Department of Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
STATE  MEDICAL  .BOARDS  AND 
- ..7 
QUALITY-OF-CARE  CASES: 
PROMISING  APPROACHES 
. 
A 
FEBRUARY  1993  OFFICE OF INSPE~OR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect  the integrity of the Department  of Health and Human Semites (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is earned out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
AUDIT
OFFICE OF  SERVICES 
The OIGS Office of Audit Setices  (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carxyingout their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and  .-
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUA~ON  AND  INSPECITONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared  under the direction of Mark R. Yessian, Ph.D., the Regional 
Inspector General,  and Martha B. Kvaal, Deputy Regional Inspector General, Boston Region, 
Office of Evaluation and Inspections.  Participating in this project were the following people: 
Boston Region  Headquarters 
David Veroff, l?roject Leader  Alan Levine 
David Schrag, Lead Analyst 
For additionalmpies of this repo~  pkase contact the Boston Regional Office at 
(617) 565-1050.  Department of Health and Human Services 
OFFICE  OF

INSPECTOR  GENERAL 
STATE  MEDICAL  BOARDS  AND

QUALITY-OF-CARE  CASES:

PROMISING  APPROACHES

. 
FEBRUARY  1993  OEI-01-92-()()()50
 .  EXECUTIVE  SUMMARY 
PURPOSE 
The  purpose  of this inspection  is to help  States  address  cases  involving  physicians  who 
provide  poor-quality  medical  care.  It describes  promising  approaches  to such  cases 
that  have  been  taken  or being  considered  by medical  boards. 
BACKGROUND 
Quality-of-care  (QC)  cases  are  among  the  most  difficult  types  of cases  for State 
medical  boards  to  address.  In the  course  of our  ongoing  inquiry  into  the  work  of State 
medical  boards,  it has become  clear  to us that  many  are  beginning  to devote  greater 
attention  to QC  cases.  In this report,  we focus on that  experience  with the  intent  of 
identifying  specific  approaches  that  appear  to be worthy  of further  attention  by boards. 
. 
In determining  what  to characterize  as a promising  approach,  we depended  on (a)  the 
judgments  of the  State  officials with whom  we conversed;  (b)  a review  of their 
experiences  in dealing  with these  approaches;  (c) a focus group  discussion  with the 
executive  directors  of eight  medical  boards;  and,  drawing  on our  own years  of 
experience  in reviewing  medical  and  other  health  care  boards,  (d)  our judgment  of 
whether  an approach  is sufficiently  different  and  important  to warrant  the  attention  of 
those  in other  States. 
Our  research  consisted  of field visits to nine  States,  telephone  calls with  agency 
officials  in nine  States,  informal  discussions  with knowledgeable  parties,  and  a review 
of available  literature. 
We  organize  the  promising  approaches  according  to the  four  phases  of pursuing  QC 
cases:  identification,  investigation,  negotiation/prosecution,  and  intewention.  We also 
include  a section  on the  prevention  of quality  problems.  The  following briefly 
describes  all of the  promising  approaches  included  in the  report. 
IDENTIFICATION 
How  can State rndical  boards get comphte  and tihdy  &ckure  of qualityofxare 
pmb~  ~   @m  reliable sources such as peezs and government  agencks? 
@age 
  Enforce  practitioner  repo~ng  requirements 
  Increase  awareness of reporting requirements 
  Improve  repomngfiorn  Peer Review  O~anizations  (PROS)  and  Medicaid  agencies 
  Randomly  audit pharmacy  recorh 
  Get refemak  from  survey agencies 
  Require  repo~ngjiom  medical  schook  and restiency  programs. 
i  How can S&zte&al  bd  that receive a hge  number of complkti  d&i@uiYh 
szgnijic~  actionable  quality probknu  @m  tir  or nonmdoribus  issues? @age 6) 
.  Establish formal  prioritization  scoring
  Use contract physicians  or stajf nunes  to set priorities among  complaints
.  Recruit  local physicians  to seine on advkory  committees  by offering them  CME
credits 
*  Gather  a board panel  to screen complaints 
  Priontizeinvestigation  of malpractice  claims 
INVESTIGATION 
How can State mtdicd  boanh  gather su@ient  and credible evidexg  pawdy  to 
demonstmte  multiple pmbkms  or hcom~tence?  @age 8) 
  Conduct  practice  reviews in response to complaints 
  Review  a lage  number  of patient  recor&  . 
9  Use information  from  hospitah 
  Get patient  names from  Medicaid 
s  Have physicians  take competency  exams 
  Request  information  from  PROS 
  Measure  competence  directly 
How can State medkal  beam% ihvolve medkallj  trained people  in ikwstigations? 
@age 10) 
9  Have physicians  on staff
  Use committees  from  the medical  society to conduct  investigations
9  Use nunes  and physician  asstitants  as investigation
  Conduct  intensive  medical  training for  investigation
.  Pay consultants  the going rate
.  Make  an intensive  recmiting  effort to get medical  experts 
.  Involve  PROS in investigations 
How can State medibal  boamk  assure that the imwtigative  proazw  h timely?  (page 12) 
o  Require physicians  to respond to requests in a timely manner 
*  Establish  legidative  requirements for  turnaround  of investigations 
  Use paraprofessional  staff  to gather medical  recorh 
How can Stab  medical  boanis  assure that they are neither pnxecuting  casm that have no 
merit nor &missing  important  cases? @age 13) 
.  Have  cases screened by two medical  reviewem prior to deciding to pursue  cases 
~her 
ii    Gather review paneh  with medica~  lega~ and investigative  expernke to dhpose  of 
cases 
  tiepare  a handbook  to guide peer reviewem 
NEGOTIATION/PROSECUTION 
How can State medical  boanik get reguku access to prvsecutihg  attorneys and heaing 
o~em  who have the knowkdge  and skilk  necessary  10 hantik  quality-ofxare  caws? 
@age 14) 
.  Have  attorneys and hearing oficem  on stafl 
  Have  attorneys dedicated  to medical  board cases 
  Train beanng oficen  to hear medical  board cases 
HOWcan Stite  &al  boati  encourage and facilitate fair and ejfective  consent 
agre~?  (page 15) 
 
  Settle minor cases before fidl  investigation 
  Get board memben,  especially physicians,  involved  in settlement  negotiations 
.  Draw up consent  agreements  before meeting  with respondents 
  Require  mediated  settlement  conferences for certain cases 
  Establish  the facts  in advance  of negotiating a sanction 
  Write detailed  consent  agreements  and make  them public 
What can Sttzternezikal boanik do to emure that W  eqxnt  witnesses pmti  ck, 
crdibk  testimony  at heatigs?  @age 17) 
  Get testimony jiom  two physicians  with diflerent pempectives 
  Provide clear instructions for  expert reviewen 
  Emphasize  the potential  duty to testi~  when soliciting expert opinions 
  Recwit  highly respected experts by paying them  well 
How can State medkal  board pmsecutms  atubfih  prevaiiikg sttmddids  of care in 
addiiion  to pmvidbzg  expert witneiw testimony?  @age 18) 
.  Have  a practitioner  in the respondent% specialty on the hearing panel 
.  Refer  to written practice parameten  as they become  available 
How can State @al  boati  ensure timeliness ti  hearings and &ckions?  (page 19) 
.  Limit  the number  of board membem  required for  hearings 
  l?rovide hearing committee  membem  with advance  background  information 
  Impose  time  limits on hearings and judgments 
  Rabe  objections  to iwe!evant arguments  brought up by defense  attorneys 
  Conduct  pre-hearing conferences  and adhere to timeframes 
... 
m  INTERVENTION 
U?@  can  State mexiida[ boarzk h  to express their concern about  the quality of care 
pmvidd  other than p-g  formal  sanctiims?  @age 21) 
  Hold  an off-the-record  discussion  between  the physician  and  one or more  board 
membem,  physician  staff  membem,  or expert consultants 
  Write an  educational  letter to the physician  explaining the boardk  concern 
How can State medical  boamk adibzw  educational  interventiims and munitorihg 
P~  forphysichns  whom they have dk@ihed?  @age 22) 
.  Refer physicians  to individually-tailored  educational  programs 
s  Grant immunity  to probation  monitom 
  Use community  hospitals as retraining sites 
PREVENTION  .-
W%atcan Stati  medkal  boarak do to makz physkians  aware of boundmiis  of acceptabk 
care k  certati  arew  of wiikspread  or egregiouspmbkms?  (page 23) 
  PubliM  detailed  anonymous  descriptions of important  cases
  Conduct  educational  programs
  Use newsiettem  to licensees to dimss  important  iwues
How can St@te medical  boati  id2nt@  and adinm  quality-of<are  pmblenzs  when 
P@ are tioiktd  @m  the mdcal  community  or when they have undetected 
.
de@um&s  b  Wpt@omumce?  @age 24) 
.  Conduct  periodic  reexamination  of physicians 
  Audit  the practices  of tiolated  physicians 
CONCLUSION 
In closing, we must  note  that  there  are  two factors  that  in all States  are  indispensable 
to successful  pursuit  of QC cases.  One  is adequate  funding.  If boards  are  to handle 
Qccases

effectively,  it is widely recognized  that  they must  have  access  to  a wide  range 
of medical,  legal,  and  investigatory  expertise  and  to computer  and  other  resources. 
