urine testing in mainstream drug treatment. In addition, many PHPs are now reaching out to serve non-physician populations and finding ways to integrate their model into other treatment programs in their communities.

On a related note, it is important to recognize that a significant minority of PHP directors are physicians who are themselves in recovery from SUDs. The presence of physicians within the leadership of PHP system of care who are open about being in recovery affects the dynamics of this group. The recovering physicians typically bring to the entire PHP system both “toughness” and sensitivity to the extended and complex process of recovery. This helps them to provide leadership, and it also inspires and validates the PHP movement itself. Indeed, the presence of physician leaders who are in recovery may help to account for the observation that PHPs, in spite of addressing problems other than SUDs, have maintained their focus on and competen cies related to addiction recovery;


OFTEN IT IS ACTIONS OF THOSE AROUND

THE USERS—FAMILY MEMBERS, COLLEAGUES,

EMPLOYERS, AGENTS OF THE CRIMINAL

JUSTICE SYSTEM, PHYSICIANS, AND OTHERS—

THAT CONVINCE THEM OF THE NEED TO

STOP THEIR ALCOHOL OR DRUG USE.


whereas, many other work-based systems of inter-ventions, such as the employee assistance field, have experienced a dilution of their focus and expertise in this important area of health care (White, 2000).

Although PHPs are not unique in the critically i mportant roles played by others in the lives of participants, their care management is remarkably different from most other environments in which treatment occurs. Those with SUDs enter treatment when something happens in their lives that convinces them that they must stop their drug use. Often it is actions of those around the users—family members, colleagues, employers, agents of the criminal justice system, physicians, and others—that convince them of the need to stop their alcohol or drug use. The actions of others play critically important roles in the treatment of all people with SUDs. Left on their own, the substance-dependent population is seldom able to interrupt the pattern of repeated drug use, especially after the behavior is well established. In most treatment settings, there are few contingencies, and those that exist are usually brief, for relapse to active substance use. Even when there are contingencies for relapse, people around the drug users rarely have the means of identifying a return to drug use, especially in the early states of a relapse.

The PHP care management of the environment in which treatment and recovery takes place is radically different from the experience of virtually all other populations of people with SUDs. In PHP care management, the standard of no use of alcohol or other drugs of abuse is not only unequivocal, it is enforced by drug testing that is random, frequent, and comprehensive. In addition, the consequences of returning to alcohol and/or other drug use may be serious. Perhaps most important, PHP monitoring with consequences is prolonged, generally lasting 5 years or longer. It is administered in a program that is widely known to produce outstanding outcomes. These factors combine to make participation accept-able, and even attractive, for physicians with SUDs.

In addition to the contingency management used by PHPs, the treatment/monitoring provided for physician participants is state of the art. Like the monitoring, the treatment in the PHP model is prolonged, inten-sive, and of high quality. We know of no other group of people with SUDs who have similar experiences, except for the increasing use of this model in a few other populations including commercial pilots,

attorneys, and other health care workers. Certainly, Drug Courts, good as they are and as much as they use monitoring and contingency management, do not rise to the level of drug testing and the quality

of treatment/monitoring that are commonly received under PHP care management. Beyond these differ-ences, the maximum duration of Drug Court care is 1 year, not long enough to maximize the benefits of this promising model of care management. The active management of the environment in which drug use and recovery take place is part of a major rethinking of demand reduction that has broad implications for both prevention and treatment (DuPont, 1999).

It is noteworthy that data from the present study provide evidence that some components of main-stream addiction treatment may not be necessary. For example, although the overwhelming majority of physician participants (78%) in this study benefited from their participation in the program, pharmacotherapy was generally not a component of treatment. Rather, only 5% of the physicians under-going treatment for SUDs were prescribed Naltrex-one, and only 1 (0.001%) was prescribed methadone, although one third of the physicians in this study were primary opioid users. Thus, although previous research has demonstrated that the use of Naltrex-one for physicians with SUDs can be successful (Gold, Extein, Perzel, & Annitto, 1982; Washton, Gold, &Pottash, 1984), it is possible that the use of medications to augment behavioral treatment of SUD is unnecessary for most patients, including those with opioid dependency under certain conditions. In addition, voluntary participation in treatment may not be necessary to achieve recovery. Although the data from this study show that individuals who continued participation voluntarily did better than those who were mandated to continue, there were a significant number of mandated participants who benefited from continued PHP involvement.

OUR F INDINGS SUGGEST THAT GREATER

EFFORTS SHOULD BE MADE TO ENCOURAGE

VOLUNTARY PART IC IPAT ION IN TREATMENT

AND MONITORING TO ACHIEVE THE BEST

OUTCOME ; HOWEVER , MANDATORY

PART IC IPAT ION I S WITHOUT QUEST ION

BETTER THAN NO PART IC IPAT ION.


Our findings suggest that greater efforts should be made to encourage voluntary participation in treatment and monitoring to achieve the best outcome; however, mandatory participation is without question better than no participation.

In conclusion, the current findings, which demonstrate high rates of success among physicians suffering from SUDs, provide further evidence that addic-tion is a serious and chronic disorder that can be treated successfully over extended periods in a large percentage of people. At least under the contingen cies that characterize the PHP programs, the SUDs need not be viewed as inevitably leading to relapse and prolonged addiction careers. On the basis of these findings, there is reason for renewed optimism among individuals with SUDs and their families. The current data replicate earlier findings reported by researchers and clinicians in other PHP programs and States (e.g., Gallegos et al., 1992; Gold, Pomm, Kennedy, Jacobs, & Frost-Pineda, 2002; Shore, 1987). It appears that physician treatment works and that it works in all states for all addictions regardless of the drug of choice and for physicians of any age. ■

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An Assessment of USMLE Examinees Found to Have Engaged in Irregular Behavior, 1992-2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .David Alan Johnson, M.A.Vice President for Assessment ServicesFederation of State Medical Boards

A B S T R A C T

Purpose: The United States Medical Licensing Examination® (USMLE®) program takes active measures to ensure the integrity of the licensing examination process. This study looks at the examinees found by the USMLE program to have engaged in irregular behavior and their subsequent success in completing the examination sequence and obtaining a full, unrestricted medical license.

Methods: Working with the Office of the USMLE Secretariat, all individuals determined by the program to have engaged in irregular behavior related to the examination were identified for the period 1992–2006. These individuals were then searched against databases at the Federation of State Medical Boards for board action history and licensure status.

Results: A total of 433 individuals were deemed to have engaged in irregular behavior by the USMLE Committee on Irregular Behavior. Subgroups disproportionately represented included males (66.7%) and international medical graduates (78.8%). Document falsification was the most common infraction under computer-based test administration. Less than half of the irregular behavior cohort (45.7%) successfully completed the USMLE sequence. Only 37.2% completed the USMLE sequence and obtained a full, unrestricted medical license in a U.S. jurisdiction. Graduates of U.S. and Canadian medical schools were the subgroup most likely to complete the USMLE sequence and obtain their medical license.

Conclusions: A finding of irregular behavior by the USMLE carries significant potential consequences. State medical boards have denied licenses to individuals with irregular behavior and been unwilling to support the prospective licensure of individuals barred from the program indefinitely.

Introduction The United States Medical Licensing Examination® (USMLE®), co-sponsored by the National Board of Medical Examiners and the Federation of State Medi-cal Boards, is the primary examination utilized by state medical boards to fulfill their statutory obligation to assess the knowledge and readiness of allopathic physicians prior to issuing a full and unrestricted license to practice medicine in their jurisdiction.1 Since its implementation in 1992–1994, USMLE has adminis-tered approximately 1.7 million Step examinations.2 The overwhelming majority of individuals pass through this high-stakes examination sequence without incident. In part, this is attributable to program measures for secure testing, e.g., audio/video taping of test admin-istrations, secure handling of test materials, identity check by proctoring staff.3 However, instances of

examinee misconduct, while infrequent, do occur. This is not entirely surprising. Though the literature relative to cheating on medical licensing examinations is relatively sparse and pre-dates the USMLE, the high-stakes nature of this testing has always led some individuals to seek unwarranted advantages.4,5

The USMLE program’s approach to investigating and determining irregular behavior has been characterized by two beliefs: (1) USMLE has a responsibility to provide medical licensing authorities with all relevant information on its applicants and examinees; (2) USMLE should not usurp the role of medical licensing authorities as the final decision-maker determining the fitness of an individual to receive a license.

