. .
LICE 
MEICA  AN DISCI 
AN 
JU 
1986 . 
NU: 
OONTL 
P-Ol-86-00064 
Reion I	 Office of IAnnlyosirs  an Inions
Boton, Masachustt	 Geer
ODffeicpe aoft   Hu 
of Heath an  Serice  Office of the Inspector General

The mission of the Office of the Inspector General 
(OIG) is to
promote the efficiency, effectiveness and integrity of programs 
in the United States Department of Health and Human Services
(HHS). I t 
does this by developing methods to detect and prevent
fraud, waste and abuse. Created by statute in 1976, the
Inspector General keeps both the Secretary and the Congress fully 
and currently informed about programs or management problems and 
recommends corrective action. The OIG performs its mission by

conducting audits, investigations and inspections with

approximately 1, 
200 staff strategically located around the
country. 
Office of Analysis and Inspections

This report is produced by the Office of Analysis and Inspections
(OAI), one of the three major offices within the OIG. The other 
two are the Office of Audit and the Office of Investigations.
OAI conducts inspections which are typically short-term studies 
designed to determine program effectiveness, efficiency and 
vulnerabili ty to fraud or abuse. 
This Report

The report is entitled "Medical Licensure and Discipline:

Overview. II It was prepared following a review conducted to help 
the u. S. Department of Health and Human Services and other 
interested parties gain a broadly based and up-to-date overview 
discipline. 
of State medical licensure and 
Specifically, the
report addresses pressures being exerted on licensure and 
discipline processes, the changes taking 
place, and the effects
being achieved. 
The study was prepared by the Regional Inspector 
General, Office
of Analysis and Inspections, Boston Region. Participating in the 
project were the following people: 
Boston Region  Kansas City Region 
Mark R. Yessian,  Ph. D. (Project -Leader) 
RaYmond Balandron 
Theodore Wall 
Barry McCoy 
Jane Wentworth 
Eleanor Ellis 
Headquarters Office 
Elisabeth A. Handley  . .. .. . 
TABLE OF CONTENTS

MAOR FINDINGS

MAOR " RECOMMENDATIONS.

MEDICAL BOARDS IN PROFILE. 

LI CENSURE. . 

FMGS IN PERSPECTIVE

THE STATE RESPONSE. . 

OVERALL IMPACT. 

REMAINING VULNERABILITIES 
THE BIGGER PICTURE. . 

DISCIPLINING 
INCIDENCE OF DISCIPLINARY ACTIONS

TYPE OF VIOLATION

SOURCE OF DISCIPLINARY ACTIONS. 

THE ADMINISTRATIVE PROCESS. . 

INFORMTION SHAING 
A FINAL NOTE

RECOMMNDATIONS.

APPENDIX I, BACKGROUND AND METHODOLOGY

APPENDIX II, BEST PRACTICES. 
 MAOR FIINGS

LICESU 
licein  :mca grdute 
hsince a b1e98 2-1983, the  coonf cf oreign  bo. cn co(FnMcse)  
the major policy  of nost 
relates to th auticity of th crenials an the :mca
edcation of PM.

ta 
nu

In respons to thae gFMr  prolem, state have 
alcitcones.  Aellx ha.v e  to us a new an nore clincaly orien
prNoe.al yt Aralib Jh a.ve  tighteed uep xtheedir  crentials
verification  the 
one-haf have  conce 
peiod of FM reidency  Ma havbe epa se laws 
medical education standards and have  reiewin an even
disapproin foreign meica scools. Som have estalised rues
govem clinca clerksips offer  their state.
to FM  in 
'Iesi nactconrs  have made it nore difficut for FbMe t ol bice leice ed,
an  likihoo tht 
the  will 
those who do 
have vaid crenials an be adeqtely trined. 
re: 
vuerilities 
Hower, tw major 
re 
st 
Most boards canot adequatelyB asose stse th e education
offer 
foreign secoxolis.s  . 
necsab y the  an  An, thetyo  flinac kt hthte 
acctin 
:mca 
the  scools 
us  to sinee  U. s. 
ar etov ugeanteir   as an effecve referce point
for  foreign scools.

trin pro, 
Reidencly ice, te  although a major gatey to

meca  inficiently 
this reality.  to be  indeqtea tcterteinvet iatol
They often have 
sc prose, a failin tht is  trin
esially seiou
pine tthse .m any stateso nfott  requiri shrei dency 
An, they  do no  bo,
inormtion on
reidents' peormce or bevior with state 
so unesin invidus
practilcie cthet.  ca lead to 
bein 
DISCIPL 
D.inb roet  yea the inestigatory an disciplin authority of
mo  ha be iinnccr.r   bugeta, pen
However, since 
nel, an proctivity  haven't ket 
exive  pace with
workloads, large backlogs and  caeloads have
conplace.

ta  bo 
'T  rate of disciplin actionisn  cr  ha be increa

ing.  by 
tahgt ri nTohlev em orset psruibmspta otrira volo lu.n ta stiphuavaeti obe ns, win hcthh ea raec otiofnts 
inorm 
to  in aInc mcos t statthes,f ovioulat ions inlvin drgs or alcool se
th for  disciplin 
oifn  inc onc the inpporro rnioarete o wf arlitli n of preiptaicotionn.s. Mot
ab 
sef 
prortion inlve the  of drgs or alcool.
im 
Stikly  diipliinn te. 
meca mapferwac tce or  acton aBr o fin on thce aba is
on  such 
to pue beus  to be
einntorricmaocusielsy  adni ftfhic vuta iationst hth tm ofti  ext ionf  dtehef i1nI  aclceptg
eabsle amteic a  th 
practce. Yet 
extions  midst of
ininlyp ulic  rens  placiinn   
untele  for action is 
poition.  bo  in
so  enorc  ltt 
. 0  Consum aan lleawr  bo  agenies ar the tw  active
of 
of posible violations. Prfessiona 
:mca soieties
rinevvieiwd uor ganizations (PRb),e   , hositas, an
relatively por so
phymsiacitaon: rh ave 
state havin  reportin laws.  , even

REa:TIONS 
MAOR 
inon  re 
Peer Review  reations an Meca ctaiiyer
report  csOrhzaatioon u d be ame(PRd)  to  nore bexoiv.e  an 
of  inonntion to Stte :mca 
Finial  Depat 
Aassdisttaicoe nby  the  of Edcation an
Veteran  for Um. Se. ca 
edcation shoud follow the
same limitations set  the vaiou heath professiona
educational assistancfoert  granin ts progam  atte 
of the Pulic Heath 
Service,C ian atnha t it should be limited to students 
U. S. am fu scools. di 
Meca 
meca 
shoud be limte ftoor g trhde ute of scools aedccactitoen  cots for
by HH or by a
privatel: deignte 
by HH. 
sta 
'!e Actation  sc  re 
COcil for Grdute Meca 
Edcation (ACX)
cshrotuida ble  amed to  tht hositas (1) condct
thoroghb  o  of reidents an (2) inOJ: state
meca  of reident peormce an coct.i  n 
exam 
HCFA shoulcd oco nsider  meca
the effec ona r 
education 
bein suidized who 
of  Mineleicgiabl e to
practice medicine in the u.
upn
coletion of reidency.  s. or paicipate  in 
Reew fee ched 
to practicin physician shoud be increaed 
suficiently to surt exionb aon .i Iroemt of the enorc
met activities of state meca  PRFI

MEICA OOA1 IN 
In th  Meca an Mecad pro we stain 
mid-1960s, as the  intrtaities 
medical boards were little noice  of state goupv, estratt,e
domte 
alt colety  Mot wer autonom bbooes , havin
little optiobnao i nctiobny  physioctiearn .o ctiona licein 
swtitth e. 
with :mca licein  oter  Whe their rensibilities tyoirc aevleyn
coer bo 
an diipline, they teed to foc  fonn an 
expa.i cuar. on the developt an admsttiorna oyf ,t heonir  tohew  licee
in  '!ey wod diipline physician, but ony  as their autority
an inclintion to  we 
do so 
qute limte.

th bo we  stirin  che. 
A decde late,  caugt up in ther ete  of 
nu  adds  The

nationwide effort to  lictehe  physician shortge  in a 
the  of meca  bein 
sh ris
issued (fro 9,147 intial 
1965 to 16, 1p975e) atn  in the prortion of intial licees bgelicieesn r g rte
to FM  859  in lice 
(fr 16.  in 1965 to 35.  197b5)e. T hs  added
to the colexty of the  job, abnpete , a s coin nce  to sphfrte fero  a 
bshoort ge to a swlus of  to inteify pulic 
diiplin  physician, it 
to 
physician  unrofessiona corxct. 
Simtaly,  nengin u  in
trqu enirntmhetr o iwf sneta ete  x:m cao gfb ootre r.  dervseelhop t s jarin the once
ta  th  mapractice
cacotido ns led ma state to  cupno wh ch ris discini  plin action
the bbeo ar.  an ctoo ns  the inestigato:t  aba n autorities of
cociTbehet e   minocemritn, r anisuin   bo  pulic acct
ability,  to an  of  (1) bein uner the 
, an 
aegis of a  agency, (2)s huavti n non-physician me (3) facin
sunset reviews. 
(The first  legislation, herded as a device for
assessin 
th overl usfuess an effeciveness oft hag encies, wat h 
aCotlioornad Lo iicn e19i7n6. )E xA n, the widesred adopon by  state of  Pa Feder
Meca Bo, rece(F L),b deeloop  ' prtioin  n19 68 by ethxe tFieodenrt ion of state
with  issues whe 
fostein intestate tmfonnty an reiproity. 
deopts  ac.ed 
bo  un  wer  oter tht 
mBy etchea  mid-1980tso,  thes  cbhy e  ceauxsed
nieenwceesp dteua ilenis xthht   pbae tcienctt haemb noit .bo T  hefionste  r dneovte plaodepieotqdst  eoilfny c lpudreo tthetehi enpyu  lthihacevae tp iuonl ico;f
the  in the  bain of prorieta meca scools gea
irvidus 
rensible 
tdoi sut.rSi.b tciiotni zoefn ;f rtahue dceonnvti :csmticocna so fc  rentias inolvin twf or the widesread
of these scools;
the disceJ of cheatin  inolvin the FL an the extions
given by the Edcationa Cossion for Foreign Medica Gradute; the
of allied heath professions; an a send genertion of meca mapractice
crise . 
bo 
In the pros, mo  trfonntion. 
th-one  ar  have ucneerotnre  major  coed  At leat
of them  nCM ulenear  a  agency,  mwithe s,  
1969. Nealy all have at  one or tw non-physician  wher 
one-half had no such  1n96u5.  Mo still have rensigbirli,ty  for
osteth, bu  me  larin er  octiona 
as poatrist also for aa ssistts, nu of other  such
, phystieciacn ian.  midwivbes,o p hymsicea t,h erpists, an
emergency medca  Mot 
have nore  who fin  -'- -
..- ); 
.. "'--.._- - '\ - -.-
- - ,. ... 
ti 
necsa  th 
cesors. tPoa idde avno at vceorngesi pdeert lye m ore tahb  $to5 0th,e  throeles  medi d their pree
diem of  th  ar tyicaly
appinte by the Goemotre fo r  spof   to six yea an, at 
the
more popou state,  to  at leat  yeleata   onin 
days a 
buiness.

