Multiple United States Medical Licensing Examination Attempts and the Estimated Risk of Disciplinary Actions Among Graduates of U.S. and Canadian Medical Schools.

PURPOSE: The United States Medical Licensing Examination (USMLE) recently announced 2 policy changes: shifting from numeric score reporting on the Step 1 examination to pass/fail reporting and limiting examinees to 4 attempts for each Step component. In light of these policies, exam measures other than scores, such as the number of examination attempts, are of interest. Attempt limit policies are intended to ensure minimum standards of physician competency, yet little research has explored how Step attempts relate to physician practice outcomes. This study examined the relationship between USMLE attempts and the likelihood of receiving disciplinary actions from state medical boards. METHOD: The sample population was 219,018 graduates from U.S. and Canadian MD-granting medical schools who passed all USMLE Step examinations by 2011 and obtained a medical license in the United States, using data from the NBME and the Federation of State Medical Boards. Logistic regressions estimated how attempts on Steps 1, 2 Clinical Knowledge (CK), and 3 examinations influenced the likelihood of receiving disciplinary actions by 2018, while accounting for physician characteristics. RESULTS: A total of 3,399 physicians (2%) received at least 1 disciplinary action. Additional attempts needed to pass Steps 1, 2 CK, and 3 were associated with an increased likelihood of receiving disciplinary actions (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.01, 1.13; OR: 1.09, 95% CI: 1.03, 1.16; OR: 1.11, 95% CI: 1.04, 1.17, respectively), after accounting for other factors. CONCLUSIONS: Physicians who took multiple attempts to pass Steps 1, 2 CK, and 3 were associated with higher estimated likelihood of receiving disciplinary actions. This study offers support for licensure and practice standards to account for physicians' USMLE attempts. The relatively small effect sizes, however, caution policy makers from placing sole emphasis on this relationship.

The Current State of Opioid Prescribing and Drug Enforcement Agency (DEA) Action Against Physicians: An Analysis of DEA Database 2004-2017.

BACKGROUND: Prescribing opioids has become a challenge. The US Drug Enforcement Agency (DEA) and Centers for Disease Control and Prevention (CDC) have become more involved, culminating in the March 2016 release of the CDC's "Guidelines for Prescribing Opioids for Chronic Pain." OBJECTIVES: Given the new guidelines, we wanted to see if there have been any changes in the numbers, demographics, physician risk factors, charges, and sanctions involving the DEA against physicians who prescribe opioids, when compared to a previous DEA database review from 1998 to 2006. STUDY DESIGN: This study involved an analysis of the DEA database from 2004 to 2017. SETTING: The review was conducted at the Henry Ford Health System Division of Pain Medicine. METHOD: After institutional review board approval at Henry Ford Health System, an analysis of the DEA database of criminal prosecutions of physician registrants from 2004-2017 was performed. The database was reviewed for demographic information such as age, gender, type of degree (doctor of medicine [MD] or doctor of osteopathic medicine [DO]), years of practice, state, charges, and outcome of prosecution (probation, sentencing, and length of sentencing). An internet-based search was performed on each registrant to obtain demographic data on specialty, years of practice, type of medical school (US vs foreign), board certification, and type of employment (private vs employed). RESULTS: Between 2004 and 2017, Pain Medicine (PM) had the highest percentage of in-specialty action at 0.11% (n = 5). There was an average of 18 prosecutions per year vs 14 in the previous review. Demographic risk factors for prosecution demonstrated the significance of the type of degree (MD vs. DO), gender, type of employment (private vs. employed), and board certification status for rates of prosecution. Having a DO degree and being male were associated with significantly higher risk as well as being in private practice and not having board certification (P < .001). In terms of type of criminal charges as a percent of cases, possession with intent to distribute (n = 90) was most prevalent, representing 52.3% of charges, with new charges being prescribing without medical purpose outside the usual course of practice (n = 71) representing 41.3% of charges. Comparison of US graduates (MD/DO) vs. foreign graduates showed higher rates of DEA action for foreign graduates but this was of borderline significance (P = .072). LIMITATIONS: State-by-state comparisons could not be made. Specialty type was sometimes self-reported, and information on all opioid prosecutions could not be obtained. The previous study by Goldenbaum et al included data beyond DEA prosecution, so direct comparisons may be limited. CONCLUSION: The overall risk of DEA action as a percentage of total physicians is small but not insignificant. The overall rates of DEA prosecution have increased. New risk factors include type of degree (DO vs. MD) and being in private practice with a subtle trend toward foreign graduates at higher risk. With the trend toward less prescribing by previously high-risk specialties such as Family Medicine, there has been an increase in the relative risk of DEA action for specialties treating patients with pain such as PM, Physical Medicine and Rehabilitation, neurology, and neurosurgery bearing the brunt of prosecutions. New, more subtle charges have been added involving interpretation of the medical purpose of opioids and standard of care for their use. KEY WORDS: Certification, CDC, criminal, DEA, opioid, prescribing, prosecution, sanctions.