USMLE maintains formal processes for investigating

*The USMLE consists of Step 1, Step 2 Clinical Knowledge (CK), Step 2 Clinical Skills (CS) and Step 3.


and resolving issues of potential misconduct threatening the integrity of the examination process. There are several ways in which instances of possible irregular behavior are brought to the program’s attention. These include ongoing quality assurance activities, the vigilance of program staff and test proctors, and information reported by third parties. ‘Incident’ reports filed by test proctors are another key mechanism for identifying and investigating potential irregular behavior.6

Information on possible instances of irregular behavior is reviewed by an inter-organizational staff committee comprised of representatives from the National Board of Medical Examiners (NBME), the Federation of State Medical Boards (FSMB) and the Educational Commission for Foreign Medical Graduates (ECFMG). This staff group reviews the information and deter-mines whether sufficient evidence exists to warrant referring the matter to the USMLE Committee on Irregular Behavior (CIB), the body established by the program to formally review cases of suspected irregular behavior that occur during the application for, or administration of, a Step examination. The CIB draws its membership from the licensing, medical education and practicing physician communities.6

Method Working with the Office of the USMLE Secretariat, all individuals found by the program to have engaged in irregular behavior were identified for the time period 1992–2006. A total of 433 individuals were identified. These individuals were then searched against the FSMB database for disciplinary history and licensure status. The purpose behind this cross-search was two-fold: (1) identify those individuals who subsequently completed the USMLE sequence and obtained a full, unrestricted medical license, and (2) identify any instances in which a state medical board took a disciplinary action either directly as a result of the

USMLE irregular behavior finding or subsequently for reasons separate from the irregular behavior. For the former, FSMB internal applications were cross-referenced with records at the Office of the USMLE Secretariat to verify whether a state medical board received a USMLE transcript on any of these individuals (alerting the board to the irregular behavior finding) or if the board made an inquiry to the Secretariat’s office as part of the license application process.

Results Demographics Male examinees are over-represented in the irregular behavior cohort when compared with their historical presence among all USMLE first-taker examinees between 1992–2006. As seen in Tables 1 and 2, male examinees accounted for 66% of the irregular behavior cohort but represented only 58% of USMLE test administrations during the same period. Conversely, female examinees are under-represented. Female examinees from U.S./Canadian medical school programs were the subgroup least represented among the irregular behavior cohort when compared with the overall historical presence as first-takers of USMLE examinations. A predominance of males in the irregular behavior cohort is not entirely unexpected, though published studies on cheating among medical students are limited and have not routinely addressed gender differences.7

International medical graduates (IMGs) accounted for 78% of the irregular behavior cohort, a percentage well above their historical presence in 49% of all USMLE test administrations between 1993 and 20072 or in 43% of all first-taker administrations from 1992–2006 (Table 2). Male IMGs comprised the largest subgroup, with 222 individuals, or 51%, of all individuals in the irregular behavior cohort. While a definitive explanation for the disproportionate presence of IMGs is lacking, it seems possible that cultural differences play some role in this regard.8,9

Table 1: Individuals Determined by the USMLE to Have Engaged in Irregular Behavior 1992-2006 (n=433)Total number of Examinees with Irregular Behavior (As percentage of Entire Irregular Behavior Cohort)

IMGs U.S./Canadian Total

Male 222 (51.3%) 67 (15.5%) 289 (66.7%)

Female 119 (27.5%) 25 (5.8%) 144 (33.3%)

Total 341 (78.8%) 92 (21.2%) 433

Category definitions mirror those used by the USMLE program. US/Canadian is defined as students or graduates of an LCME- or AOA-accredited medical school program in the United States or Canada. IMG is defined as a student or graduate of a medical school located outside the United States or Canada. US citizens attending these schools are classified as IMGs. These definitions apply to Tables 1 through 3 and 5 through 9.


Another characteristic of the irregular behavior cohort considered was age. Specifically, the study looked for differences in mean age within the cohort and compared with the overall population of USMLE applicants and examinees. Among the irregular behavior cohort, no significant gender differences in mean and median ages were present. However, the mean age of the IMG subgroup (34 years) was higher than that of the U.S./Canadian subgroup (30 years). This may be attributable to timing differences by which IMGs interact with the USMLE. ECFMG internal data shows 70% of all Step 1, Step 2 CK and Step 2 CS applicants in 2008 reported having already graduated from medical school. Thus, most IMGs do not take their first Step examination until after graduation from medical school in their native country—a marked difference from the students of LCME-accredited medical education programs who routinely take Steps 1 and 2 before leaving medical school.10

The mean age of the U.S./Canadian subgroup appears somewhat higher than what would be anticipated based upon the average age of matriculants to LCME-accredited programs. Data from the Association for American Medical Colleges for the time period 1992–2008 indicates a mean age at matriculation of 23–24 years for both male and female students.11 Because the infractions for the U.S./Canadian subgroup were fairly equally distributed across all three Steps and presuming the sequence by which this group proceeds through the USMLE (i.e., Steps 1–2 prior to graduation; Step 3 during residency training), one might have anticipated a mean age for this subgroup perhaps closer to 27–28 years.

The mean age for the IMG irregular behavior cohort (34 years) seems consistent with what one might anticipate based upon the later start for most IMGs first interaction with the USMLE program. An FSMB query of all IMGs sitting USMLE Step 1 between 1992–2006 provided a mean age of 30 years.

InfractionsTable 3 summarizes the infractions identified by the CIB as their basis for the irregular behavior finding. Timing violations constituted the most common irregu-lar behavior infraction—163 findings in 433 cases. This infraction (specific to the paper-pencil test administrations from 1992–1999) involved marking answers or “bubbling” on the answer sheet after time was called ending an examination or section within an examination. Because scoring for the USMLE was cumulative and guessing was not penalized, examinees had an incentive to complete all items and leave no omissions on the answer sheet.

Setting aside infractions unique to the pencil-paper format utilized until 1999 (e.g., timing violations, looking at another examinee’s test book), the most common irregular behavior infractions fall under the general heading of falsification. This might involve providing false information as part of the application for a USMLE Step or falsifying/altering a document (e.g., score report, diploma, document signatures). Nearly one-third of cases (129/433) involved some form of falsification. This is not surprising based upon published studies of academic cheating that identified comparable behaviors, e.g., fake lab or research results, false information on a patient chart.12,13,14 This is also consistent with reported problems centered upon falsified credentials and/or application materials for exams pre-dating the USMLE, i.e., the Federation Licensing Examination (1968–1994).15 The next most frequent infraction involved making, possessing or accessing notes during a test administration (58/433).

The transition to computer-based testing in 1999 and broad reach of the Internet created new and different security challenges and potential infractions for irregular behavior. USMLE applicants are prohibited from “any unauthorized reproduction…of examination materials by any means, including the Internet.”2 The program actively monitors chat rooms and discussion boards

Table 2: Irregular Behavior Cohort Compared with All USMLE First Takers 1992–2006Percentage All Examinees with Irregular Behavior (As percentage of All USMLE First Takers, 1992–2006


Male 51.3% (26%) 15.5% (32%) 66.7% (58%)

Female 27.5% (17%) 5.8% (25%) 33.3% (42%)

Total 78.8% (43%) 21.2% (57%)

Category definitions mirror those used by the USMLE program. U.S./Canadian is defined as students or graduates of an LCME- or AOA-accredited medical school program in the United States or Canada. IMG is defined as a student or graduate of a medical school located outside the United States or Canada. U.S. citizens attending these schools are classified as IMGs.


dedicated to USMLE topics and has successfully pursued 21 cases of irregular behavior involving “web posting.” The prevalence and increased sophistication of electronic devices (e.g., cell phones, scanners) pose a continuing potential threat to examination security. These are reflected in many of the irregular behavior cases for “security” and “procedural” violations.

Sanctions Imposed by the Committee on Irregular Behavior: Barring an Individual from USMLE Administrations and Reporting to the FSMB Board Action Data BankAs noted previously, allegations of possible irregular behavior are generally routed through a staff com-mittee for additional research and/or review. Internal data from the Office of the USMLE Secretariat shows that in recent years (2004–2008) this staff committee reviewed approximately 400 incident reports annually. This committee provides a function akin to a grand jury by reviewing available infor-mation to determine whether sufficient evidence exists to warrant case referral to the CIB for formal disposition. Once a case is referred, the CIB conducts a review of the evidence, including any

statement from the individual under investigation, and make its determination—either a finding of irregular behavior or a finding of no irregular behavior. While this study is focused on individuals deemed to have engaged in irregular behavior, it should be noted that the CIB issued a finding of no irregular behavior at comparable rates for both U.S. and IMG candidates—39% and 45% respectively for the period 2002–2006.

Records from the Office of the USMLE Secretariat show 703 cases referred to the CIB between 1992 and 2006. The committee found for irregular behavior in 61.6% of the referred cases (433/703). A finding of irregular behavior results in an automatic annotation to the individual’s USMLE record. This is a significant action as any USMLE transcript subsequently produced by the program alerts the transcript recipient (e.g., residency program, state medical board) to the irregular behavior finding.

For those individuals found to have engaged in irregular behavior, two further sanctions are possible. The first involves the decision to bar the individual from future USMLE administrations. (See Table 4.)

