Licensing Boards Research Articles

Effects of primary care physician density, urologist presence, and insurance status on stage of diagnosis for urologic malignancies

ObjectiveTo evaluate effects of PCP density, insurance status, and urologist presence on stage of diagnosis for urologic malignancies. Cancer stage at diagnosis is an important outcome predictor. Studies have shown an inverse relationship to primary care physician (PCP) density and insurance coverage with stage of cancer diagnosis. MethodsData was obtained from OK2Share, an Oklahoma Central Cancer Registry, for bladder, kidney, and prostate cancer from 2000 to 2010. Physician data was obtained through the State Licensing Board. The 2010 national census was used for population data. High PCP density was defined as greater than or equal to the median value: 3.17 PCP/10,000 persons. Chi-square and multivariate logistic regressions were used to analyze effects of PCP density, insurance status, and urologist presence on advanced stage diagnosis. Results27,086 patients were identified across 77 counties. As PCP density increased by 1 PCP/10,000 persons, the odds ratios (OR) of an advanced stage at diagnosis were 0.383, 0.468, 0.543 for bladder, kidney, and prostate cancer respectively. Compared to private insurance, being uninsured had OR of 1.61 and 2.45 respectively for kidney and prostate cancers. The OR of an advanced stage diagnosis for bladder and prostate cancer were 3.77 and 1.73, respectively, in counties with a urologist. ConclusionsIncreased PCP density and insurance coverage reduced the odds of an advanced diagnosis. Implementation of policies to improve access to healthcare including through increasing PCP density and reducing the number of uninsured patients should result in diagnosis at an earlier stage, which will likely improved cancer-related outcomes.

Diagnosis Dangerous: Why State Licensing Boards Should Step in to Prevent Mental Health Practitioners from Speculating Beyond the Scope of Professional Standards

This Article reviews the use of mental health experts to provide testimony on the future dangerousness of individuals who have already been convicted of a crime that qualifies them for the death penalty. Although this practice is common in many states that still retain the death penalty, it most frequently occurs in Texas because of a statute that makes it mandatory for juries to determine the future dangerousness of the defendant they have just found guilty. Both the American Psychiatric Association and the American Psychological Association have protested the use of mental health professionals in this setting because there are no scientifically valid methods to make these predictions for people who face long periods of incarceration in maximum-security prisons. Existing models of prediction consider the behavior of individuals in the free world. Moreover, the Supreme Court has upheld these predictions of dangerousness in capital sentencing hearings on the grounds that neither of the protesting professional organizations actually license mental health professionals. Therefore, this Article suggests that these state licensing boards be held responsible for assuring mental health professionals do not testify beyond the scope of medical support or evidence. In so doing, it analyzes cases in which health care professionals, in general, have been held responsible by state licensing boards for testimony that is beyond what is acceptable practice in that profession.

Physicians Look to Disrupt Longtime Regulatory Tradition for APRNs

In June 2017, at the American Medical Association’s (AMA’s) House of Delegates meeting, an amendment to a resolution impacting regulation of advanced practice registered nurses (APRNs) failed by a margin of 254-204, exposing not only a divide among AMA delegates, but a growing and continuing threat to the autonomy of APRNs ( Basen, 2017 Basen R. AMA does not want PA autonomy. MedPage Today. 2017, June 15http://www.healthleadersmedia.com/technology/ama-does-not-want-pa-autonomy?nopaging=1 Google Scholar ). The amendment called for placing “APRNs under state medical board and regulatory control, with AMA developing model state legislation” ( Basen, 2017 Basen R. AMA does not want PA autonomy. MedPage Today. 2017, June 15http://www.healthleadersmedia.com/technology/ama-does-not-want-pa-autonomy?nopaging=1 Google Scholar ). The underlying resolution was a measure opposing physician assistants from creating their own regulatory boards ( American Medical Association, 2017 American Medical Association House of Delegates handbook: 2017 annual meeting. Author, Chicago, IL2017https://www.ama-assn.org/sites/default/files/media-browser/public/hod/a17-handbookandaddendum-updated.pdf Google Scholar ). The amendment pertaining to APRNs stated that “AMA will adopt policy that APRNs are subject to the jurisdiction of state medical licensing and regulatory boards for the regulation and discipline of APRNs in their performance of medical acts and that AMA will develop model state legislation in support of states to accomplish this policy” ( American Association of Physician Assistants, 2017 American Association of Physician Assistants New AMA policy opposes autonomous PA boards [Press release]. https://www.aapa.org/pas-connect/2017/06/new-ama-policy-opposes-autonomous-state-pa-boards/Date: 2017, June 14 Google Scholar ). The physician assistant measure, however, was successful ( American Association of Physician Assistants, 2017 American Association of Physician Assistants New AMA policy opposes autonomous PA boards [Press release]. https://www.aapa.org/pas-connect/2017/06/new-ama-policy-opposes-autonomous-state-pa-boards/Date: 2017, June 14 Google Scholar ). The AMA House of Delegates discussion mirrors legislative efforts by medical societies across the country. Even without AMA-sanctioned model legislation, physician groups have been advocating for moving regulatory authority over APRNs to state boards of medicine (BOMs) from boards of nursing (BONs), where these professionals have long been regulated. Most of these efforts, however, have gone the way of the AMA measure, while proposals calling for the removal of physician and BOM oversight have been successful.

Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions

ObjectiveTo determine whether state medical licensure application questions (MLAQs) about mental health are related to physicians' reluctance to seek help for a mental health condition because of concerns about repercussions to their medical licensure. MethodsIn 2016, we collected initial and renewal medical licensure application forms from 50 states and the District of Columbia. We coded MLAQs related to physicians' mental health as “consistent” if they inquired only about current impairment from a mental health condition or did not ask about mental health conditions. We obtained data on care-seeking attitudes for a mental health problem from a nationally representative convenience sample of 5829 physicians who completed a survey between August 28, 2014, and October 6, 2014. Analyses explored relationships between state of employment, MLAQs, and physicians' reluctance to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure. ResultsWe obtained initial licensure applications from 51 of 51 (100%) and renewal applications from 48 of 51 (94.1%) medical licensing boards. Only one-third of states currently have MLAQs about mental health on their initial and renewal application forms that are considered consistent. Nearly 40% of physicians (2325 of 5829) reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure. Physicians working in a state in which neither the initial nor the renewal application was consistent were more likely to be reluctant to seek help (odds ratio, 1.21; 95% CI, 1.07-1.37; P=.002 vs both applications consistent). ConclusionOur findings support that MLAQs regarding mental health conditions present a barrier to physicians seeking help.

Lessons Learned from Litigation

Editor's note: To the surprise of many, a Canadian nurse's Facebook post complaining about the medical care a family member had received resulted in disciplinary action by the licensing board. We asked our legal and ethical contributing editors to provide some insight on the issues of this case.

Software Engineering of Safety-Critical Systems: Themes From Practitioners

This study addresses two important questions related to engineering of safety-critical software and software-intensive systems. The first question is: which software and software-intensive systems should be considered safety critical? The second question is: what processes, design practices, and tools have practitioners been using for building these systems? We answer these questions through an analysis of unstructured interviews with experienced engineers who self-describe as working on safety-critical systems. Then, a thematic analysis of these responses was conducted. The results of this study are intended to provide guidance to those building safety-critical systems and have implications on state engineering licensure boards, in the determination of legal liability, and in risk assessment for policymakers, corporate governors, and insurance executives.

Does Defensive Medicine Reduce Health Care Spending?

The medical community often argues that physician fear of legal liability increases health care spending. Theoretically, though, the effect could be positive or negative, and empirical evidence has supported both cases. Previous empirical work, however, has ignored the fact that physicians face risk from industry oversight groups like state-level medical licensing boards in addition to civil litigation risk. This paper addresses this omission by incorporating previously unused data on punishments by oversight groups against physicians, known as adverse actions, along with malpractice payments data to study state-level health care spending. My analysis suggests that health care spending does not rise in response to higher levels of risk. An increase in adverse actions equal to 16 (the mean, absolute value of year-to-year changes within a state) is found to be associated with statistically significant average annual spending decreases in hospital care and prescription drugs of as much as 0.25% (nearly $29 million) and 0.29% (almost $9.3 million). Malpractice payments were generally estimated to have smaller, statistically insignificant effects.