The  other  factor,  which may be  the  most  important  of all, is having  sufficient  will to 
make  a serious,  ongoing  commitment  to QC cases.  State  legislators,  executives,  and 
board  members  must  recognize  that  a more  activist  board  posture  in addressing  QC 
cases will generate  some  controversy  and  some  pressures  to pull back.  At such  times, 
they must  provide  boards  with  the  support  necessary  to persevere  in carrying  out  their
responsibilities  to the  public. 
iv  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVE  suMMARY 
INTRODU(XION  . . . . . . . . . ..  .  1 
0.0..  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
PROMISING  APPROACHES 
Identificati  o n. . . . . . . .  .  4 
                ..00..  .  ...0..    o*....    . . .  .  .  . . . . . 
Investigation  . . . . . . . . . .  .  8 
..  0..0.    *.....  .  ..*...    ...*..    0.....  .  .  .  . 
Negotiation/Prosecution  . .  14 
.  .  .  .  .  .  .  .0,  .  .  .  .  .  ..*.*.  .  .  .  .  .  .  .  .  ...0..  ..*.  . 
InteNention  . . . . . . . . . . .  21 
. .  . . . . .  . . . . . . . .  . .  . .  . . . . ...*.  . . . .  .  . . ..*O 
Prevention.  . . . . . . . . . . .  23-
.0  .0...  .0  .0...  .  .  .  ...*  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
CONCLUSION  . . . . . . . . . . .  25 
  0....0  .  .  .  .  .  .  .  .0  ..0..  .  .  .  .  .  .  .  .  .  ...*.  .  ..0 
APPENDICES 
Related  Reports  fkomthe  OfEice of Inspector General  . . . . . . . . . . . . . . . . A-1 
Medical  Boards Mentioned  in This Report..  . . . . . . . . . . . . . . . . . . . . . . .  B-1   INTRODUCTION 
PURPOSE 
The  purpose  of this inspection  is to help  States  address  cases  invoking  poor-quality 
medical  care.  It describes  promising  approaches  to such  cases  that  have  been  taken 
or are  being  considered  by medical  boards. 
BACKGROUND 
State  medical  boards  provide  a vital  front  line  of protection  for the  millions  of peopie 
who receive  medical  care  including  those  in the  Medicare  and  Medicaid  programs. 
They  determine  whether  or not  a physician  meets  the  minimum  necessary 
qualifications  to  practice  medicine.  And  through  their  enforcement  of State  medical 
practice  acts,  they  identi~  and  take  action  against  physicians  responsible  for  poor- .. 
quality  care,  unprofessional  behavior,  and  other  violations  of these  acts. 
Because  of the  boards  significance  to quality  medical  care,  we have  since  1986 issued 
many  reports  addressing  their  performance  (see  appendix  A).  In these  reports,  we 
have  made  it quite  clear  that  quality-of-care  (QC)  cases  are  among  the  most  difficuh 
types  of cases  for boards  to address.  They  tend  to be  complex,  time-consuming, 
expensive,  and  controversial.  Accordingly,  boards  are  often  inclined  to avoid  or 
downplay  such  cases.l 
Many  others  who  have  reviewed  the  performance  of boards  have  reached  similar 
conclusions.  Illustratively,  at a  1991 conference  sponsored  by the  Agency  for  Health 
Care  Policy and  Research  in the  Department  of Health  and  Human  Semites,  an 
expert  panel  found  boards  to be severely  lacking  in how they  address  QC  cases.2 
They  offered  several  suggestions,  but  made  it clear  that  much  remains  to be  learned  in 
this area. 
In the  course  of our  ongoing  inquiry  into  the  work  of State  medical  boards,  it has 
become  clear  to us that  many  are  beginning  to devote  greater  attention  to QC  cases. 
Their  efforts  are  sometimes  tentative  and  invariably  incremental;  no one  board  that 
we are  aware  of seines  as a comprehensive  model  for  how to address  QC  cases  from 
beginning  to end.  Yet  the  boards,  it seems  to us, are  gaining  some  valuable 
lMark  R  Yessian,  State  Medical  Boards  and  Quality  Assurance,  Federafron 
 
Bulletin,  September  1992, pp.  126-135. 
2EIeather  Palmer,  Professional  Review  Sanctions,  in Agency  for Health  Care 
Policy and  Research,  Issues in Medical  Liability: A  Working Conference  (Summa~ 
Report),  Washington:  Government  Printing  Office,  1991, pp. 51-56. 
1 
  experience  which  can  be of enormous  significance  in learning  how to approach  these 
cases more  efficiently  and  effectively. 
In this report,  we focus on that  experience  with the  intent  of identifying  specific 
approaches  that  appear  to be worthy  of further  attention  by State  boards.  We  cannot 
be sure  that  all of the  approaches  we describe  have  in fact  been  successful,  as 
objective  evaluation  criteria  and  hard  data  are  almost  always lacking.  Indeed,  some  of 
the  approaches  we describe  have  never  been  tested  in any States.  Furthermore,  we 
recognize  that  what  appears  to work  in one  State  w-illnot  necessarily  work  in another, 
given the  great  variations  among  the  States. 
Even  with  these  limitations,  however,  we expect  that  a compendium  of approaches 
that  we deem  promising  will be  helpful  to State  legislators,  executives,  board  officials, 
and  others  as they  consider  ways in which they  might  improve  a States  capacity  to 
address  QC  cases.  Our  aim is to stimulate  ideas  and  exploration,  not  to present  a 
blueprint  for  action. 
We list many  approaches,  each  in a succinct  manner.  State  officials  are  likely to find  -
them  to be  most  helpful  if they  consider  them  in the  context  of their  own States 
overall  system  for  addressing  QC  cases. 
To facilitate  such  consideration  we organize  the  promising  approaches  by five major 
sections  and  in each  include  statements  of pertinent  issues  and  questions.  The  first 
four  sections  are  sequential  phases  associated  with the  pursuit  of QC  cases: 
  Identification  -- learning  about  physicians  who  might  be  responsible  for  poor-
quality  medical  care  and  deciding  which complaints  merit  further  study. 
  Investigation  -- obtaining  the  pertinent  facts  and  deciding  whether  to pursue 
discipline  or other  actions. 
  Negotiation/Prosecution  -- using evidence  and  testimony,  in either  a formal  or 
informal  setting,  to establish  that  one  or more  violations  of State  law occurred. 
  Intervention  -- imposing  an appropriate  remedy  in response  to proven  or 
admitted  violations. 
The  final  section  focuses  on the  prevention  of quality  problems  and  includes  efforts  to 
educate  and  otherwise  avert  or minimize  QC  problems. 
METHODOLOGY 
In determining  what  to characterize  as a promising  approach,  we depended  on (a)  the 
judgments  of the  State  ofilcials  with whom  we conversed;  (b)  a review  of their 
experiences  in dealing  with these  approaches;  (c) a focus  group  discussion  with the 
executive  directors  of eight  medical  boards;  and,  drawing  on our  own years  of 
experience  in reviewing  medical  and  other  health  care  boards,  (d)  our judgment  of 
whether  an approach  is sufficiently  different  and  important  to warrant  the  attention  of 
2 
  those  in other  States.  These  are  certainly  qualitative  criteria.  Their  effectiveness  will 
depend  on the  reactions  of those  reading  this report. 
In selecting  the  States  from  which we identified  promising  approaches,  we drew  again 
on our  own experience,  on a review  of available  literature,  on information  obtained 
from many  national  conferences  concerning  health  care  quality  assurance,  and  on word 
of mouth.  We  did not  seek  to establish  that  these  States  were  the  best in handling 
QC cases.  We  sought  States  having  some  specific  procedures,  laws, or styles that 
might  be instructive  to a wider  audience  and  that  reflect  some  balance  in terms  of size 
and  geography.  Given  that  orientation,  we conducted  the  bulk  of our  research  during 
site visits to nine  States:  California,  Maryland,  Minnesota,  New York,  Ohio,  Rhode 
Island,  Texas,  Vermont,  and  Wisconsin.  We also talked  by telephone  to agency 
officials in the  following  nine  States:  Arizona,  Arkansas,  Florida,  Massachusetts, 
Michigan,  Nevada,  North  Carolina,  Oregon,  and  South  Carolina  (see  appendix  B for a 
list of the  boards  telephone  numbers  and  addresses). 
During  our  site visits, we typically  spoke  with executive,  investigative,  medical,  and 
legal staff involved  with QC  cases.  In some  States,  we spoke  with board  members  and  -
State  attorneys  as well.  We  also  examined  laws, documents,  and  individual  case 
records.  In each  State,  we sought  a thorough  understanding  of the  boards  procedures 
for handling  QC  cases. 
We conducted  this study in accordance  with the Intenm Standard  for  Impactions 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
3  IDENTIFICATION 
ISSUE  state  medical boards need  to receive good information about quality-of-
care problems.  The bulk of complaints to boards come  from consume~ 
but reports tiom  medical  professionals may be more likely to indicate 
violations  of medical  practice acts. 
QUES7TOJW How  can State medkal  boamk get compide  and timely disckure  of 
W@*f~~e  Pmb~  p artud@  @m  reliable soumm such m peem 
and government agencies? 
PROMISING  APPROACHES: 
> 
  ENFORCE  PRACTITIONER  / 
REPORTING  REQUIREMEN7X  \  E.NFORCRVAG SMTCHLAW  1 
Minnesota,  like many  other  States,  ~.7 
In January  198~  the Minnesota  Board  of 
has  a law that  requires  health  care 
Medical  fiaminers  dkciplined  three
practitioners  who have  personal 
physicians  for failing  to report  to the board 
knowledge  of violations  of the 
a colleague  who  was  habituated  to a dug 
medical  practice  act to report  these  or intwcanL  The discipline  included 
incidents  to the  board.  Unlike  most  reprimands  and fines  up to $7500. 
other  States,  Minnesota  has shown a  *L 
willingness  to enforce  this law (see 
box).  Since  1987, according  to the  board,  reporting  from  licensed  health  care 
professionals  has increased  significantly. 