Review of Rhode Island Physician Loss-of-Licensure Cases, 2009-2019.

Disciplinary actions against physicians are uncommon, and loss of license is less common. This unmatched, case-control, and descriptive study reviews disciplinary actions involving physician loss-of-license cases from January 1, 2009, to December 31, 2019. There were 82 physician loss-of-license cases involving 66 physicians, which were categorized by age, sex, and specialty and were compared to 4,347 non-disciplined controls. In this study, males (OR 4.69, p<0.001) were associated with an increased risk of loss of license; age was a separate risk factor (OR 1.24, p<0.05). Preventive strategies are discussed to reduce future physician loss of license.

Experiences and outcomes of nurses referred to a peer health assistance program: Recommendations for nursing management.

AIM: To provide recommendations for nursing management based on the experiences of current and former nurses who were served by a peer health assistance program (PHAP). BACKGROUND: Providing help for nurses with impaired practice is critical to their health and well-being, assuring patient safety and public trust, as well as returning competent nurses to the healthcare workforce. METHODS: Nurses (n = 268) who were current clients or former clients of a PHAP were surveyed about their experiences. RESULTS: Nearly half of nurses were referred by the board of nursing with 69% reporting the referral was due to substance use, alcohol being the most common. Most (62%) did not believe that their substance use affected their practice yet relayed that recognition of their emotional or physical condition could have led to earlier identification. Key barriers to seeking assistance were fear and embarrassment, along with concerns about losing their nursing license. CONCLUSIONS: Nurses in management are in key roles to identify and intervene with nurses who are at risk for impaired practice. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses in management and nurse colleagues would benefit from workplace education on the warning signs of impaired nursing practice and how to address it.

Association of Participation in the American Board of Physical Medicine and Rehabilitation Maintenance of Certification Program and Physician Disciplinary Actions.

OBJECTIVE: The study analyzed the relationship between participation in the American Board of Physical Medicine and Rehabilitation maintenance of certification program and the incidence of disciplinary actions by state medical boards over a physician's career. The hypothesis is that physicians who do not maintain their board certification have a higher likelihood of state medical board disciplinary actions. DESIGN: This retrospective cohort study analyzed American Board of Physical Medicine and Rehabilitation maintenance of certification data from all board-certified physiatrists who were enrolled in the American Board of Physical Medicine and Rehabilitation maintenance of certification program from 1993 to 2007. RESULTS: Matching examination and license data were available for 4794 physicians, who received a total of 212 disciplinary action reports through the Federation of State Medical Boards. The results showed that physicians who have a lapse in completing the American Board of Physical Medicine and Rehabilitation maintenance of certification program have a 2.5-fold higher incidence of receiving a disciplinary action report through the Federation of State Medical Boards (95% confidence interval = 1.76-3.63) and had higher severity violations (χ = 7.14, P < 0.05) than physicians whose certificate never lapsed. CONCLUSIONS: For physicians in physical medicine and rehabilitation, loss of board certification through failure to fulfill the maintenance of certification program requirements is associated with an increased risk of disciplinary action from a state medical licensing board.

The Association Between Maintaining American Board of Emergency Medicine Certification and State Medical Board Disciplinary Actions.