bo 
In nealy all state, meacba  twtrehen es derive entirlyc froo  fee iIse

on physicianl.i cUesu ly  co  fro reew
fee  licer eiofn thse fere   incfo ro extion 
fee pcahide bdy  to tEh xpseheyn.esi c riasnt;  the  bais of  lice aldyfe e or
on the  held
in anoter state or of  ceuifisc ate reiveldi cfroe  
Bo  of a  th Nation
of Meca  )(T Bh ios  the  rote to  for grdu
ar tyicay pa 
ate of U.S. meca scools.  of the state buget
pros an sujec to the sa bugeta an pennel contrls as oter state
agencies. 
rens  in 
exed 
hInav te h  to their  rerte nysiebai.lai tnRiee se wa n workloads, unesallyy  aclloer tw 
or  raise thyeir efeea  , have  in  cut  fee, awbhcth  
Ci$fn1 a60 cin1t  o9t8h5 t.C P br(oi'nco!nese  c Iciarcoeruxe'.) r)t,    Yatnhe eters,ara  eiiif sfl rf yoohr nr oeaaa  nlntey ola  oaw   :ei tnonxll eesatv tyrepiielo ne  nocfw  inr tf.oe e  aTi$3n1c h Pc,int  e,ad 1ld(9veu7d9sa c ittonaoo l  lt t$ehh5cee1  
, ha left ma  avllu teher lneon ey they 
fro fee adtrtive  an 
hinaeesi gtaht o:t anb  e  oaf theml  t  in we:lm bceoaw  ltihc leev eplo niteiocn,s awith
job before them. Thus, even though  an discipline
have grown to  an  $50 miluiopn tar y. ea enterise, ma
officials fee  ar swim 
as though they 
ANNUAL STATE MEDICAL LICENSE

RENEW A L FEES

.1979 - .1985 (SELECTED VEARS)

U. S. Ave:rage 
InElation Adjusted
30 
Ave:rage 
.10 
.1980 .1982 .1983 
.1979 
.1985
Sou:rce: 
AMe:rican Medical Association &

ta te 
Medi cal Boa:rds

LICESU 
bo 
tiI co 
OgVere  ner r,e qsteatme  ts:  have  to pjuedgne aa papltitcraitbs teon  (tuhes lbya is of fou
"so  (1) accptale 
law as  mora chct"  (2) grdution fro a meca sdcefinoed ol; 
meca licein ex; ar  (3)
pasage of a  (4) coletion of a 
of grdute meca edcation.  spified peiod
pros, the bo be 
aInb tth s  licein  , as ealy at the 1930s  to exres conce
the  of FM.  wa not until the ealy-
However, it  to mid-1980s  revin  atton. '!
th 
pthat rthei cponoei 
tati ecv a  a dmaijloor son ,  Pnaotio nde 
sclsi ble for th wdai itbh on of sebey rth et Uh.S .p  faJk ms.ere iccae  odfb ae on e tfwrrk
in tch tch   ar. Alar  dec:, ms 
by  set
ou to tighte  apalibca tion am veification  In th pros, 
th adcy  th autcity 
as wel as 
teh  dtion of ma PM.
 of the
errs cr 
is th 
Widey  on Stte bo exve dir, 
view ofb  e  wh sad:

of th edtion  reved 
t'h'!  tqhui tpyh    by Fm  issu
trl.  cooni.n It  ist han  cisae  tshct ilisss  la.e  s1m cwh ibtihgg oeru  con
An son tth t is no  to 
th 
Whe th no thtt  :  oef exxe nr  e. 
oinfefriciioars c to Ua. S . mthet cJaO s oacrf a  lths .rsn lm'cI  ls , esiayp tahfco urneaegrn   coscn:l,s  aar fbar
insa.d eaqnu te clincsa cls ar aamc cte  ;Idmission  O:tt  CUy
mi 
Edtion (ro), a bo cailed of :rrbey tht  ivie;li  of th Amicoan  MMeeccaa
th Amca Asiation  ca.  ra,
Ahsoiaetri,o nd oam  no apcrx.t 
 scls aIoidf M  eca Colleg (MM). '! 
th 
enty do  of th u.s. or  No u.
at  co 
th  ga 
In th ealy 
rYmi1ty980s,  Nov  wer earlt   fsoar c in thf bur.oer

mtecah   baist orf o.n. i teA  reiew o1f9 s8i0x G fAo rign spcrlosid,e d  of tthheer  Ceaib
docented ntuhmf dte,i cienies
region, it  , pacutha  rsly inwtit h 
pclaisnec aal  irceleu,to n uSgrOirn t eSt te mecian  bJU o19 8t2o,  rthe A tMh Htou of Deeogrtde 
to gteht    be  of meca scls meti  . Fme, qivn aent
ical scshelts .f ort by th roo, ntcfh : otyftfei c ia acxti bo for U.S. me
Ony tw am  foc  1979, 
qifinn urerti l
tvy eof  eid.s5t ionb yJ t:hv AeM',  b. on waso nyteoa l:i e.mrf, 
ain  ac	ffaii litate th lincoe on
of De in th Amca meca 
th  nu  revi

A:insr  tri eco . aibn E H wa riin, so to wa th  of F! 
Stte lice  ffrr  3, pe  pe  (se ch). '!
in inti alni ce. Alth161 . 36t1 ph in e 198 1 tot o2 34., 753 in 198o3 f agll thros  rev-
of 1973, wh r7e,4o19n E H (44.  leveol wfi atbh s t tilol )we lw ubee nCM  th pein yteia 
lice, tbh o  of th  C0it to th  bein felt
ma state  officis.  gr 
INITIAL LICENSES ISSUED BY 
STATE MEDI CAL BOARDS 
000 
25 
gTo tal

000	
8FMG 
20 
000 
1.5 
1.0	 000

5000

1.965  1.970  1.975  1.980  983

1. 
Sou:rce:  AMe:rican Medical Association
 '! 
ac: 
pBiyhs y19 s8i3c-i1a9 8i4n,  tihn  ttUh.i S S.t, tteh  licbeoin. o ffo Fr Mthe h agdr bt emaj orirty eof p ractcin
facint h  meca extu  policy
for tw ctoo  t,h  Stte grte  Disitphli nl,i cwehcihn t,hte  yicprera  ly accts
ar  a vita
imrtt 
of  poin ma 
w1ility po  policy ises. Hoer, thf ourreetn.  an
teed to brin it to th 
by th FM prolem 
PEPE 
m: 
IN 
gIsnor ttth   teoa lhy e1p9 7f0isl,  wthsh u e.foSr e. ilpgihnc ynsaeictiio a ns hPtMhg  e(c,F maN).F  w ae cacctve lfyo br etihn
hc, th  FM  in  th 
majority of  be 
sitution hat h emto ecnhe , bo cbeauisb o fBs tych  l tsil gagthee t1a9e70s,
S.  of th 
iJgrtion law am 
citien.  is reflec 
FFSNN.    apacccip ati in apccete  by threet rioeda etiCnv ep Oprro ort.o nW of phUS eFM  an
oU.fp  st.h e    in 1979
tfhor  1s2.l ipp  writoh  6.  for
U(sSeF Mch, b)y. 1 984  to 8.  whe USPM  to 9.
PERCENT DISTRIBUTION OF FMGs IN ACCREDITED

RESIDENCY PROGRAMS. USFMGs a FNFMGs

984
PERCENT  9?9 -
.FNFMGs 
FMGs 
ESU S 
Sou:rce:  AMe:rican Medical Association  in.
ser elic e 
Sin 
1984, th prorretotnr cotf  UFSNFM   han u 
iJgrtion contls  have coeda s the  ci
tizen grtin efsrt efo rceigon s cools ha  to ris.  of U. s. 
GerseexnAtpg iolrglrnitee ncr ti mi.toe ne  Ocaaintnn e  rta hobmtrb ofedoec, rart  ht shtac  ropteohal estrt  hho y aate1r  0abt  h 01eoe030r   l  d0ttaw0otr0 e 1 itt1 nho,e e0s 10 9sin0,im g0et.tue0 ne0  fU ii.os cfs  a.aU  y.'cci ti!zi.nSe ne o.  i1tcd9hie8te 5i1zr9el8en0
in foreign 
arivi 
nely  it app tht  atted
Osfc otohel  in the DocaU SFM,  the isgr esaut emasjtoeri ty have  tht
pofe tth) 5  w02e6t  Atom sciocoal R ewipunlhico  ot rh tMoeeco. k fP ot:hhce  il1ai9np8 4:1 iE, a2C7p7  q(p2u5 .i fypaienc tec)xb  y,i n t2h te,h 0fea7 cl9ta  (4t1t..
Among FNFMGs, India and the  to  for th 
concetrtion .
 maj or
is 
peive  acrs  cotr, it 
pFirnelsyai,nr   winhl se ath es tFaMte  p the tios  at er. Ing 1r9to83ne,e   the lattheet  yea for whicsh nore