Active Engagement in APA Called Remedy to Burnout

Back to table of contents Previous article Next article Professional NewsFull AccessActive Engagement in APA Called Remedy to BurnoutMark MoranMark MoranSearch for more papers by this authorPublished Online:28 Jul 2017https://doi.org/10.1176/appi.pn.2017.8a16AbstractSuicide deaths of medical students, residents, and physicians have brought the subject of physician well-being to public attention and turned the issue into an acute one for organized medicine.Burnout—the phenomenon of mental exhaustion and emotional depletion—is experienced and understood by physicians perhaps more so than many other professionals. When physicians talk about burnout, other physicians—that is, you—know what they are saying. That’s why Psychiatric News will be featuring commentary over the next year from APA members offering their unique perspectives on burnout, wellness, and resilience. Experts from the recently appointed APA Work Group on Physician Wellness and others who have a special insight on the subject will provide personal accounts of their experience of burnout and strategies for maintaining wellness and resilience, and offer knowledgeable commentary about research, treatment, and institutional and health system approaches to dealing with the problem.“Burnout is pervasive in modern medicine,” said APA President Anita Everett, M.D., who has made the subject a priority of her presidential year. She noted that a December 2015 report in Mayo Clinic Proceedings found that in 2014, roughly 54 percent of the physicians surveyed had at least one symptom of burnout. When compared with 2011, rates of burnout among physicians were higher in 2014, and satisfaction with work-life balance was lower (41 percent versus 49 percent).Everett added that many aspects of modern American medicine—with its cumbersome electronic health records, excessive productivity quotas, limits on the time physicians can spend with each patient, loss of professional autonomy, and excessive documentation requirements—have become sources of professional dissatisfaction. Some stressors adversely affect psychiatrists uniquely: limited resources, high work demands, and patient violence. “Most of us have felt some degree of compassion fatigue in our careers,” she said. “Some of us may have even experienced deep and pervasive episodes of burnout that have had an impact both on our practice of medicine and on our home lives.”Tragically, Everett noted, suicides by medical students, residents, and physicians have brought the subject of physician well-being to public attention and turned the issue into an acute one for organized medicine.Everett believes the subject of burnout—powerfully impacting the professional lives of APA members—is ripe for address by professional organizations like APA. And active engagement of members in the organizational life of APA can be a strong deterrent to burnout, she believes. “Involvement in a professional society can empower members, providing a sense of collegial community and a venue for re-embracing the passion that caused us to want to be physicians in the first place,” she said.The Psychiatric News series will begin in the next issue with a report from work group chair Richard Summers, M.D., on the town hall discussion on burnout that was held at APA’s 2017 Annual Meeting in San Diego. Other subjects to be addressed in coming issues include evidence-based interventions for physicians with depression, perspectives on burnout and resilience from senior psychiatrists, efforts to promote medical student wellness, incorporation of mindfulness training into professional practice, ACGME efforts around the issue of wellness and burnout, physician mental health issues and state licensing boards, and organized-medicine and institutional-level approaches to preventing and treating burnout. Everett said she believes the Psychiatric News series will be a popular feature and one that members will look forward to from one issue to the next. “It is my hope that the series will provide real tools that our members can use in their daily professional lives to stay healthy and to remain passionate about the vital work we do with our patients,” she said. ■ ISSUES NewArchived

AMA Calls on Licensing Boards to End Discrimination for MH Treatment

AMA Calls on Licensing Boards to End Discrimination for MH Treatment

Ethical and Intrapsychic Issues in Ending a Practice

Ethical and Intrapsychic Issues in Ending a Practice

METHODOLOGICAL FEATURES FOR RESTRAINING THREATS TO ORGANIZATIONS

Methodological features of an original model for restraining threats to organizations are presented in this paper. It is worked out in three sections. Conceptual fundamentals of the model for restricting threats are clarified in the first section. Instruments of the model for restricting threats are presented in the second section. These are focus groups, an open investigation by questionnaires, and confidence intervals with four evaluations, fuzzy trapezoidal numbers, fuzzy expertons, fuzzy random incidence matrices and aggregate licensing board of threats to the organization. Stages and procedures of the model for restricting threats are explained in the third section of the paper.

Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation.