Table 3: Number and Type of Irregular Behavior Infractions: By Gender and School Classification within each Category (n=444)

IMG US/Can Total

Male Female Male Female Male Female

Timing violation 81 59 22 1 103 60 (163)

Falsified information 41 16 14 4 55 20 (75)

Notes (make/possess) 25 19 8 6 33 25 (58)

Falsifying documents 14 8 4 2 18 10 (28)

Altered score report 15 3 6 2 21 5 (26)

Security breach/violation 14 2 1 0 15 2 (17)

Web posting 14 5 1 1 15 6 (21)

Looking at neighbor’s test booklet 5 3 6 2 11 5 (16)

Unauthorized access, assistance or possession

7 1 3 3 10 4 (14)

Behavior (e.g., disruptive, unscheduled breaks)

6 1 1 2 7 3 (10)

Procedural violation 4 0 3 5 7 5 (12)

Communicating with another examinee

2 3 0 0 2 3 (5)

Total 228 120 69 28 297 148 (445)*

*Some individuals were found to have engaged in irregular behavior under multiple categories; thus, 445 infractions involving 433 individuals.


score reports or diplomas. It would seem these actions are viewed by the CIB as inherently more egregious than the procedural violations (e.g., timing violations) characterizing the paper-pencil era. (While timing viola-tions might also be seen as “character” issues, only one of these cases was sufficiently egregious—and with other factors involved—that a bar was imposed).

The decision to limit access to USMLE occurred at a rate fairly close to the overall demographic composition of all examinees deemed by the committee to have engaged in irregular behavior during the 1992–2006 time period. In comparing the demographic breakdown for individuals sanctioned with a bar (Table 5) with the overall demographics of the irregular behavior cohort in Table 1, it appears that IMG males were somewhat more likely to have a bar imposed by the CIB.

Upon a finding of irregular behavior, the CIB then makes a separate decision whether this determination should be reported to the FSMB board action data bank. For the 433 cases of irregular behavior, approxi-mately one-third (142/433, or 32.7%) also resulted in a decision to report their finding to the board action data bank. This sanction ensures that any inquiry by a state medical board to the FSMB board action data bank will result in information on the irregular behavior

Table 4:Length of Bars Imposed by Committee on Irregular Behavior (CIB) for Irregular Behavior Cases 1992–2006

Time served*

1 yr 2 yr 3 yr 4 yr 5 yr >5 yr Indefinite Total

8 39 20 25 4 7 1 17 121

Mean: 2.19 years** Mode: 1 year Median: 2 years

*Time served—In some instances, after finding for irregular behavior, the CIB determined that the period of time the individual was ineligible for USMLE while awaiting final hearing and disposition of the case represented an appropriate length of time for a bar and imposed no additional time.

**Calculation does not include time served or indefinites.

Table 5: Bars Imposed by the Committee on Irregular Behavior (CIB) After Finding for Irregular Behavior (n=121)Number of Examinees With Bar Imposed by CIB (As percentage of All Irregular Behavior Cases Resulting in a Bar)


Male 75 (62.0%) 12 (9.9%) 87 (71.9%)

Female 26 (21.5%) 8 (6.6%) 34 (28.1%)

Total 101 (83.5%) 20 (16.5%) 121

Nearly one-third of all irregular behavior cases (121/ 433, or 27.9%) resulted in the imposition of a bar. Most of these bars (84/121, or 69%) were for a period of 1–3 years. In 29 of these cases, the bar was “tolled,” meaning the time-specific bar did not take effect until the individual established, or re-established if applicable, their eligibility for USMLE. In these instances, the actual length of time the individual was precluded from sitting USMLE was likely even longer than the time-specific bar.

A small number of bars (17/121, or 14%) were “indefinite,” i.e., the CIB precluded the individual from sitting USMLE until they met all eligibility criteria and/or until a state medical board, fully apprised of the facts of the case, requested that the individual be able to sit the examination. The average bar imposed by the CIB ran approxi-mately 2 years.

In reviewing the 121 cases for which the CIB imposed a bar, it appears the committee reserved this sanction primarily for cases involving issues of “character.” These cases all appear to have involved premeditation and intent to deceive, e.g., falsifying applications, unauthorized access or dissemination of test materials, altering key documents such as


finding being shared with the inquiring board. It also means that any USMLE transcript will also carry an annotation indicating board action history exists on the individual and a copy of the board action report (with information explaining the basis for the board action) would be included with the transcript.

The decision by the CIB to report a finding of irregu-lar behavior to the FSMB board action data bank (Table 6) occurred at a rate consistent with the overall demographic composition of the irregular behavior cohort (Table 1).

Completing the USMLE Sequence Fewer than half of the individuals with findings of irregular behavior from 1992 to 2006 were subse-quently successful in completing the USMLE sequence (198/433, or 45.7%) by the end of 2008 (Table 7).

This overall percentage is lower than might have been expected, particularly so for U.S./Canadian examinees who otherwise have performed at a high level on the USMLE. First-taker pass rates for students and graduates of LCME-accredited medical school programs have consistently been above 90% throughout the history of the USMLE. When this performance is com-bined with the fact that the program does not impose any attempt limits upon a USMLE Step, the resulting ultimate pass rate on the USMLE for U.S./Canadian examinees is likely 99% or higher.2 Yet among the irregular behavior cohort, only 60% of the U.S./ Canadian subgroup have been able to successfully complete the USMLE sequence.

There are several possible explanations for this moderate achievement in successfully completing the USMLE sequence. First is the below average

Table 6: Reporting to FSMB Board Action Data Bank After a Finding of Irregular Behavior (n=142)Number of Examinees Reported to Data Bank (As percentage of All Irregular Behavior Cases Reported to Data Bank)


Male 81 (57.0%) 21 (14.8%) 102 (71.8%)

Female 31 (21.8%) 9 (6.3%) 40 (28.2%)

Total 112 (78.9%) 30 (21.1%) 142

Table 7: Irregular Behavior Cohort and Successful Completion of the USMLE SequenceTotal Number of Examinees With Irregular Behavior/Number and Percentage Completing USMLE


Male 222/ 88 (39.6%) 67/ 44 (65.7%) 289/132 (45.7%)

Female 119/ 54 (45.4%) 25/ 12 (48.0%) 144/ 66 (45.8%)

Total 341/142 (41.6%) 92/ 56 (60.9%) 433/198 (45.7%)

Table 8: USMLE Performance of the Irregular Behavior Cohort Number of Individuals Passing on First Attempt/Total Number of First-Taker Administrations Involving Irregular Behavior Cohort (Percentage Reflects First-Taker Pass Rate for All Examinees With Irregular Behavior, 1992–-2006)


Step 1 77/304 (25%) 39/68 (57%) 116/372 (31%)

Step 2 92/292 (31%) 46/71 (64%) 138/363 (38%)

Step 3 39/175 (22%) 45/61 (73%) 84/236 (35%)

Notes: The finding of irregular behavior may be associated with the first-take administration, a subsequent administration, or a non-administrative event. Not all individuals with a finding of irregular behavior had an administration for each Step.


performance of the irregular behavior cohort as first takers of the USMLE (Table 8). This cohort’s per formance was noticeably below that of all U.S./Canadian and IMG first takers throughout the 1992–2006 period. The U.S./Canadian first-taker pass rate has never fallen below 91% for any USMLE Step over the history of the program; IMG first-taker pass rates have ranged between 47–81% on each Step.2 Another consideration is the imposition of a bar in 121 cases. Recall that in 17 of these cases the CIB imposed an indefinite, rather than a time-limited, bar upon the examinee. To date, no state medical board has requested that any of these individuals be provided access to the USMLE. Additionally, the imposition of a time-specific bar seems to significantly lower the like-lihood of completing the USMLE sequence. Only 12 of the 121 individuals with time-limited bars successfully completed the USMLE. Thus, the decision to impose a bar upon access to the USMLE appears to significantly reduce the likelihood that subsequently an individual will successfully complete the licensing examination sequence. Another explanation may be the basis behind many findings of irregular behavior, i.e., falsification of an application or key document. In those instances where the falsification is directly related to the individual’s eligibility status for a Step examination, the USMLE has required the individual to establish (or re-establish, if applicable) eligibility before the clock begins on the time-limited bar. Finally, for those indi-viduals whose irregular behavior finding dates to more recent years (e.g., 2004–2006), it is possible these individuals are still progressing through the educational/training system toward licensure.

Obtaining a Full, Unrestricted License in a U.S. JurisdictionA review of licensure information available on the 433 individuals identified with irregular behavior shows that 37% of these individuals obtained a full, unrestricted U.S. license (Table 9).

There are several possible explanations for these relatively modest percentages. For example, none of the 17 individuals sanctioned with an “indefinite” bar has yet been, or is likely ever to be, licensed by a U.S. jurisdiction. Furthermore, individuals with bars imposed more recently (i.e., 2004–2006) may not have had sufficient time to finish moving through the USMLE sequence and gain/complete sufficient residency training to be eligible for licensure. Additionally, other individuals appear to have diverted from the USMLE pathway entirely. This may reflect pursuit of an alternate career pathway (e.g., seven individuals gained licensure in Canada). Some individuals may have chosen to pursue other professional opportunities or, in the case of some IMGs, they may have returned to, or opted to remain in, their native country.

