Judging and being judged: The thankless job of doctor discipline

He doesn't wear a police badge or a carry a nightstick, but some people make themselves scarce when David Garza, DO, enters a room.

"Sometimes the conversation in the doctor's lounge dies down a little or changes topics when you walk in. Sometimes people just scatter," said Dr. Garza, a family physician in Laredo, Texas.

Such reactions often come with serving on a state medical board; Dr. Garza is a member of the Texas State Board of Medical Examiners.

Physicians who serve on the boards that license and regulate doctors acknowledge that their work is often thankless. Charged with policing the profession, they are viewed by some as the equivalent of internal affairs officers of a police department -- a position that can attract guardedness and disdain from colleagues.

Their decisions also come under scrutiny from state legislators and consumer watchdog groups, who sometimes criticize boards for doing a lousy job of disciplining doctors.

But board members say the positive aspects outweigh the negative.

They say many colleagues respect and credit them for keeping watch over the few doctors who get into trouble. They believe their actions promote professionalism, and that medicine is made better by guidelines they create on matters such as pain medication and end-of-life care.

"It's tough to sit there and make decisions that affect a physician's livelihood. Nobody praises the work the board does," said N. Stacy Lankford, MD, a retired urologist and member of the Medical Licensing Board of Indiana. "There's a healthy tension between the general physician public and the board, and I think it's appropriate. We're not there to represent physicians. We're there to represent the public."

All but three state medical boards consist of physician and public members (Alabama, Louisiana and Mississippi have physician-only boards). The governor usually appoints board members, who serve terms ranging from three to eight years, depending on the state.

Members include MDs and DOs, both young and old, who practice in a wide range of specialties. Some are well-known in the medical community and were recommended to the governor by a state medical society or colleague.

Ron Morton, MD, was recommended by a colleague and appointed to the Medical Board of California in 2001. The Bakersfield, Calif., ophthalmologist had been a leader in the California Medical Assn.

"I didn't seek the post. They called me up," Dr. Morton said.

Before the governor appointed him, he was familiar with the board's powerful reputation. "They were kind of considered the big dog in the yard."

Tales from the front

When someone makes a complaint against a physician, boards follow a process that may lead to an investigation and a hearing. Some meet monthly to hear cases and vote on discipline while others convene a few times a year. Physicians who are close to someone brought before the board recuse themselves.

The work is not without hazards.

The Florida Board of Medicine has security at most meetings.

"In the past, board members have gotten death threats," said Lisa Tucker, MD, an obstetrician-gynecologist in Pensacola, Fla. and Florida board chair. "We had a gentleman at our last meeting say, 'Why don't you all go and drop dead?' "

One time, a physician who went to prison for drug trafficking came to get his medical license back. He spoke harshly, recited his prison number, then waited outside the meeting room after the board refused to reinstate his license.

"It was frightening to sit there and listen to him. I was afraid to get up and go to the bathroom," Dr. Tucker said.

Almost as unnerving are physicians who show no remorse for their actions.

A Florida neurosurgeon shaved the wrong side of a patient's head and made an incision before catching his mistake. The doctor blamed his nurse for prepping the patient incorrectly and claimed no harm came to the patient.

"A board member said, 'We're all going to take a pair of clippers and shave your head and you tell us it's no big deal,' " Dr. Tucker said. "When the doctor got up to leave, his knees buckled."

Boards instruct new members on the law and procedures of their state's medical practice act, but part of the learning comes firsthand.

When Dr. Garza was new to the Texas board, a surgeon came to a hearing with two supporters. When one spoke up on the doctor's behalf, Dr. Garza spoke out.

"I told him how the cow ate the cabbage and to shut up. I found out later he was a state senator," he said. "After that I made sure I knew the identity of every person in the room."

Some call boards ineffective

Board members are used to hearing criticism of their work. Newspaper articles in Texas and Virginia have slammed boards in those states for doing a poor job handling complaints, disciplining doctors and protecting patients. Last year, Texas legislators passed a law calling for speedier handling of complaints and more board funding.