In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among "early adopters." Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers' reasons for interest or lack of interest in VCP participation. Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

Factors Influencing Occupational Therapists' Decision to Supervise Fieldwork Students

ABSTRACTThe purpose of this study was to identify factors that influence the decision to supervise a Level II occupational therapy fieldwork student. A survey was sent to occupational therapists identified from licensure boards and alumni rosters, including those who have and have not supervised students (n = 548). The results identified both positive and negative influences along with predictive factors of supervising a student. While positive factors included continuing education units, education on fieldwork expectations, their own fieldwork experiences, shared supervision, and access to educational resources, negative influences consisted of: job responsibilities, caseload, productivity standards, working part-time, and fear of failing a student. The discussion focuses on how to address the needs of the clinician and facilitate fieldwork placement.

Mobilizing and Equipping the Church for Soul Care and Counseling: A Classic Resource Updated and Revised

Lay Counseling: Equipping Christians for a Helping Ministry (Revised Edition) by Siang-Yang Tan and Eric T. Scalise, Grand Rapids, MI: Zondervan, 2016. 318 pp. ISBN 978-0-310-52427-4, $19.99. Many years back, my inspiration willingly subject myself the five years of deprivation and torture associated with doctoral studies in professional psychology came from a relatively short stint as a college pastor. I had sensed a call shepherd souls, to equip the saints for the work of ministry, for building up the body of Christ ... (Ephesians 4:12, English Standard Version). And yet as I walked alongside this small group of college students, I grew painfully aware of my own inadequacies and deficits in my shepherding efforts, especially as they applied the care of the many mental health concerns that arose in these students' lives. Now, as a licensed psychologist and a pastor, I still haven't forgotten that call. While the state psychology licensing board may have commissioned me practice mental health counseling within the state of California, the lack of an ecclesial body commissioning me practice pastoral counseling activities within the church troubled me. My intention in becoming a psychologist was not corner the market on counseling and soul care within the church--far from it; from my perspective, doing so would have been ask the church abdicate one of its most crucial responsibilities. In line with the Reformation principle of the priesthood of all believers, Paul Stevens (2002) asserted that the work of the pastor was not do all the work of the ministry himself/herself, but rather equip all the saints do this work. Extending this point, I believe that it is not the role of mental health professionals (even Christian ones) perform all the care and counseling work of the church; in fact, part of the important role that such individuals play is equip the church body for this kind of work. I don't think it will take much convincing for Christian therapists agree on the point that the church needs equipping in this regard, for it is commonplace hear sentiments like the one expressed by one of my colleagues not too long ago, Sadly, it's the church that keeps me in business. If the training and equipping of the church body for care and counseling work is indeed an important priority of Christian mental health professionals, a body of knowledge needs exist that outlines best practices, common approaches or models training, ethical considerations, and biblical foundations for such activities. The development of this body of knowledge and literature is crucial given how many Christian mental health professionals (such as myself) were trained in non-religious public institutions and never had opportunities incorporate church ministry into their professional development; moreover, it is unfortunately unlikely even for clinicians (at the masters-level or doctoral-level) trained in Christian institutions receive dedicated instruction in this regard either. Accordingly, when Dr. Siang-Yang Tan (Professor of Psychology at Fuller Theological Seminary and Senior Pastor of First Evangelical Church Glendale) published the first edition of his book, Lay Counseling: Equipping Christians for a Helping Ministry back in 1991, it addressed this very important gap and eventually established itself as the classic text on the subject. Now, 25 years later, Lay Counseling has been revised and updated for the first time include new chapters on ethical and legal concerns for lay counseling ministries as well as chapters on stress, burnout, and self-care among lay counselors. The remaining chapters have been revamped include new examples and illustrations as well as recent theoretical and empirical research. In all, this revised text represents a comprehensive, definitive, up-to-date resource for individuals interested in developing a new church-based lay counseling ministry or already actively engaged in an existing ministry. …

A Census of Actively Licensed Physicians in the United States, 2016

An accurate understanding of the demographic and state medical licensure characteristics of physicians in the United States is critical for health care workforce planning. Overall changes in the nation's population demographics, state and federal medical regulatory policies and dynamics surrounding the ongoing health care reform debate further highlight the need to have an up-to-date census of actively licensed physicians across all medical specialties. This article uses data received by the Federation of State Medical Boards (FSMB) from the nation's state medical and osteopathic licensing boards to report and summarize key features of actively licensed physicians in the United States and the District of Columbia. Our biennial census, current through the end of 2016, identifies a total of 953,695 actively licensed allopathic and osteopathic physicians serving a national population of 323 million people. This represents a net physician-increase of 12% from the 2010 census. From 2010 to 2016, the actively licensed U.S. physician-to-population ratio increased from 277 physicians per 100,000-population to 295 physicians per 100,000-population. Females now make up one-third of all licensed physicians, with osteopathic physicians and Caribbean medical graduates continuing to demonstrate substantial increases in both their absolute numbers and as a percentage of all actively licensed physicians from the 2010 to 2016 time period.

