The Nader report was based on data compiled by the Federation of State Medical Boards, a Fort Worth association of the agencies that oversee doctor discipline. However, the federation criticized the Nader document, arguing that it ignored all but the most serious discipline cases and failed to include in its tabulation such actions as fines, censure notices and voluntary surrenders of licenses by doctors.
The Nader report "emasculated our figures," asserted Dr. Bryant Galusha, director of the federation. "I'd like to see an honest-to-God study. I think we're making giant steps forward but, no doubt, there is a long way to go."
Differences in Reporting
Dr. Sidney Wolfe, director of the Nader group, countered, however, that there are major differences in reporting of minor license actions by states and that the three most major sanctions are often the only ones that succeed in ending or forcing major improvements in the care delivered by inferior doctors.
The federation supplied to The Times its own tabulations for 1984--figures the Nader group said the board had declined to release to it. The 1984 figures reflected some differences among states and indicated that only 721 physicians were subject to the three most stringent types of discipline last year--with another 728 drawing less serious forms, including censures and reprimands.
But the license federation's figures appeared to group at least one category often used by California authorities--the stipulated settlement in which a doctor agrees to surrender his license to resolve a revocation case but does not officially admit guilt--among the less serious outcomes. The stipulated settlement has been a principal means by which the California agency has separated bad doctors from their licenses for at least the last five years.
Most states reported about the same number of serious actions in 1984 as in 1983. But there were some distinct differences between the two years. Florida, for instance, dropped from 71 to 48 serious actions while New Jersey increased from 38 to 57. Kentucky's total nearly doubled from 11 to 21 and California's dropped from 117 to 80--though the exclusion of some stipulated settlement cases may have accounted for much of the difference.
Ohio improved its total from 11 to 29 and Pennsylvania increased from 10 to 34 while Illinois upped its number from nine to 28. Massachusetts improved its showing from two actions to 12, which would have propelled Massachusetts into about 30th place in the standings among states. Utah still recorded the highest total ratio. Only three states--Alaska, Delaware and Montana--and the District of Columbia took no serious actions.
The American Medical Assn. quickly disputed the accuracy of the Nader estimates of the number of people injured or killed by doctors. A check by The Times of supporting data used in preparation of the Nader estimates found that the middle figure between the two estimates--203,000 killed or injured a year because of doctor negligence--is in line with formulas developed by a federal government investigating panel in 1976.
Publication of the formula developed by the old U.S. Department of Health, Education and Welfare (now Department of Health and Human Services) included a warning similar to the major conclusions of the new Nader study: That, in the mid-1970s rush to enact laws to cushion the impact of malpractice action against physicians and limit their liability, state legislatures ignored an underlying cause of the malpractice problem.
"The issue has less to do with defects in the existing litigation and claims . . . process than it does with the vast number of injuries, complications and other adverse results sustained by patients," predicted the nearly decade-old report government report on which the Nader group based one of its three separate estimates of the malpractice toll.
As alternatives to permitting doctors further immunity from civil malpractice liability, the Nader report recommended that:
--All states increase their medical license renewal costs to $500 a year and put all the money raised from the fees into special budgets earmarked for expansion and strengthening of doctor discipline agencies. States now charge only $15 to $150 a year, with California's charge at $100.
--States that have not yet done so take action to expand substantially their doctor discipline agencies, following the pattern of Florida, Kentucky and California. Florida, which recently made major changes in its agency, has tripled its number of disciplinary actions since the new board took over in 1979, according to Dr. Richard Jay Feinstein, the agency's immediate past head.
--Malpractice insurance carriers use a system of experience rating in which doctors with the worst claims histories are charged premiums far higher than the vast majority of doctors whose work does not result in injury or death to patients.