The U.S./Canadian subgroup was most likely to successfully complete the USMLE sequence and obtain a full, unrestricted license in a U.S. jurisdiction. This examinee subset possesses a strong financial incentive, stemming in part from student indebtedness, pushing them to persist in their progress toward licensure (2006 graduates averaged $130,000 in medical school debt),16 and, unlike IMGs, there is no option to return to a native country to practice medicine. Additionally, as noted above, this group has demonstrated strong performance on USMLE and other standardized examinations.17,18,19

State Medical Boards and Examinees with Irregular BehaviorThe USMLE transcript serves as the primary means by which the program alerts state medical boards to instances of irregular behavior. State medical boards licensing graduates of medical schools issuing the M.D. degree routinely require an original USMLE transcript as part of their licensing application process. If the CIB delivers a finding of irregular behavior, the official record of the individual is annotated to reflect the committee’s finding and

Table 9: Individuals with Irregular Behavior Who Subsequently Passed All USMLE Steps and Obtained a Full, Unrestricted License in a US JurisdictionTotal number examinees with irregular behavior/number and (percentage) obtaining full license

IMGs US/Canadian Total

Male 222/ 71 (32.0%) 67/40 (59.7%) 289/111 (38.4%)

Female 119/ 41 (34.5%) 25/ 9 (36.0%) 144/ 50 (34.7%)

Total 341/112 (32.8%) 92/49 (53.3%) 433/161 (37.2%)


any official USMLE transcript subsequently gener-ated carries this annotation alerting the document’s recipient. A comment reading “irregular behavior” appears in bold cap lettering on the USMLE transcript along with a brief description of the infraction imme diately underneath the irregular behavior com-ment. For all findings of irregular behavior since 2001, a copy of the determination letter† from the Office of the USMLE Secretariat also accompanies the transcript.

A second pathway for flagging irregular behavior and bringing it to the attention of a state medical board occurs when the CIB finds for irregular behavior and decides to also report this finding to the FSMB board action data bank. This means that any subsequently produced USMLE transcript carries an annotation at the bottom indicating the individual has board action history on file with the FSMB. A copy of the board action report (listing the basis for the board action) would accompany any USMLE transcript produced by FSMB, NBME, or ECFMG. Any state medical board querying the FSMB board action data bank as part of its licensing processes (standard practice for all boards) would be made aware of the irregular behavior finding by virtue of this history in the FSMB board action data bank.

One of the questions originally prompting this inves-tigation was, “What actions, if any, are taken by state medical boards when they are presented with an individual who has been found previously to have engaged in irregular behavior by the USMLE program?”

In order to answer this question it is first necessary to establish that state medical boards are adequately alerted to the presence of irregular behavior history.

Most state medical boards (47 of 70) issue resident or training licenses. However, only 15 of the 47 boards issuing a resident or training license require passage of USMLE Steps 1–2, which would be verified through a USMLE transcript sent to the board.20 Consequently, state medical boards do not generally become aware of an individual’s examination history with irregular behavior until the point when the individual directs FSMB to forward a transcript as part of the application process for a full, unrestricted license. As noted in Table 9, only 161 individuals with irregular behavior obtained a full, unrestricted medical license by the end of 2008. FSMB internal applications for transcript production and records on file with the Office of the USMLE Secretariat were consulted to ascertain whether state medical boards were alerted to the presence of the irregular behavior. This review determined that for 150 out of 161 individuals, the state board issuing the license either received a transcript alerting them to the indi-vidual’s history of irregular behavior or contacted the Office of the USMLE Secretariat to obtain information concerning the irregular behavior, indicative of their awareness of the irregular behavior infraction prior to license issuance. Incomplete records at FSMB and the Office of the USMLE Secretariat may account for the 11 instances in which it appears the state medical board issued a license without apparent knowledge of the irregular behavior finding.

†The determination letter sets forth the official finding(s) of the CIB along with any sanctions imposed.

Table 10:Prejudicial Actions Taken by State Medical Boards Against Physicians with An Irregular Behavior Annotation

Physician IRB** infraction Board Action

Physician 1 Time violation MA Fine and reprimand for fraudulent misrepresentation

Physician 2* Web posting IN Denial of license

Physician 3 Making notes MD Reprimand for unprofessional conduct

WA Denial of license

Physician 4* Falsified score CA License issued on probation (unprofessional conduct); required enrollment in ethics course

Physician 5* Falsified score NY Restricted from practice of medicine (fraudulent misrepresentation on license application)

*indicates the medical board’s action stems from USMLE’s finding of irregular behavior **IRB=Irregular Behavior


irregular behavior in 1992–2006, accounting for 66% of the irregular behavior cohort compared with their historical presence as first-taker USMLE examinees for the same period (58%). IMGs were disproportionately represented among all individuals with irregular behavior during the 1992–2006 period, accounting for 78% of the irregular behavior cohort compared with their historical presence in 49% of all USMLE test administrations for the same period (43% of all “First Taker” administrations).

Neither gender nor location of medical school played a statistically significant role in the decision by the CIB to report the irregular behavior to the FSMB board action data bank. The decision to apply this sanction took place at a rate statistically consistent with the demographic composition of the overall irregular behavior cohort. However, the decision to impose a bar limiting access to USMLE did occur slightly more frequently for IMGs (83%) compared with their overall presence accounting for 78% of the irregular behavior cohort.

In looking at outcomes and external measures, 45% of individuals found to have engaged in irregular behavior during the 1992–2006 period were sub-sequently able to successfully complete the USMLE sequence. Only 37% of the irregular behavior cohort obtained a full, unrestricted medical license after passing the USMLE. In part, these outcomes reflect the low first-taker pass rate of the entire irregular behavior cohort on all Steps.

There were no statistically significant gender differences relative to subsequent likelihood for successfully completing the USMLE and obtaining a full, unre-stricted medical license in a U.S. jurisdiction (male = 38%; female = 34%). However, graduates of U.S./Canadian medical school programs were the sub-group most likely to complete the USMLE sequence and obtain a full, unrestricted license (53% vs. 32% for IMGs).

State medical boards routinely require a USMLE transcript as part of their license application process. A finding of irregular behavior by the USMLE program carries significant consequences for the prospective career of an individual. State medical boards have denied licenses to individuals with irregular behavior and been unwilling to support the prospective licensure of individuals with indefinite bars. The irregular behavior annotation to the transcript appears to divert the license application from its routine adminis-trative handling to a more individualized review of the candidate’s qualifications, including his/her character and fitness to practice medicine.

Another avenue of research looked at actions taken by state medical boards against licensure applicants found previously to have engaged in irregular behavior. A cross check against the FSMB board action data bank on the 433 individuals in this study found only a handful of instances where a state medical board took a subsequent prejudicial action against an individual previously found to have engaged in irregular behavior. Of the 198 individuals who completed the USMLE sequence, five individuals had subsequent action taken against them by a state medical board (5/198, or 2.5%). The actions taken ranged from fine and reprimand to denial of license. This number is likely influenced by the actionable bases upon which a licensing board is empowered to act, e.g., non-criminal matters pre ceding the candidate’s application for licensure may not be actionable.

This study also examined another subset of individuals with irregular behavior who completed the USMLE sequence, i.e., 87 cases “non- administrative” irregular behavior.‡ In this subset, 12 individuals completed the USMLE sequence with seven subsequently obtaining a full, unre-stricted U.S. medical license. For the remaining five individuals, three were denied licensure or withdrew their license application to avoid a reportable denial of licensure by the board; one individual has a license application pending currently; the final indi-vidual’s location and circumstance is unknown.

Additionally, it should be noted that the ‘official’ actions taken by medical boards discussed above do not represent the full extent of inquiry boards may take when presented by a licensure candidate with irregular behavior history. Conversations with executive directors at several state medical boards confirmed that individuals with irregular behavior were required to appear before a board panel or sub-committee to answer questions regarding the nature and basis for the irregular behavior annota-tion and/or board action history. It appears that an irregular behavior annotation diverts a license applicant from the routine administrative processing of the application.

Conclusions Assessment of the demographic composition of the irregular behavior cohort shows several notable characteristics. Male examinees are dispropor-tionately represented among all individuals with

‡These cases involved infractions not tied directly to the actual administration of a Step, e.g., web posting, document falsification, etc.