data  avalable, 56  of PM  intial  jus
six state: NY (12. 5); NJ (12.3); MA (9.4);r GaA (s7. 6); MDl ic(e 6we.  9); tane C Ain (6. 8).
Perhaps of even more reevce ar th  of th
of FM  in  '! 
lice 
inti 
acct 
ra 
prortion of all  theyp  et),f or in a state. Her, usin
the 1983 data, N.  highes (72.  follow by ME (68. 0); FL
(54. 4); MDt(5h3. 3m); aGeAr (, 4i7t. 8is); a IAp (p45t. l4t)ih;c tN Me (n 44.u7) ;o MfA t h(4e3 .le0s)s;  paonp uSoDu ( 4s1t.a 6t)e.  
Viewed  in  signficat 
also have a  the  of FM.
st  in 
ST REro 
TH 
rens 
ta ma 
ssitxa tmeaj  hoarv ce anen to itntiahtives   state rinens, eactho  otfh we hFcMh  pisr aoldedm.s e'! beero w. 
Meca 
Edcation 
tht 
While state laws have required  applicats for a :mca lice
gcrodnuctee o f a :smuctaa csec oolt, hthty e tyditciaolyn .h ave offered few if an spifics
the  of 
gr, However, as the conce abt
the edcation exience of PM have  remtas s tate have amed these 
ealier. D.in  Pa 
ylawse aloang ,th e at lea line  of the AM releunticont  cite  tht  the  fou
sta 
eight statse htav,e   all applicats be 
graduatess eoft  bsyc hthooel Irs .ot h.a t SmOee to oter ra sreta "tes utatiallys benqlvaare cnth"e sto  tthhte

have mae 
wer no tied to the  clea the bo' 
bu tht made 
to approe or dipproe sa fotrei gn :mca scool.  rets  s authority
state tht haI e.s talised the no exctin 
is Caiforfnraa.
Conced tht the  did no proide a 
suficiently exlicit 
of referce for assesin 
tht  foreign scools, th Caiforna 
tht,1 983 issued
gudelines  set fort nore detailed spifications abo  n  in for
protection reasons, applied to u.s. as well as foreign grdute. '!es
specifications, whch  late  cal 
apnpliuca ts to have c:lsewue tenecjt e tch. -twint o monstattmhe l aow f mi ecin  a intrc1t9io85n,  coerfionr
of identified  '!e inction Imt encos 4, 000 hou 
fou yea an 
actual course work over  of seenty-tw wee
clninuca  inction, at lea fift-fou wee of  a hosita.
suis:t
of addtiona spifications conce thew hcah Ifmtf ibel iation ainn 
apptu 
hoita. 
of the 
Ilen aa stswe sointe wrh estthaeart efr or.e iagnn  scools met theniru s ta, Caiforna an at
(NY  NJ) have visite a  of the scools, mainy
in the Caribbe  Oter statet hha ve relied on mateial 
set by the
scools. Awa of the lbntations of  fift-fou licein 
approcha, galrl  
mjureiisndi ctoti eonms th at are part of the Federtion  at the 1b98e4f.
rens, it  the Federtion to collec inormtion on their 
tu,  estalished a Cossionb ono Fo.re ign Meca Edcation whsceh, in
develop a  tht it 
coc oreenive assesmt questionnir  will 
foreign scools idenified by state  '!e Cassion 
will reiew the
inonntion,  followsutpt seit.e  visits as it fetehlss  npercosas,  an then pas
the inormtion on to the  At ths tim,  is just gettin
unery.

num of state  lice.  invidu 
Tthhues rf ar, a  have disapproed  foreuignn escxooyls,

denyin their grdute  '!es 
leg chlenes. Defer  actiobnes,  not  til 
have led to  the suts ha  a costly am  cons 
pros  so  rete 
state. It 
rsettaly,   fCora  lin.  ha 
in Nort  in a few set-back, one 
be  Caiforna, whch ha th not strinent
Yset uccin sfuly 
the suts have  defened. 
tr 
Clinca Inction 
att 
Beus the clinca  caib 
S. stuents 
s. hositasof  aUr.  beus  abt  exscto ols is 
of conce 
tosftu aobped e ravcistiioonn  tthoi ne csoe nsttle tnhtes c rleinivcea, i na cfetiwo onf  toheff enorr e potoheu  stateof h atvhee
their state.  to foreign stuents in
Ir 
ta 
forcfu  be 
The  action ha  Pelvaa; it ha  st
fro  by  preluded foreign 
hdaevnets a  llotwhs i tr beuct l,oi nnlcya i fc lteher kpspas ti nf othreeid gsnta istrec.o  Ool thear  b(NeY , NapJ,p rCoAe,d  absyr  ttIhL e)
satra.ate c.Ac mIpnn tgl eo  t thsN,e wt Jheeyr cy ahla f odr etvhsee loep t he noof tt heex lcilciint csae tp otrf roin
be  to the state an for  stent 
fift ane aschi x  rtoe su ccsfuly colete 
by tJhee reyq vaent to the  S. meca scool. 
as wel as Caiforna an  of U. Also,
mNewe ca  ex  New York  trins.tuents to Pas a writt
tscaien ce  before they 
sot  bein clinca 
Te, 
differt 
approch, 
reation
concerning the supervision proided to stenintu ts  in 1984 a 
taking their clinca clerksbp o  ofm foaretiegn t shcto oslsru wnihsoin
in the state. It 
physician registeg woiteh rt he  so doin cefy to a 
spific cRorxteiotn s  their rolear  as insuisor. 
Reidenev 
Mclasilaisncyu checaaev  e,c  acoso tmaee  wctaeoyr  .or eef gaa srdsu girndi ntuhtcee rd i:emnv cenlao upedt c oaft iao nc easi na  mmei o f quity
Thus, an  oft srtaitne   ameldev el of
exive  have  thth eir
laws to  nore  reidency  for FK 
grdute  meca  for
scools.

of U. S. 
with Masarcheuqstt ' :iition  mi 
State ancacw edte  at leat thoft  a one yeaa mreitrd eoenfc lgy i r
redtc  uete. m ecina 1e9d8c5a,t iaolnl

an  rens
in  order to be eligible for 
yttore thiaen  F.M  prolemprto , atrtr lei.anin  t  twane natty -lteha st tfaitfet ee maFteK t tho h Bautv  e tinw or
of reidency  yea 
reir 
At leat fou state also  grdute  of such
yea  u. S.  to have tw 
of grdute  or more
Verification 
Inrs' 
bo  ta  disclos  pro. pro 
The U. s. Posta 
to  a clos  proon .ph ony credentials  restatt,e
look at their verification 
nealy all  thes  As a 
have made ch'
es  in 
ches 
Aretv tiehweiirn  core, the  inorlevfel ea cn ore thorogh an leny pros for
applicattiroanip npfolin cna tciaonlisn.  Ifto ri,s   btyh thsre, e detveslo pt of more detailed
amng other 
an emloyt exience;  a ful chonologica listin
of all  by  to preent origin
einduoclavtiinon afli bcr ecdeonntitealt sa annyds cise ioffi eddO tCrtlsations; by verification effort
, finer printin of applicats  '!, 

bac: ch 
crim 
an  jusce  ta
diipblion  acton rebyr td tihit bin Ipratea geanclli etsh;  bfyo ar mgr atceti ouns  of the
Stte  mny  th 
faum t ht ar  on a re bais by  Federtion; an
by a careful review of pphyseici a profile inormstioon  made avaabclea b,y  the
AM. As a  ap ch, so state also  all
applica  iniew.  or, in a few 
to  for a 
Reiden Tr:i Pets 
reide  t:  lice.
Ernetr t o a  is a gatey to meca 
recogititohn to fr ethiadt eat:  booubt o nphroagafm o f alr teh S,t tpe,e tfo r sloi ctUe.,  h'a!ve
a reidecy  or 
bo, if it  stf  bac: ch 
enles a  ha suficien  re 
on th an to trck  prog  reiden prtoo d.o 
 a 
ion :i a 
th 
Am th Stte tht have ne eslised  ar ma of th

such a  admtive 
more heavily populated on. '! is beuse ocf othc  t bac: bcuhen 
tr, 
btihnevt olwv etd,h  tthetU  srhao rp.th  tiicmiea f irsa mae caxvapitl aibnl ea  froeri den pro an trhe ibbelien
reide  an th opitciono of  meca scls am hoitas 
for 
th  ibnqeu ies  so
HoweveSr,t ttehe itore   n. '!D Jre awbae  onff otrh u dveuner iclrittiiaeclsa st  hhta vee lxed  at 
vaictcoau nptosi nf oorf  almosst.  one-htah  toaf  th PoMabpi ocipnu lirayni ct hace  tes ricen iNde we Ynork,e wxhech  
poition in th U. fou tfhotr ct h  by th goverrp troo  s 
exy 
tarhdem epihoonn y t oc rfediennti alD pirsaseum a  siina tthe  srtaetet wiao  n  lilteO amc    for
qiustseu.  '!t reide  an an 
tht  led to an  1984
by th Stte  ca  of Heth  set fort detaed verification
th  for heth  facilities. '!ey wet fhol lCaMr. b y works to hep
facilities  roe 
deop an  tequ  in 
intu 
cote/
In 1985, th Stte, via the Federtion,  a ne an DlJirec  e. '!
pfriarct icaed otrrietino FnL o,f  tthh  enxe  tehxt  wacal  FinM: J  1t1 1 p98a5 .p r'!ieo ro tvo erl ppeeo:r
ta  th sa  c: 
ptohn ete hree  ptee tew a abt ttha t e faasi eind ,t he preiou yea. Hpoweer,  75  , an 
ch)  of all PM  it faied,  witwhi t6h5  4pe3    in  i1n9 841984 (s'5e0
FLEX RESULTS