	 INCREASE  AWARENESS  OF REPORTING  REQUIREMENTS:  Staff  from 
the  Ohio  medical  board  attend  county  medical  society  meetings,  conferences, 
and  courses  and  make  presentations  to try to facilitate  referrals.  These 
presentations  include  information  about  anonymity,  immunity,  and  the  amount 
of documentation  and  narrative  required  for reports.  Ohio  officials  are  hoping 
that  this new  program,  by improving  understanding  of the  law, will increase 
reporting  from  physicians. 
	 IMPROZE  REPORTING  FROM  PEER  REP7EW  ORGANIZATIONS  AND 
MEDICAID  AGENCIES:  In both  New York  and  Ohio,  when  the  Peer  Review 
Organization  (PRO)  determines  that  a physicians  mismanagement  has  caused 
significant  adverse  effects  to a patient,  the  PRO  refers  that  case  to the  medical 
board.3  In  1991, the  New York  PRO  referred  100 cases  to the  board.  Thirty-
30ur  draft  report  entitled  The Peer  Review  Organizations  and  State  Medical 
Boards:  A Vitai  Link  (OEI-01-92-00530)  recommends  that  all peer  review 
organizations  submit  this level  of information  to medical  boards.  Most  PROS 
currently  do not  because  they  are  concerned  about  confidentiality. 
4  four  of these  spurred  investigations.  In Ohio,  approximately  2 percent  of the 
1,654 complaints  received  in 1990 were  from  the  PRO.  In addition,  these 
States  Medicaid  agencies  release  to the  boards  information  on overprescribing, 
presumed  overutilization,  and  excessive  use of invasive  testing  and  procedures. 
. RANDOMLYA  UDiT PH4R.M4CY  RECORDS:  North  Carolina  conducts 
frequent  random  audits  of pharmacy  records.  Pharmacies  with computerized 
systems  are  able  to print  out  records,  by physician,  of prescriptions  filled. 
Although  designed  to detect  illegal drug  diversion  and  other  misuse  of 
controlled  substances,  these  audits  can also indicate  quality  problems  with 
physicians.  Because  the  audits  need  not  be spurred  by distinct  complaints,  they 
represent  a proactive  and  timely source  of referrals. 
  GET  REFEIUVILS  FROM  SUR~AGENCIES;  In New York,  the  medical 
board  is in the  same  division  of the  Department  of Health  as the  hospital  and 
nursing  home  suxvey agencies.  These  agencies  occasionally  become  aware  of 
quality-of-care  problems  for physicians.  Because  the  agencies  are  in the  same  ._ 
division,  the  board  receives  referrals  for these  problems  quickly and  can  follow 
up on them  easily.  In California,  a proposed  initiative  would  make  it easier  for 
the  States  long term  care  ombudsmen  throughout  the  State  to report  quality-
of-care  problems  to the  medical  board. 
  REQUIRE  REPORTING  FROM  MEDICAL  SCHOOLS  AND  RESIDENCY 
PROGRAMS:  The  Nevada  medical  board,  which  requires  medical  residents  to 
have  licenses,  mandates  that  medical  schools  and  residency  programs  report 
disciplina~  actions  taken  on students  and  residents.  In one  case,  the  board 
revoked  the  license  of a resident  who had  been  placed  on probation  by a 
program. 
5  ISSUE:  III order to respond quickly and effectively  to important compkdnts and 
to not  waste  resources  on groundless  or unimportant  - State 
medical  boards need  to make wise decisions  about which cases  to 
pursue. 
QUESZTOiW How can Stak  medkd  boanis that receive a large number of complabus 
dkhguidz  signijiaq  actiwzabk  qua@  pmbiimu  fium  mihor or 
nonmenbrbus  iwua? 
PROMISING  APPROACHES: 
  ESTMLISH  FORMAL 
PRIORITIZATION  SCORING;  PRIORX17Z+i170SNYS~ 
Wisconsin  is testing  a formal  priority 
WUconsin b drafi pnontization system 
evaluation  system  for complaints. 
assigns  points  as follows: 
Each  complaint  is screened  by a staff 
attorney.  The  attorney  decides  if the   7ke  conduct  could  result  in: 
board  has jurisdiction  over  the  case. 
Death  or permanent  impairment 
If it does  and  the  complaint  falls into  limiting  major  [ife activity  --30 
one  of a number  of specific  Tempora~  impairment  [imiting  major 
categories,  such as sexual  misconduct,  i~e activity  --20 
Tempora~  impairment  not  limiting 
discipline  by another  licensing 
major  life acnv@ --10 
authority,  or suspension  of hospital 
Minor  impabment  --5 

privileges,  the  complaint  will be  Complaint  involved: 
investigated.  If the  complaint  does  Death  of patient  --20 
not  fall into  one  of the  categories,  Permanent  impairment  [imiting  major 
the  complaint  is reviewed  by three  life activity  -- IO 
Temporaq  impairment  limiting  major 
board  members  and  the  Department 
Ire  activity  -- S 
of Regulation  and  Licensing 
dMsrepresentation  or j?aud: 
Secretary  to  determine  if it should  be 
If pattern  or over  $1,000--20 
investigated.  All complaints  that  will  If no pattern  and  less than  $1,000,  but 
be investigated  are  then  given  significant  -- IO 
Relatively  minor  --5 
priority  scores  (see  box).  Complaints 
. Violation  of a specific  prohibition  in the 
with high  scores  are  investigated 
medical  practice  act such  as divulging 
sooner  than  lower-scored  complaints. 
privileged  matters  --10  each 
 ore  than  3 previous  complaints  --10 
  USE  CONTRACT  P~SICL4NS  OR   One  to three previous  complaints  --5 
STflF  NURSES  TO SET  4Xore  than  one patient  affected  --10 
PRIORITIES  AMONG  A!coho[  or drug abuse,  physical  or mental 
impairment  --5 
COMPLANTS:  California  hires 
contract  physicians to screen  quality-
of-care  cases  after  staff  members 
gather  the  medical  records  associated  with the  complaint.  The  contract 
physicians  write  reports  on the  cases  and  recommend  whether  to dismiss  or 
investigate  the  cases.  In Ohio,  staff nurses  review  quality-of-care  complaints  to 
provide  safeguards  against  the  premature  closing  of cases.  New York  has  staff 
6  nurses  who  review  all incoming  complaints.  The  nurses,  with  advice  from  staff 
physicians  if necessary,  identi~  which complaints  involve  legitimate  quality 
concerns. 
RECRU,  LOCAL  PHYMCIANS  TO 
I 
SERK5  ON AD KLSORY  PRtNCRJWVZNGSAV7NGS 
COM..~EES  BY  OFFERING 
lZ?EM  CME  CREDIT&  In Florida,  F10n2ia h Medical  Advko~  Committee 
saves  monq  by ciosing  rnendess  cases 
the  board  and  the  Department  of 
before  thty  are reviewed  by expen 
Professional  Regulation  recruit  local 
consultants.  Z4e average  cost  of a MC  ~ 
physicians  to serve  on a medical 
review  is $49,  compared  with  $305  for  an  ~ 
advisoxy committee  (MAC).  The  erpert  review. 
committee  meets  over weekends  to 
evaluate  complaints  and  make 
recommendations  about  whether  to investigate  or drop  them.  The  physicians 
serving  on this committee  get continuing  medical  education  credits  in return  for 
their  efforts.  The  board  has found  this an effective  and  low cost way to get  ._ 
medical  input  prior  to investigating  a case  (see  box). 
GATHER  A  BOARD  PANEL  TO SCREEN  COMPLAINT  Magdand

convenes  weekly  a review  panel  composed  of medical  board  members  and  staff

to screen  pending  complaints.  By combining  medical,  legal,  and  investigative

expertise,  the  panel  makes  immediate  decisions  about  whether  to investigate

the  complaints. 
P~ORIT.IZE  INVESTIGATION  OF MALPRACTICE  CLAMS:  States  that 
receive  reports  of all malpractice  claims  generally  do not  launch  full 
investigations  of those  reports.  Rather  than  discarding  all such  reports,  the 
Texas  board  uses a scoring  system  much  like Wisconsins  (see  page  6).  Points 
are  awarded  to each  report  based  on the  number  of recent  claims  against  the 
physician  involved,  amounts  of payments,  physician  specialty,  and  practice 
setting  (urban  vs. rural).  The  point  total  determines  whether  a full investigation 
is launched  and  the  priority  given to any such  investigation. 
7  INVESTIGATION 
ISSUE:  When investigating QC cas~  boards often need  to gather evidence  that 
demonstrates  multiple acts of negligence  or incompetence.  Obstacles 
include  difficulty selecting  records  of patients  other  than  the 
complainan~  reluctance  by physicians  to  cooperate  in investigatio~  and 
the  limitations  of relying  solely on medical  records  to determine 
competence. 
QUESITON:  How  can State medical  boati  gather suj@iknt  and credibk  eWencg 
pmtudMy  to demomtmte  mdii@  prvbkms  or incom~tmce? 