3. United States Medical Licensing Examination. 2010 USMLE Bulletin of Information. Pages 22–25. Accessed February 18, 2010 at http://www.usmle.org/General_Information/ bulletin/2010.html

4. Carson, JD. Doctor Convicted on Criminal Charges in Connection with Licensing Examination. Fed Bulletin 1983; 70(7):200–201

5. Morton, JH. Report of the FLEX Board. Fed Bulletin 1983; 70(11):330–334

6. Johnson, DA. The United States Medical Licensing Examination (USMLE): Maintaining the Integrity of the Examination Process. J Med Lic Disc 2006; 92 (3):16–19

7. Baldwin, DC, Daugherty, ST, Rowley, BD, Schwarz, MR. Cheating in Medical School: A Survey of Second-year Students at 31 Schools. Acad Med. 1996;71(3):267–273

8. Whelan, GP. Coming to America: The Integration of Interna-tional Medical Graduates into the American Medical Culture. Acad Med. 2005;81(2):176–178.

9. Searight, HR, Gafford, J. Behavioral Science Education and the International Medical Graduate. Acad Med. 2006;81(2):164–170

10. Association of American Medical Colleges. Curriculum Directory. Accessed March 3, 2009 at http://services.aamc.org/currdir/section1/start.cfm

11. Association of American Medical Colleges, Age of Applicants to U.S. Medical Schools at Anticipated Matriculation by Sex and Race and Ethnicity, 2006–2009, Accessed February 18, 2010 at http://www.aamc.org/data/facts/applicantmatriculant/table6–facts2009age-web.pdf Matriculant Age at Anticipated Matriculation, 1992–2001. Accessed March 5, 2009 at http://www.aamc.org/data/facts/archive/famg122001a.htm

12. Sierles, F, Hendricks, I, Circle, S. Cheating in Medical School. Acad Med. 1980;55(2):124–125.

13. Petersdorf, RG. A Matter of Integrity. Acad Med. 1989;64(3):119–123.

14. Anderson, RE, Obenshain, SS. Cheating by Students: Findings, Reflections and Remedies. Acad Med. 1994;69(5):323–332.

15. Carson, JD. Cheating on Licensing Examinations—A Legal Perspective. Fed Bulletin 1985; 72(2):35–42

16. Fuchs, E. With Debt on the Rise, Schools and Students Face an Uphill Battle. AAMC Reporter January 2008. Accessed February 18, 2010 at http://www.aamc.org/newsroom/reporter/jan08/debt.htm

17. Case, SM, Swanson, DB. Validity of NBME Part I and Part II Scores for Selection of Residents in Orthopaedic Surgery, Dermatology and Preventive Medicine. In Gonnella J, Hojat M, Erdmann J, Veloski J, eds., Assessment Measures in Medical School, Residency and Practice: The Connections, pp. 101–114. Springer Publishing Company, 1993.

18. Swanson DB, Case SM, Koenig J, Killian CD. Preliminary study of the accuracies of the old and new Medical College Admission Tests for predicting performance on USMLE Step 1. Acad Med. 1996;71(1 suppl):S25–S27

19. Basco WT, Way DP, Gilbert GE, Hudson, A. Undergraduate Institutional MCAT Scores as Predictors of USMLE Step 1 Performance. Acad Med. 2002;77(10): S13–S16.

20. Federation of State Medical Boards. Resident Licensure and Post Graduate Training Programs. Accessed February 18, 2010 at http://www.fsmb.org/grpol_issueoverview.html

Only a small percentage of the individuals in this study who completed the USMLE sequence had a subsequent action taken against them by a state medical board (5/198, or 2.5%). This number is influenced, in part, by the legal bases upon which boards may take action. A finding of irregular behavior is more likely to divert the license applicant from the board’s routine processing of applications.

Finally, some individuals among the irregular behavior cohort (n=8) diverted from the USMLE and U.S. licensure pathway medicine. One left his allopathic program for an osteopathic medical education program; seven others completed the Medical Council of Canada’s Qualifying Examination and obtained licensure in Ontario. It is unclear whether a gap in the educational and/or professional career of these individuals was disclosed as part of the licensure application process in these jurisdictions. Records at FSMB show no requests to forward USMLE transcripts to either jurisdiction on these individuals. Licensing boards may wish to review their existing procedures to ensure that they are being adequately alerted to any history of irregular behavior within the USMLE program.

AcknowledgementsThe author wishes to acknowledge the assistance of the following individuals in data collection for records at the Educational Commission for Foreign Medical Graduates, the Federation of State Medical Boards and the National Board of Medical Examiners: William Kelly (ECFMG); Denise Bransford, Frann Holmes (FSMB); Diane Convery (NBME); and Susan Deitch with the Office of the USMLE Secretariat. The author also wishes to thank NBME Senior Vice President, David Swanson, Ph.D., for insightful suggestions on an early draft of this article.

Funding/Support: None.

Other disclosures: None.

Disclaimer: The opinions expressed in the article are those of the author and do not reflect the views of the Federation of State Medical Boards or the United States Medical Licensing Examination program. ■

References

1. Federation of State Medical Boards. State Require-ments for Initial Medical Licensure. Accessed February 18, 2010 at http://www.fsmb.org/usmle_eliinitial.html

2. United States Medical Licensing Examination. USMLE Performance Data. Accessed February 18, 2010, at http://www.usmle.org/Scores_Transcripts/performance.html


I N T E R N AT I O N A L B R I E F S

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . United Kingdom

New Era for Medical Education and Training Begins in the UKOn April 1, 2010, the General Medical Council (GMC) became responsible for regulating every stage of medical education in the United Kingdom. For the first time ever, one organization now sets standards for education and practice, oversees medical education and training, operates the regis-tration of doctors and ensures they are competent and fit to practice.

The new arrangement follows the merger of the Postgraduate Medical Education and Training Board (PMETB) with the GMC, which is intended to create a simpler and more coordinated system of regulation that seeks to raise standards and spread good practice. The four main functions of GMC are:

fitness to practice is in doubt

Report Offers Implementation Recommendations The GMC will soon publish the final report of the Patel review, which has examined the details of the merger. The report addresses the different stages of education and training (undergraduate, postgraduate and continuing practice) and the links between them, as well as the position of medical graduates from other countries.

The report’s recommendations have implications not only for doctors and those involved in their training, but also for patients and for health care organizations throughout the UK. The GMC will consider the review’s recommendations and take forward any further actions to achieve the full benefits of the merger.

“Bringing all stages of the regulation of medical education and training under the GMC will bring a number of significant benefits, including a more

robust and streamlined system of quality assurance that is more effective and less burdensome on the NHS,” said Ann Keen, health minister with responsi-bility for professional regulation. “This is a significant step towards achieving our aspiration for excellence in medical education and training.”

For now, PMETB’s structures and standards will carry on unchanged within the GMC. This includes setting national requirements for specialty and GP training as well as the quality assurance of training and of the routes and processes for certification.

The GMC will remain the regulator for doctors, continuing to set the standards for professional practice and receiving and investigating allegations about their fitness to practice.

Starting in April of 2011, the adjudication of fitness-to-practice cases involving physicians will transfer from the GMC to a new body called the Office of the Health Professions Adjudicator (OHPA). OHPA is being created to ensure clear separation between the investigation of fitness-to-practice cases and the process of determining whether a professional’s fitness to practice is impaired. ■

Source: General Medical Council news release and website, April 1, 2010

GMC Launches Professionalism Podcast and e-Bulletin for Medical Students A major new initiative has been launched by the General Medical Council (GMC) to help medical students to develop and maintain high standards of professionalism throughout their training and careers.

Medical students featured on a new podcast describe how good clinical knowledge, patient con-fidentiality and other attributes help demonstrate high standards of professionalism. Newly qualified doctors discuss the challenging issues they can face and how the professionalism training they received at medical school helps them to offer high standards of care to patients.


“Doctors must demonstrate good clinical competence and be able to communicate complex information to their patients effectively,” said Professor Jane Dacre, GMC Council member and vice dean and head of education at UCL Medical School in London. “We spoke to doctors and medical students who acknowledge on the podcast that this is one of the

most challenging parts of a doctor’s role, especially when facing testing situations on issues like patient confidentiality.”

The GMC plans to engage medical students on professionalism using both the podcast and an e-bulletin to which they are encouraged to sign-up.

The e-bulletin updates medical students on develop-ments related to medical education and regulation and asks them to contribute ideas on ethical issues that should be covered in future issues. In the latest edition, the GMC updated students on the recent merger of PMETB with the GMC and new guidance from the GMC being launched this year.

GMC’s activities promoting professionalism include creation of “Tomorrow’s Doctors,” a guide that sets the standards that medical students have to meet before they graduate. The guide was first published in 2009 and among other things highlighted the importance of communication skills and a good bedside manner as well as ensuring that medical students acquire the scientific background and technical skills they will need to be effective doctors.

To listen to the podcast and subscribe to the e-bulletin, please visit www.gmc-uk.org/students.

For more information, visit the GMC website: http://www.gmc-uk.org/information_for_you/uk_medical_students.asp ■

Source: General Medical Council website and news release, March 4, 2010.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Australia

New Medical Board of Australia Continues To Define Roles, Responsibilities The newly constituted Medical Board of Australia met for its sixth meeting March 23–24, 2010.

