Training Matters: A Retrospective Study of Physician Disciplinary Actions by the Louisiana State Board of Medical Examiners, 1990 2010
THE EXPERIENCE OF BOARD STAFF OVER MANY YEARS SUGGESTED AN ASSOCIATION BETWEEN PHYSICIANS WHO DID NOT COMPLETE A RESIDENCY PROGRAM AND A HIGHER RISK OF DISCIPLINARY ACTION. Training Matters: A Retrospective Study of Physician Disciplinary Actions by the Louisiana State Board of Medical Examiners, 1990 2010 Susan H. Allen, DrPH, MBA; Robert L. Marier, MD, MHA; Cecilia Mouton, MD; Arti Shankar, PhD JournalMedReg_Vol102_4_r2.indd 7 1/10/17 12:24 PM Copyright 2016 Federation of State Medical Boards. All Rights Reserved. 8 JOURNAL of MEDICAL REGULATION VO L 1 0 2 N O 4 self reported specialty and years of training observations with seeming inconsistencies (i.e. a self described surgeon with only internship training) were verified before de identification took place. It is important to note that while completion of an ACGME or AOA residency is now required to be board eligible, this was not always the case. Pathways to board eligibility for various specialties have changed over the years.12 15 A power calculation was performed to ascertain how large the non sanctioned sample should be in order to obtain a confidence interval of 95% This analysis indicated that a 10:1 ratio of non sanctioned to sanctioned physicians would be sufficient for the analysis. All non sanctioned physicians from the study period were stratified by self declared primary specialty and randomly sampled to create a comparison group. LSBME data contained 108 different self designated specialties, which were reclassified into the basic categories in Table 1. Different types of surgeons were classified as such, pediatric and adult non surgical specialists were classified as medical specialists. The many kinds of pathologists and radiologists, those self described as practicing legal medicine, administration and other specialties that do not spend the majority of their time with patients were classified as "non prescribe/other. Because Doctors of Osteopathy (DOs) represent less than 2% of the entire Louisiana physician population as well as the sample population, degree type (MD/DO) was not included in the study. Normative changes over time A control variable was created to reflect changes in medical training norms over time. This time variable classified physicians into four groups based on their year of graduation from medical school: before 1950, 1950 1976, 1977 1989, and 1990 or later. This variable was created to reflect changes in: 1) the required length of internal medicine and other common residencies accredited by the ACGME; 2) pathways to board eligibility; and 3) modifications in hospital accreditation policies and training and certification expectations brought about by managed care.12 19 Statistical methods The data was divided into two groups based on disciplinary status by the LSBME. The groups are described in demographic variables as well as other covariates: international medical graduate (IMG) status, specialty, graduation year by category, years of post graduate training, and board certification Methods Data and classifications The data consists of disciplinary and other information on physicians who were licensed by the LSBME from 1990 to 2010. The 652 physicians who were publicly sanctioned during the period were originally compared to a non sanctioned sample of 6,977 physicians who were licensed in Louisiana at the same time. Physicians given a letter of concern or confidential counseling were not included in this analysis. Physicians sanctioned during residency, physicians presumed to be still in residency, and observations with missing data were dropped from the analysis. The final analyses utilized 624 sanctioned and 6,552 non sanctioned physicians for a total of 7,176 observations. The study protocol was approved for exemption by the Institutional Review Board of the Louisiana State University Health Sciences Center. The data were extracted from the board's licensing and investigation files and merged with training and certification information from the AMA Master Datafile obtained in December 2011. Using information from proprietary board files, the American Board of Medical Specialties, and practice specific websites, training information was verified before the data was de identified. Access to proprietary investigation and licensing files allowed us to ascertain that 9.5% of the 652 physicians sanctioned during the period had not completed a residency program (8.7% of the physicians who were eventually included in the analysis) We used a minimum of three years PGT for the 6,977 physicians in the non sanctioned group as a proxy for residency completion. The three year minimum was selected because that is what is required to complete an accredited residency program in Internal Medicine, the largest physician specialty, and because the Federation of State Medical Boards (FSMB) endorses a minimum of three years PGT for full and unrestricted licensure.11 Physicians in the non sanctioned group with less than three years PGT were further reviewed with respect to ACCESS TO PROPRIETARY INVESTIGATION AND LICENSING FILES ALLOWED US TO ASCERTAIN THAT 9.5% OF THE 652 PHYSICIANS SANCTIONED DURING THE PERIOD HAD NOT COMPLETED A RESIDENCY PROGRAM. JournalMedReg_Vol102_4_r2.indd 8 1/10/17 12:24 PM Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VO L 1 0 2 N O 4 9 Over dispersion was tested through the Deviance and Pearson tests and statistical adjustments were performed to account for heteroscedasticity and to assure goodness of fit. These tests as well as those for multicollinearity and regression analyses were performed using SAS 9.3.