PROMISING  APPROACHES: 
CONDUCT  REVTEWS  OF ENTIRE  PRACTICE  IN  RESPONSE  TO 
COMPLAINTS;  Investigations  of single complaints  in Maryland  may  lead  to  --
reviews  of physicians  entire  practices.  Peer  review  committees  visit respondent 
physicians  offices,  examine  samples  of medical  records,  review  procedures  and 
safeguards  in the  offices,  and  test  the  respondents  medical  knowledge  and 
judgment. 
REWEWA  LARGE  NUMBER  OF 
SVMW5A!AAUZiYOIUTY 
PATIENT  RECORDS:  Success  in 
quality-of-care  cases often  depends 
Kq  statuto~  language  in New  York  allows 
on broadening  the  scope  of 
the State  to conduct  record  reviews: 
investigation  beyond  the  original 
complaint.  New York  board  staff 
Aecnon  230. 10(iv)  of the Public  Health 
have  the  explicit  legislative  authority  Law  specifies:  The director,  in addition  to 
II 
to conduct  reviews  of physicians  the authority  set forth  in this section,  shall 
records  (see  box).  Boards  in Oregon  be authorized  to conduct  a comprehensive 
review  of patient  records  of the licensee 
and  Minnesota  can issue subpoenas 
and  such  ofice  records  of the licensee  as 
for patient  records  without  naming 
are related  to said  determinanon.  
the  patients  in advance.  Investigators 
can request  that  physicians  turn  over 
any number  of cases  that  meet 
certain  criteria. 
USE INFORMATION  FROM  HOSPIZALS:  The  New  York  board  identifies 
patients  for record .reviews  by using the  Statewide  hospital  discharge  database 
(SPARCS).  This  database  contains  clinical  and  financial  information  for each 
hospital  stay in the  State  and  identifies  the  hospital,  patient,  and  physician 
involved.  From  this database,  the  investigative  staff can get  preliminary 
information  about  all of the  respondent  physicians  cases  that  are  similar  (in 
terms  of diagnosis  or procedure)  to the  complaint.  The  State  can  then  gather 
and  examine  specific  patient  records  from  a sample  of these  discharges.  Also, 
8  the  State  mandates  reporting  of all incidents  in hospitals  which  result  in 
unexpected  death  or injuV.  Because  many incidents  do not  involve 
substandard  care,  these  reports  are  not  often  used  to start  investigations. 
However,  they  frequently  provide  evidence  that  supports  the  complaint. 
  GET F!ATXWT NAMES FROM  MEDICAID:  In California,  investigators 
cannot  subpoena  records  without  having patient  names.  They  can,  however, 
use Medicaid  patient  records  to generate  a sample  of cases  that  might 
demonstrate  a pattern  of poor  quality  care.  The  State  has  legal  access  to 
medical  records  of Medicaid  patients  without  getting  their  consent  through 
incorporation  in the  State  Medicaid  agencys quality  assurance  plan. 
  DISCIPLINE  LICENSEES  IF 
THEY  DO  NOT  COMPLY  W~H  COMZL4NCE FW7TBlO- ORDERS 
BOARD  ORDERS:  In Oregon, 
Oregon  statute  requires  licensees  to compiy  with 
the  board  has  disciplined 
board  orders  and  requests: 
licensees  for  not  complying  with 
board  orders  to take  competency 
Jection  677.190  of the Oregon  Regulatory 
exams,  to be  interviewed,  or to  Statute  specifies:  The Board  of Medical 
submit  medical  records  (see  box).  Eraminers  for  the State  of Oregon  may  rejitse 
By virtue  of the  fact it enforced  to gran~ or may  suspend  or revoke  a license  to 
practice  inued  under  thti  chapter  for  any of the 
the  rule,  it is getting  much  more 
following  reasons:  . . . (18)  ?Wlfidly  violating 
frequent  and  rapid  compliance 
any provision  of this chapter  or any ru!e 
with requests  and  orders.  II	
adopted  by the board  board  orde~  or failing  to 
comply  with  a board  request  pursuant  to  ORS   
  REQUEST  INFORMATION  677.320.  . . . (23)  Refising  an invitation  for  an 
FROM  PROS:  In South  Carolina,  infonna[  inteview  with  the board  requested 
under  ORS  677.415 . ... 
board  staff  regularly  request 
information  on physicians  the 
board  is investigating  for QC 
problems.  The  PRO,  after  a 30-day waiting  period,  must  respond  to the 
boards  request  and  provide  whatever  material  they  have  on that  physician. 
  M4P2? PHY31CL4NS  T- COMPETENCY  EX4.MS:  California  regularly  asks 
or demands  physicians  to take  competency  exams,  particularly  when  the  board 
feels  a physicians  competence  is lacking but  does  not  have  enough  evidence  to 
support  such  an accusation.  The  exams  and  scoring  criteria  are  written  by a 
panel  of physicians  who are  familiar  with the  complaints  and  investigation  on 
the  respondent  physician.  This  panel  then  conducts  the  exam  orally  and grades 
it.  If the  physician, passes  the  exam,  the  board  must  drop  the  case.  If the 
physician  fails the  exam,  the  board  has a valuable  piece  of evidence  in its case 
or can  take  immediate  action  to reeducate  the  physician.  Oregon  also 
frequently  requires  competency  exams. 
9
 ISSUE  States  need  access to medical expertise  in the investigation  process  in 
order to conduct complete  and informed inquiries on quality-of-care 
cases. 
QUESZ70N:  How  can Stite  mdkd  bd  involve medically  tmined peopk  in 
ihveslzgations? 
PROMISING  APPROACHES: 
.  WIYE  PHXSICMNS  ON STAFF  Both  California  and  New York  use  medical 
consultants  in their  investigative  offices.  They  are  full-time,  permanent 
employees  of the  State.  These  medical  consultants  often  conduct  intemiews 
with the  respondent  and  other  physicians,  assist  in directing  the  course  of the 
investigations,  and  help  recruit  medical  experts  to conduct  intensive  reviews  of 
cases. 
  USE COMM.EES  FROM  THE MEDICAL  SOCIETY  TO CONDUCT  - 
INVESTIGATIONS:  Maryland  is required  to  refer  all quality-of-care  cases  to 
the  medical  society  (MedChi)  for investigation.  The  board  staff  collects  basic 
medical  records,  then  sends  the  complaint  and  the  records  to MedChi. 
MedChi,  in turn,  refers  complaints  to peer  review  committees  organized  by 
county  or  specialty  societies  throughout  the  State.  The  committees  recruit 
volunteers  to review  either  single cases  or entire  practices  (see  p. 8).  When  a 
review  is complete,  MedChi  must  deliver  to the  board  a comprehensive  report 
evaluating  the  case and  must  make  recommendations  as to what  action  (if any) 
the  board  should  take.  Although  the  Maryland  experience  suggests  that  a State 
medical  society  can be  a promising  source  of medical  expertise,  a recent  review 
of that  experience  raised  significant  resemations  about  the  boards  statutory 
obligation  to refer  all QC  cases  to MedChi.4 
  USE NURSES  AND  PHYSICL4NASSISTANTS  AS  INSTIGATORS:  The 
Texas  board  has special  classifications  for its investigative  staff which  allow it to 
recruit  nurses  and  physician  assistants  as investigators.  These  investigators  are 
able  to dig deep  into  medical  matters. 
  CONDUCT  INTENSIY13  MEDICAL  TUINING  FOR  INVESTIGATORS: 
California  has  its own two week  training  academy  for investigators  which  it 
4See Sunset  Review:  State  Board  of Physician  Quality  Assurance:  An Evaluation 
Report  Prepared  Pursuant  to the  Maryland  Program  Evaluation  Act, Department  of 
Fiscal  Sexvices, State  of Maryland,  October  1991.  According  to this report,  the 
delegation  of investigative  authority  has limited  the  boards  flexibility and  control  over 
cases.  Furthermore,  the  report  notes  that  required  medical  society  control  has  raised 
public  concerns  that  investigations  are  overly protective  or biased  to the  point  where 
the  boards  credibility  has been  affected. 
10  conducts  twice  a year.  The  State  brings  in its own medical  consultants  and 
instructors  from  the  Attorney  Generals  office  to conduct  training  on  the 
handling  of medical  cases. 
  J4XKE  AN  INZENSIJL!? RECRUITING  EFFORT  TO GET  MEDICAL 
EXPERTS:  In Massachusetts  in the  late  1980s, the  board  actively  recruited 
medical  experts  by sending  information  to and  meeting  with  leaders  of medical 
schools,  the  medical  society,  medical  specialty  associations,  and  hospitals. 
Because  of this effort,  the  board  has been  able  to maintain  a list of medical 
experts  (50 -75) in a wide variety  of specialties.  South  Carolina  recently  mailed 
every  licensee  a newsletter  that  included  questions  and  answers  about  seining  as 
a medical  expert  and  a reply  coupon.  Seven  percent  of all licensees  responded. 
.  INVOLVE  PROS IN  INSTIGATIONS:  When  the  Arkansas  medical  board 
needs  a peer  review  in a quality-of-care  case,  it obtains  the  medicai  records  and 
refers  the  case  to the  States  PRO.  The  PRO,  in turn,  engages  two or three  .= 
physicians  in the  respondents  specialty  to review  the  case  and  prepare  a 
summary  for  the  board.  The  board  pays the  reviewers  approximately  $60 per 
hour  for  their  services  (reviews  for Medicaid  or Medicare  patient  records  are 
fkee to  the  board).  Key to the  success  of this program  is the  boards  good 
working  relationship  with  the  PRO. 