The Board was established under the Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008 and had its first meeting in September 2009.

At its March meeting, the Board held a planning day to consider the role of State and Territory boards and the delegated powers that they should exercise after July 1, 2010. The Board also agreed on a work-plan to develop additional policies and guide-lines specific to medicine.

The Board also made decisions about a range of matters that will impact the transition to Australia’s new national registration and accredi tation structure.

State and Territory Board Structures and Delegations The Medical Board of Australia will be responsible for developing and approving registration standards, codes and guidelines, approving accreditation standards and negotiating the health professions agreement which determines funding and service arrangements with the Australian Health Practitioner Regulation Agency (AHPRA).

State and territory boards will become committees of the national board and will be known as, for example, the ‘Queensland Board of the Medical Board of Australia.’ The National Board has decided to delegate responsibility for all matters related to individual practitioners to state and territory boards. It will rely on these boards to make decisions about applications for registration and about notifications (complaints). The state and territory boards will be supported by a range of committees, made up of state and territory board members and as necessary, external experts. These committees will be delegated some decision-making powers, but very serious decisions, and those open to appeal, will be made by the full state and territory board.

‘DOCTORS MUST DEMONSTRATE GOOD

CL INIC AL COMPETENCE AND BE ABLE TO

COMMUNIC ATE COMPLEX INFORMATION

TO THEIR PATIENTS EFFECTIVELY.’


Likely Committee StructureCommittees are likely to include a Registrations Committee, Assessment Committee, Health Committee and one or more Performance and Professional Standards Committees. The number of committees and their role may vary between jurisdictions, subject to local needs.

The Board will delegate to the AHPRA decisions that it considers to be routine and all administrative functions. The National Board plans to host regular teleconferences and collaboration across states and territories with members of functionally similar committees; in addition, an annual national con-ference of Board members is planned.

Codes and GuidelinesThe Board has decided to reissue Good Medical Practice, a code of conduct for doctors in Australia, with minor modifications to reflect the Health Practitioners Regulation National Law Act 2009 (the National Law). In addition, the Board will develop

specific guidelines about a range of issues, including professional boundaries, sexual misconduct, medical practitioners and medical students with blood-borne infectious diseases and unconventional medical practice. Consistent with the national law, the Board will consult widely about any guide-lines that it develops.

Transition Arrangements April LetterThe Medical Board of Australia will write to every registered medical practitioner in late April, in an effort to support the transition of all registrants into the national structure. The letter will explain each practitioner’s registration type starting on July 1, 2010. The letter will also detail the information that will appear on the online national Register of

Medical Practitioners. The Board is urging all medical practitioners to make sure the contact details held by their current State or Territory Board are accurate and up to date before June 30, 2010.

The Board made a range of decisions about this transitioning process. In general, medical practitioners will transition to the type of registration that matches their current registration. While the name of some registration categories will change, the Board has no intention of changing any medical practitioner’s scope of practice

Specialist RegisterIn order to ensure that a specialist register is in place when the new structure begins, the Board agreed to use data from trusted sources to establish the register. State and Territory Boards with specialist registers, specialist colleges and Medicare Australia will all be asked to provide data. Specialist colleges will be asked to provide lists of fellows and a list of international medical graduates (IMGs) who have been found to have qualifications that are substantially comparable to Australian qualifications and who have completed any additional requirements for eligibility for fellowship. Medicare Australia will be asked to provide lists of medical practitioners who are recognized as specialists. The Board agreed to include on the specialist register medical practitioners assessed by the Specialist Recognition Advisory Committees (SRACs) or the Overseas Specialist Advisory Committees (OSACs) as specialists.

Because construction of the specialist register is a complicated process requiring data to be sourced, cleansed and de-duplicated, the Board’s April letter will include reference to specialist registration and medical practitioners, encouraging them to check that the information that AHPRA proposes to enter about them in the specialist register is correct.

Medical Courses and Specialist QualificationsThe Board confirmed that the graduates of medical courses that are currently accredited by the Australian Medical Council (AMC) will continue to be accepted for provisional or general registration after July 1, 2010. Similarly, fellows of medical

I N T E R N AT I O N A L B R I E F S

THE MEDIC AL BOARD OF AUSTRALIA

WILL WRITE TO EVERY REGISTERED

MEDIC AL PRACTIT IONER. . . IN AN EFFORT

TO SUPPORT THE TRANSIT ION OF

ALL REGISTRANTS


colleges that are currently accredited by the AMC will be accepted for specialist registration after July 1, 2010.

Conditions, Undertakings and Reprimands on the RegisterThe national law requires the Board to publish conditions imposed and undertakings accepted from medical practitioners on the Register of Medical Practitioners. However, the law also allows the Board to choose not to record a condition imposed

or an undertaking accepted if the practitioner has an impairment, it is necessary to protect the practitioner’s privacy, and there is not an overriding public interest for the condition or the details of the undertaking to be recorded.

The Board decided that it would not routinely publish the details of conditions imposed or undertakings accepted as a result of impairment. However, in the interests of transparency, the Board will place the statement that the practitioner has conditions related to health in the register. There may be circumstances when the Board will decide on a case-by-case basis to publish the details of some practice restrictions imposed due to impairment when there is an overriding public interest.

For the first time, the Board is required to publish in the Register reprimands issued to a practitioner. The Board decided that it will routinely remove reprimands from the registers after five years if there has been no other health, conduct or performance action against the practitioner during that period. This

THE MEDIC AL BOARD OF AUSTRALIA WILL

BE RESPONSIBLE FOR DEVELOPING AND

APPROVING REGISTRATION STANDARDS, CODES

AND GUIDELINES, APPROVING ACCREDITATION

STANDARDS AND NEGOTIATING THE HEALTH

PROFESSIONS AGREEMENT WHICH DETERMINES

FUNDING AND SERVICE ARRANGEMENTS

WITH THE AUSTRALIAN HEALTH PRACTITIONER

REGULATION AGENCY (AHPRA).

applies to reprimands issued after July 1, 2010.

Proof of IdentityThe Board approved an approach for authenticating the identity of an individual who applies for regis-tration. This approach relies on a 100-point check, consistent with the Attorney General’s standard. It applies to all new applications for registration beginning July 1, 2010.

The Board will require applicants for limited registration to have their documents certified by a staff member of AHPRA or a nominated delegate. Applicants for other types of registration can have their documents certified by an authorized officer. A list of class of persons that are authorized officers will be published.

Registration StandardsThe Board approved for consultation registration standards for limited registration for teaching and research and limited registration in the public interest. The draft statements will be published and stakeholders are encouraged to provide feedback to the Board.

Communications PlanThe Board approved a communications plan with the key features that include risk assessment and issues management, external communications, stakeholder engagement, government relations, media management and consultation strategies. ■

Source: Medical Board of Australia Communiqué and website, March 2010


S TAT E M E M B E R B O A R D B R I E F S

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California

Medical Board of California Launches New Web Applicant Access System Applicants for licensure in California now have the ability to go online to check the status of their application for a Physician and Surgeon License or Postgraduate Training Authorization Letter. The Medical Board of California launched its new Web Applicant Access System (WAAS) on February 10, 2010, providing significant features that help make the application process much more convenient.

The new system displays information regarding each required application document; specifically, when a document is received and whether that document is approved or deficient. Applicants must use an Applicant Tracking System (ATS) number, which is provided upon receipt by the Board of an application and application fee. For more information www.medbd.ca.gov/ ■

Source: Medical Board of California website, April 2010

California Physicians to be Required to Notify Patients of Medical Board of California LicensingEffective June 27, 2010, physicians practicing in California must inform their patients that they are licensed by the Medical Board of California, and include the Board’s contact information. The infor-mation must read as follows.

NOTICE TO CONSUMERSMedical doctors are licensed and regulated by the Medical Board of California(800) 633-2322www.mbc.ca.gov

The purpose of the new regulation is to inform consumers where to go for information or with a complaint about California medical doctors.

“The Medical Board’s mandate is public protection, and this new requirement will assist patients by directing them to our Web site and our call center, where they can access very basic yet important

information about our public services,” said Medical Board President Barbara Yaroslavsky. “And it will take very little effort for physicians to comply.”

Physicians may provide this notice by one of three methods:

offices conspicuous to patients, in specified type.

signed and dated by the patient or patient’s rep-resentative, and kept in that patient’s file.

discharge instructions, or other document given to a patient or the patient’s representative, where the notice is placed immediately above the signature line for the patient in specified type.

The three options are designed to serve a multitude of practice settings, including emergency depart-ments, skilled nursing facilities, and surgical settings.

