Stronger safeguards are needed generally, critics argue, but prison populations are particularly vulnerable. In some cases, rehabilitating physician offenders has included licensure restrictions that led them to jobs in correctional settings, where surging inmate populations have sorely stressed medical staffing and care.

"Too many state medical boards, despite a clear duty to protect the public, still believe their first responsibility is to rehabilitate 'impaired physicians' and to protect them from the public's prying eyes," said Sidney M. Wolfe, MD, director of Public Citizen's Health Research Group, in Washington, DC.

Dale L. Austin, deputy executive vice president of the Federation of State Medical Boards in Dallas-Fort Worth, rejected Wolfe's complaint. The first duty of medical boards is "to protect the public," he said, and that would include patients who happen to be incarcerated.

"When faced with an impaired physician, a medical board strives to rehabilitate that physician if the public can be protected in the process," Austin said. "However, that should be a secondary focus to the primary reason for the medical board's existence—to protect the public."

Correctional health experts say many physicians providing medical services to inmates are caring and competent. Still, several inmate deaths allegedly due to physician neglect or substandard care are focusing attention on the practice of licensing restrictions that, as part of the rehabilitation process, could funnel impaired physicians into prison health care (see following article).

For example, the civil suits that followed the death of two inmates in Alabama's Kilby Correctional Facility revealed that the chief psychiatrist and mental health director for Alabama's prisons was licensed by that state after twice losing his medical license for sexual misconduct in other states.

In November 1994, Correctional Medical Services (CMS), a St Louis-based, for-profit provider of correctional health care, hired Gail R. Williams, MD, to direct mental health services in Alabama prisons, even though he no longer had a medical license. The year before, Oklahoma revoked his license for sexually battering and harassing a nurse and other female staff members. Williams lost his first medical license in 1985, after Michigan's Board of Medicine found him guilty of engaging in sexual relations with a patient and fraudulently billing an insurance company for the sexual encounters as therapy sessions.

In September 1990, after concluding that Williams had lied under oath when he claimed that he never engaged in sexual relations with other patients, the Michigan board denied his request for reinstatement of his license. That same month, however, Oklahoma issued Williams a medical license that restricted his practice to a supervised setting of a public agency and prohibited his treating female patients without the presence of a female chaperon. He was hired to head mental health services for Oklahoma's Department of Corrections (DOC).

He lost that job and his Oklahoma license in November 1993 when the Oklahoma State Board of Medical Licensure and Supervision found him guilty of sexual battery and harassment. Williams, however, continues to deny the charges. He said he was a victim of a "power struggle" and a conspiracy led by the nurse. He didn't appeal the revocation of his license, he said, because he missed the cutoff date for filing an appeal.

Restricted to Treating Prisoners

After losing his Oklahoma license, Williams applied to Kansas for licensure but was refused. Despite his troubled past, lack of a medical license, and the fact that he had worked as a physician for fewer than 3 of the previous 8 years, CMS hired Williams in November 1994 and helped persuade Alabama's Medical Licensure Commission to give him a license restricted to practice in penal institutions.

Williams also applied to Mississippi, which granted him a similarly restricted license. However, unlike his Alabama license, his Mississippi license prohibits him from treating or seeing female patients without the presence of a woman chaperon, as Oklahoma had done 4 years before.

Williams was hired "because he clearly was the most qualified physician who applied for the job," said Larry A. Linton, regional manager for the Alabama office of CMS. "His experience in managing a statewide mental health program made him an ideal candidate. It's very rare to find someone with experience in both correctional health and in psychiatry. Dr Williams had both to offer and had done a good job previously. We believed he was the best qualified to provide mental health care for Alabama prisoners."

CMS was fully aware of Williams' past mistakes and discussed them with the board of examiners, said Susan B. Adams, CMS' director of marketing and communications. "We are confident that we have measures in place to prevent him from repeating his past mistakes," she said. CMS supervises and provides quarterly reports on Williams to the medical licensing board. "There hasn't been a single incident reported that even suggests Dr Williams is anything less than what he needs to be, and that is a professional," Linton said.