BACKGROUND: In certain medical specialties, board certification is associated with a lower risk of state medical board disciplinary actions. OBJECTIVE: The association between maintaining American Board of Emergency Medicine (ABEM) certification and state medical disciplinary actions had not been studied. This study was undertaken to determine if maintaining ABEM certification was associated with a lower risk of disciplinary action. METHODS: This investigation was a historical cohort study using Cox regression. Physicians who did not have a lapse in ABEM certification were compared with physicians who had a lapse to determine the risk of disciplinary action. Lapsing was determined at the expiration of the initial certificate. This study included all physicians who obtained initial ABEM certification from 1980-2005. Additional covariates of interest included the number of attempts on the ABEM Qualifying Examination (1 vs. >1), the geographic region of the physician's residence, and the country of medical school. RESULTS: There were 23,002 physicians in the study cohort. Of these, 3370 (14.7%) let their certification lapse after initial certification. There were 701 (3.0%) physicians with disciplinary events. Lapsed physicians had higher rates of disciplinary actions than physicians who did not lapse (6.4% vs. 2.5%). ABEM-certified physicians who did not lapse were significantly less likely to be disciplined as physicians who let their certificate lapse (hazard ratio 0.50 [95% confidence interval 0.42-0.59]). CONCLUSIONS: The absolute incidence of physicians with a disciplinary action in this study cohort was low (3.0%). Maintaining ABEM certification was associated with a lower risk of state medical board disciplinary actions.

The Relationship Between Board Certification and Disciplinary Actions Against Board-Eligible Family Physicians.

PURPOSE: Lack of specialty board certification has been reported as a significant physician-level predictor of receiving a disciplinary action from a state medical board. This study investigated the association between family physicians receiving a disciplinary action from a state medical board and certification by the American Board of Family Medicine (ABFM). METHOD: Three datasets were merged and a series of logistic regressions were conducted examining the relationship between certification status and disciplinary actions when adjusting for covariates. Data were available from 1976 to 2017. Predictor variables were gender, age, medical training degree type, medical school location, and the severity of the action. RESULTS: Of the family physicians in this sample, 95% (114,454/120,443) had never received any disciplinary action. Having ever been certified was associated with a reduced likelihood of ever receiving an action (odds ratio [OR] = 0.35; 95% confidence interval [CI] = 0.30, 0.40; P < .001), and having held a prior but not current certification at the time of the action was associated with an increase in receiving the most severe type of action (OR = 3.71; 95% CI = 2.24, 6.13; P < .001). CONCLUSIONS: Disciplinary actions are uncommon events. Family physicians who had ever been ABFM certified were less likely to receive an action. The most severe actions were associated with decreased odds of being board certified at the time of the action. Receiving the most severe action type increased the likelihood of physicians holding a prior but not current certification.

The Lackland Behavioral Questionnaire: The use of biographical data and statistical prediction rules for public safety screening.

Screening for public safety positions (e.g., police officers, fire fighters, military service members) is a difficult and challenging task. Notably, the military has been widely criticized because of the general lack of an empirically based system or program for mental health screening. The purpose of the present study is to describe the use of statistical prediction rules for this task. Prediction rules were derived and validated using U.S. Air Force (USAF) recruits in basic military training (N = 50,322). Items from the Lackland Behavioral Questionnaire were used as predictors. General attrition (discharge for any reason before completing term of service) and disciplinary offenses (including criminal charges) were used as outcomes. For trainees in the top 2% or 1% of the general attrition prediction rule, 63% and 68% were discharged before they completed their first 4 years. The base rate was 25%. Similarly, for trainees in the top 2% or 1% of the disciplinary offenses prediction rule, 35% and 39% had a significant disciplinary offense over the following 4 years. The base rate was 15.5%. The results suggest that we may be able to use biographical data inventories and statistical prediction rules to identify a small percentage of trainees in public safety fields with significant mental health or behavioral histories who are at elevated risk for general attrition and disciplinary offenses. (PsycINFO Database Record

The American Board of Internal Medicine Maintenance of Certification Examination and State Medical Board Disciplinary Actions: a Population Cohort Study.