When Being Human Is a Boundary Crossing

Back to table of contents Previous article Next article Ethics CornerFull AccessWhen Being Human Is a Boundary CrossingClaire Zilber, M.D.Claire ZilberSearch for more papers by this author, M.D.Published Online:19 May 2017https://doi.org/10.1176/appi.pn.2017.5b27“Many people are so overwhelmed by the intensity and intimacy of the therapeutic relationship that they experience an otherwise inconsequential gesture or statement as a full-fledged romance or romantic intrusion.” —O.B. Caudill, quoted by Thomas Gutheil and Archie Brodsky, Preventing Boundary Violations in Clinical PracticeAfter a busy day in the office, a psychiatrist goes home to have dinner with her family. At 8 p.m., when the kids are settled into doing their homework, she returns a call from a patient from earlier in the day. To the doctor, this is merely an issue of time management. For the patient, it could seem like unusual behavior and be interpreted as a sign that the patient is either very special or very troublesome to the doctor. Rising from her chair at the end of a session, a patient stumbles and loses her balance. The psychiatrist reflexively catches the patient’s elbow to steady her and leads her to the door with this support. This chivalrous gesture could leave the patient feeling either grateful to the doctor, romantically aroused, or intruded upon, depending on the patient. Like many subtle boundary crossings, these examples demonstrate ways in which a psychiatrist may view his or her behavior as innocuous or helpful while a patient might perceive it as confusing, frightening, unwanted, or seductive. The psychiatrist may remain oblivious to the effect of his or her behavior unless the patient is brave enough to discuss what happened, which temporarily shifts to the patient the responsibility for managing the therapeutic relationship, a function ordinarily assumed by the psychiatrist. Left unaddressed, the tension from these rifts in the therapeutic relationship occasionally lead patients to initiate a complaint to an ethics committee or a licensing board. A single hug initiated by a psychiatrist in celebration of a patient’s achievement, an exchange of a photograph of the psychiatrist so the patient can have a transitional object, or frequent phone contact outside of regularly scheduled sessions, while potentially therapeutic, can at times be perceived by the patient—and regulatory authorities—as inappropriate. How might a psychiatrist behave in the fairly human ways in the above illustrations while fulfilling the expectation that his or her behavior not disrupt the treatment? Any time a psychiatrist’s behavior varies from its usual course, the psychiatrist should consider discussing it. As is often stated in residency training, “It’s not what you say (or do), it’s what you say (or do) next.” It may be useful to run through the following steps each time professional behavior falls outside the norm.Reflect on what happened. How was this behavior different from the usual? Is there something about this particular patient that elicited unusual behavior? Is there something going on in the psychiatrist’s life that is shifting him or her away from standard practice? What are the ways the patient might perceive and respond to this departure from the norm? Consider consultation. If the transference or countertransference feels unusual or intense, supervision may be beneficial. If the psychiatrist is vulnerable because of a life crisis, psychotherapy may be helpful. Seeking guidance, even if it’s just for reassurance, is always a good idea. Acknowledge the boundary crossing to the patient as a way of inviting discussion. This might happen right away at the moment of the unusual behavior, such as, “I know I’m calling later than usual. I sometimes return calls in the evening so I can have dinner with my family.” Or it might happen in the next session or several sessions later if consultation is required.Apologize if the patient expresses discomfort as a result of your behavior and invite further exploration. “I’m sorry that when I grabbed your elbow, it felt patronizing to you. Are there other times when you have felt patronized by me or by others?” Psychiatrists are not automatons. It is inevitable that at times a psychiatrist’s behavior will surprise or upset a patient when it differs from expectations of how the profession behaves. Employing one’s observing ego to preempt departures from the norm when possible, reflecting on what precipitated a boundary crossing, seeking consultation, and discussing the interaction with the patient, including an apology if appropriate, allow the psychiatrist to reestablish his or her professionalism and restores equilibrium in the treatment relationship. ■Claire Zilber, M.D., is chair of the Ethics Committee of the Colorado Psychiatric Society, a corresponding member of APA’s Ethics Committee, and a private practitioner in Denver. ISSUES NewArchived