Explaining the decision to license Williams, Larry D. Dixon, executive director of the Alabama Board of Medical Examiners in Montgomery, which gathers information for the licensure commission, said the board had thoroughly reviewed his application and conducted appropriate interviews. The board was advised repeatedly that psychiatric services were "desperately" needed in the state prisons. The board was assured by the DOC and CMS that Williams would not see or treat women without a female chaperon. The board restricted his license to practice in state penal institutions, and his license specifically requires his supervisors to provide the board with quarterly reports. "I think that the board has placed sufficient safeguards to protect the patient population—and for 4 years it appears that quality medical services have been provided without incident," Dixon said. "We have gotten nothing but exemplary quarterly reports from the other physicians he works with as well as the DOC and CMS. I don't know what else is demanded of us."

Defendants in Lawsuits

Williams first came under public scrutiny following the 1995 death of Billy Roberts, a psychotic inmate who committed suicide after his antipsychotic medication was discontinued. When Williams took charge of mental health services in Alabama's prisons, he ordered the medical staff to greatly reduce the number of inmates who receive psychotropic medications. He also discontinued the policy of sending the most severely mentally ill inmates to Taylor Hardin, the state's secure medical facility. Instead, they had to be treated within their prison, despite the shortage or absence of acute psychiatric beds and psychiatric staff in the state's 12 correctional facilities that house approximately 20,000 inmates—an estimated 1500 to 2000 of whom have a serious psychiatric illness.

A wrongful death suit brought by Billy Roberts' family, in which the plaintiff was not allowed to present evidence of Williams' past professional misconduct, was unsuccessful, said Gayle H. Gear, a Birmingham attorney who has represented inmates or their families in two wrongful death and one class action lawsuits against CMS, Williams, and other CMS health care providers. In the class action suit, US magistrate judge John L. Carroll ruled in April 1997 that the system Williams instituted when he took charge of mental health services in Alabama prisons was "woefully inadequate" in meeting the constitutionally mandated medical needs of mentally ill inmates. A federal district judge is now considering whether to issue an order that would mandate changes recommended by the magistrate judge. Because litigation is still pending, CMS declined to comment other than to say that CMS and the DOC dispute the magistrate judge's ruling and that mentally ill inmates' needs are being adequately met.

Gear's other wrongful death suit against CMS, Williams, and other CMS health care providers was settled without an admission of wrongdoing on August 31 for an undisclosed amount. That suit was brought by the family of Calvin Moore, a 19-year-old inmate who died in Kilby Correctional Facility after serving only 7 weeks of a 2-year sentence for burglary. According to the affidavit of an authoritative forensic pathologist with Boston-based Physicians for Human Rights, Moore's death was a negligent homicide.

Prison records show that, shortly after being admitted to Kilby on January 3, 1996, the inmate began to display severe psychiatric symptoms. He stopped eating and, although he lost about a third of his body weight, he received no medical treatment other than one injection of haloperidol. He spent the last several days of his life in an isolation cell sitting or lying in his own urine, most of the time in a catatonic state. For more than a week, until a few hours before his death on February 21, 1996, no one took his vital signs. Although the state medical examiner concluded that Moore died a "natural" death "possibly related to an unidentifiable heart lesion," Robert H. Kirschner, MD, senior forensic consultant to Physicians for Human Rights, who served as an expert witness in the case, said that postmortem findings clearly show Moore's death was the result of dehydration and extreme hypernatremia.

According to Adams, the CMS staff at Kilby provided Moore with appropriate and compassionate care. "The settlement was for the compromise of a doubtful and disputed claim," she said. "A consideration in CMS' decision to settle this case was the anticipated high cost of trial and the healthcare providers' time and attention which would be diverted from their duties."

Crime Against Nature

Another physician named in the Moore wrongful death suit was Walter F. Mauney, MD, who was medical director at Kilby when the inmate died. According to CMS records, Mauney was hired in 1995 shortly after being released from a drug addiction treatment center, where he said he was treated for an addiction to pain medication resulting from complications following knee surgery.

On his job application to CMS, Mauney wrote, "In 1978 while on vacation, I got drunk and had sex with an 18-year-old. The age of consent was 19. I pleaded guilty to sexual misconduct and received probation."