BACKGROUND: Some have questioned whether successful performance in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program is meaningful. The association of the ABIM Internal Medicine (IM) MOC examination with state medical board disciplinary actions is unknown. OBJECTIVE: To assess risk of disciplinary actions among general internists who did and did not pass the MOC examination within 10 years of initial certification. DESIGN: Historical population cohort study. PARTICIPANTS: The population of internists certified in internal medicine, but not a subspecialty, from 1990 through 2003 (n = 47,971). INTERVENTION: ABIM IM MOC examination. SETTING: General internal medicine in the USA. MAIN MEASURES: The primary outcome measure was time to disciplinary action assessed in association with whether the physician passed the ABIM IM MOC examination within 10 years of initial certification, adjusted for training, certification, demographic, and regulatory variables including state medical board Continuing Medical Education (CME) requirements. KEY RESULTS: The risk for discipline among physicians who did not pass the IM MOC examination within the 10 year requirement window was more than double than that of those who did pass the examination (adjusted HR 2.09; 95% CI, 1.83 to 2.39). Disciplinary actions did not vary by state CME requirements (adjusted HR 1.02; 95% CI, 0.94 to 1.16), but declined with increasing MOC examination scores (Kendall's tau-b coefficient = - 0.98 for trend, p < 0.001). Among disciplined physicians, actions were less severe among those passing the IM MOC examination within the 10-year requirement window than among those who did not pass the examination. CONCLUSIONS: Passing a periodic assessment of medical knowledge is associated with decreased state medical board disciplinary actions, an important quality outcome of relevance to patients and the profession.

Physicians working under the influence of alcohol: An analysis of past disciplinary proceedings and their outcomes.

INTRODUCTION: The intoxicated person may cause harm to others, often requiring expert evaluation for the determination of guilt. The primary aim of this study was to determine the mechanisms of mistakes that led 17 doctors accused of working under the influence of alcohol to face malpractice. We also wanted to clarify what were the legal, professional, and financial consequences - depending on specific patient outcomes. METHOD: We based analysis on the review and meta-analysis of the past forensic evaluation reports of institution-run forensics programs. Furthermore, we apply thematic analysis using combination of grounded theory and Pierre Bourdieu's theoretical framework. RESULTS: During the 2010-2016 timeframe, the regional forensic service opinionated on 17 physicians (3F, 14M) subjected to disciplinary action due to providing treatment under the influence of alcohol. In total, there were 157 patients potentially affected by malpractice - out of those, four were harmed; only one qualified for compensation. In the remaining 153 patients - only 11 persons reported having had awareness about the doctors' intoxication and apparent inability to perform the job, yet they agreed to receive care. Overall, in over 90% of patients, the physician did not harm anyone to a degree threatening patient's life. The supporting staff did not report experiencing distress either. The results of a blood test for the presence of alcohol were available for only four cases. Therefore, it was impossible to analyze the correlation between intoxication level and performance in providing care. All in all, in our analysis - less than 10% of 157 patients' care were compromised by provider's intoxication, either due to a mistake in diagnosis, medical procedure, or lacking communication skills. CONCLUSION: For physicians, working under the influence of alcohol is an uncommon phenomenon, but when it occurs - patients are at risk for receiving poor treatment. Presented analysis indicates that patients - just as much as supporting staff - frequently agree to receive supervision and care from a drunk doctor, despite possible harm. Therefore, it is evident that patients as much as supporting staff fear retaliation, leading to underreporting of these cases.

Self-regulating profession? Administrative discipline of "pill mill" physicians in Florida.

BACKGROUND: A relatively large number of "pill mills," in which physicians prescribed and sometimes dispensed controlled substances without medical justification, operated in Florida beginning in the mid-2000s. Investigations into these operations have resulted in the arrest and conviction of dozens of physicians for activities related to illegal trafficking in controlled substances. METHODS: Using information from the federal Drug Enforcement Administration, the Florida Department of Health, and court records, we constructed a database of Florida-licensed medical doctors who had been indicted or convicted of crimes related to illegal prescribing of controlled substances in Florida during 2010-2015. We then determined whether and when physicians in this data set were temporarily or permanently barred from practicing medicine in the state. RESULTS: We identified 43 physicians who faced criminal action for prescribing-related crimes during the study period. Twenty-eight of these physicians had been convicted or pled guilty as of September 30, 2016, of which 25 (89%) had been permanently barred from practicing medicine in the state. Only 1 of the 25 physicians permanently lost their license before they had been convicted or pled guilty. On average, physicians did not lose their license to practice for more than 9 months (291 days) after being convicted and 587 days after being indicted of a crime directly related to illegal prescribing of controlled substances. Seventeen physicians (68%) maintained their licenses for at least 1 year after being indicted. CONCLUSIONS: This review suggests that the adoption of a more proactive and streamlined process may reduce the time from when physicians are indicted or convicted of illegally prescribing or dispensing controlled substances to board investigation and potential sanction, potentially reducing opioid-related adverse events in the state.

Review of General Dental Council and General Medical Council "fitness to practise" hearings related to maxillofacial surgery.

