Dr. Booker Rogers, an anesthesiologist, trafficked in child pornography. Dr. John Howard Simmons II, a psychiatrist, engaged in the sexual assault of a patient. Dr. Keith Palmer Pensom, an osteopath, traded prescriptions for sex.
When they committed those felonies, all three held licenses to practice medicine. Long after they pleaded guilty, all three still held their licenses.
That's the way medical regulation often goes in Texas, where doctors who molest patients routinely are allowed to stay in business. So are physicians who coerce sex from women they are treating. So are doctors who perpetrate a wide variety of sex crimes.
In the last five years, the Texas State Board of Medical Examiners has permanently revoked the licenses of two doctors for sexual misconduct.
Two other physicians - one who was accused of abusing children and one who was a repeat offender - were allowed to surrender their certification and retire.
The remaining 37 medical doctors and doctors of osteopathy who were disciplined for sexual misconduct were given less severe forms of punishment, a review of records by The Dallas Morning News has found. That allowed them to continue practicing - and, in some cases, to engage in more sexual escapades.
"If I were a physician who had problems with medical boards, I would want to come to Texas," said Susan Oswalt, a former staff lawyer for the Texas board. "You could skate along for years without them catching you or taking your license away."
Ms. Oswalt said she quit in 1997 after a year of frustration with the board's failure to pursue bad doctors, including those who committed sexual offenses, with sufficient aggression.
"The physicians were very hesitant to be too hard on other physicians," she said. "I don't understand the reason for that, other than professional courtesy."
With 18 voting members - 12 of whom are physicians - appointed by the governor, the medical board licenses doctors and handles patients' complaints. Supported by a staff of 100, its mission is to protect public welfare.
If a doctor violates the state's Medical Practice Act, the board can administer punishment ranging from license revocation to reprimand.
But this is a state agency beset by funding problems and staff turnover that undercut its best intentions. Compounding that is a reluctance to be as tough as possible on doctors who use patients for sexual gratification.
Not enough time, money for tough investigation.
"We're not really in the business of jerking licenses," said state medical board president Dr. Lee Anderson, a Fort Worth ophthalmologist. "Our primary purpose in the disciplinary process is remediation."
Dr. Anderson acknowledges that the agency does not investigate all patients' complaints as well as it should. "We don't have the time
and money," he said.
The process of taking a doctor's license can be lengthy and expensive, Dr. Anderson said, so the board often negotiates a lesser punishment. "A lot of times we are put in the position of trying to work something out because of the cost of revocation," he said.
Sexual misbehavior by doctors is one of the biggest disciplinary issues facing the Texas medical board, exceeded only by substance abuse. The sexual offenses, all of which involve male physicians, range from the making of lewd remarks to engaging in pedophilia.
In the vast majority of cases, the sexual misconduct was directed toward women the doctors were treating. About 60 percent of the cases brought to conclusion in the last five years involved apparently consensual sex between doctor and patient, which under certain circumstances is a felony in Texas.
Nationwide, medical boards revoke doctors' licenses in about 10 percent of all disciplinary proceedings for sexual misconduct. The revocation rate in Texas is less than 5 percent.
Most boards favor revoking licenses
Dale Austin, chief executive officer of the Federation of State Medical Boards, said boards across the country have become increasingly tough on sexual misbehavior. The trend is toward removal of doctors' licenses, he said, and away from second chances predicated on treatment for physicians' sexual problems.
"There is not a strong belief that this is behavior that can be remediated," Mr. Austin said.
The Texas board's tendencies in sexual misconduct cases, however, run counter to that. Physicians who promise to right themselves, and who consent to certain restrictions, are almost always given relatively minor rebukes.
Dr. Steven Mathieu Payne, for example, kept his license. Accused of molesting women during examinations, the Houston family practitioner agreed to stop doing pelvic exams and to seek psychiatric treatment.
The board put him on probation in 1998. Two years later, Dr. Payne had sex with two patients. The medical board's response did not exactly inaugurate an era of toughness.
Board members voted in September to place the doctor on probation again. Their reasons are not known, and board members and staff say they cannot discuss individual cases.
Less than 10 years ago, the Texas Legislature set out to reform the agency. In the early 1990s, the board was widely regarded as inefficient, disorganized, and far too permissive toward bad doctors.
"It was a semi-joke," said Dr. Skip Langley, executive director from 2000 to 2001.
In 1993, the Legislature doubled the number of nonphysician "public members" on the board to six, in part to counteract a pro-doctor bias. Whether that made for a more aggressive approach is debatable.
State Rep. Glen Maxey, a member of the House public health committee, said the board's situation sounds familiar. "My anecdotal feeling is we're not much further along than we were a decade ago," he said.