The Medical Board is an agency within the Department of Consumer Affairs (DCA). At least nine of DCA’s other agencies have similar disclosure requirements, including the Pharmacy Board, the Contractors State License Board, the Bureau of Automotive Repair, and the Board of Optometry. ■

Source: Medical Board of California News Release, April 5, 2010

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York

Policy for Medication Reviews by PTs is ClarifiedA recent agreement between the New York State Board for Physical Therapy and the state’s Depart- ment of Health helps clarify the role of physical therapists regarding medication reviews by physical therapists. Specifically, the new agreement clarifies the role of physical therapists in completing compre-hensive assessments, including drug regimen reviews for certified home health agency (CHHA) and long term home health care program (LTHHCP) patients who are receiving therapy services only.


BackgroundThe Federal Home Health Agency Medicare/Medicaid Conditions of Participation require that providers conduct a comprehensive assessment including a drug regimen review (DRR) for all patients as outlined in regulations. This stipulation became effective

in 1999 and has permitted the completion of the comprehensive assessment by the appropriate therapist for therapy-only cases.

After recent concerns were raised regarding the propriety of physical therapists (PTs) conducting medication regimen reviews, however, the Board for Physical Therapy determined that the conduct of a drug regimen review is outside the scope of permissible practice for physical therapists.

New PoliciesAfter discussion, it was determined that the comprehensive assessment may be completed by a physical therapist only if the agency has implemented a policy and procedure that requires collaboration between the physical therapist and other agency staff. The physical therapist, in this situation, will:

by the patient, including any overt issues regarding the drug regimen, e.g. rash, obvious non-compliance with regimen, or continued presence of symptoms such as pain.

to the designated drug regimen reviewer at the agency.

designated reviewer when the DRR is complete and what, if any, actions were taken to address issues identified by the review to the extent required to complete the assessment.

The physical therapist cannot make medication changes, but can document that such changes were made, by whom and what they were. The date of receipt of this information from the reviewer by the PT will be the completion date of the assessment as directed in the CMS OASIS-C Guidance Manual, Chapter 3 page L-1. The designated drug regimen reviewer must document the review, including date and signature in the clinical record. If areas of concern are identified during the DRR, the agency must notify the physician and obtain orders for any nursing intervention to further assess and resolve issues and educate the patient regarding medication changes and management. Documen- tation in the clinical record by the designated reviewer must include all actions reflected in the DRR. ■

Source: New York State Office of the Professions website, April 2010; State of New York Department of Health letter to administrators, January 26, 2010

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Washington

Death with Dignity Update: Washington Issues First Annual Report Washington’s first annual report on use of the Death with Dignity Act shows lethal doses of medication were dispensed to 63 people in 2009. The law allows terminally ill adults to request these prescriptions from physicians.

The state Department of Health issued the report as required by the act, which went into effect March 5, 2009. The report covers March 5 to December 31, 2009. The 63 prescriptions were written by 53 different physicians and dispensed by 29 different pharmacists.

Of the 63 individuals who received lethal doses of prescription medication last year, 47 are known to have died. Thirty-six died after ingesting the medication. Those who died were between the ages of 48 and 95. More than 90 percent resided west of the Cascades. Most had terminal cancer and all were expected to die within six months.

THE PHYSICAL THERAPIST CANNOT MAKE

MEDICATION CHANGES, BUT CAN DOCUMENT

THAT SUCH CHANGES WERE MADE, BY WHOM

AND WHAT THEY WERE.


According to prescribing physicians, all of the patients who received medication and died had expressed concern about loss of autonomy as a reason for requesting a prescription. Other common reasons included concerns about loss of dignity and loss of the ability to participate in activities that make life enjoyable.

Under Washington’s Death with Dignity Act, the Department of Health must collect information from patients and providers who choose to participate, monitor compliance with reporting requirements, and produce an annual statistical report.

More information about the 2009 Death with Dignity report is available at www.doh.wa.gov/dwda/ ■

Source: Washington State Department of Health News Release, March 4, 2010

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wisconsin

New Rules on Remote Pharmacy Dispensing Sites

The Wisconsin Pharmacy Examining Board has approved a change to the Wisconsin Administrative Code that governs pharmacy practice related to establishing and operating remote dispensing sites. The changes went into effect on April 1, 2010.

In general, the new rules allow for remote dispensing of medications in certain facilities and with certain safeguards in place. Examples:

For Pharmacy CustomersA pharmacy technician with appropriate training may staff a remote dispensing site, but a pharmacist is required to check the prescription and talk with customers each time they pick up prescriptions. If the pharmacist is not available or the technology to connect customers with a pharmacist is not working, the staff at the remote site cannot provide them with medication.

S TAT E M E M B E R B O A R D B R I E F S

The remote dispensing site is required to display a sign informing customers that prescriptions may be filled at that location, and letting them know the name, address and telephone number of the store that is responsible for the supervision of the site.

For Pharmacists and PharmaciesAs with all other pharmacy operations, a remote dispensing site must follow state dispensing and labeling law and federal controlled-substances law.

Managing pharmacists must have written policies and procedures for system operations and safety, security, accuracy and access as well as implement an on-going quality assurance program.

Managing pharmacists are required to visit the remote dispensing site at least monthly to perform a prescribed list of responsibilities. Documentation of the visits must be kept for two years.

For Pharmacy TechniciansBasic requirements must be met to staff a remote dispensing site, including completing at least 1,500 hours of work as a technician within the three years prior to employment or completion of a train-ing program approved by the board. ■

Source: State of Wisconsin Department of Regulation and Licensing website, April 2010


L E G A L B R I E F S

By Tim Miller, J.D. Senior Director, Government Relations and Policy Federation of State Medical Boards

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Americans with Disabilities Act and State Medical Board License ApplicationsRecently attention has been placed upon the health-related questions state medical boards ask on initial and renewal licensing applications. The authority and appropriateness of these health related questions have been scrutinized and criticized. Some suggest that asking health-related questions as a part of the licensing process can run afoul of the Americans with Disabilities Act (ADA).1

This scrutiny comes at a time when the ADA has undergone significant changes that have increased the number of people who it potentially protects.2

The Americans with Disabilities Act Amendments Act of 2008 (ADAAA) did not directly amend Title II, which applies to governmental entities.

Given the broadened parameters of the ADAAA, it is important for state medical boards to carefully consider their use of health-related questions in the licensing process to ensure they fulfill their mandate of public protection but do so within the bounds of federal law. This article offers background and suggestions that will help state medical boards as they review the language they use in their licensing applications.

What Protections Does the ADA Extend?Title II of the ADA protects qualified individuals from discriminatory actions taken by state entities. Under Title II no person with a disability can be unjustly excluded from participation in or be denied the benefits of services, programs or activities of any public entity.3

Three components in the ADA are of particular importance in evaluating the impact of the ADA on health-related licensing-application questions:

Definition of coverage. Those covered by the act include anyone who is disabled and who, with or without accommodation, meets the essential eligibility requirements for the receipt of services or the participation in programs or activities provided by a public entity.4

Definition of discrimination. Title II discrimina-tion occurs when a qualified individual with a disability, by reason of such disability, is excluded from participation in or is denied the benefits of the services, programs, or activities of a public entity, or is subjected to discrimination by any such entity.5

Use of eligibility criteria. The ADA forbids a public entity from imposing or applying eligibil-ity criteria that screen out or tend to screen out any individual with a disability or any class of individuals with disabilities from fully and equally enjoying any service, program, or activity, unless such criteria can be shown to be necessary for the provision of the service, program or activity being offered.6

The original ADA, and now the ADAAA, are clearly meant to provide the broadest possible reach to protect all disabled persons in all public activities. The courts have explained that “the ADA should be interpreted broadly as all remedial statutes are.”7 The Lee court pointed out that “the ADA’s broad language brings within its scope anything a public entity does.”8 The law prohibits a public entity from administering “a licensing or certification program in a manner that subjects qualified individuals with disabilities to discrimination on the basis of disability.”9 Finally, the Hanson court ruled that “medical licensing is without a doubt something that the medical board does. As such, we conclude that medical licensing clearly falls within the scope of Title II.”10

With these definitions, some courts hold that medical boards conduct business falling solidly within the realm of activities covered by the ADA. Assuming the ADA does, indeed, apply to state medical board activity, medical boards cannot administer their licensing applications in a manner that discriminates against disabled people. Further, medical boards

SOME SUGGEST THAT ASKING HEALTH-RELATED

QUESTIONS AS A PART OF THE LICENSING

PROCESS CAN RUN AFOUL OF THE AMERICANS

WITH DISABILITIES ACT (ADA).



cannot use criteria that screens out or tends to screen out disabled applicants.

But these regulations do not define what is “discriminatory” in the licensing process. By its nature, licensing is a discretionary process that discriminates between those who are capable to practice medicine and those who are not.

If this is the case, how can state medical boards know what is considered “discriminatory” in their licensing processes?