An ad hoc committee created by the Texas Medical Assn. started meeting in November 2003 to develop recommendations on improving the Texas board. Its findings will be presented to legislators this summer.

"I am hearing of some unrest, of board members who are not getting along with physicians in the community" because of disciplinary decisions, said Paul Handel, MD, committee chair and TMA board of trustees member.

State legislators in Nevada and Arizona last year questioned the effectiveness of their medical boards and ordered audits.

Each year, consumer advocacy group Public Citizen uses board data to evaluate how well boards do their jobs. The Washington, D.C.-based group bashes some boards for not doing enough to protect patients.

"One of the factors that appears to have a lot of influence on whether the board is doing a lot of discipline or not has to do with [the boards'] relationships with the medical society and governor," said Sidney Wolfe, MD, director of Public Citizen's Health Research Group.

Board members dispute claims they are politically motivated, saying they base decisions on the facts of a case.

Bryant Welch, PhD, is a psychologist and attorney who has represented psychiatrists before medical boards. For the most part, he said, board members seem hardworking and reasonable. But there are some who are suspect.

"There certainly is one personality type who approaches it with a personal agenda of how virtuous they are and they can, in effect, become hanging judges. Some [members] have wonderful motives and some don't," said Dr. Welch, who is based in Hilton Head, S.C.

Richard Willner, president of the Louisiana-based Center for Peer Review Justice, said board members need better oversight and that members' terms should be limited to prevent some members from becoming entrenched.

"They're often dominated by a few who have strong personalities. There is no one watching them," said Willner, whose organization advocates for doctors it believes were wrongly disciplined by boards.

Juggling practice and board

Board members said critics don't understand how seriously they take their role and how much time and effort they put into these duties.

Dr. Tucker, of the Florida board, reviews 10,000 to 20,000 pages of documents each month to prepare for her board's monthly meeting. She drives from her Pensacola office to meetings in Orlando, Jacksonville and Miami. She gets $50 on meeting days and a $12 food allowance.

She has a solo practice, so another doctor in town covers her patients. While she's away, she checks in with her staff and nurse practitioner, handling what she can by phone.

Marty Crane, MD, doesn't see patients on Wednesdays when the Massachusetts Board of Registration in Medicine meets. To prepare for a meeting, he may spend several hours of his weekend going over reports. He has cut back some of his hours in his gynecology practice in South Weymouth, Mass., but he said the board's work is worth it.

"Giving back something is what it's all about," said Dr. Crane, the board's chair. "Here's an opportunity to make a contribution at the system level and stand up for quality issues."

Kim Edward LeBlanc, MD, PhD, heard one case for seven days as a member of the Louisiana State Board of Medical Examiners. He figures he lost $20,000 to $25,000 at his family practice in New Orleans.

"If income is an issue, you shouldn't sit on the board. Some things you do because it's the right thing to do," he said.

Phoenix emergency physician Patrick Connell, MD, agrees. He got a $6,000 stipend last year for his work on the Arizona Medical Board. "That was probably for 1,500 hours of work. You do the math. That's obviously not why you do it."

Many board members voice satisfaction at impacting the profession. They cite having a hand in adopting board guidelines on pain medication, office-based surgery and other issues. George Barrett, MD, a retired radiologist in Charlotte, N.C., points to guidelines on end-of-life care adopted by the North Carolina Medical Board.

"I got verbal applause for that walking down the halls of the hospital," said Dr. Barrett, who served nine years on the board to 2003. "If medical boards use their authority properly, they can enhance the quality of care in their community."

And in their offices.

Family physician Kenneth Walker, MD, has learned more about laws that govern medical practice by serving on the Virginia Board of Medicine. For example, after he saw some doctors get into trouble for lapses in documentation, "it's made me focus on my medical record- keeping a great deal."

Dr. Morton, learned, through a case before the California board, that a manufacturer had misled him about which staff members could operate one machine in his office.

"I thought, 'I've got to stop this. I can't arrest myself.' "