Where's doc disciplinary data?

People waiting to read the Federation of State Medical Boards' annual report summarizing national statistics for doctor discipline are waiting in vain. The FSMB has quietly killed its Annual Summary of Board Actions report. The Federation, which has published the report since 1985, promises that a new and improved report—which will not necessarily include statistics on each state medical board's disciplinary actions—should be out in the fall.

The change will make it harder for the consumer advocacy group Public Citizen to publish its widely followed annual report ranking state medical boards by their number of disciplinary actions against physicians. Its rankings, first published in 1999, have been based on the FSMB report. Public Citizen contends that the federation deep-sixed its report to stop Public Citizen from putting out the rankings that state medical boards and physician groups hated. But Public Citizen has vowed to continue ranking state boards even if the FSMB no longer supplies it with the readily available raw material to do so.

“We'll figure out a way to keep doing the rankings,” says Dr. Sidney Wolfe, founder and a senior adviser of Public Citizen's health research group. “We're not throwing in the towel because that's not our style.”

Underlying the back and forth over the federation's report are longstanding disagreements over how to measure state medical boards' effectiveness in policing doctors and how best to ensure that doctors are practicing and behaving well.

The FSMB represents the 70 licensing boards of the 50 states, District of Columbia and U.S. territories (15 states have separate osteopathic boards). The FSMB has compiled disciplinary actions taken against physicians the previous year by its member organizations. The annual summary has listed the number of physician licenses revoked, suspended, modified and ordered to be surrendered or retired by each medical board.

Lisa Robin, the FSMB's chief advocacy officer, says the federation is revising the format of the report. While the annual summary released in 2012 was the last of its kind, it won't be the last report the FSMB ever publishes compiling individual board activity. “It's not that there's not going to be any data reported in the future, it's just that it's going to be different,” she says.

Traditionally, the federation's annual reports are released in the spring. They have begun with the same qualifying statement: “Because states operate with different financial resources, levels of autonomy, legal constraints and staffing levels, the FSMB discourages using data from this report to compare or rank states.”

Since 1999, Public Citizen has ignored the federation's warning, using federation data to rank the state boards by number of disciplinary actions. Public Citizen has done this by calculating a three-year average of the number of licenses revoked, suspended or modified by the state board. It divided that figure by the number of doctors in a state to create a “serious actions per thousand physicians” metric. Its report is typically widely covered in the general news media and often used to criticize or praise state boards for their purported laxity or rigor in scrutinizing physician conduct.

The federation, medical board officials and physician groups have accused Public Citizen of presenting misleading information, arguing that the number of board disciplinary actions is heavily affected by the number of bad doctors in a state rather than whether the board is doing its job well or not. The federation's report “was never meant to be used as a ranking that this board is better than that board,” Robin says.

But Public Citizen has opened its report with this statement: “Absent any evidence that the prevalence of physicians deserving of discipline varies substantially from state to state, this variability must be considered the result of the boards' practices.” Wolfe argues that it's likely that states all have the same percentage of misbehaving doctors—around 1%, he estimates—so differences in board activity are likely to be linked to variables such as board leadership and resources.

He charges that the FSMB's decision to cease publication of the annual summary was motivated by the Public Citizen annual reports and the desire to avoid the controversy they created each year with their state-by-state comparisons. “It doesn't take any great insight to realize that they didn't like the reports,” he says. “ 'Infantile' is the best way to describe it: 'We don't like these reports, so we're not going to make the data public.' ”

Public Citizen's supporters say the ranking report provides a valuable tool that has prompted state legislatures to take action and increase the resources available to low-ranking medical boards so they can do a better job.

But critics such as Mark Grapentine, the Wisconsin Medical Society's senior vice president of government relations, call the rankings misleading and unhelpful. “We've had a pretty long history of questioning the usefulness of that (Public Citizen) report,” Grapentine says. “It's an apples-to-oranges comparison because different medical boards handle things differently. Some boards tend to be punitive. Wisconsin tends to be rehabilitative.”

Grapentine notes how Wisconsin and neighboring Minnesota tend to be “bottom feeders” on the Public Citizen ranking even as federal measures indicate the states are leaders in delivering high-quality and high-value care. “We support having a strong, well-funded licensing board that can do the job it's expected to,” he says. The big question, he says, is “how do you promote high-quality healthcare and give the most value to consumers? Dr. Wolfe's report doesn't move us to that.”