11  ISSUE  State  medical board investigations must be timely to protect  both the 
safety of the public and the rights of the respondent. 
QUESZ701W How  can State medkai  boati  assure that the investigative pmctxs  is 
timely? 
PROMISING  APPROACHES: 
  REQUIRE  P~SICMNS  TO 
RESPOND  TO REQUESTS  IN A  RESPONSETO REQUES~ 
TIMELY  lkL4NNER:  One  of the 
The Ationa  board h poiiqv  requires  physicians 
stumbling  b~ocks in executing 
to respond  to a notification  of compiaint  within 
timely  investigations  is the  length 
20 days.  Physicians  responses  must  inciude 
of time  it takes  physicians  to 
copies  of patient  records  and  a wntten response 
respond  to  requests  for patient  to the compiaint.  If the physician  does  not 
records.  Arizonas  statute  allows  respond  within  20 days,  the staff  notifies  the 
the  board  to discipline  physicians  board  (who  can  initiate  dticiplina~  action)  and  , 
.7 
subpoenas  the information  j?om  the physicia~ 
who  fail to or refuse  to furnish 
The physician  has  10 days  to respond  to the 
information  in a timely  manner 
subpoena  before fimther  [ega! action  k  taken 
(see  box). 
  EST~LISH  LEGISblT~ 
REQUIREMENTS  FOR  TURNAROUND  OF lVIZSTIGATIONS:  The 
Maryland  board,  which refers  all quality-of-care  cases  to the  medical  society  for 
investigation,  requires  a complete  investigation  within  90 days.  The  medical 
society  may  request  a 30-day extension  in writing.  The  State  legislature  in 
Michigan  has  proposed  a new requirement  that  the  Department  of Licensing 
and  Regulation  complete  its investigations  within  45 days (with the  possibility  of 
a 30-day  extension  upon  request  to the  board). 
  USE PARAPROFESSIONAL  STAFF  TO GATHER  MEDICAL  RECORDS:  In 
California,  consumer  semice  representatives,  who are  not  trained  as 
investigators,  gather  basic  medical  records  early  in the  investigation  process. 
Investigators  then  do not  have  to spend  large  amounts  of time  tracking  down 
medical  records  and  have  more  time  to do intensive  investigation  work. 
12  ISSUE:  State  medical boards decisions about whether  to dismiss or pursue cases 
further  after investigation are crucial to their credibility and success  in 
prosecuting  cases. 
QUESZ70JV: How  can State medical  boati  assure that they are neither prosecuting 
cases that have no med  nor dimiwikg  impo@mt  cases? 
PROMISING  APPROACHES: 
13XVE  CASES  SCREENED  BY  ~0  MEDICAL  REVIEWERS  PRIOR  TO 
DECIDING  TO PURSUE  CASES  FURTHER:  h  California,  the  district  offices 
recruit  two  physicians  -- an academic  physician  who is an  expert  in the 
respondents  specialty  and  a local  physician with  a practice  similar  to the 
respondents  -- to review  each  case  and  make  recommendations  on its 
disposition.  By getting  two perspectives  that  are  often  vexy different,  the  offices 
can  double-check  facts  and  confirm  or question  conclusions. 
. 
GATHER  REWEW  PANELS  WpH  MEDICAL,  LEGAL,  AND 
INSTIGATIVE  EXPERTISE  TO DISPOSE  OF CASES:  Maryland  convenes 
weekly  review  panels  consisting  of board  members,  investigative  staff,  and 
lawyers  from  the  Attorney  Generals  office to review  investigative  reports  from 
the  medical  society  and  decide  how and whether  to pursue  the  case.  Oregon 
has a similar  committee  which  meets  monthly.  These  multidisciplinary  panels 
allow the  boards  to make  decisions  based  on medical  and  legal  merits  of cases 
and  allow  investigators  to provide  valuable  input  and  explanation.  They  also 
assure  that  medical  records  that  will be used  as evidence  are  in order  and  are 
legible. 
P~PARE  A  HANDBOOK  TO  r
S/lh4PLEPRACZ7CEIUZKWWRHVRT 
GUIDE  PEER  REV7EWERS: 
By providing  explicit  instructions 
Maryla@  in its peer  review  handbook  includes 
to peer  reviewers,  Maryland  and 
a sample  practice  review  report.  77i3  sampleis 
New York  assure  that  there  is 
an example  of what  the State  expects  its peer 
greater  consistency  in reviews  and 
reviewers  to complete  and  includes  sections  on 
that  all important  information  is  information  gathered  reasons  for  referra~ 
covered.  Topics  covered  in New  biographical  information,  background 
Yorks  peer  review  handbook  information,  qua~eriy  review  notes,  discussion 
and  conclusions,  recommendations,  and  case  by 
include  immunity,  confidentiality, 
case descnptions.
investigations  and  hearings,  stages 
of expert  review,  the  opinion,  and 
reimbursement.  Marylands 
covers  similar  topics  and  includes  guidelines  for  practice  review  and  sample 
worksheets,  letters,  reports,  and  subpoenas  (see  box). 
13  NEGOTIATION/PROSECUTION 
ISSUE  To  represent  cases effectively  against respondents  attorneys who are 
often very experienced  malpractice litigators, States need  prosecutors 
who are familiar with medical practice and terminology  to handle QC 
cases. They also need  hearing officers who a  follow the arguments of 
both sides and make fair rulings. 
QUESZ70M  How  can State medical  boamk get rqydhr  access to prosecuting  attorneys 
and  hearing o~em  who have the knowkdge and skilk  necessa~  to handle 
W@-ofxwe  cases? 
PROMISING  APPROACHES: 
hMKE  A~ORNEYS  AND  HEARING  OFFICERS  ON STAFF  Texas  has 
prosecuting  attorneys  on staff to the  board.  These  lawyers  are  available  full -= 
time  and  acquire  substantial  expertise  in medical  competency  cases.  It is also 
important  for boards  to have  hearing  officers  who  are  knowledgeable  about  and 
experienced  in the  law of medical  discipline  and  readily  available.  In Ohio, 
hearing  officers  are  hired  by the  board.  In Wisconsin,  they  are  employed  by 
the  Department  of Regulation  and  Licensing,  which  includes  the  medical  board. 
EiXKE A~ORNEYS  DEDICATED  TO MEDICAL  BOARD  CASES:  If the 
board  cannot  hire  attorneys  on its own, it can  still obtain  full-time  prosecutors. 
The  New  York  board  is located  administratively  within  a large  Department,  and 
teams  of lawyers  are  assigned  only medical  board  cases.  In Maryland  and 
California,  where  the  medical  boards  must  rely on their  Attorneys  General  to 
prosecute  cases,  there  are  Assistant  Attorneys  General  devoted  full-time  to 
medical  board  affairs. 
TWN  HURING  OFFICERS  TO H~R  MEDICAL  BOARD  CASES: 
Attorneys  in Maryland  stressed  the  importance  of holding  hearings  on QC  cases 
before  administrative  law judges  (AIJs)  who are  comfortable  with medical 
issues.  A senior  ALJ  there  brought  to the job  her  experience  hearing  medical 
cases  for  CHAMPUS,  the  militarys health  insurance  plan.  She believes  that 
ALJs  without  extensive  medical  backgrounds  can  handle  quality-of-care  cases 
well, but  only with proper  training  on terminology  and  the  reliability  of medical 
texts.  She  has  compiled  a manual  for ALJs  new to medical  board  cases  that 
covers  these  and  other  topics. 
14  ISSUE  Quality-fare  cases are timeumsuming  and costly to litigate.  Medical 
boards can conseme  resources if they reach desirable  outcomes  through 
consent  agreements  instead.  Boards must no~ however,  allow public 
safety to be compromised  by weak settlements. 
QUES7TON: How  can State mdkd  boati  encourage and facihte  fau  and flective 
conwnt  agreemenG? 
PROMISING APPROACHES: 
SEITLE  MINOR  CASES  BEFORE  FULL  INSTIGATION  In Wisconsin, 
committees  of two board  members  (the  board  member  who  has been  involved 
in advising  the  investigators  and  a specialist  in the  respondents  field)  try to 
settle  some  cases before  launching  a full investigation.  The  meetings  involve 
the  committee  and  the  respondent  (whose  legal  counsel  does  not  usually 
attend).  The  board  pursues  early  settlement  only when  both  sides  agree  on the 
facts  of the  case  and  the  infraction  is relatively  minor.  The  board  settles  wo  or.-
three  cases  a month  this way.  Commonly,  the  settlement  results  in reprimands 
or requirements  for continuing  medical  education.  This  process  is faster  and 
less expensive  than  formal  settlements  or hearings. 
GET  BOARD  MEMBERS,  ESPECL4LLY  PHYSICHNS,  INVOLVED  IN 
SETTLEMENT  NEGOTMTIONS:  Medical  board  staff  in Maryland,  Texas, 
and  Minnesota  emphasized  the  importance  of having  physician  members  attend 
settlement  conferences.  They  say that  respondents  seem  less threatened  and 
more  willing to cooperate  in negotiations  when  other  physicians  are  present.  In 
these  States,  the vast  majority  of formal  charges  are  resolved  without  a hearing. 
DRAW  UP CONSENT  AGREEMENTS  BEFORE  MEETING  WITH 
RESPONDENTS:  Rhode  Island  medical  board  staff  prepare  a draft  consent 
order  and  send  it to the  respondent  in advance  of the  conference.  If not 
agreed  to by the  respondent,  this document  at  least  seines  as a starting  point 
for negotiations. 