However, criminal court records in Monroe County, Tennessee, show that in 1979 a Tennessee grand jury charged Mauney with three counts of having oral sex with and "sexually penetrating" a 16-year-old "mentally defective" boy. Mauney, who was 40 years old at the time, pleaded guilty to one count of "crime against nature" and was sentenced to 10 years in the state penitentiary, but the sentence was suspended.

In explaining his false statement to CMS, Mauney told JAMA that he thought the boy was 18 years old. He blamed his behavior on alcohol. He stopped drinking in 1990, he said, and pointed out that his mistakes never involved a patient. "I've taken care of a lot of people over the years," Mauney said. "I've tried to be a good, caring doctor."

Mauney's crime occurred almost 19 years ago, said Louis Tripoli, MD, CMS's chief medical officer. "Dr Mauney underwent 10 years of probationary supervision and has paid his debt to society," he added. "Given Dr Mauney's remorse, his desire to make amends, and based upon a review of his professional credentials and record available to us at the time, CMS believed that Dr. Mauney was a satisfactory candidate to provide inmate healthcare services."

Mauney's criminal conviction led to misconduct charges being filed against him in 1980 by the medical licensing boards in Tennessee and in North Carolina, where he lived and practiced. The Tennessee board revoked his license in April 1980, but reinstated it in November 1981 after Mauney sued the board.

In February 1982, the Alabama Medical Licensing Commission gave Mauney a medical license. According to Dixon, the commission's decision was influenced by letters from physicians, patients, a judge, and other supporters urging that Mauney be licensed.

In a letter dated December 20, 1982, North Carolina's licensing board informed Mauney that it would indefinitely postpone its investigation and told him to give the board 90 days' notice should he ever return to North Carolina to practice medicine.

When CMS contacted the Tennessee Board of Medical Examiners to inquire about Mauney's discipline record, it received a letter dated May 5, 1995, stating that "there is no derogatory information in our files concerning this medical doctor."

Easier to Refuse Than Revoke

These events show how willing some medical licensing boards are to forgive and forget the crimes and misconduct of physicians, said Wolfe. "North Carolina said to a doctor who sexually abused a mentally defective 16-year-old boy, 'Stay out of our state and we'll let you keep your license,' and Alabama said, 'Come to ours, we'll give you one.' This is outrageous."

However, according to Austin of the Federation of State Medical Boards, "medical licensing boards in each jurisdiction have the prerogative to review and reconsider the facts in each case. Their interpretations of the facts don't always agree. Being composed of humans, each board makes good decisions and, from time to time, may make bad decisions."

In a recent article on physicians disciplined for sexual crimes or misconduct (JAMA.1998;279:1883-1888), Wolfe and Christine E. Dehlendorf reported that, despite the seriousness of these offenses, discipline was no more severe than probation or license restriction for more than 25% of physicians found guilty. "Physicians disciplined for sex-related offenses apparently are being allowed to continue to practice with, at most, safeguards, such as having a chaperon present during examinations and having another physician monitor patient records," they wrote. "This finding is problematic considering that there are difficulties in properly assessing the potential for successful and sustained rehabilitation of these professionals. Furthermore, safeguards such as monitoring are often inadequately overseen by medical boards."

An accompanying Editorial (JAMA. 1998;279:1915-1916) discussed the reasons licensing boards must be more discerning when considering the application of a physician whose license was revoked in another state. Because of the need for due process and the likelihood of litigation, "it is more difficult for a board to remove a medical license than to issue one," wrote F. Douglas Scutchfield, MD, of the Center for Health Services Management and Research, University of Kentucky Medical Center, Lexington, and Regina Benjamin, MD, MBA, a fellow of the Federation of Medical Licensing Boards, a member of the Alabama State Board of Medical Examiners, and former member of the American Medical Association's Board of Trustees. "Accordingly, it should be the goal of each licensing board to ensure that their processes at the front end, before they issue a license, as well as their processes for license renewal, are such that, in an ideal world, the board should never have to remove a license from a physician for misconduct. The responsibility is to guard the profession and safeguard the public from the relatively small proportion of problem physicians, and to prevent these physicians from practicing not only in the state taking the disciplinary action, but also in other jurisdictions."

—by Andrew A. Skolnick

Research for this article was supported in part by a Rosalynn Carter Fellowship in Mental Health Journalism.

(JAMA. 1998;280:1387-1390)