The research and advocacy group Public Citizen, in its 1999 ranking of serious disciplinary actions by state medical boards, put Texas 34th in the nation on a per capita basis. Texas placed well behind the neighboring states of Arkansas, Louisiana, Oklahoma, and New Mexico.
"The Texas board is not doing as good a job as the best states, or even the average states," said Dr. Sidney Wolfe, director of Public Citizen's health research group.
No details of complaints are released
Last year, the Texas board opened about 1,300 investigations as a result of complaints concerning doctors. By law, no details are released to the public. Because of the way it codes the complaints, the board cannot say how many of them concern sexual misconduct.
If an investigation shows that a complaint has merit, one or two board members negotiate with the offending doctor regarding punishment. Those discussions take place in closed sessions.
Disciplinary measures must be approved by a vote of the full board. That is done in secret.
Then, in some cases, a public document called an agreed order is issued. It lists the doctor's misdeeds and his punishment.
Patients' advocates have long agitated for a more open process, but to little effect.
"I don't know what they do with complaints because it's illegal for me to know," said Lisa McGiffert, senior policy analyst for the Consumers Union in Austin. "The doctors have always gotten special treatment. ... They have managed to convince the Legislature it [more disclosure] would be dangerous to them and hurt their business."
The board's computer database of disciplinary actions, which is open to the public, cloaks doctors' offenses in vague language. A Fort Worth pediatrician, to cite one among hundreds, is listed in the database as having engaged in unprofessional conduct, with no further details provided.
Actually, he was attempting to fondle the mothers of patients while their children lay on his examining table. He received probation from the board after undergoing treatment for sexual addiction.
The specifics of that doctor's case can be found in one of 37 loose-leaf binders stored at board headquarters in Austin. Roughly 20,000 pages of records show every agreed order produced by the board since the late 1980s.
About 90 cases since 1987 dealt with sexual misconduct.
Dr. Timothy John Wright of Mexia is among them. The board revoked his license in 2000.
Dr. Wright had pleaded no contest in state court to charges of felony indecent exposure. He originally had been charged with aggravated sexual assault of a child.
The only other permanent revocation for sexual misconduct since 1997 was Dr. Robert Bruce Wurtsbaugh of Austin, whose license already had expired when the board acted last month. He had been accused of molesting one patient and having a sexual relationship with another.
The board's action against Dr. Wurtsbaugh was taken in part because he did not show up for his hearing.
Doctors who got light punishments
Others who have come before the board got off lighter:
* Dr. Arthur Nilon Tallant of San Marcos lost his certification in 1997 after pleading guilty to 19 counts of sexual performance by a child. He was 64, and she was 17. In June, the board voted to give him back his license.
"The punishment was beyond what was reasonable," said the doctor's lawyer, Jimmy Alan Hall. "The woman in question was a stripper. It was all a set-up to fleece the guy for money."
* Dr. Pensom of Dallas pleaded guilty in state court this year to fraudulent delivery of prescriptions. Police said he was swapping them for sex. Last month, the medical board put the 32-year-old osteopathic physician on five years' probation. He could not be reached for comment.
*Dr. Rogers of Flower Mound sent, via the Internet, images of a child having sex. His 1998 transmission went to an undercover police officer in California.
He pleaded guilty to federal charges of possession of child pornography, was fined $10,000, and underwent treatment for sexual disorder and bipolar disorder.
In December 2000, more than two years after his arrest, the board placed Dr. Rogers, 45, on five years' probation. The extent of his current practice is not clear. Dr. Rogers did not return phone calls seeking comment.
*Dr. Stephen Harrison Ware III of Corpus Christi admitted to "boundary violations, sometimes including sexual relations," with at least 16 patients. In 1998, the board required him to seek treatment and have a chaperon present during physical exams of female patients.
Refuge in Texas after losing license elsewhere
Buried in the thousands of pages of the Texas board's agreed orders are numerous cases of doctors who lost their licenses elsewhere for sexual misconduct but found refuge - and lighter punishment - in Texas.
In 1996, for instance, Dr. Romeo Rojas Walsson was suspended from all practice in Canada for 12 months because he had a one-year sexual relationship with a patient. But he was allowed to practice in Texas.
The problem of state-line-jumping doctors is not new. More than 20 years ago, Glenn David Blaisdell was found guilty in Wyoming of committing an obscene act in the presence of a child.
Doctors at the Wyoming State Hospital diagnosed him as a manic depressive, drug addict, and pedophile. Wyoming authorities seized his medical license.
But the Texas board, which had also licensed Dr. Blaisdell, took no action. So he set up practice in College Station and treated students at the Texas A&M health center.
In 1992, he was accused of molesting teenage boys on a church ski trip. Police who searched his car found the ingredients for a "kiddie cocktail" - chocolate syrup, sugar, and Nembutal - which investigators said pedophiles have used to sedate children.