Historical influence on the practice of chiropractic radiology: Part I - a survey of Diplomates of the American Chiropractic College of Radiology

BackgroundIt is known that not all chiropractors follow mainstream guidelines on the use of diagnostic ionising radiation. Various reasons have been discussed in the literature, including using radiography to screen for congenital anomalies, to perform postural analysis, to search for contraindications to spinal manipulation, and to document chiropractic subluxations, i.e., tiny anatomical displacements of vertebrae thought to affect nerves and health. The visualisation of subluxations was the reason chiropractic first adopted the x-ray in 1910. There has never been a study of the influence of this historical paradigm of radiography on the practices of chiropractic radiologists (DACBRs or Diplomates of the American Chiropractic College of Radiology).MethodsA survey was administered with a modified Dillman method using SurveyMonkey and supplemented by hard copies distributed at a professional conference. The target population was all active DACBRs. There were 34 items, which consisted of multiple choice and open-ended interrogatives on all three areas in which chiropractic radiologists work: education, clinical practice, and radiology practice.ResultsThe response rate was 38% (73 of 190 DACBRs). Respondents reported that the historical paradigm of radiography was found in all areas of practice, but not as a major aspect. The majority of respondents did not condone that historical paradigm, but many tolerated it, particularly from referring chiropractors. Radiographic subluxation analysis was reportedly perpetuated by private clinical practitioners as well as technique instructors and supervising clinicians in the teaching institutions.ConclusionsWithin the chiropractic profession, there is a continuing belief in radiographically visible subluxations as a cause of suboptimal health. This situation is sustained in part due to the reticence of other chiropractors to report these practices to licensing and registration boards. Investigation into other structures supporting a vitalistic belief system over science in chiropractic is recommended. In addition, it may be useful to explore remunerative systems that move beyond the inherently conflicted fee-for-service model.

Future Development for the Board Licensing Examination of Internal Medicine

Future Development for the Board Licensing Examination of Internal Medicine

Does Regulation of Physicians Reduce Health Care Spending?

The medical community argues that physician fear of legal liability increases health care spending. Theoretically, though, the effect could be positive or negative, and empirical evidence has supported both cases. Previous studies, however, have ignored the fact that physicians face risk from industry oversight groups like state-level medical licensing boards in addition to civil litigation risk. This article addresses this omission by incorporating previously unused data on punishments by oversight groups against physicians, known as adverse actions, along with malpractice payments data to study state-level health care spending. My analysis suggests that, contrary to conventional wisdom, spending does not rise in response to increased risk. An increase in adverse actions of 16 (the year-to-year average) is associated with statistically significant, annual decreases in state spending on hospital care of approximately $22 million, and on prescription drugs of nearly $10 million. Malpractice payments are estimated to have smaller, statistically insignificant effects.

Implementing a Public Health Objective for Alcohol Premises Licensing in Scotland: A Qualitative Study of Strategies, Values, and Perceptions of Evidence.

The public health objective for alcohol premises licensing, established in Scotland in 2005, is unique globally. We explored how public health practitioners engaged with the licensing system following this change, and what helped or hindered their efforts. Semi-structured interviews were conducted with 13 public health actors, audio-recorded, and analysed using an inductive framework approach. Many interviewees viewed the new objective as synonymous with reducing population-level alcohol consumption; however, this view was not always shared by licensing actors, some of whom did not accept public health as a legitimate goal of licensing, or prioritised economic development instead. Some interviewees were surprised that the public health evidence they presented to licensing boards did not result in their hoped-for outcomes; they reported that licensing officials did not always understand or value health data or statistical evidence. While some tried to give “impartial” advice to licensing boards, this was not always easy; others were clear that their role was one of “winning hearts and minds” through relationship-building with licensing actors over time. Notwithstanding the introduction of the public health objective, there remain significant, and political, challenges in orienting local premises licensing boards towards decisions to reduce the availability of alcohol in Scotland.