.June.. 
TOTAL  1.985 
E:June.. 1.984 
REPEA TERS 
FMGs

US FMGs

FNFMGs

PERCENT FA I LED BOTH COMPONENTS
Sou:rce: 
Fede:ration o  State Medical Boa:rds  sctaete ,h ave diifnfecrein,  policies inolvitna th,e  admsttion opf tahe  FL - con
for  ret w 
dsiumint atheeo plya,  foerw e hyoxwe wa mha,ea naf  i tttn  icaual   cb oeeon fie n sct aant et wuahhae vt ehie tr  wthieth outt phat saipcnpal.i  cbHaeotws evwehro,
wdo iln ot pass the  trin  of at  ts (usly ttahe )i,t
ta so addtiona 
have to  before bein allowed to 
again. 
Fsitn lyr, iet s heoxud  abse  pnotea tht   inliacddetio np tor othse .F BL,o a  few state adm
statea n ora  usfuof  the  these 
addtiona chec of  officials  in
thiirt  as a  an applicats' knowledge 
as well as 
capacity to  Enlish.
cocate  in 
OV 
IMACT 
lice
to trform  dir 
pInr omasny states, the FM prolem seed  the entir 
grdute  :mca scools as well as for PM. 
, for  of U. s. 
of state  on of the mJre poou state in the nation, obed: 
licein,  in no 
us  th 
"Licein her  stain -pros. If
you pase the ex, tyoo b ew er all nsoeret .  sc. 
the FL cheatin sc an  '! ched
 swin .19 82, with
th  then the fraudent crentials 
tisa  
Now, with all  reform we've made, ou stafnf   We have 
mparnoy sth ousands of applications on file  much longer to
even the roine ones. 
be  drtic. 
In most states , the transfonnation ha  less  In gener,
however, the greater scrutiny of applications fro FMs ha 
thorogh reiew of thos fro U.s. grdute as well. An, bleedu tso  sntoarfef
increases and  be  buen,
prosin  computerization have not kept pace with the added 
backog an sla-CM have  widesred. 
Somt  nocele 
less  the pros
proso  motu, ha be  , the reiproity moem,
whch had gained  is tht  in bo  be 
their ow  an rets, mlisace tsebtaa ctek . As thheya vhea ve tighitneecd rup
inly wa of automticaly grtin 
bo  diotor a  rpehyfsliecican  already havin 
one in anoptherr osta te. One  exective  the mi-
said:  set of 
mlaicnye ibnoa rd officials when he  "Why work  imroin you ow
ha  in
an disciplin you ow docrs  lice oter 
if you go 
by maril?e If  we did tht we'd be much more vuerle.  pro
desib 
Wpdaiigfthfei sc uatr ef ohrat Fov iMtnhge  t oaF  Mbsu pberlsoit lcaelnemitnc,i at hle eo v.ste arTtehle  ayci atIiroc ntas. d dTih etoy  athroe n m litkheea lih oito  mthorte
pthroosied iwnh o do obtain a  grte will be adeqtienlvy idtruinse da.r  An they
thpe rpoulsi c with  assuce tht  not slippin
thugh the  with frauduent credentials. 
VUILI 
REG 
Notwithta 
the abe developts, ther ar  vuerilities
two major 
tthraitn re mpairn.o O.n e concerns foreign meca scools; the 
other, residency "'! 
re 
re 
bo 
with  tos tthse  scools,  officials in not state  sowht
usunfeicaie. n'!te iyn onntiotnh at bthe yt hdoe  nsoct ohoavles t.t eh'!ee  y ar hopofr ues txiallib sftee e lt o obtain
ation' s inonntion gatherin effort, bu  tht it  the Feder
long-te pros.
 to feel  will be a slow
bo 
Bu even if cs:hleat eg arn  accte isnotnnatio n is obtained, not  fee

they are on 
proision tht foreIig.n  scoionls  dmiseatp proin scools.I A.  stsatet-laeve l statuto:t
wshctha ar  sutatially eqva
gsleentsntua ettora . t thAivos seon .oe  fb  o oisff iocifa sl ono hteel: p". IY.e t, the  ar not vera cro cqruttee
or  '!ey don  t give us mu to drw upn in estalish cuicua
for lice. 
bein  abt 
delibtions 
Also havin a  on stte 
tht  foreign scools as well as 
gener is the feacxt  i.  suficient politica suport for toghen
on PM  in  '!s  is esially  tht 
up frequently does not  states 
have
claerei nc ohncoestirttaison.  of practicir PM anor rey heavsoi  lyi n on FM reidents in
lice 
But, ther  all state a seitivity to effort
ttahhrt   iznere din  toon  pforreoign  grdutexests  an ain  suicion tht togher  laws
of the practicin physician nore
the heath an  th ecnomc  plliicnte .

safety of the 
ar 
bo 
'!us,  conce oPffMici.a ls, there isr ea tcioonnsisde, rle surt for so nationa

action  beruese   tht 
action cod lead to  '!ey have  the  tohfe sy tafteea  liceisnuc.h
But , at the sa ti Fedmer incauio nsf  ee tht theintoy   nee help. Along ths 
line, one
state board director commented:  shoud be a Feder level effort. 
state ar to clos to their constuencies to  adeqtely. 
do the job 
trin pro,
The other major vulnerability, involvin reidency 
reived less pulic attetion bu  ver 
tw.  tht conmcaye   indweelql tbee  sthec mo re psigrnfoica t of the
One prolem her, 
reidency ptaro i ldritrt s, ha aldy be  by the
anort,e . Whle Caiforna an 
Yroerk tha,v es o FM an peipnstia tives in tmhse ca gmrdau steta taer  have not. AsN ewa
vaiou rens  even U. s.  exle  bein admtte 
who for  shoud not be admtte. An  of ths sort wa
proide by a hosita offibciael  who upn  lteraiedn t ht a num
foreign nationan FoM   had  admtte sto o reiniqudency  poitions even
though they did  have a Visa allowin them to  sum trin
trin prpoaicipate   in 
Another prolem inolvin reidency 
conce  is tht they seldom pas
on to the board infonntion  the peonnce anor bevior
r(AeCsGidMeE)n rtse.a Wc hcailteon th  e Aevcutaatitoionsn o Cf roecidile nfotsr,  Gprardout e dMbieordc,sa   Eadcra tion
shin  not 
inclined or  to  those assessmts with the 
reident peonnce is Ultisfact:t.  even twhhetn
Worse yet, ther ar inications 
sfoimret  hyosepi, t als, when disstisfied with a reident's peonnce dutirni tnhe 
will ackowledge the c:letion of onpe yreoa .of  residency 
but then not allow him or her to  the  nealy all
the state for  meica scooclon ttigne rrdiunte ins   an abt miYet,   in
lic, eth. t  U. s.  c:lete  one-haf rteheq stiartte  for
one yea of  meets the  for '! 
- -
- - - -  - - -  - - 
pro, 
Eavcetnio nfo br ethtwos  tchael eptirno a  amnut i:m-yceaa  rbeidoen ccya   the lack of  inte
is illuste  cta rin.lv in  have seiou consence.
he wa practicin anb y a  a physician waho lefft aw  sthatec h he also  in liwcheceh 
an hadl aatttte d reidretteed  n  in  abnotero stSat,e h rty  in  estalish had a 
the  meca  ino:rly, hea tht his practice 
iin nesgate ons tcthe,e sth eo f seo batba  in his fonn state. rreh eb woa  bbeein
pro 
tithst o dwu inine sttwiga tion ant hup ns yeea   hist rreiidnenc y  rerd, ilneateed
protion  foro fc hthee s of  aofb hi.s  rre bot here, he wbae on  inorm.

had never 
PIC'

'! BIGG 
iIrt 
bo 
As  as state  ocianct ions  alleviatin the FM prolem, ther

ar oter developts  tht ar may in proe to be evena ncorce ctoen sential. 
conce 
Two of the most notale  tEheC a veaixla. bility of  reidency
poitirones a n the peormce 
on the 
fin 
with  actcot teh e fonn, FtMr ianr  proi.t  incirIinrltyt  
nenatri tno   reidenn u  diinffciacutot rt oi sg ain
pro agna pt hbee ntwu t he  s. :omf pcoai tsiocnoso lo ffger  Arnd  uitne.a Fccr te reidentchye
of U.  1979 to 1984, 
POSITIONS OFFERED IN ACCREDITED RESIDENCY 
PROGRAMS & U. S. MEDICAL SCHOOL GRADUATES 
984 
000  9?9 -

2 0 
 Posi tions  ed in
000  i d. 
Acc  ed. Res  og.
000 
S. Medical School 
000 
adua tes 
000 
000 
000 
ce:  984 
Sou 9?9  A98M0  e  ican Medic982a  l Ass98o3 ciation &

National Residency Match P

ha grduly be  ch). '!s
closin 
tehse igaatple ly  omou for PM, beup-s r faroso   m2,e8c58a  teo d2c,a1t3o3r s( wseid ely ackCMledge, 
FMs  to be seec  in thos  only when u.s. meica grdute ar
not available.

occe, 
In assessin this 
clec1:, state:t he Naatri ona Reidaecnccy aMtaitnc h Prog (NR), 
in  its 1984  ar  ''We  rapidly  as saiz eale pol of 
pithsy ssictaiatnis wtihcoa  repnootr t eilnicgaibtele t hfotr  folriecieg.n"  nAr,a  tionatin hFMt hse  (FNsp)u,li cation,
pol.  if they
remain in the U.S., will be  Wherea the 
pprorpoorti on of U. s. seniaobrst  suovcerp-recpresstee futl y matcedin  with accedte residency
ha reined at  fro 
FN  92  pet 
succsfulpy ematt c(esde  ch).h a declined fro 451 9t8o1  2t2o  1984, thae np rUoSpoFrMtsi onf roof 
68 to 44  . . . . . . . . .- ." .- . . . .,  .'  . . .- ". .- . " . -' -..  . '.-  . -.  -.  .-  .. . "'-.  -. .-. . -. . ...  .. -.   -..-.. .  .. " . .,- .  .  .-... ..-.  . ..-   . .-.  . -..   -.  ..- . .. -.. . .-..   ..  . ... . . . . .
PERCENTAGE OF NRMP APPLICANTS SUCCESSFULLV

MATCHED  U. S.  U. S.  FNFMGs 
SENI ORS  FMGs 
1.981. - 1.984 
1.00 
U. S.  Sen i o:rs 
U . S. FMGs 
FNFMGs 
1.982 
1.0 
1.981.  1.983 984 
Sou:rce:	 Na t i onal Res i dency Ma tchi  1. 
P:ro g:raM ( NRMP) 
re 
ser 
incred 
Also of note  in  tEheC prFiv catee ficatpe,i rs othe.   rigor assoPiaMte  weintht etihne  
granting of an  wphchr ioTs h t  of arlelf lec 
accredited residency training 
refin  rigor is 
exensive and  evexri fication  apn atig hte  by nothree
asdom binois tion of the  tht given in differt  of thseeity   world (int hough
refleofcfi cials fee  the rlaetet dp rets a continui daer). It is
also 
widely  meca
by wht is,  th  as a much nore difficut 
science exsame.  '!t ex Foreigrn Mee ca Grdute  ta the
MecFa NSc i	 en (FM), wa fir  July 1984. EIxttion  	mutta b e  in
all  s. Vis. Sttegiv en  in tht  it. 
a u. USPM also 
ECFMG TEST RESULTS