The courts are divided on this question. Some courts believe health-related questions are impermissible—a way of looking at the question that is referred to as “status analysis.” Other courts believe that the nature of questions are not the issue, but rather, how a government agency goes about determining a license applicant’s com-petency. This way of approaching the question is called “behavioral analysis.” Finally, some courts have concluded that the ADA does not apply to licensing entities at all. This way of looking at the question is called “necessity exception analysis.”

Status AnalysisStatus analysis holds that the ADA prevents the medical boards from inquiring into an individual’s disability status. A status-questions-only approach solicits an applicant’s condition rather than an applicant’s competency. The Ellen court, which

concluded that asking questions was a violation of the ADA, illuminates the status discrimination analysis.11 In Ellen an affirmative response to the first part of a question automatically triggered subsequent questions and possible subsequent investigation. Ellen held that “the Board can dis-criminate against qualified disabled applicants by placing additional burdens on them and this

discrimination can occur even if these applicants are subsequently granted licenses to practice law.”12 The board’s requirement that applicants answer the challenged questions, and that they sign a broad medical authorization, violates the ADA because it discriminates upon the disability status of disabled applicants rather than more narrowly tailored questions designed to elicit the applicant’s behavioral fitness.13

Behavior AnalysisBehavior analysis holds that it is not screening questions, but what a medical board does with the answers to those questions, that indicates discrimination. The Jacob court best illuminates the difference between status analysis and behavioral analysis. The Jacob court held that it was not the challenged questions that created the ADA problem; in fact, the court stated that a board may ask anything it wants.14 The court ruled that the board could not place extra burdens on an applicant who answered status questions rather than behav-ioral questions.15

The Jacob ruling suggests that a board can create behavior and capabilities questions that focus on behavior.16 The court pointed out however, that “that it is not actually the questions themselves that are discriminatory under the Title II regulations.”17 The Lee court was also troubled that the “board pre-sented no evidence of correlation between obtaining mental counseling and employment dysfunction, and question had strong negative stigmatic and deter-rent effects.”18 Even the Ellen court agreed that behavior focused questions might be acceptable “as long as they do not substitute an impermissible inquiry into the status of disabled applicants for the proper, indeed necessary, inquiry into the appli-cants’ behavior.”19

Necessity ExceptionA few courts have found that the ADA does not apply to licensing authority because of the so called “neces-sity exception.” The relevant ADA provision reads:

“A public entity shall not impose or apply eligibility criteria that screen out or tend to screen out an individual with a disability

MEDICAL BOARDS MUST CAREFULLY BALANCE

THEIR STATUTORY DUTY TO PROTECT THE

PUBLIC WITH THEIR POSSIBLE REQUIREMENT

TO COMPLY WITH THE ADA.


or any class of individuals with disabilities from fully and equally enjoying any service, program, or activity, unless such criteria can be shown to be necessary for the provision of that service, program, or activity being offered.”20

The necessity argument stems from the last clause, which reads: “Unless such criteria can be shown to be necessary for the provision of that service, program or activity being offered.”

The ADA states: “Under the necessity exception to the ADA, public entities may utilize eligibility criteria

that screen out, or tend to screen out, individu-als with disabilities if the criteria are necessary to insure safe operation of the program or if the individual poses a direct threat to the health or safety of others.”21

The Alexander court stated the necessity exception as it applies to medical boards:

“Due to the nature of the practice of medicine, plaintiff’s mental condition exposes the public to some measure of risk to which the Board was duty bound to consider when considering whether to reinstate plaintiff’s license. The very nature of the police powers exercised by state boards of medicine require the state to discriminate on the basis of, among other considerations, a mental condition harmful to the public’s safety. The Board cannot exercise its duty without the discretion to consider the impact of a mental disability upon one’s ability to practice with reasonable skill and safety. The danger of irreparable harm to the public is too great to deny the Board such discretion.”22

The Pat Doe court also pointed out the necessity of asking health related questions as part of the

appli cation and licensing process:23 “The boards must determine if an applicant is fit to practice medicine and as such, the boards must obtain all necessary information in order to make an informed decision.”24

These differing opinions leave the medical boards in an uncertain environment in determining to what extent the ADA applies to the application and renewal questions. The following analysis of three health-related application questions is designed to help medical boards as they review their processes for gathering health-related information in the licensing process. The three questions are a hybrid of those found in various state applications.

1. Have you ever suffered from any physical, psychiatric, or addictive disorder?

This question is an example of a status question as it does not inquire into the applicant’s abilities but only into the applicant’s status as someone with a disability. This question would not pass a status analysis, but may pass a behavioral analysis depending on how the medical board follows up on a “yes” answer.

2. Do you currently have, or have you had within the past 5 years, any physical, mental or emotional condition which impaired, or does impair your ability to practice medicine safely and competently?

This question is both a status question and a behavioral question. The question’s five year look-back may create a problem with a status analysis. The question would probably survive a behavioral analysis challenge, and it could survive a status analysis because of the link to an impairment.

3. Do you currently have a mental, physical or behavioral disability that may impact your ability to practice safely?

This question is an example of a behavioral question, as it focuses only upon the qualifica- tion of the applicant and not the applicant’s disability status. This question would survive both a status analysis and a behavioral analysis.

…DIFFERING OPINIONS LEAVE THE MEDICAL

BOARDS IN AN UNCERTAIN ENVIRONMENT

IN DETERMINING TO WHAT EXTENT

THE ADA APPLIES TO THE APPLICATION

AND RENEWAL QUESTIONS.


14. Medical Society of New Jersey v. Jacobs, 1993 WL 413016, 8

15. Id.

16. Id. at 6

17. Id. At 8

18. Lee at 69

19. Ellen at 1494

20. 28 C.F.R. § 35.130(b)(8) (emphasis added)

21. Americans with Disabilities Act of 1990, § 2 et seq., 42 U.S.C.A. § 12101 et seq.; 28 C.F.R. § 35.130(b)(8); Part 35, App. A.

22. Alexander v. Margolis, 921 F.Supp. 482, 488, 13 A.D.D. 1017, 8 NDLR P 30 (W.D.Mich., Nov 01, 1995) (NO. 1:93-CV-585)

23. Pat Doe v. The Judicial Nominating Commission for the Fifteenth Judicial Circuit of Florida, No. 95-8625-CIV. Nov. 13, 1995. Nunc Pro Tunc Nov. 9, 1995 906 F.Supp. 1534, 64 USLW 2329, 5 A.D. Cases 1, 12 A.D.D. 551, 7 NDLR P 240 (S.D.Fla., Nov 09, 1995) (NO. 95-8625-CIV-HURLEY)

24. Id.

These three questions demonstrate the spectrum of questions that may occur in the licensing process; from an open-ended “status” question to a very narrow “behavioral” question.

ConclusionMedical boards must carefully balance their statutory duty to protect the public with their possible require-ment to comply with the ADA. Unfortunately, the courts have not provided clear guidance on how best to comply with the ADA and protect the public. The challenge for medical boards is to craft questions narrow enough to survive a judicial challenge but broad enough to gather all information necessary to protect the public. ■

References

1. Pub.L. 101-336, 104 Stat. 327, enacted July 26, 1990, codified at 42 U.S.C. § 12101.

2. ADA Amendment Act, Pub. L. 110-325, 122 Stat. 3553 (2008), effective January 1, 2009.

3. Olmstead v. L.C., 527 U.S. 581 (1999)

4. 42 U.S.C. § 12131(2)

5. 42 U.S.C. § 12132

6. 28 C.F.R. § 35.130(b)(8)

7. Arnold v. United Parcel Serv., Inc., 136 F.3d 854, 861 ( 1st Cir.1998); Kornblau v. Dade County, 86 F.3d 193, 194 (11th Cir.1996) & Tcherepnin v. Knight, 389 U.S. 332, 336, 88 S.Ct. 548, 19 L.Ed.2d 564 (1967)).

8. Lee v. City of Los Angeles, 250 F.3d 668, 691 (9th Cir.2001)

9. Ellen S., Annabel R., Katherine F. and Sally M., Plaintiffs, v. The Florida Board Of Bar Examiners, 859 F.Supp. 1489, 1493, (S.D.Fla., Aug 01, 1994); Clark v. Virginia Bd. of Bar Examiners, 880 F.Supp. 430, 442 (E.D.Va.1995); Hason v. Medical Bd. of California 279 F.3d 1167 C.A.9 (Cal. 2002) & Kirbens v. Wyoming State Bd. of Medicine, 992 P.2d 1056, (Wyo., Dec 06, 1999))

10. Hanson at 1172,

11. Ellen at 1493, (S.D.Fla., Aug 01, 1994); Clark v. Virginia Bd. of Bar Examiners, 880 F.Supp. 430, 442 (E.D.Va.1995); Hason v. Medical Bd. of California 279 F.3d 1167 C.A.9 (Cal. 2002) & Kirbens v. Wyoming State Bd. of Medicine, 992 P.2d 1056, (Wyo., Dec 06, 1999)

12. Ellen at 1493

13. Id.



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