Weeding Out the Incompetents

By Claudia Wallis

. After repeated complaints by colleagues about his incompetence, Dr. Jacinto Lopez was stripped of his privileges at Artesia General Hospital in New Mexico. That hardly put an end to his operations. Three years later, in his own meagerly equipped and unsanitary office, Lopez undertook a lower-leg amputation with the help of an untrained assistant. Though the operation was reported, it took the state board of medical examiners six months to investigate and nearly three years to revoke Lopez's license. Meanwhile, Lopez took a standard route out of trouble: he packed his scalpel and moved to another state.

Cardiologist Felix Balasco was the pacemaker king of Rhode Island. In the 1970s he implanted more of the devices than any other doctor in the state--a practice that helped him rake in more than $100,000 a year from Medicare patients alone. Balasco's penchant for pacemakers was well known to colleagues, his hospital and insurers. A peer review five years ago confirmed that dozens of his implants were unnecessary and had put patients in needless danger. But not until this year, when he was convicted for taking kickbacks from pacemaker manufacturers, did the medical board attempt to slow Balasco's pace.

Dr. Roger Mamay looked great on paper. Over the years, he had worked in hospitals in four states, always arriving with sterling references from past associates. Thus Mamay's colleagues were astounded last August when he was convicted in Massachusetts for raping one patient and assaulting three others. An investigation by the Boston Globe showed that Mamay had come under question many times for unprofessional behavior and for sexually assaulting patients. He had been tried (and acquitted) for molesting a 15-year-old as far back as 1978. Apparently, none of this had been reported to licensing officials, and somehow, nothing appeared on his record.

What is perhaps most shocking about the cases of Lopez, Balasco and Mamay is that their transgressions were ignored or smoothed over by fellow doctors, including those who are directly responsible for policing the profession. Looking the other way is an unfortunate but time-honored tradition within the medical fraternity. Says Dr. Richard Kusserow, Inspector General for the U.S. Department of Health and Human Services (HHS): "We have long had a mystical society of physicians; they protect each other's incompetency from the public."

In recent years a number of studies and widely publicized malpractice suits ( have spotlighted the problem of medical incompetence and, particularly, the lack of disciplinary surveillance. The court-martial of Naval Surgeon Donal Billig earlier this year for involuntary manslaughter was a notorious case in point. Despite a record of having been fired by hospitals in two states, being legally blind in one eye and demonstrating skills that were described by a colleague as those of "a first-year resident," Billig had risen to be chief cardiac surgeon at Bethesda Naval Hospital, one of the nation's premier military medical centers.

An estimated 5% to 15% of the nation's half-million practicing doctors are Billigs of one sort or another: incompetent because of inadequate skills, poor education or addiction to drugs or alcohol. Most of these perilous practitioners "have an excellent chance of never being disciplined," says Dr. Sidney Wolfe, head of the Public Citizen Health Research Group. A survey by the group found that in 1983 only about one-tenth of 1% of U.S. doctors were subjected to serious disciplinary actions. In several states not one doctor had even been reprimanded.

Much of the problem stems from the historic weakness of state medical boards, which are responsible for upholding standards, licensing and discipline. Too often the boards have been more interested in protecting the good name of the profession than in sorting out bad apples. Compounding the problem is the fact that many boards are underfunded. Says Wolfe: "Some states, like Massachusetts, have more investigators checking the competency of beauticians than of doctors." When charges of incompetency are brought to its attention, a board often finds it easier and certainly less expensive to allow the doctor to surrender his license "voluntarily" and leave the state than to initiate disciplinary proceedings. "The board makes deals with these doctors," says Steven Schonberg, a New Mexico malpractice attorney who is himself a doctor. "They say, 'Just go away, and we won't put anything derogatory in your files.' "

When state medical boards do take action, it is often at a snail's pace. A 1984 study by the General Accounting Office found that it takes more than 2 1/ 2 years, on average, to revoke a physician's license. The study also showed that a lack of interstate coordination enabled a large percentage of those whose licenses were revoked to get credentials in another state. Dr. Alan Fields, a Michigan osteopath and part-time drug peddler, may hold the record as champion border jumper: he obtained licenses in 14 states before being put out of business and in jail.

Now mounting pressures are forcing changes in medicine's cherished but faulty self-policing system. The need to cut costs has led Medicare and other insurers to look harder for doctors who are abusing the system or practicing ineptly. The soaring cost of malpractice insurance has made doctors less tolerant of incompetent cronies whose blunders push up the rates for everyone. Finally, the publicity surrounding cases like Billig's and scandals about bogus medical degrees have embarrassed the medical profession into taking action to heal itself.

Changes in Medicare have helped spur reform. Beginning two years ago, professional review organizations, which monitor the system in each state, were thoroughly revamped and given new powers to institute sanctions against offending doctors and hospitals. "We have told the PROs that we expect them to get aggressive," says Philip Nathanson, director of the Health Standards and Quality Bureau at HHS. Indeed, the bureau terminated the contracts of three PROs that failed to get the message. This year, the department reports a sizable leap in disciplinary actions.

In a major turnaround, state licensing boards are seizing the initiative and clamping down. Several have received new authority and beefier budgets. In Pennsylvania, for example, the board has been given emergency powers to suspend temporarily the license of any doctor who appears to pose a clear danger to the public; such a decision may even be made in a telephone conference call among board members. The board is now required to investigate every complaint and has been given the staff and money to do so. The result: disciplinary actions in the state rose from .7 per 1,000 doctors in 1982 to 1.5 per 1,000 last year. Other states that have vastly improved their records include Texas, Florida and Minnesota.

The most important step in the reform movement has been taken at the interstate level by the Federation of State Medical Boards, a Fort Worth-based organization that acts as a clearinghouse for the individual state licensing boards. Under the leadership of Executive Vice President Bryant Galusha, the federation has done away with its ancient collection of dog-eared file cards on problem doctors and replaced it with a computerized data bank. It has persuaded the state boards to report new disciplinary actions swiftly, so that the information can be promptly entered into the system. This summer individual boards will begin hooking into the system, enabling them to check a doctor's record in a matter of minutes and crack down on would-be border skippers. The data will also be made available to the military medical system and hospitals. Says Galusha: "We've gone from the turkey quill and laborious manual searches to state of the art in the past two years. The net is tightening."

A major report due to be released next month by the Inspector General's office recommends drawing that net tighter. It calls for more cooperation between state boards and the Federal Government and urges higher medical licensing fees to provide more money for enforcement. Kusserow also favors legal immunity for doctors who report incompetent colleagues. Says he: "They need protection from being sued." Galusha would like to see more pressure on hospitals to inform state boards of any internal disciplinary actions. "There should be civil penalties against hospitals if they do not report," he says. Reformers like Sidney Wolfe and New York State Health Commissioner David Axelrod go even further, suggesting that doctors should be periodically reviewed when their licenses come up for renewal. Though most doctors would probably balk at such a measure, the profession as a whole would gain rather than lose stature, says Axelrod. "We've got to get away from the guild mentality--members banding together to protect themselves. Such an attitude is antithetical to our responsibility as physicians."

With reporting by Jonathan Beaty/Los Angeles, with other bureaus