Dually-registered specialists in oral and maxillofacial surgery (OMFS) may be subject to disciplinary hearings by the General Medical Council (GMC) and the General Dental Council (GDC) for the same allegations, a phenomenon referred to as "double jeopardy" within the specialty. Previous efforts by both councils to simplify regulatory arrangements have made little progress. We have therefore reviewed the range and scope of fitness to practise (FTP) proceedings relevant to OMFS. We searched the online GMC register to find registered OMFS specialists and obtained FTP proceedings from 2004-2016 through a Freedom of Information request from the GDC. We then searched for cases relevant to OMFS, and cross-checked GMC and GDC registers for dual registration before reviewing relevant cases and identifying and discussing themes. Seven OMFS specialists are currently subject to GMC sanctions. A total of 22 GDC hearings related to OMFS, all of which began after 2011. Six involved the practice of OMFS, work within an OMFS department, or work by a dually-registered doctor. While "double jeopardy" is uncommon, it does happen. The cases reviewed raise issues about the remit of the GDC and their understanding of clinical practice in OMFS. We found no evidence of progress in attempts to simplify FTP proceedings. The number of GDC hearings relevant to OMFS is increasing.

Variations by state in physician disciplinary actions by US medical licensure boards.

OBJECTIVE: To investigate the variation in the rate of state medical board physician disciplinary actions between US states. METHODS: Longitudinal study of state medical board physician disciplinary action rates using the US National Practitioner Data Bank and American Medical Association estimates of physician demographics across all 50 states and the District of Columbia from 2010 to 2014. Results were reliability adjusted using a multilevel logistic model controlling for year of disciplinary action, physicians per capita in each state and the rate of malpractice claims per physician in each state. RESULTS: From 2010 to 2014, there were a total of 5046 506 physician licensure years present. Medical boards reported a total of 21 647 disciplinary actions, of which 5137 (23.7%) were major disciplinary actions involving revocation, suspension or surrender of licence. The mean, reliability-adjusted rate of all disciplinary actions was 3.76 (95% CI 3.21 to 4.42) with a significant variation between states. State rates ranged from 2.13 (95% CI 1.86 to 2.45) to 7.93 (95% CI 6.33 to 9.93) actions per 1000 physicians. The mean rate of major disciplinary actions was 2.71 (95% CI 1.93 to 3.82), ranging from 0.64 (95% CI 0.53 to 0.76) to 2.71 (95% CI 1.93 to 3.82) actions per 1000 physicians. The correlation between the rate of major disciplinary action and minor disciplinary actions was 0.34. CONCLUSIONS: There is a significant, fourfold variation in the annual rate of medical board physician disciplinary action by state in the USA. When indicated, state medical boards should consider policies aimed at improving standardisation and coordination to provide consistent supervision to physicians and ensure public safety.

Outcomes of notifications to health practitioner boards: a retrospective cohort study.

BACKGROUND: Medical boards and other practitioner boards aim to protect the public from unsafe practice. Previous research has examined disciplinary actions against doctors, but other professions (e.g., nurses and midwives, dentists, psychologists, pharmacists) remain understudied. We sought to describe the outcomes of notifications of concern regarding the health, performance, and conduct of health practitioners from ten professions in Australia and to identify factors associated with the imposition of restrictive actions. METHODS: We conducted a retrospective cohort study of all notifications lodged with the Australian Health Practitioner Regulation Agency over 24 months. Notifications were followed for 30-54 months. Our main outcome was restrictive actions, defined as decisions that imposed undertakings, conditions, or suspension or cancellation of registration. RESULTS: There were 8307 notifications. The notification rate was highest among doctors (IR = 29.0 per 1000 practitioner years) and dentists (IR = 41.4) and lowest among nurses and midwives (IR = 4.1). One in ten notifications resulted in restrictive action; fewer than one in 300 notifications resulted in suspension or cancellation of registration. Compared with notifications about clinical care, the odds of restrictive action were higher for notifications relating to health impairments (drug misuse, OR = 7.0; alcohol misuse, OR = 4.6; mental illness, OR = 4.1, physical or cognitive illness, OR = 3.7), unlawful prescribing or use of medications (OR = 2.1) and violation of sexual boundaries (OR = 1.7). The odds were higher where the report was made by another health practitioner (OR = 2.9) or employer (OR = 6.9) rather than a patient or relative. Nurses and midwives (OR = 1.8), psychologists (OR = 4.5), dentists (OR = 4.7), and other health practitioners (OR = 5.3) all had greater odds of being subject to restrictive actions than doctors. CONCLUSIONS: Restrictive actions are the strongest measures health practitioner boards can take to protect the public from harm and these actions can have profound effects on the livelihood, reputations and well-being of practitioners. In Australia, restrictive actions are rarely imposed and there is variation in their use depending on the source of the notification, the type of issue involved, and the profession of the practitioner.