Only after his arrest did the Texas board make its move. Dr. Blaisdell, who is now deceased, surrendered his license.
Police step in after board fails to act
That's not the only case of the police stepping in after the board failed to act.
A female patient accused Fort Worth gynecologist Belden Coomansingh of offering painkillers in exchange for sexual favors. This came after Dr. Coomansingh lost his privileges at four Tarrant County hospitals, in part after questions of sexual misconduct.
In 1994, the medical board put him on 10 years' probation, which Dr. Coomansingh believes was unjust. "They don't give you a fair hearing," he said.
The patient who made the sex-for-drugs allegations had a different slant. "He should have gotten his license taken away right there," Dr. Coomansingh went back to his practice. Less than 14 months into his probation, he was arrested. An undercover officer, posing as a patient, said the doctor gave her narcotics, then demanded oral sex.
The doctor denied the allegations but pleaded guilty to delivery of a controlled substance. This time, the medical board revoked his license.
Revocation of a medical license is required when a physician is convicted of violating some drug laws. The statute makes no such requirements regarding sex crimes, as long as the offender is not sent to prison.
A better job, but aiming for 'zero tolerance'
Dr. Anderson, the board president, said he believes the agency is doing a better job with sexual misconduct than it did 10 years ago, and he would like to see "zero tolerance" of such cases. "Zero tolerance means the physician would know if an allegation was proven, the penalty would be embarrassing, if not permanent."
Ms. Oswalt, the former board attorney, said weak laws and reluctant board members made the aggressive pursuit of offending doctors nearly impossible. "I found it very frustrating, and the board members were a part of that," she said. "They tended to be too easy on everyone."
The current system has managed to sow dissatisfaction among many.
"It really made me feel foolish," said a 31-year-old woman who took her case to the board. Her psychiatrist, John Howard Simmons II, was convicted of felony sexual assault after they had a long affair.
She expected his license would be suspended. When the board put him on probation, the woman said, "it made me very angry."
Dr. Leo Lawrence Altenberg of Bedford was put on probation last year because of affairs with three patients.
"I think they're political hacks," he said of board members. "They think they're going to become surgeon general because some governor appointed them to a board."
Board finds its lawyers overmatched
Even some members speak of a general frustration with the system.
"The sexual conduct really gets my goat," said member Nancy Seliger of Amarillo, a nonphysician. "But when I've been trying to go after somebody's jugular, they always have to rein me in and say, 'Nancy, if you do that, this person's going to go to trial, and he'll be out practicing for the next five years.'"
Doctors have the right to contest disciplinary actions before an administrative law judge, and in state court beyond that. The board tries to avoid adversarial proceedings, former director Skip Langley said, because it finds its lawyers are often overmatched.
Dr. Langley hastened to add that agency staff members are "dedicated individuals who would work their heart out for the state with very little reward." But he and others within the agency say low pay has caused high turnover.
The starting salary for board lawyers is between $42,000 and $46,000. Of the seven staff attorneys who handle cases, five joined the board within the last 13 months. The other two have been with the board since 1999.
Attorneys for doctors have the advantage, Dr. Langley said. "The smart local lawyers know if they stall long enough, the young [board] lawyers will leave, and their case will get put on the shelf."
The board has funding woes because it can't keep what it makes. The agency collects more than $9 million in physician licensing fees a year, but is allowed to spend less than $5 million. The rest goes to other state government operations.
The result, Dr. Anderson said, is an agency that continually runs short of money for vital functions.
It has more than 600 cases under investigation - involving all manner of offenses, including sexual misconduct - but only 20 investigators to cover the state. "Are all the investigations done as well as we would like? No," Dr. Anderson said.
About 300 physicians are on probation, which sets conditions that require monitoring. But the board has only four compliance
No one is optimistic about a financial turnaround. "With the crunch in the budget, it's going to be ugly," Dr. Langley said.
"Something's going to give, and investigation is going to be one of them."
Long case delays expected to continue
One consequence could be long delays in handling cases. But that's nothing new.
In 1995, the Oklahoma medical board heard a female patient's complaint that Dr. Phillip Harwell, a gynecologist, had lowered his pants to show her a tattoo of a dragon on his hip.
The patient also said the doctor delivered a pornographic video to her residence.
The allegations were "totally fictitious," Dr. Harwell said.
Nevertheless, the Oklahoma board revoked his license.
Even before Oklahoma ruled, the doctor had moved his practice to southeast Texas. So the Texas board had to respond to the Oklahoma action. But not that year, or the next, or the next, or the next.
Finally, five years after Oklahoma canceled Dr. Harwell, Texas considered his case. A staff attorney in Austin, who had drawn up an eight-page complaint, recommended that the doctor's Texas license be revoked.
Board members, however, voted to put him on probation.