.July 
1.984
TOT A L 

1.985 
g)Janua:ry 
USFMGs . ... 
X . 
FNFMGs 
PERCENT FA I LED
Sou:rce :	 Educational COMMission Eo:r Fo:reign
Medical G:raduates 
ta 
thos  EC tet (FM) 
The failur rate of  the new  wa exemly high 
pin  eitts  firt tw admsttartiao nn s, paicuarlyJ faorn U SFM. Ovcehrl,) a. bt
tthhe  mafjirofartile-di ttyim ofin   ttahJueolysr  1984 cth:8e 5  tpetet ar in repete,s 1tw9r8hi5ok  t(lysyei c aly do Wwohrlse
, the failur rate is still  mnh, igh. In the
eraaltey  r1a97e0ds ,f rwhoe na FbMt  wepr et  to thpe Ue.S. . in greate  the failur
60 
to 69   
 . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-,-
,. ., - - -"" - - - . . . . . .. ., .. ..  . . . . . . . . . . . .
DISCIG 
Dors? st. ros
"Balm for Errat  critics Fault Agency" 
DisPtc
, April 13, 1980) 
"Dor  TiI, ar 
Heain"  Tribe
SUed 14  No state  Chicaqo  , May 
10, 1982)

'I" 
"Dors Prctice Whe Whs  Detrit Fr Prs
, April 1,
1984) 
bo 
illuste, 
As the abve newspape bheea dsliunj ec  state  rensscibinle for 
medica diipline have  to considerle pulic 
criticismt rin' bthet  1980s. Tyicay ttheoy  have be viehwa aisn b einc toa .l enent 
theeirx    of physician am  their  of 
in  slow  in stren 
:ict. 
'i!nee stigatory hpao ehard  oafn b  o (foIrt  inhtaa cceontrigb rtot ia  of supo poofe rt)h;e
exion  su disciplin  , the 
an imateyof  their  authorities (not noptarlye, tth e autorization
to 
physician poin a "clea an  daer" 
pulic); a widen of their accs to disciplin actions  9rt oo ttehre
place (thgh tmaat ory reportin laws); an a broden  ta  in
ca  disciplin  of the  upn
whch they  action. '!e latter developt, 
, ha  sfoell owsipn ian 
efaiclaiteiro nwsa voef  ouf nsucrh oactfiveitys siona coirn xctth,e  c19o70esrin suclhed m toa tntoer ea dse tailed abe,
sutace 
liencao mptece, an violations of contrlled  ex  1982, at
20 state have amed their laws to clarify arolaws. r  Since  the 
disciplin.

upn whch physician cai bne  f u 
bo  incr. 
D.in th sa peiod, th  avaable to  ha 
as not  ha be main,  goverts But,

ealier, the  bo'  as state  have 
stict contrls on the  bugets an pennel ceilin. 
DISCI 
INCIENCE OF  ACTONSn  u  ta 
yea 
OVer the past bfeew  incrtihne .  of disciplin actions  againt
in  taations 
physician ha  Nationa 
reea  made by the Federtion 
an  actions (exclud siIlep aedtm strtive 
953 in 1982inc r to 1,  in (se ch)a ctons) fro
381 in 1984, an  of 45 
STATE DISCIPLINARY ACTIONS

600

400

200  To tal 
OOO 
800  aneous 
Mi sce II 
600  Reuocations  oha

400 
tions 
& Suspensions

200 
9 82  983  984 
Sou  ce :  Fede  ation o  State Medical Boa  clos  abe ch, it is appt tht 
However, with a  look at the  tier-1
actions  seiou actions 
the noreb  e incrin  inolvin reoctions, protions
fro 
suions - have  only slightly  ce, 
1984.  the mi6s00 cllina  n1e982o to, 6 78or tier-2
cateo:rTh,e  bwulkh ocf thhe   incorpratincer   such haa cbe tions ains   reipnrimc r  an stipu
late  , it is liky tht 
agrts. Inee
ths cateo:r 
eavgen rgtrst e th  su suthe  es, beuins  e ma stipuate
ar  the Federtion' 
report
made on a confidential bais, with the ino:ction not 
to the Federtion. 
pro  oft
hSoamee dob servers have dismissed thes send-tier actions, whch are 
in  bein reatively 
oft  , as 
actity, tihno:ry   ar  qutet s4ig nficat, inolvin ai ncvonsoeqelntuialn. Yteta   suener 
or peps a retriction of preiption
a license for a period of 
privileges. Moreer, thes actions rerperoetu a  practica rense 
face with inficient inestigato:r  an  me:rb yof 
with tpher os  may
caes tht have liner duin the heain an judcial  for tw 
more yea, whle the physician inolved have contined to practice. 
re 
licein, it
In view of the FM prolem' s p  the  of 
pertinent to inquire if FM ar aencen   noin re likly to be disciplined
S. meddiciaslc sicphloionl  grdute. '!e ino:ction  available is inJcoancnlusive.
Of 1, 166  actions report by the Federtion betwee 
, ou taations 
Sept 1985 incate tht ony t6o38, s pified thpe emteca 
sotth s 
scool fro whch the physician grdute. Of  th16 7 or 26 pet
the physician wer FMs. Whe ths is  higher 
nu  ar PM (accrd  the 2t1 o 
u. S.  to the AM), the spred is  th an
physician who 
tlhike y  of "not availtahble s" to grt to conclude tht FMs ar an nore
to be disciplined  oter physician. 
TY 
OF VIOIAON 
preiptions  con 
Ttihoen  iunpppnr owrhicaht ed wiriittpianl  io.f  actionsb aro b.ia s,,  bay cftacre,t  itnhe  mfoor ta  bt onvei-ohlaaf 
of all such actions  by state  Thes  to be seiou matte
inolvin not ony exceive or urecsa preibin toef  drgs to 
bu alsko iu nawcf adi tribtion to addict.  patients
They also  to be amng the
eaier  of  for inesigators to 
develop,
state with 
triplicate presiption laws.  esially  in 
ty  ex, 
send  self-ab 
The  major  of drgs anor alcool: 
of violation is the 
mot state ths cateo:r is  ablute an
ptIt rhapop tph-t ofrotiouna te tin erm  preibinin  isbo tah cctin 
, and toether with over- for
discipli. 
or nore of all  actions.

ex  pro 
Thghout the nation,  .iired 
designed to help  physician have been

an reivin incrse attetion. Tyically, they are ru by meca 
bgsyo irteht ei sebess ooior  nio,tt essrlig fpn.er idvWa ahatlsege  o rtrhtgesz ea xtscitoti pnausp,pa rtaoilncthh eothusg ehv  tiaen ,C  tahoieffy op graneiacn ietphraelytyi  oiannroe,  laven
paegiodrct smo.n itorine txo t  tthyt  paiacicpta ttir pthmysitc ian ar adsheeri n to the
The  an  of  offered  to  pro, 
coidely,  so  stsin 
with  trtJt. oron,  intient ca 
focin 
an oter  such as  in 
on outptient 
pro 
Whe the  hasvoe t eed to be wel-reived an apptly beeficial,
unerlyi 
they have met with haabc r iticism an  skpticism. At 
thes inolve conce  the core
physician bein trte to sythsoet icaly for
bbeevi ort itghth ctae  be  to their patients. '!e  state ha
extion 
of nonitoprinr pora ctice  ret  in
anor a clos  bo.
nu  of the 
rensibilities tht thes  have to report violations to tpher  o
Th sutatial  thes 
their ow intiative, woift hpohuy sbioci ain nwohol vhaevme ts,i ghnead  up for  latte 
esiallym  rer  made the  oft issue an
res eitive atmh dti fficut one, since these physician  sign up
with the  their paicipation is confidential. 
ty 
lJlyin diiplin 
'!e  of violation  ca 
actions coer a 
wide
rsfealenogne y.a  oAbrm ,nf gra tuhde.  nMo.rceh  plresose pntr oaern   ar cinkaoli v inino ctlhvaein  c oinnvcicatitoen cfyor a 
m: 
whch ar anng the  difficut  of 
mi  to develop. 
ar  bo
'!e  th  incatece is placin 
of physician 
an incrinrlens y untein le poition as 
abt  the incidence of mapractice caes
pulic concne u  the iJlications of thes  D.in 
be incrin  the pat
decde the  of mapractce caes ha  ca  incr. rapidly an since
s19a79  tthben a,v tehrege c soet tolfe mptr ehUa Ij ufomr  sfroo  $5, 000 to abt $330 000. At the
high risk spial ties ha exceed 
so ar. 
$100 
000 in
 re 
soth 
mi  abt 
Bsiotaurdtsi ,o nit.  is intchre,a singly felt, ca an shoud do  th  ths
seW  hy,  the 
factrs  to be inlved:  to date? At leat  major
conce  (1) the colexty, len, an cot of
reer;  alleged incotece wher a matpera ctice judgmt ha be
, even 
(2) th sutaial tbhu en of prof tht  to cal for "clea an 
preporrer 
evidence rather  the " ; an 
cconvoincinn" siderable variations anng  of evidence" d(3)i trhe
ascucp tle  phySician themlvesb aobt  wht constitutes
ma facets of mecine.  execve 
hi  ar  One 
practce  in ths 
up  an 
frutrtions  in  by notin:
se 
jus ca't 
tn"Weeveee  rr  hleadg a  gdirs,c itpo ldion  action bwiath  monap mraacptircaec.t iInce f.a Ictt',  we'
s such
ca,  evetn eth ough we have a statute. So when ther is
a mapractce  we  to look for another bais for discipli
na action. 
co 
ta 
Yet,  thin  i nrtthieaet i ves thotf  acaodmdde sptsrisone   rtios bine  cmoapnrsaecqteinctei aclo. tPsa, icsuoa rlsyta ntoet aaler 
ar tw  its meca 
pin ractice act. Osnee ea llow for at chto W isfcnisnin  made  in  1985  in
ppneargltoiieglneentc  ce aoef  ttor tJt.a s 'bc!sousonc chlf u rcseieva et h.eve i Admennecocea thtl hbetro fo  paahy s imcpfiahnr yntoegs, lii gtecpnhciee ea npn iesse   gtou htoyld a
signficatcau,s  hepainr oides thein   with a lesser buren of  diesvceinp mloirne
proceedings, one tht cals for "a preponderce of  prof  in 
clea an  evidence" rather
convincin evidence.  no ar  bo 
Aal spoh yosfic isan tto, t ala was  icnl iCnaciafo CrnOa taenc yo reoxn  tifh tt haeurth iosr irzee onalet o COl
beieve  indeqte.  cause to
gettin tht hi or her skil level is  proTsh et Chati forna effort, just
rather intricate 
tw chce to Paisn oalnve os raa   nu  allow a physician
ex condct by a pael of tw physician. 
oron effort, uneJY for a  of yea, ca inolve ora or writTthee
, bu ha  latte beus it  fou 
emloyed the  lice  iIwian    fiD leg
bais for suently denin a  to offer a 
or  discipline. 
DISCIY 
SCCE 
OF  ACrONS 
nu 
bo pa  cons colain 
DJin th  few yea of 
bo ha be risin, o, ftthe   grtbeei n reived by
so stte  qeuste: tsluitsatti ally. The  visibility of 
cotrib  th  the  of toll-free colaint 
an  int b  developt.
 lines have
cons 
Thes  generte colaints 
gdoivye rt  entooerthcetr  with inormtion proided by other

