A physician whose medical license was suspended or surrendered for misconduct in five mainland states still practices in Hawaii.

A doctor who lost his California license in 2013 for gross incompetence, unprofessional conduct and dishonesty still has his Hawaii license.

A psychiatrist convicted years ago of falsifying records in a scheme to overcharge Medicaid in Colorado was denied a license in two states. He got one in Hawaii — and subsequently was indicted for similar charges here.

A six-month investigation by the Honolulu Star-Advertiser found dozens of examples of doctors who were disciplined in other states and either received new licenses in Hawaii or kept their existing medical licenses for long periods without sanctions here. One kept his Hawaii license for nearly five years after his New York license was revoked for having a sexual relationship with a patient, fathering her child and then lying about it to an investigator.

The Star-Advertiser examined thousands of pages of discipline, court and other public records from all 50 states and contacted dozens of analysts, attorneys, physicians, regulators, consumer advocates, patients and others to assess the local system.

Among the newspaper’s findings:

>> After other states imposed sanctions on physicians who were also licensed in Hawaii, regulators here often took more than two years to issue reciprocal discipline even though timely action is considered vital to protect the public. In more than a dozen cases over the past decade, the process dragged on for three years or more.

>> Even when other states declared emergencies to justify immediately pulling a license, Hawaii didn’t take action right away. One case involved a Florida physician who thought he was Jesus, attempted to kidnap a boy at a playground and then choked the boy’s mother into unconsciousness when she tried to intervene, regulatory records show. Hawaii didn’t revoke that doctor’s license until two years later.

>> The state website that patients rely on to check a physician’s background is hard to navigate, is inconsistent and lacks important information routinely provided in other states.

"The oversight there is failing patients," said Lisa McGiffert, the Texas-based director of a patient safety project with the national advocacy group Consumers Union. "There’s really a lack of putting the public first."

Officials with the state Department of Commerce and Consumer Affairs, which regulates doctors, say the system has improved significantly over the past decade and, thanks to a dedicated staff and board, is resolving cases on a more timely basis while fulfilling its mission of protecting the public — despite funding and other challenges.

In 2004 the advocacy group Public Citizen rated Hawaii the worst state in the nation for disciplining doctors. By 2012, the last year in which Public Citizen issued its rankings, Hawaii was rated 18th best.

"We believe Hawaii continues to rank in the top half of all states for serious disciplinary actions," said Jo Ann Uchida Takeuchi, DCCA deputy director, the department’s deputy director, in written responses to Star-Advertiser questions. "Both the [medical] board’s and the DCCA’s commitment to protect consumers is clear."

Outdated operations

The task of providing oversight to more than 9,700 licensed physicians comes with challenges not just limited to that occupation. DCCA regulates 48 licensed professions and vocations, ranging from doctors and dentists to barbers and boxers.

Yet while the number of license holders has risen 67 percent over the past two decades, to 143,062, the staff of the department’s Regulated Industries Complaints Office, the enforcement branch, has dropped 14 percent, to 56, according to DCCA data.

Adding to the challenges, licensing fees, which fund oversight operations, have not increased in more than 25 years, though the department is working on new rules to change that. The agency also is constrained by licensing and enforcement databases that are about 30 years old — an eternity in the fast-changing technology world. A $1.3 million project to replace the licensing database is in the works, and one to replace the enforcement database is expected to follow.

"We all give our best, but the lack of resources, mainly personnel, make it very difficult to keep up," said Ahlani Quiogue, the medical board’s executive officer.

While the challenges have not affected the quality of the agency’s work, said Daria Loy-Goto, DCCA’s complaints and enforcement officer, "we do believe it has affected our ability to process the cases as timely as we would like."

The vast majority of Hawaii doctors never have to deal with the state’s discipline process. They stay clear of licensing violations and typically interact with DCCA and the medical board only when getting new licenses or renewing their credentials every two years.

But consumer advocates say a critical measure of a system’s effectiveness is when problem cases arise. Those are the ones that test the process and indicate how well regulators are able to do their jobs.

On that front the Star-Advertiser found numerous cases that exposed a deeply flawed process.

The most egregious cases involved physicians who lost the ability to practice in other states because of serious misconduct — or to settle misconduct charges — but were able to keep their Hawaii licenses for months or even years after that. The Star-Advertiser found about 20 such examples, including roughly a quarter of the reciprocal discipline cases that went before the medical board over the past decade.

Only in Hawaii

Take the case of Dr. Wendell Danforth.

The board has yet to take action against Danforth, whose Hawaii license is valid but whose credentials have been suspended over the past two years in four other states and surrendered in a fifth. He is practicing on Oahu.

North Carolina indefinitely suspended Danforth’s license in October 2013 after regulators determined he had prescribed oxycodonelowercase it is generic, a powerful narcotic, to five people without obtaining medical histories, examining them or maintaining medical records for them, according to regulatory documents. He also prescribed Xanax, another controlled substance, to four of the five and had an intimate personal relationship with one, the documents say.