REQUIRE  MEDL4TED  SE~LEMENT  CONFERENCES  FOR  CERTAIN 
CASES:  In California,  every  time  a hearing  is slated  to last  at least  five days, 
the  parties  have  to meet  for  a settlement  conference.  An ALJ  listens  to both 
sides arguments,  presents  proposed  solutions,  and  mediates  to try to get  a 
settlement  on the  case.  Even  when  this conference  does  not  result  in a 
settlement,  the  Attorney  Generals  Office believes  it often  starts  both  sides 
thinking  about  settlements  and  induces  them  to settle  at a later  point  prior  to 
the  hearing. 
ESTMLISH  THE FACTS  IN ADVANCE  OF NEGOTL4TING  A  SANCTION 
Virtually  all quality-of-care  cases  in Minnesota  are  resolved  after  conferences 
involving  respondents  and  Complaint  Review  Committees  (CRC),  which  include 
15  two physician  board  members  and  one  consumer  member.  Each  respondent  is 
told  of the  allegations  against  him or her  a month  before  the  conference  and 
has  the  opportunity  to respond.  If, in conference,  the  respondent  agrees  with 
the  State  on the  truth  of the  allegations,  a stipulation  can  then  proceed.  In 
South  Carolina,  a respondent  can sign a Memorandum  of Agreement 
stipulating  the  facts  of the  case  and  admitting  the  allegation.  A sanction  is then 
worked  out  based  on these  facts. 
  W~E  DETAILED  CONSENT 
A COMIVW.WWS~ CONSENT 
AGREEME.NZS  AND  iktXKE  THEM 
ORDER 
PUBLIC:  Stipulation  and  Orders  in 
Minnesota  contain  explicit  accounts 
A recent  Stipulation  and  Order  in 
of the  patient  case histories  that 
Minnesota  ran for  23 pages.  It included 
justi&  disciplina~  actions,  as well as  ail pertinent  facts,  such  as compiete 
the  disciplinary  measures  imposed.  prescribing  histories  for  six patients,  and  a 
All of this  information  becomes  a  seven-step  course  of remedial  action.  The 
remedy  included  three specific  education 
public  document,  and  is released  to  --
courses,  supervision  by another  physician, 
the  press.  In this manner,  the 
quatierly  meetings  with  a board  member, 
Minnesota  board  answers  the 
practice  audits,  and  a $1,500  fine. 
criticism  that  consent  agreements  are 
vehicles  for  respondents  to hide  their 
behaviors  from  public  and 
professional  scrutiny. 
16  ISSUE	 Medical  board members  and staff generally agree that the strongest 
evidence  at hearings is convincing and consistent  testimony fkom a 
crediile  expert witness. 
QUESTTOM  What  can State medkal  boank  da to ensure that their expert witmmes 
pmv&ie cleq  credible testimony at hetigs? 
PROMISING  APPROACHES: 
	 GET  TESTIMONY  FROM  TWO PHYMCL4NS  W~H  DIFFERENT 
PERSPECTIVES:  Establishing  the  standard  of care  solely through  the 
testimony  of experts  who  practice  in settings  quite  different  from  respondents 
may not  be  appropriate.  For  example,  using physicians  who  practice  at  major 
teaching  hospitals  to comment  on the  care  provided  by community-based 
respondents  may not  adequately  account  for issues  in community  practice.  In 
California,  in every quality-of-care  hearing,  two physicians  testi~  -- one  whose 
practice  is very similar  to the  respondents  and  one  who is an academic  expert.  .-
  PRO~DE  CLEAR 
INSTRUCTIONS  FOR  J5XC~  FROiUNEW YORKS9GUWlZllV15SFOR 
EXPERT0PMON9 
EXPERTS:  The  strength 
of an experts  testimony 
 Your opinion  shouki  be expressed  to a reasonable 
will likely be  determined 
medical  certainty, n if possible. 
to a great  extent  by the 
dfake  your  opinion  readi~  understandable  to kzy people. 
strength  of the  experts  Avoid  using vague  language  such  as  inadequate  or it 
review  and  written  would  have  been heipfil  if .... 
opinion.  The  instructions  . You shouid  not  use the terms  negligence  or 
incompetence.  Zhese  are legal  conclusions  based  on 
that  medical  boards  give 
specific  legal definitions. 
on conducting  an expert 
review  can  help  experts 
craft  their  opinions  so as 
to be  useful  at hearings.  New York  has prepared  helpful  instructions  (see  box). 
	 EMPHASIZE  THE POTEN7Z4L  DUTY  TO TESTIFY  WHEN  SOLICITING 
EXPERT  OPINIONS:  At one  time,  the  Minnesota  medical  board  found  that  it 
was investing  time  and  money  in having expert  consultants  review  cases  and 
form  strong  opinions,  only to have  the  experts  refuse  to testi~  at  hearings 
about  those  cases.  It now makes  clear  before  contracting  with an expert  that 
testimony,  when  necessary,  is an essential  part  of the  experts  obligation. 
	 RECRUIT  HIGHLY  RESPECTED  EXPERTS  BY  PAYING  THEM  WELL: 
Reputation  of experts  often  has great  significance  to the  credibility  of 
testimony,  particularly  in appeals.  Minnesota  has found  that  paying  physicians 
their  going  rates  (up  to $350 per  hour)  makes  recruiting  renowned  experts 
easier.  ISSUE  Medical  board prosecutors mus~ before  arguing that a respondent 
provided substandard care, establish the relevant prevailing standard of 
care.  Because  hearing panels include nonphysicians or physicians 
unfamdiar with the specialty involved and expert witnesses  representing 
the board and the respondent  often present  conflicting testimony, 
establishing 
StZIKhiS  is  diffxuk 
QUESZ70N:  How  can State medkal  bod  pmsecuttm  estabkh  prevailing stan.durukof 
care  h  addition to pmtig  +  ~  ttdmony? 
PROMISING  APPROACHES: 
  kOIVE  A  PRACT~IONER  IN  WE  RESPONDENTS  SPECMLTY  ON  THE 
H~NG  PANEL:  Hearing  panels  in New York  consist  of two physician 
members  and  one  consumer  member.  In quality-of-care  cases,  one  of the 
physician  members  is usually  a practitioner  in the  respondents  specialty.  (The 
boards  large  size makes  this possible.)  This  physicians  training  and  experience  __ 
allows him  or her  to probe  and  evaluate  the  testimony  of experts  to  determine  -
whether  the  conduct  alleged  constitutes  substandard  care. 
  REFER  TO  WR17TEN  i 
\ 
PUCTICE  PARAMETERS  AS  ADMNISIRAIWE  RULES 
1 
THEY  BECOME  AVAILABLE: 
Oregon  has  an admimk?ative  rule that  specijies  ~ 
Written  standards  have  potential 
acceptable  use of amphetamines  for  obese  I 
for alleviating  the  difficulties 
peopie.  Physicians  who  violate  thti  nde  are 
:1 
medical  boards  face  in 
subject  to dticipiinary  action.  The board  has 
prosecuting  quality-of-care  cases.  communicated  cieariy  and  very specifical~  to  ,/ 
Some  medical  boards  and  medical  physicians  what  the boundaries  of care  are for  : 
I 
societies  are  working  together  on  thh  type of treatment.  There has  been  a  1 
dramatic  reduction  in amphetamine  use since  ~ 
practice  parameters  that,  if 
the rule  was  established  /1 
followed,  can  constitute  defenses  , 
i 
against  malpractice  claims. 
Specialty  societies  and  the 
Federal  government  are  also active  in developing  practice  guidelines.  Many 
medical  board  members  and  staff argue  that  written  standards  are  not well 
established  enough  in most  areas  to replace  expert  testimony.  Written 
standards  might,  however,  be precise  and  accepted  enough  to be helpful  in 
some  areas  including  medical  record  keeping,  prescribing  of controlled 
substances,  and  anesthesia.  Oregon  has established  strict  parameters  in one 
specific  area  (see  box). 
. 
18  ISSUE  Cases that go to hearing can be a huge drain on resources  and can be 
very difficult to schedule.  Boards owe both the public and respondents 
timely hearings and decisions. 
QUESZ70M  How  can State medical  boanik ensure tirndkw  k  hearings and dxiiiiw? 
PROMISING  APPROACHES: 
  LIMIT  THE  NUMBER  OF BOARD  MEMBERS  REQUIRED  FOR  HEARINGS: 
New  York,  which has  169 board  members  spread  across  the  State,  uses  only 
three  board  members  at  each  hearing.  The  full board  never  hears  or votes  on 
individual  cases.  While  limiting  the  number  of board  members  involved  is a 
necessity  for New York,  it can be  helpful  in much  smaller  States.  Vermont, 
which  has  14 board  members,  recently  changed  its policies  to allow as few as 
two board  members  to hear  each  case.  In contrast  to  New York,  though,  cases 
in Vermont  are  ultimately  voted  on by larger  panels.  Some  boards  have 
removed  board  members  from  hearing  rooms  entirely.  In many  States,  - 
administrative  law judges  hear  cases  and  render  opinions,  which  are  subject  to  -
approval  by the  board.  The  Florida  medical  board,  which  rules  on cases  only 
after  all relevant  facts  have  been  agreed  to or determined  by a hearing  officer, 
can issue  final  rulings on 40 to 50 cases  in one  two-day  board  meeting. 