agbenocie s (mainy law  te  acageetn cies) an inormtion obtained
by  inestigators  to  disciplin
accati ons eventually taken by ar ebota rd. Strikfolry m ost of the  firt
to a bo'  refers  few such actions 
s attetion as a  of  meca societies, pe
review orgzations (PR), heath ca intitutionbsy , or invidu 
ca  heath
professionas.

cotin  th  bo 
aInn  esially ound nirorsv iteu tsioon,  of inooffrimcitailosn o. ft pointe to cthoe PtR, 

pThoe afotlel owin 
tehne oerxsec buyt imvea  of his coolfl eaag uboe  s acinr  s at hhee acvailtyJ :  state, wod
PR. 
"We get ver litte fro th  !hheay .t a ca of their 
hou \mil 
plroolemt   nore iin normtion  they get out of  We shoud be gettin a
fro them. 
:irtt 
Aswtaat et ht mtuach   exineodrm,t ion is not bein Pased on to bo, ma
have intiate,r e  or tighteed reportin laws. At leat
tstaaste.  have  such action since 1982. Mos of btheos  laws foc on hospi
physiciaTnh' ey tiyniccarliyn  rn trhte hos soit asst aitneon on f an resoifg anntyi ocnhs ferso  of a
staff. Ans  staff privileges or  in  the
anor seemts, usly  ceitnhe  armepotr tin of mapractice judgmts
iin nvN.i,d $u30  p00r0
actini  tioCnA)e.r. 
latolvyer,  aa  few state have(e .rge.p,o $r1t0i,n0 00 lawin
s dGAie, $c25 , t0o00
ex 
oft 
Nevereles
aski  , reportil laws  have not had the  imct. 
inertw hy, on oft hea referce top tehe  "broemoo of silence"  When

reistace to  leg  to an
report on one'  anc rtoi ma f ea of  llliatbyility,
even, it se  state tht have grted  an civil 
in 
those who report  goo faith. 
inormtion  in  AISTTI PRS 
TH 
ar  incrin strin  hain 
Boards  facin  in  the dischiuplniI  workload
before them. It is not uncan for them to have backogs of  of caes
waitin to be ascsigane.d  whle inestigators ar weibghote  da; with caeloads of 
thos 
60-70 or nore  Not swrisin1y, 
identify the FM prolem as their btoo epnrioercit y conce woefrf iclciikaalyisn  two h og idvied  tnhott  
bdiilliipngl itno  the administrative  out their 
rensibilities.  they face  in
nu 
'r!iesyi nid enniufy  ao f conosf  factrs tht haveni ncoucnrt rinibltye , to thms asitteut ion. The
COlaints an,  the  reportin
of mapractice caes ar mutiplyin the  boo f caes to 
Sever bugeta constrints ar ,preludi  fro addb e inestigate.
ptherir coor p of inestigators an fro ma  COsuutfei ctieenotllyo tgo
and trainignge taha t could improve productinies'bvts ity overin   til. An, labriou
to quete tim contrib 
to the tiI an COlexty
hearin prose cordtion 
internal review and  , asp dro otihte y  of effort
with the Attorney Geer' s Office an the 
seriou ches, to maze  pros rights.  of physician, facin
their due 
rens 
'!us far the  tht  be  ths  teed
foc  eain  boha ve  bmoad e mto e. situtitohn  chahvee s 
on ways of  the buen on  AIng  of ths
dsoerlet gatre  tthho sc oalrloxw oinf  heaintso  todr win ovn itdhue  wmork eof  haena tion  hoifefi :cme,ca 
inr eou.
aror leg constats to hepb goud me thee 'u st ioIf  inestigatory 
Colorados,e a  che tht psprloitsi n.  Ap  betwee  an heain
paels  esially 
(See  II) 
INRMON SHG 
It app tht  ttahe. r 
each of the statce noaw p roides the Federtion (an  the
other  disciplin 
repreSttsa tes) wi th regular reports on  actions  Ths
signficat proess 
with the sitution tw to thee yea
ago. 
ext 
lice  report vaies fro 
However, the  of the actions  state to state.
boards do not report  denals.  ma 
tier-2 discipliI  More notaly,  do not report
actounsn ief rthteay  ditdh tn ot inolve a fonn heain aror
were imosed with the  thecy wao d 
rationale offer for holdi  thes  be confidential. The
back oan grts  is tht confidentiality
im 
or lack of pulicity wer a key to the  tht enled discipline to be
withou a fonn heain. Yet caes
tht  , the failur to report such 
inothretr tst ate ar preente fro obtain inormtion whch cod proe to
be 
to them if a disciplined physician decides to relocte to their
jurisdction.

te 
Fuenre, fro  ta
state to state an  with states
even 
discipli,n t here  to be

considerable inconsistency in the type of  actions ty
relation to the ches an  the mein  different 
so of the 
baecstotiaon lsi.s hTh ea  Fcedeort iosny shtae ,s ocevegno  hnt ctin oe p droiftefe  rt tcoynsistency   in ths area by
reportin their disciplin actions toof  tvhieo lFateidoensr,ti ofonr.  the
to us  in  But  ma state fai  or us it irarly, leavin it to 
to us it  the Federtion 
to apply what appear to be the mot appnrouria te coe. To foster grte
with 
consistecy  the state, Caiforna a  of yea ago develop
disciplin 
mraenauarll yo f disciplintaor yk egpui delines ancdh moidnel  developts.o rder an ha
reised it  pace with  (See
II) 
ba 
sees  prim 
Whe the Federtion' sd diastac iplin  as the  vehcle for the state 
tcoo kceaepti oabnre ast of  actions  other state, follow-
ta  in for obtain 
amng the sctaotne ctheer l ves proides the vehcle 
nore detaed intorhmtio n  the spifics of a cae. In 
oc  it awe,  sthhsi nco nte,
tohner. eI ti s substantia an, main  efffeicniv eb inoo rmtion  goin
thgh  the  ofb thoe   order on a ca an
nore inorm netwrki  inestigators an admstrtors.
Wher  ca gainp acec s to inngo bnon tion have oc tee:
to copnrolemc  e  in  still  agrfto rm  , they have 
gred  action or tier-2 caes, wher the
action wa 
in an  of confidentiality.

bo 
Finally, within the rsteate ,  meca soieties an

Mecaid state  formty dicisalcyi pilninor m  ar 
liky  agencies of all  actions. 'Iey incleess
coesto,  dao nso  hwiotiht as.  to toethe r entititeas,  such as HH, PR, 
Mot  an active  inorm
the bgeone,r  pulic aors sevueno nth et hmt ecnao tC tOo  ty of the acpta onsin.  However, a
few  pulicizin the inormtion ha 
on the  preventive
ar rearly 
value, see that disciplined physician 
identified in news
lette pulised by the bo, meca soiety, anor other paies. 
FI 
NOI 
DJin the 1970s the widesred adopion of th FL had contribte sign
ficabtlye to  the sbilliofic ation an rotinzation of :mca licein. 
doin, it enled  :mca  In so
to devote more attetion to  discipline, whch
wwaa  ocin,a  much more visiblbe aebn  oco.n trrereial  issue. Yet, as ths shft
the FM prolem 
the dominatidng iiss ouef tf orc omosnt s btoo i ntLeiifcye ainn  brye s1n98s2i-b1i9l8i3t iheasd  
an  gaine:
erenewned atctetioen,  .  eneries tht wod 
othezise be  to meca discipline.o 'Iupsr,t ttoy t he exent tht the FM
prolem ca be broght uner contrl, taher  
statial an  to develop more
the 
effecive effort in  of discipline woud see to
re 
bo 
happ 
Whteer  waithr  tht  to FM, however,  facte ha  festein prolem 
in  the disciplcinoen tcae   may proe to be even greiantec  otethcee F.M B proolem.
Tnhot tp, rolemb  e  thse ap henomon of physician 
, as
pulic heaxvet ions for retsinti ativhes avien bce rrin i stinhs  ar. But,t uhnq utehset ibonoaly', 