Once North Carolina took action, three other states suspended his license, and he surrendered it in a fourth to settle allegations related to the North Carolina case.

In January the Hawaii board unanimously rejected a proposed agreement to settle charges against Danforth, according to minutes from that meeting. As with all pending cases, DCCA officials declined comment, citing state law.

Danforth did not respond to Star-Advertiser requests for comment, but he told regulators in North Carolina that his judgment about prescribing had been impaired by alcohol use, according to the records. In North Dakota, another of the five states, documents indicated Danforth started a five-year monitoring program for health care professionals in Hawaii in March 2014.

On authorities’ radar

The case involving Dr. Daniel Susott has raised similar questions about the lack of timely action.

In November 2013 California revoked Susott’s license for gross incompetence, unprofessional conduct and dishonesty after investigators discovered he was recommending medical marijuana without adequately examining patients or taking medical histories, according to Medical Board of California documents. He sometimes approved medical marijuana from Hawaii, even though the patients were in California, the records said.

At one medical marijuana event in the Bay Area, Susott saw 254 patients over two days, checked hearts and lungs by looking at the patients and recommended marijuana in all cases, the records show.

After his California license was revoked and while a DCCA investigation was pending, Susott continued to practice on Oahu, and his prescribing activities attracted the attention of state narcotics enforcement authorities, according to court records.

In seeking court permission for a search warrant, an agent with the Department of Public Safety in July said he believed Susott had violated laws related to the prescribing of controlled substances, according to the court documents. The agent cited several cases from earlier this year.

DCCA acknowledged a pending licensing complaint against Susott but declined comment. His Hawaii license still is listed as valid.

Todd Eddins, Susott’s attorney, declined comment, citing the pending state investigation.

Paralegal Steve Lane, who has been involved in past physician discipline cases, said he was appalled the agency has yet to take action against Susott. "That shows a gross disregard for public safety," Lane told the Star-Advertiser.

Dire consequences

Probably the most notorious case of a Hawaii physician continuing to practice after losing a license elsewhere involved Dr. Robert Ricketson.

Less than a year after his Texas license was revoked, Ricketson in 2001 implanted the sawed-off shaft of a screwdriver into the back of an elderly Big Island man after the titanium rods that were supposed to be used could not be found during surgery.

The patient, Arturo Iturralde, fell at least once after the surgery, shattering the shaft in his spine, and Ricketson within a week performed a second operation to implant the titanium rods. But Iturralde’s condition steadily worsened and he died two years later.

In 2006 a jury awarded more than $5 million in damages to Iturralde’s family, finding Ricketson and the Hilo hospital negligent. The jury determined the hospital was at fault because it granted Ricketson privileges despite prior sanctions in Texas and Oklahoma.

The mainland sanctions prompted the Hawaii board to put Ricketson on probation for four years in 2000. By then his track record included falsifying medical records, violating state and federal drug laws, abusing his authority to write prescriptions, lying to licensing authorities and failing to report prior actions against his license, according to court records.

It wasn’t until 2007 that his Hawaii license was revoked. Ricketson attempted to get a new one in 2013, but the board rejected his application. He could not be reached for comment.

The fact that physicians guilty of egregious misconduct elsewhere can continue practicing here for a year or more signifies a broken system, particularly if they continue seeing patients over multiple years, experts say.

"That’s really scary," said Robert Oshel, retired associate director for research and disputes at the National Practitioner Data Bank. "It’s like they’re protecting physicians rather than protecting the public."

Even current and former board members expressed concern.

"If your license was revoked in another state, I think you shouldn’t be able to practice here while we sort out what happened," said Dr. Niraj Desai, Hawaii Medical Board chairman, who stressed he was not speaking on behalf of the board, but sharing his personal opinion.

Crackdowns elsewhere

Given the stakes involved, some states have laws enabling them to quickly pull the licenses of physicians whose credentials are yanked elsewhere.

In California, for instance, a doctor’s license automatically is suspended for at least 90 days following a suspension or revocation in another state. If regulators don’t file a formal charge to pursue a more permanent sanction before the 90 days expire, the suspension is lifted.

In Washington state the board is required to suspend the license of any health care provider who is prevented from practicing in another state because of a revocation, suspension, surrender or other action, according to Michael Farrell, policy development manager for the Washington State Medical Quality Assurance Commission. The suspension remains in place while the commission pursues more permanent discipline.

"The rationale for the law is simply that if a state deems a licensee unsafe or unfit to practice in that state, then the licensee is presumed to be unsafe or unfit to practice in Washington as well and should be immediately suspended until the commission can assess all the facts and circumstances," Farrell wrote in an email to the Star-Advertiser.

Hawaii has had a law since 2013 that allows the board to summarily suspend a physician’s license to address an immediate public safety threat. But regulators have yet to use that authority.