Rhode Island Board of Medical Licensure and Discipline: Illustration of the disciplinary process as it pertains to cases involving opioid prescribing.

Prescription-drug overuse/overdose and misuse is an important and pivotal issue to state medical boards. This is an illustration of how some cases involving overprescribing of opioids have been addressed by the Rhode Island Board of Medical Licensure and Discipline.

A Prorating Method for Estimating MMPI-2-RF Scores From MMPI Responses: Examination of Score Fidelity and Illustration of Empirical Utility in the PERSEREC Police Integrity Study Sample.

The purpose of the current study was to identify Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) correlates of police officer integrity violations and other problem behaviors in an archival database with original MMPI item responses and collateral information regarding integrity violations obtained for 417 male officers. In Study 1, we estimated MMPI-2-RF scores from the MMPI item pool (which includes approximately 80% of the MMPI-2-RF items) in a normative sample, a psychiatric inpatient sample, and a police officer sample, and conducted analyses that demonstrated the comparability of estimated and full scale scores for 41 of the 51 MMPI-2-RF scales. In Study 2, we correlated estimated MMPI-2-RF scores with information about subsequent integrity violations and problem behaviors from the integrity violation data set. Several meaningful associations were obtained, predominately with scales from the emotional, thought, and behavioral dysfunction domains of the MMPI-2-RF. Application of a correction for range restriction yielded substantially improved validity estimates. Finally, we calculated relative risk ratios for the statistically significant findings using cutoffs lower than 65T, which is traditionally used to identify clinically significant elevations, and found several meaningful relative risk ratios.

New Zealand's Health Practitioners Disciplinary Tribunal: An Analysis of Decisions 2004-2014.

Established under New Zealand's Health Practitioners Competence Assurance Act 2003 in 2014, the Health Practitioners Disciplinary Tribunal (HPDT) hears and determines charges in relation to 21 health professions. Using publically available information, an exploratory descriptive analysis was conducted of 288 published HPDT decisions between 2004 and 2014 to assess the procedural factors (practitioner and hearing characteristics) and outcome factors (findings, penalties and appeals) relevant to these decisions. In particular, the study compared the two health practitioner groups (medical practitioners and nurses) with the highest number of decisions. The study found that nurses were significantly less likely to have legal representation or to lodge an appeal than medical practitioners, with nurses also more likely not to attend the hearing, have their registration cancelled and not receive permanent suppression. The study also revealed important characteristics of the decisions that are not contained in the summaries available on the HPDT website. These characteristics provide opportunities for future comparison across and within occupational groups. While relevant to health practitioners, lawyers, professional bodies, employers, educators and policy-makers, the findings also contribute to the international scholarship on professional discipline and tribunal decision-making.

DISCIPLINARY PROCEEDINGS AGAINST DOCTORS WHO ABUSE CONTROLLED SUBSTANCES.

This study examined 27 reports from disciplinary tribunals throughout Australia (save Tasmania where reports were not accessible) against medical practitioners who abused narcotic analgesics (often combined with other drugs of addiction) between 2010 and 2015. The reports revealed that 12 medical practitioners were in their 40s; five in their 30s; and one person still in their 20s. Although the majority were general practitioners (15 out of 27), other medical specialties were also represented. Self-administered pethidine was the most prevalent opioid (11 out of 27) and was the only drug used alone. Morphine was self-administered by six doctors; the same number used high doses of Panadeine Forte, codeine and codeine phosphate. Fentanyl was abused by five doctors. Surprisingly, fewer medical practitioners appear to use propofol, and similar opiates such as tramadol (Tramol) and/or oxycodone (Endone). The examination of cases suggests lack of consistency in the imposition of professional sanctions and penalties by the relevant tribunals. To remedy this problem, it is suggested that disciplinary tribunals should apply the test of proportionality in the form of "reasonable necessity" when deciding whether to remove or suspend the addicted medical practitioner from the Register.