Consider the cases of two physicians. One of them had consensual sexual relations with an adult patient. The other demonstrated repeated lapses in clinical judgment, technical skills and knowledge, leading to poor outcomes, even deaths, in multiple patients.

If you were seated on a medical board or tribunal, charged with protecting the public from bad physicians, how would you judge these two cases? If you could only remove one of these doctors from practice, which one would you choose?

Of course, this is a false choice, since boards can severely sanction anyone they choose. But their actual decisions, guided by both statute and precedent, illustrate that they do not see these transgressions in the same light. The interesting study by Elkin and colleagues [please update ref to bmjqs-2012-000941 shown as Ref. 1] in this issue of BMJ Quality and Safety suggests that they are far more likely to ‘throw the book’ at physicians who engage in sexual relationships with patients than at others who fail to meet professional standards, including those who provide unsafe care.1

Elkin and her colleagues examined 485 cases in which disciplinary tribunals in the most populace areas of Australia and all of New Zealand found doctors guilty of professional misconduct during the decade that began in 2000. The sanctions meted out were serious: the offending doctor was removed from clinical practice nearly half the time. Guilty physicians were overwhelmingly male and two-thirds were general practitioners.

In perhaps the study's most striking finding, tribunals removed physicians from practice in 81% of cases in which misconduct involved sexual encounters with patients. In a multivariate analysis, the authors found that the odds of removal from practice were 22 times higher in such cases than in all others. Given the widespread knowledge among physicians that having a sexual relationship …