Steve Alexander, a public affairs consultant and former president of the Medical Board of California, argues that the Public Citizen rankings don't advance the general mission of medical boards, which he says is to provide consumers with accurate, timely and useful information. “The Public Citizen ratings are highly controversial—you can do anything you want with data,” Alexander says. “The Public Citizen rankings aren't reflective of how effective medical boards are.”

He explains that, for example, boards can take on highly volatile cases that take a long time to prosecute, thus reducing their disciplinary actions in a given year, and that this not be reflected in the rankings. But Alexander, who served as board president in 2006-07, acknowledged that Wolfe's assertion that the level of a state board's activity is related to its level of staffing and funding “is likely to be accurate.”

“The medical board was always hampered by limited resources,” Alexander says.

Patient-safety advocate Helen Haskell, a member of the National Patient Safety Foundation's board of governors and founder of Columbia, S.C.-based Mothers Against Medical Error, says “desperate underfunding” has kept her state's board at the bottom of the Public Citizen rankings.

“I feel sorry for medical boards because often their hands are tied by their legislatures,” says Haskell, whose 15-year-old son died while undergoing elective surgery at the Medical University of South Carolina in November 2000. “I think Public Citizen plays a vital role, and they're the only people taking on this issue,” she adds. “If doctors are licensed by the state, they need to be regulated by the state, and someone needs to keep an eye on (the state boards) to make sure that happens.”

Haskell also suggested that the reason why states such as Massachusetts, Minnesota and Wisconsin ranked low in Public Citizen's reports is because the boards there may be overly concerned with protecting the reputations of their states' physicians and healthcare institutions.

The federation's Robin says, however, that she has never seen any statistics linking “the number of actions taken by a board and patient safety and quality of care in a state.”

When the federation first began publishing the annual reports, Robin says, disciplinary actions were the only metric available, and information on board activities was hard to access and compile in the pre-Internet days. But now every board has its own website, and it's time for the FSMB to include different information such as board structure, board staffing, frequency of board meetings, what authority a board reports to and the number of nonphysicians on a board, she says.

She says the Federation is working with HHS' Health Resources and Services Administration on a “minimum data set” for state boards to post information on individual licensees so consumers can see “who's practicing where.”

Though the discontinuation of the federation's annual summary took many by surprise this spring, the FSMB started on the path to do so in June 2011 when a workgroup was assembled to consider alternatives to the annual disciplinary-action summary. Among the workgroup's recommendations approved by the FSMB's House of Delegates at its April 2012 meeting was to stop publication of the summary in 2013. “I don't recall anyone being opposed to it,” Robin says.

Wolfe says the complaints about the Public Citizen medical board rankings are “nothing I haven't heard before.” He's heard the argument that Public Citizen doesn't consider board actions such as reprimands and getting doctors into education programs or alcohol and drug treatment. His response has been that they want his organization to give state boards “credit for slaps on the wrist.”

But Kevin Bohnenblust, executive director of the Wyoming Board of Medicine, says the issue is more complicated than that. Bohnenblust, who chaired the workgroup on revising the annual summary's format, says the report needs to change with the times—and that includes acknowledging the realities of physician shortages in states such as Wyoming. “If we can make a physician better—with additional training or drug and alcohol treatment—then taking a license away doesn't ultimately serve the community if you can get a doctor to practice safely again,” Bohnenblust says.

He says the old report didn't explain the driving forces behind the statistics being reported. The goal of the planned new report is to “give the full flavor and fabric of what boards are doing and what resources they have to do it with.” Ultimately, he says, what the public wants is information on the individual doctor treating them.

Bohnenblust didn't put much stock in his own Wyoming board receiving the top ranking from Public Citizen last year (See chart). The physician workforce in Wyoming is so small, he says, that if the state board's number of disciplinary actions declines slightly, its ranking would “drop precipitously.”

“We have the same staff, the same burden of proof that we had three years ago when we were 20th,” Bohnenblust says.

Follow Andis Robeznieks on Twitter: @MHARobeznieks