  PROWDE  BOARD  MEMBERS  WIZH ADVANCE  BACKGROUND 
INFOJWL4TIOM  Board  members  in New York  used  to go into  hearings  with 
no knowledge  of the  charges  involved.  Now they  are  provided  with a statement 
of charges  and  all relevant  medical  records  a week  in advance.  This  can  speed 
up  hearings  by focusing  committee  members  attention  on the  most  important 
issues and  allowing them  to prepare  questions.  In Florida,  board  staff  expedite 
decisions  by providing  board  members  with copies  of all pertinent  written 
materials  three  weeks  before  board  meetings. 
.  IMPOSE  TIME  LIMIXS  ON HEARINGS  AND  JUDGMENTS:  Proposed 
legislation  in Michigan  would  require  hearing  examiners  to conduct  a hearing 
within  45 days of receiving  a referral.  The  board  would  then  have  60 days to 
conduct  a hearing  in which  they  review  the  findings  of fact  and  conclusions  of 
the  law that  the  hearing  officer  presented.  New York  and  Vermont  require 
their  hearing  committees  to report  their  recommendations  within  60 days of the 
hearings  conclusion.  In California,  the  board  must  make  a final decision  within 
90 days of receiving  a proposed  decision  from  the  ALJ  (they  are  allowed  one 
30-day continuance). 
  CONDUCT  PRE-HEARING  CONFERENCES  AND  ADHERE  TO 
TIMEFWES:  Timeframes  set in pre-hearing  conferences  can  limit  the 
possibility  of defense  attorneys  dragging  out  the  process  leading  to a hearing. 
In Wisconsin,  the AIJ  assigned  to the  case  presides  over  a pre-hearing 
19  conference  in which all procedures  of the  hearing,  especially  timing,  are  worked 
out.  The  ALJ  takes  very seriously  the  timeframes  set at these  conferences. 
- 
20  INTERVENTION

ISSUE  State  medical boards sometimes  receive  complaints  involving poor
qua.litycare that  do not  compel  them to pursue formal sanctions. 
Reasons  for these  decisions might include a) the evidence  is not 
sufficient to sustain formal charg~  b) the poorqudity  care seems  to 
have resulted from a single lapse in judgment  or technical sk@ or c) the 
maximum sanction would not be worth the resources  necessary  to secure 
it. 
QUESZTON: W?@ can State medidal boati  do to expresstti  concern about the 
PW  of cue  pmw  other than pursu@  fond  sanctions? 
PROMISING  APPROACHES: 
  HOLD  AN  OFF-THE-RECORD  DISCUSSION  BETWEEN  THE PHYSICMN  --
AND  ONE  OR MORE  BOARD  MEMBERS,  PHl?SICIXN  STAFF  MEMBERS, 
OR EXPERT  CONSULTANTS:  Research  has shmvn that  face-to-face 
discussion  is the  most  effective  method  of changing  physicians  behaviors 
When  a board  is concerned  about  the  care  provided  by a particular  physician 
but  chooses  not  to press  formal  charges,  it can  use  the  physicians  at its disposal 
to explain  its concern  to the  physician  who provided  questionable  care. 
Vermont  uses  physician  board  members  for this purpose.  New York  uses 
board  members,  staff medical  consultants,  or independent  expert  consultants. 
California  uses medical  quality  review committees  which  are  regionally 
organized  groups  made  up  of 60 percent  practicing  physicians  and  40 percent 
lay people  (all are  nominated  by the  medical  schools,  the  board,  or medical 
societies). 
	 WRITE  AN  EDUCATIONAL  LE7TER  TO THE  PHYSICiXN  EXPLAINING 
THE  BOARDS  CONCEM.  In conjunction  with  or instead  of the  discussions 
described  above,  boards  can  put  their  concerns  in writing  and  send  them  to 
physicians.  These  letters  need  not  become  public  records,  although  they  are 
usually  added  to physicians  permanent  files.  New York,  Maryland,  and 
California  are  among  the  States  using this approach.  In California,  recipients 
of these  letters  must  respond  to the  boards  concerns  in writing.  These  letters 
can  serve  as warning  signals should  further  complaints  be  lodged  against  the 
physicians  involved.  With  identi~ng  information  removed  they  also  could  be 
used  as a preventive  measure,  educating  all physicians  about  practice  patterns 
that  the  board  considers  questionable. 
Kathleen  N. Lohr  (cd.), Medicare: A  Strategy for  Quality Assurance  (Volume  I), 
Washington:  National  Academy  Press,  1990, p. 292. 
21  ISSUE  Physicians who boards find in violation of the medical  practice act may 
have poor knowledge and skills in their fields.  They need  further 
education  if they are to continue or resume  practice.  But  not  all medical 
schools  are  equipped  for or receptive  to training  physicians  who  have 
been  identified  as substandard- Traditional  continuing  medical  education 
is often  perceived  as ineffective  for these  physicians. 
QUESITON:  How  can Sfafe medical  bti  adiress  educa&nud  intmmdons  and 
monilwiiag pmgmms for physicians whom they have dkiplinai? 
PROMISING  APPROACHES: 
  REFER  P~SICL4NS  TO INDIWX%ALLY-TAILORED  EDUCATIONAL 
PROGRAMS:  An  aspect  common  to educational  programs  that  board  staff 
find effective  is individual  focus.  Before  providing  training  or any other 
intervention  to physicians  who have  been  disciplined,  these  programs  diagnose 
the  physicians  practice  and  personal  problems  and  design  a course  of action  to  . 
mee~ their  specific  needs.  ~amples  of individually-tailored  programs  include 
the  Remedial  Continuing  Medical  Education  Program  in Madison,  Wisconsin; 
the  Physician  Prescribed  Educational  Program  in Syracuse,  New York;  and  a 
course  in pharmacology  taught  by a professor  at the  University  of Minnesota. 
  GRANT  IMMUNITY  TO 
LMMXWTYFORPROBA7ZONMOMTORS 
PROBATION  MONITORS:  In 
some  States,  physicians  are 
Any health  care provider...,  hospitaL.,  or 
hesitant  to  accept  assignments  to 
medical  school  that pamcipates  in a 
monitor  physicians  on probation, 
monitotig  or remediation  program  [for  the 
fearing  lawsuits  against  them 
medical  board]  shall  not  be liable for  the 
stemming  from  the  actions  of the  negligence  of the monitored  licensee  in 
probationers.  The  New York  providing  medical  care pursuant  to a 
legislature  addressed  this concern  monitoring  program.    (New  York Public 
Health  Law  230) 
(see  box).  The  law grants 
immunity  to  monitors  and 
requires  physicians  being 
monitored  to  carry  a minimum  of $2,000,000 in malpractice  insurance. 
  USE COMMUN~  HOSPITALS  AS  l?ETUINING  SITES:  A peer  reviewer 
at the  Maryland  medical  society  suggested  that  if boards  are  unable  to find 
teaching  centers  willing to accept  physicians  in need  of oversight  and  retraining, 
they  should  establish  monitoring  programs  at  community  hospitals  instead. 
Keys to  improvement  in practice,  this physician  said,  include  not  only formal 
educational  intementions,  but  also regular  interaction  with  and  feedback  from 
peers.  Community  hospitals  can provide  this interaction. 
22  PREVENTION 
ISSUE  Medical  boards are in a position to notice  quality-of-care  problems  that 
are common or particularly egregious.  In order to improve  overall 
quality of care, boards need to fid  ways to reduce  these  problems  on a 
broader scale than they can by disciplining individual physicians. 
QUESZTOM  JWat can Stale medical boamk db to mdz  physiciims  aware of boundtuia 
of acceptabk  care in cedk  areas of widxp read or egregiouspmbknw? 
PROMISING  APPROACHES: 
 
.  PUBLISH  DETAILED, 
PUBLISHEDWE  DESCRLPTTOJVS 
ANONXWOUS  DESCRIPTIONS 
OF IMPORTANT  CASES:  In the 
Included  in the amcles that  the Netherlands) 
Netherlands,  the  courts  publish 
coum  pubi~h  are detailed  descriptions  OF  -
very detailed  descriptions  of   l%e inctient  leading  to a complaint  of poor 
important  cases in medical  medical  care; 
journals  (see  box).  If medical   what  the  complaint  was; 
boards  published  cases  in this   the reasoning  of the person  complaining 
 the reasoning  of the physician  who  is accused 
manner,  they  could  make  clear 
of poor  pracnce; 
boards  positions  on certain  types 
 and  the reasoning  of the court  and  its @al 
of problems  and  discourage 
dectiion. 
physicians  from  continuing 
inappropriate  practices.  Texas 
uses this  approach  in a limited 
fashion.  It prints  short  summaries  of complaints  in a newsletter  column  titled 
Illustrative  Disciplinary  Cases. 
  CONDUCT  EDUCATIONAL  PROGRAMS:  In  1984, the  Oregon  medical 
board  helped  create  an  educational  and research  foundation.  The  foundation 
conducts  programs,  workshops,  and  courses  and  produces  audio  cassettes  and 
.d-
reports  on board-identified  issues including  prescribing  of anti-anxiety 
medication  and  chronic  pain  management.  In  1989, Minnesota  conducted 
seven  seminars  on prescribing  issues.  There  was a minimal  registration  fee  for 
attendees  and  all attendees  received  continuing  medical  education  credits. 
Attendance  was very high at these  sessions. 