capacity to peo:r. Imee, the  apprmourciaht ifoansst ea nour anutehorrittiaes 
mtahdet  abvaoila bwle otdo  dbo o: soiint h1 ;ect yea have ofttied eb eoefn  1wriptrha tchteic e caes. 
to help ste the 
se 
Contribtin to the 
of urency is tht meical malpractice (or
cinac,o tbeuct ea)l shoa i tmsa jocro ti.l lTichast iiosn sm coot nocbeviionu  nwotit hon rlye thse  quity oefs mlaetiicna 
to the  ince 
malpractice  preum an awa an 
mize  ex  the defenive mecine 
practice to  ethxe l ikihoo of succsfu  often
ar the  mapractice suts. But
calosot elncoel  viesd  deficient. '!eir mig  enertoe bbye prh ysician whos clinca
a, mna   exbeitevue,. u necsaily
add billion of dollar to  heath 
bo  the nation' 
For  to play an :irt pa in addrsin thsg marjo r issue
clea tht hrthaeeri nm  ut be sutatiacl cah.e s  leg  , it is
in their  of mapractice  No ilnep stshr eec lte at ii1s ,t ht trhubeeso go ver
asvuafiilcaibelnet  to them mutto  dbeev oint csreeiodu.  aAttt ttihoen   to  cam ost  jeloack
such  without 
dizin their 
other diiplin am licein reibilities. 
REcnTIONS 
Rections 
Consen 
Ba  retions 
on intial rections to the drft report an  am fuer
dcioscnusssi on within the Dreepatriteonnt osf :H eath an Hu Serice
, there is
on the followin 
Pe 
Review Orzations (PR) reations an Medca caier intrc
tions shbouod b e amcead  to reire  exive an 
more  repOrtin to state
meica  of  lnol vin phySician miscndctt io1rl  ivn cotence. 
ret 
fos 
'!e  of ths wod  bette cocation 
be to 
soth 
position tao bidte nitt.i fy unrofessiona practice am thos with amangu thtosh ority toin do
HH shoud notifv hositals of' the ches noted abe concein PR
Mstaetdei cmaee ccaai ebr oa nc assheou odf  'u9rhev shicoiasn imtaissc otond bce tm oroe arct iiven  cotencine  . repOrtin to
cocation 
of ths ki woadr g.e nerte grte attetion to wht ths
study has shown is a problem  It wod  reinorc 
also help to  the
reportin laws tht have  ma of 
rbee Pasei  n  in  the state.
Federl leqislation  disciplin 
or its desi ee  states to repOrt  actions to
ician  licaene asll ow  bHeH  to exclude sfruo eMded ica an Medicaid
phvs  whose  have 
reoked or  by a state
(H. R. 1868. S. 1323) shoud be encted as auicky as 
pOssible. 
Passage of dthiissc ilepgliisnla tion wod facilitate more exenive am effecive
vsehhacrlien gf oorf  fosterin (1)i fnounenrt ioann  amng the starteep.o Irtt  woofu dd ipsrcoiipdeli na
more timly 
actions to a cetr cleainou, (2) more exenive nationwide distribtion
of inonntion cono stutceh  action, an (3) more consistet defintions of the
of violations 
by physician. 
Depat 
AdFiisntarntciioanl a ssistace by the U. s.  of Edcatsioan  an the Veter
for meical edcation 
shoud follow the  limtations set 
the vaiou  qrts proq
health professional edcation assistace 
fort  in  tht 
of the Pulic Health 
 eliqibilitv 
attenin u. S. an Casedricei.  an mein ical scools.  shoud be limted to students '! 
att  sees 
Such sactteionn  would  unccte  effec nCM  as a stilus for
uC. Sa. ib ar.t o  eliminate wht  in  foreign :mca scools, mainy in the
Inor 
Geer Rections 
Office of  Inr 
retions 
'!e Office of  Gdeireer  hmae tcwa a edddttiioonna   for Feder 
action. one concern  cots an the adeqcy of
education reived by FM. '!e oter cotnrci nin ec Inca 
edcation
cots an  suidizin the  retioof ninvsid uas 
the illications of  S.  ar  who will 
set fort 
Both 
not be practicin :mcine  in  the U. 
beCM:  fu  di 
co 
Medca  for the  mecal edcation  for FM 
lwted to qrdutes of scools accited  bosh oud be
by HH or by a private  desiq
nate by HH.  acclished 
'!s shoud be di  over a phase-in peiod. 
ab  rens tht wod lice. 
conlceegi slativei nacdtieotne ilsy a   seek greatly reievIet  state
mesm for glridtrcuitneeed   physicbiaen tt  :mca  wod 
proide a  of the  foreign  scools to
ente  s. pathy to  an, if 
thos tthee cU.h hositas tht ar heavily dephp  ent oin n gFMrdsu tol ym,a w onde callsCcM
adjusts. accts 
. In New Yorrke, wth ch  for one-th of all FM reidency
poitions in th U.S., a  report of the Goeror' s Cossion on Gradute
Meca  diions tht 
Edcation ures state policy  woud lead to a rection 
with 
retion.  '!eir effort wod 
in  reidency poitioansb e  the stte.  , therfore, be
consistet with the 
Actation 
acctin enitsi tipersa ctica if hHaH  is allCMed to (1) accpt the decisioncso of
tdriae st;h (2t )a urs s thuet isawehliclchye i  to f a prapiproved ate acarrocr  teina  ccte boa;c catniinn  ( 3ou)t .huses.r   s:mta
eqvaent to thos 
ca scools.s Meoreee r wod inolve reativeulseyd   liitn te goverta
t,h eit  acctation we  to be 
if schools  the assoiate
cots . 
re
cot 
DJin the  the draft report an retions
rection 
peiod on  be enct  '!t  , we made
another  whch ha since  into law. 
tion caled for rein cut 
Extion  rfeiuden ts who have not passed the Foreign
Medca Gradute  in the Medca Science (FM) 
order
for hositas to reive Meca  of their diec mto doe soc  a  in
edcation 
FM 
ha 
1984 , pasage of the 
cots.  since  rbee reqetd ion  in ordera tco cobtteaidn 
ECFMGt creritinfi cpatrioon,.  which is required to gain entry to an 
U. S.  '!e effec of ou  an 
the new law is 
to impose the same requiremt on cuent FM reidents an 
obtained apn rEoC.F
  ceificate prior to July 1984, but have not yeont   enst ewho
reidency 
'1!9s85 .p rHoCiFsAi oan cwtiae cosntain ed estimtine   tthhet  Cito nslidate Omus Renciliation Ayc
ea
will save $41 million over a five 
peiod 
1987.
(bein  in  ex 
HCF shoud consider  atrh e effec on inir meca edcation
cots of FM bein suidized 
who  ineligible to practice  the 
Medca uionr co letion of reiden.  meicine  in 
U. s. or paicipate  in 
se 
With lare Feder deficits, it wod  pruent for the Feder govert
as a gener rue to  :mca 
pay for the  ths coteJd cation cots of only those 
practice 
reidents who wiMll eca  :mcine  in  or who will be eligible to
pacipate in  upn caletion of their reidency.

retions 
abe  Goent, 
Beyond the  for the Feder  we offer the

lice 
following recoIlendations to state gove:rts an private orgzations
conceed with meca  an diipline.  sta 
re 
s'c!e A ctation Cocil for Grdute Medca Edcation (ACG) 
shoud be amened to  tht hositas (1) cobndouc t thoroCl credential
of reidents an (2) inorm State meca  of reident peor
an 
mace  condct. 
acctin 
SUch actopn bryo the  private orgzatitoenc rhen sible for  reidency
trainin  wod reinorc  hosita anm meec a scool re
asItp bwn soidb ilaitliseos s iene t hass  aanr  iaJnr twto dsi pgrnoi de an a:dmdecd a cotyof  oI vSe criognhct.e
licein  of the 
the  the  fuction. 
inteity of 
reir 
Residencv trin lice shoud be 
by all states 
suis 
ar  bo  ar 
Aclitahnousg, hp rreaicdteinc-i4n  :msctuenits ne. Aincrdly, all Ssettttei n, they  also physi
lice  shoud have the
autority to  an, if necsa, to diipline 
them  them. 
'!e Federtion of state Medica Bo-r shoud (1) sen its discipli1
to all  boa n 
Oactrizoan trioepnorst.   Medica caier. Medicaid aqencies.  Peer Review
(2) proide additiona qudace to state 
addrsin cases inolvin pOsible meical moanl phraowc titcoe  boer 
more effecive  in  prote 
incompetece. an (3) intenifY its effort ito: in  qreater inter-state 
defin  disciplin 
tcohnsieste nbcy abotih s of thesin  violationsv.i
olations an  in  actions on
licee

!he Federtion ha played an iJrt pa in helpin to imroe the :irtt
an disciplfinuee prra ctice of the state. Thwe aabtee th. ee area ar iJrtt
one where  Federtion leaderp is  Paicuarly 
conce 
her wod be an assaelni ni naCn Odistteri.b t'i!osn c oof db et practice  the
area of mapractice  include spific statuto:r 
ches tht cod  state :mca practice act. 
be made  in
cientlR ye ntoe ws uferestb  cehoxari.eo
d nto  aprna citlircoine mphytS iocfi athn es ehonudf ober cint crsed suffi
re  activities of
the state meical 
bo 
Mproost tae rt hien fpacucleir ca .  Until thshsto hsrtittfua ltli otnht i ss aederdleys slei 1atns  ththee iar ncap acrietey wto

mfeesi  .  to a level  far exce theb cou ent $50 averge, the 
possibilities for major overall  peormce will 
imroemt  in APIX

lice  BACKGR AN MEOOOLO

an 
The  discipline of physician is a 
govert. It  trditiona fuction 
such as Virinad' ast e: mbaccka t op rtahcet cpeio ancete oinf  effort of the Amica coofl osntiaetse,


Te 1639. But it did not gain pe

manence until the alnat e 1800s, when  CoP ase the firt moer meca

vpraaicdt iecxe earcits e( 1o8f7 3)  the U.Sp. cSeUrr em  upeld West Virina's act as a

state police  (1889). 
retion  th 
In  of  trditiona  , Congs
the Meca an Mecaid  eJ state role , when it esdtaelitseheed 
whether a physician is leprogly autinhor1i9z6e5d ,  tloe ft it to the stattehse stoe  pro.
SsaUncetqioennst olyn,  pChopynsirgcsioa hn. aa  n oter hHeHa tha nc aiptai csipapt e prreoec soin r (HE) atob eiIdse
defrauded thes  Feder goverwth oh aha ve 
depe don ithye s tate to seeH oawse vthere, d tihsec iplin  pro.tresscioontninsue dt htot
Meca an  agent for 
do not  relate to the  Mecaid 
Thus, state have be pprrooid.i  v'!au ale proion 
tw FederlY  fued  miiIp r oion hafo r bpaiceipat s  in  these
Feder govert an  govate rnot .c ot to the
the co have be coeatr  only  cot to state  Nealy all
gr  by fee  on physician. 
Taibhneo tute o neo-ff oMuerc a an Mecaid, ctoa th ee poxintt wuhe, r hthaey  fnoows atec ct for
di  th  of U. s. health  Feder
effeciveness of state meca 
bo. However 
in  the 1980s
three Generali nActceou.n ting Office  initn eified an
(GAO) report have both 
th 
Sept
Tw of the report,  Novem  an 
1in98c5,r rianis ne cuon ceon e apulbishetd  the quin itya otf tth e 1e9d8c0a tionth e botheeri n recinived 
se  of U. S. citsitzaent ew.h o  foreign meca scools anby t htehne
to talicek  e actionin  tthhet  Uwnoitde  help statBeo t:hm recpoar tl uicreedi tnh e Feder govert
agencies dea 
more
effecively with ths matte.