  USE NEWSLEIT.ERS  TO LICENSEES  TO DISCUSS  IMPORTANT  ISSUES: 
Minnesota  and  California  use periodic  newsletters  and  other  publications  to 
communicate  about  key quality-of-care  issues.  For  example,  Minnesota  has 
produced  articles  on controlling  cancer  pain  and  prescribing  controlled 
substances.  California  has a quarterly  newsletter  that  usually  addresses 
important  patient  management  topics.  A recent  newsletter  discussed 
combatting  breast  cancer. 
23  ISSUE:  Many physicians are isolated from peer review because  they do not 
practice  in hospita&  clini~  or other situations where  informal and 
formal peer  review occur.  These  physicians can have quality-ofae 
problems  that go undetected  until a severe  incident happens  that causes 
a referral to the medical board or a malpractice  suit.  Even physicians 
who  are subject to regular peer review may have particular deficiencies 
in their knowledge  or ability that go undetected  for long periods  of time. 
QUEST70M= State metikcd  beds  iimtzjj  and addrizw quality-of<are 
HOW  Cm 
probkm  jium  the medical  community  or 
Wht??l @#Cid7U  we  isohxi 
when they have undekcted  &@kncia  ih theirPe@ormunce? 
	 CONDUCT  PERIODIC  REEXAMINATION  OF PHYMCL4NS:  The  New  York 
State Advisory  Committee  on Physician  Recredentialing  is finalizing  a report 
that  recommends  legislation  requiring  reexamination  of all licensees  every nine 
years  and  reexamination  of licensees  70 years  old and  older  every  three  years. 
Although  there  are  different  issues in specialty  board  certification  than  in  -
-7 
licensure,  it is interesting  to note  that  the  American  Board  of Internal  Medicine  -
established  a policy of periodic  reexamination  in  1990.  This  certification  board 
requires  all persons  certified  in  1990 or thereafter  to be  reexamined  every  10 
years. 
. AUDIT  7HE  PRACTICES  OF ISO~TED  PHYWCJWVS;  The  Canadian 
provinces  of the  British  Columbia  and  Ontario  conduct  random  practice  audits 
of physicians,  focusing  particular  attention  on elderly  and  isolated  physicians. 
Physician  consultants  conduct  detailed  reviews  of office  procedures,  facilities, 
and  patient  care  and  then  meet  with the  physician  to go over  minor 
deficiencies.  If the  assessors  find major  problems,  a peer  assessment  committee 
may  intefiew  the  physician  also.  Physicians  often  change  their  practices  as a 
result  of this face-to-face  interaction.  Written  reviews  are  forwarded  to the 
medical  colleges  (the  equivalent  of our  medical  boards).  Although  the  colleges 
regard  their  programs  as non-punitive,  physicians  with  QC  problems  are 
referred  to retraining  programs.  Often  deficient  physicians  will voluntarily 
retire  or  limit  their  practices  after  the  reviews. 
24
 CONCLUSION 
Quality-of-care  cases  present  a major  challenge  for State  medical  boards.  In this 
report  we have  presented  a variety  of approaches  that  boards  and  their  State 
governments  can  take  to meet  this challenge.  Some  are  minor  measures  conducive  to 
quick  enactment;  others  are  far-reaching  and  difficult  to implement.  Some  are  aimed 
at helping  boards  operate  more  quickly,  others  at enabling  them  to function  more 
effectively.  Some  can be earned  out  by boards  themselves;  others  require  State 
legislation.  All, we believe,  are  worthy  of consideration. 
As we noted  in the  introduction,  it is important  to consider  each  approach  we 
identified  in the  context  of a States  own environment.  What  works  well in one  State 
may not  work  so well or at all in another.  Yet,  in closing, we must  note  that  there  are 
two factors  that  in all States  are  indispensable  to successful  pursuit  of QC  cases. 
One  is adequate  funding.  If boards  are  to handle  QC  cases  effectively,  it is widely  --
recognized  that  they  must  have  access  to a wide range  of medical,  legal,  and 
investigatory  expertise  and  to computer  and  other  resources.  These  are  costly.  State 
medical  boards  can  use physician  Iicensure  and  registration  fees  to raise  the  needed 
funds,  but  their  State  governments  must  be willing to allow boards  to set  the  fees  they 
need  and  to allow  the  revenue  from  the  fees  to be  passed  on to the  boards.  As we 
have  noted  in other  reports,  that  is often  not the  case. 
The  other  factor,  which may be  the  most  important  of all, is having  sufficient  will to 
make  a serious,  ongoing  commitment  to QC cases.  State  legislators,  executives,  and 
board  members  themselves  must  remain  firmly rooted  in the  conviction  that  the 
boards  are  responsible  for protecting  the  interests  of the  public,  not  the  physician 
community.  They  must  recognize  that  a more  activist  board  posture  in addressing  QC 
cases will generate  some  controversy  and  some  pressures  to pull back.  At such  times, 
they must  provide  boards  with the  support  necessary  to persevere  in carrying  out  their 
responsibilities  to the  public. 
25  .  APPENDIX  A 
RELATED  REPORTS  FROM  THE  OFFICE OF INSPE~OR  GENERAL 
  Medical Licensure and Discipline: An Ovemiew, June  1986 (P-01~  ) 
Identified  vulnerabilities  associated  with  licensing  of foreign  medical 
graduates  and  significant  problems  and  patterns  in discipline. 
  State Medical  Boards  and  Medical  Discipline  August  1990 (OEI-01-89-00560) 
Assessed  disciplinary  practices  by, among  other  things,  examining  key 
changes  taking  place  and  impediments  to improved  performance. 
  State Medical  Boards  and  Medical  Discipline:  A State-ByState  Review,  -
August  1990 (OEI-01=89-00562) 
Profiled,  State-by-State,  the  authorities  and  policies  relating  to  discipline. 
  @dity  Assurance  Activities  of Medical  I&ensure  Authorities  in the  United 
States  and  Cana@  February  1991 (OEI-01-89-00561) 
Provided  an ovemiew  of the  extent  and  type  of quality  assurance 
activities  being  undertaken  in the  United  States  and  Canada. 
  Performance  Indicators,  Annual  Reports,  and  State  Medical  Discipline:  A 
State-By-State  Review, July  1991 (OEI-01-89-00563) 
Profiled  on a State-by-State  basis the  use  and  content  of annual  reports, 
focusing  on performance  indicators  relating  to discipline. 
  The  Peer  Review  Organizations  and State  Medical  Boards:  A Vital  Link 
(Draft):  August  1992 (OEI-01-92-00530) 
Reviewed  the  status  of PROS efforts  to provide  boards  with information 
about  substandard  medical  care. 
  National  Practitioner  Data  Bank  Usefulness  and  Impact  of Reports  to State 
Licensing  Boards  (Draft)~  October  1992 (OEI-01-90-00523) 
Assessed  the  utility of National  Practitioner  Data  Bank  reports  to State 
licensing  boards. 
A-1  .  APPENDIX  B 
MEDICAL  BOARDS  MENTXONED IN THIS REPORT 
Arizona State Board of Medical Examiners  Nau York State Board of Professional Medicd 
2001 West Camelback Road,  #300  Conduct 
Phoer@  Arizona  85015  Room  438, Coming  Tower  Building 
(602) 255-3751  Albany,  New York  12237-0614 
(518) 474-8357 
Arkansas  State  MedicalBoard 
2100 Riverfront  Drive,  Suite  200  North  Qroiina  Board  of Medieal Examiners 
Little  Rock  Arkansas  72202  P.O. Box 26808 
(501) 324-9410  Raleigh,  North  Carolina  27611-6808 
(919) 828-1212 
Medical~  of cdifOrnia 
1426 Howe  Avenue,  Suite  54  Ohio  State Medial  Board 
Sacramento,  California  95825-3236  77 South High  Street,  17th Floor 
.-
(916) 920-6393  Columbus,  Ohio  43266-0315 
(614) 466-3934 
Florida  Board  of Medicine 
Northwood  Centre,  #60  OregonBoardof MediealExaminers 
1940 North  Monroe  620 Crown  Plaza,  1500 SW First  Avenue 
Tallahassee,  FIonda  32399-0750  Portland,  Oregon  97201-5826 
(904) 488-0595  (503) 229-5770 
M@and  Board  of Physician Quality Asuranee  Rhode  Jsland Board of Lieensure and 
P.O. Box 2571  Discipline 
Baltimore,  Maryland  21215  3 Capitol Hill, Cannon Room  205 
(410) 764-4777  Providence,  Rhode  Island  02908-5097 
(401) 277-3855 
Massachusetts  Board  of Registration in 
Medicine  South Carolina State Board of Medical 
Ten  West Street,  3rd  Floor  Emminers 
Boston,  Massachusetts  02111  P.O. BOX 12245 
(617) 727-3086  Columbia,  South  Carolina  29211 
(803) 734-8901 
Michigan  Board  of Medicine 
P.O. Box 30192  Texas State Board of Medieal Examiners 
Lansing,  Michigan  48909  P.O. Box 45805 
(517) 373-6650  Austin,  Texas  78714-9134 
(512) 834-7728 
Min.n=ta  Board  of Medieal&uniners 
2700University  Avenue  West, Suite  106  Vermont Board of Medicil  Practice 
St. Paul,  Minnesota  55114-1080  109 State  Street 
. 
(612) 642-0538  Montpelier,  Vermont  05609-1106 
(802) 828-2673 
Nevada  State  Board  of Medieai Examiners 
P.O. BOX 7238  W-nsin  Medieal Fhum.nmg  Board 
Reno,  Nevada  89510  P.O. BOX8935 
(702) 688-2559  Madison,  Wisconsin  53708 
(608) 266-2811 
B-1  .7