The othaerb GA O report, 
conce  published  thin  eiMr aliyc 1e9e84s,  helpe crstalize nationa
sltiactee a.n   physicmiano  who have  revoked or  one 
w'!hos  then  re  suedwhch thein y 
tht reptohrt c,o tnheitr rpriacbticte eto  antoother  tsthatee   intrction of Finebdeor l egislation
, amng other  wod (1)  state licein 
disciplin  to report
wlalihlco  wethioenidr   tbheon s;h aen t hatc tiinoonsn nttoi otnhe w HitHh  oStheecre etnat iti(eosr ,a i ndecsliugdneine  tahlle srtfa)te,
(2) albloew  HH to exclusdue ferdo  Medcae or Mbeoca.i d an
physician whos lice ha  reoke or  '!s
legislation Pase the Hou of  by a state 
bein  Repreentatives in July 1985 (H-1868) an is
Sente 
considered in the  (S-1323).  Inr 
I:inn tht  sa 
peiod, the  Geer 
in a  tbhOfotf ic e of thei ncrinly  (OIG) wa inolved
with whPch oosft a atIcet nmvitreicsesa    madwe eirt o  ptin.  awae of the liItations
the Us. sc. s  an the Feder Buu  out of the OIG's cwoorkn wciteh
the  inolvin (1) fraudent:mca  of Inestigation  Caib
meca  crentials fro two 
ussc ools an (2) theb adem strtion  Licein Ex
(FL)  state it  appt tohf tt he Federtion 
by tnheo    the crentials verifications
capailities of  state wer qute 
in imposin clos to 1,  liIte. Alsoc, aou t of the OIG's effort
appt tht cacatio0n0 0 exclusions on heath  proider, it
a poition to 
siona practice an those wbiettweeh t hotseh  e authoin rity to do sotwhit naessb 1 .pirtofes
indeqte. 
Giniveino thne s developts, the Ilr Geer' pro
oter intete  s Office condcted a 
to help HH an  paies gain a brodly baed
uppr-teos-dua te overevxieew ro,f  state medical licee an discipline 
bein  the issues bein addsed, the chese  x,o f the

and the effects being achieved.  ta  ta place
facilitate an anysis  diioSnUcsh  atnh to veriew, it is  will
Stte  of policy  shoud be  at Feder an
levels.

fin 
'!s  report plriectse   of the inion. It foces 
the major  sepa

atey ocn othne ce  an discipline rspeetri, oann  s  so 
mets  the tw  conclcudaels iwnit h  assess
sper an 
Feder an state goverts an  orgzations.  for action by
by private 
ba surtin 
'!e inonntion  the pretation emes fro 
lnqu: 
of  four maj or
Reiew of litetu an data ba, includ jou aricles
goverta 
boks  report, an statistica c:ilations 
of pulic
an private orgzations. 
fou 
VdPiAs,ii t'rsI ,st ov, r ,a nWI )s,t ainfsot; aldtveii ne( cCdAri,ss  c00s,i ocFnLes,  tIwrNi, t hM Am, eMJc,a N Jb, oNY,  mNC, eOR,
of  agencies repnrsoibgl;e for
medical boards; directors of 
hospital preesi dency 
representatives of medical societies,  reiew orgzations
(PR), 
state Medcaida abgen ciesp, aent M edca contrctors. '!e state
visite accunt for  58  of the physician liceed in
th u.

bo 
Telephone discsions with meca 
state  another
Colum(iaAL. ,' !AeZs,e  cjur,r isDdE,c tIioN,n sK ga, cMIc, tV A, WAd,ior s WpY) eatn  tin he District of
an  for 14  of the physici
lice  in  the U. 
Discsions with  ralei ce 
tht  repbreseen tatives of a wide  of orgzations an
agencies  have  addrsin meca  an 
discipline
issues. 'Ies include the Accedtation Cocil for Gradute Medca
Education; Association of American Medical 
Colleges; America
Hospital Association; American Medical Assciation; Edcationa  Cossion for Foreign Meca Grdute; Federtion of state Meca
Boards; General Accounting Office; Liaison Cottee on Meca 
Cleainou 
Education; National  for Lice, Enorct
Reation; Nationa CossionP forr .H eath Ceifyin Agencies;
the Nationa Reident Matcl  APIX II

BE PRCTCE

co 
pro 
Dlin the  inion, 
of the  inwtee idte ntified may Csta0tet pJr.a ctice
that wnouuld  appear to be of considerle ar.  acrss the 
Below 
ar a  of such  fou brod 
practice  in 
FACIG '! 
DISCIY PRS 
Californa ha adop a set of noel disciplin 
gudelines whch 
peties 
include minimum andw maixtihm utmh ere cbomom' ended  for each of 24 
statuto:r violations  authority. '!e set includes 
disciplin 
moel  order. 
bo 
Colorado and Vermont divide their  into sepate inqu an
heain  admste 
Paels. '!e form Paels  phe
the inestigato:r 
cIonmvpildaiunt  bprooc emssineg,  wsheee  the blaot te corrct the fonni nhveaidinu.
ca  on  Paels, but for an 
will see on ony one. 
Masachustts statute (MLf il  issuce of
duin  app  112-64) preclude theb o. 
stay  the 
of a  decision by the 
Illinois maintains a diar contrl syste uner whch trheee inde sti
protion is 
gator of a 
required to commpolainnti wthicoh rre sulc toedr ntienuin g compliian nce with the te, usly
at six nonth intes. Also, at thes ebo ' s disction, the intiator 
oifn at ceosl.a in report is  to  coprrore,s s report at six nonth
is 
If the report prolem  the colaint file is
pued. 
ADG TH DISCIY PRS rr DIFF SI'TIONS 
em 
bo  ce 
Florida  the  arne de sist order for uni
ceed  tao dimssuset rtive 
practitioner as an.  whcch,o i.f  violate,
fODn a bais for  s petition to the 
the state Attorney'
bo 
New Jersey, New York, an Florida  have disction to asses 
pe 
administrative fines or penalties 500 
Jersey. Tbheo m onettaa a.s sessmt is,  audpd ittoi o$n2a, to any ocoutnth  er lini  ceNeew 
action the  may 
pue 
a loc 
Pennsylvaniaa mra y 
new-
tice.  an  wher a dai sdiscplaiyp adlvienriseemtd   physician reiidn  es anor prac
pape in  Affirtive pulicity ca also be a negotiatin 
pros of reach an agree settemt.  point  in the
che lice  ar 
Texas and Florida  retnhew a fee whch  higher for
for reidents. '!e 
those with out-of-state addresse  Florida 
fee is cutly $1,000 for the 2-yeat rceis trtion. 
Jery  cote  fufill1t  suion 
New  excludes fro tim 
of a 
an tim 
another state. 
spt  in  practice  in IN 
PRS 
PRCTG TH  OF TH LICESING 
retly 
lice. 
Missoi an Wiscnsin ar amng th state whch have  reised 
dani eyx ed  fo:r
their arppleica tiona fno:err f or physician  The 
ask for uneqvoc  to calete licee an disciplin
ar 
histo:t. They  detailed edcation an work histories whch
ar reiew 
stteftosr .c
 onsistecy, an they include brod authorizations an 
waiver 
Florida reiqnu p,e na inteiew  met 
of applicats who  defined

criteia  grdute attpcaeic uar  th 
(e. g.,  of a  foreign scoo:lm, tchaos e with a 
hito:t of  or  at nore  one  thgschoo l).
inteiew ca dete  suace 
The  proisn:o rmtion whch fais to  the 
pape credentialin  Eplis  exle. 
proficiency, for 
mera 
thgh  Depat 
its  of Heath a 
New York issued  (84-90)
clarifyin heath facility rensibilities  crentials 
for physician 
facility ha rensibility
vtoer aifsiscuaeti tohn.t  As a state pinolciclyu, dth e heath  proly trined an
all tstha ff,  physician, are 
quified an have  approriate crentials. 
IMAI/rnCD 
ADDRSrnG ISSU OF  FHSICIS 
Caiforna diver fro the fonn discipl:i pros cein 
physi
cian 
gr. who paicipate  a State-nm reilitation pro
Paicipats genveolunrtailly  ya cgonrtitnine  to practice duin rperhoilit,a tion 
uner a signed  ab  with the diverion  whch 
pain ncrluroeedr  e sa arc cspetifn- rraeofmer d.n g  tets. Somp 4r0%o of  entrts to the
saon figu  The succs of the 
low  for dng  Caiforna (JiAs reMflec-ed\ an. 1983). 
trsef-abt  It prin o 
opte  thgh  :mca 
Oron  a monitore  the state 
ma 
assoiation. Unlik p  state, the Oregon approch to
alcoholism an chemca depseinetnrccy tp ets defer of fonn
discipl:i action duin a  prol ong-te trbnt an follow-
chnic  emis to in
up of the  illness. The  gives major 
tient trtmt an 
to follow-up nonitorin. 
refer 
Nort calcino a n other state have  somr ephtyrsiincia np wrhoos
cotecy  an 
into question to an edcation 
directed by 
Dr. Edward rKoewatlreisnki  at the University of Marylan.
Pinervsoindaul e valuations of  potetial areb diosc.s ed wipthr tohe
sujec an report to the referin 
The 
report an 85% succs  roin both quity of ca an safety. 
rate, 
pro
state opetin 
Wisconsimn ies ranao theru  nerta  an i1ired physician 
uner a  porfo   :r  with the state meca society. A 
thgh tw rehilitative 
portion of the 
Milwaukee has proved attractive to youer phbysoic ianfac ilitwies ho develop
asloco olil cane deru g prolem daur iin1 reiird ency. The  is finin tht
applicats  physician an is attemtin to 
assist these persons to enter the medical IDlltrea though the 
reilitation p