For years, Dr. George Richards was a leading light in Maryland's medical community. A Johns Hopkins man, he was warm and charming, a favorite with patients. He was also a big asset for Greater Baltimore Medical Center, where, as chief of radiology, he drew patients from around the state for cancer treatments.

But during the late '60s and early '70s there was an undercurrent of concern in some Baltimore medical circles about Richards and problems in the Medical Center's Radiology Department. Former patients have alleged in lawsuits that Richards had a crushing caseload -- as many as 100 patients a day -- and that there was talk among doctors that the treatment itself might be killing some patients.

It wasn't until 1980 that the Maryland Commission on Medical Discipline took action against Richards, banning him temporarily from the practice of radiation oncology. By then, he was well on his way to becoming the most frequently sued doctor in Maryland. He had already administered treatment that now has been the subject of more than 30 malpractice lawsuits and cost his insurers an estimated $20 million in paid claims.

Even Richards' lawyer says the commission action against Richards came too late. "The commission could have acted in the early '70s" by requiring Richards to cut back his caseload after problems began surfacing in the 1960s, said attorney Roy Mason.

"If the commission in Maryland worked the way we'd like it to work, {it} could have intervened and assisted him early on, and made a difference for him and his career, his patients, the hospital and everybody else."

Cancer patients who sued Richards lost limbs and internal organs and were horribly disfigured by radiation burns, according to lawsuits that have resulted in settlements or jury verdicts in their favor. Some patients died. Some who settled lawsuits contended they never had cancer to begin with. Richards, a believer in aggressive radiation therapy, often began treatment before confirming cancer diagnoses from other doctors, according to Mason.

The Commission on Medical Discipline found Richards incompetent, a violation of one of the 28 provisions of Maryland's Medical Practice Act.

The commission did not take away his license. It put Richards on supervised probation for one year, barred him from treating cancer patients during that period and required him to undergo retraining in radiotherapy. In 1981, the commission restored his license in full.

"They didn't permanently revoke his license because he's not a bad guy. He's a guy who got in way over his head," said Dr. Israel Weiner, former president of the state medical society.

Richards currently sees a few patients at his home office in Towson, but he does not administer radiation therapy. He declined to be interviewed.

Commission members refuse to discuss the specifics of any case involving disciplinary actions against doctors, including Richards.

An examination of the commission's formal actions since its creation in 1968 shows that physicians, even those found by the commission to be grossly incompetent, are rarely put out of business in Maryland.

Why hasn't the commission imposed stronger sanctions on incompetent doctors?

Part of the reason can be found in the commissioner's philosophical outlook. Commissioners say their primary job is to rehabilitate problem doctors, not to punish them.

Incompetence, they say, is also hard to prove.

A total of 18 doctors have had their medical licenses revoked since the commission was created two decades ago. Only two of those doctors lost their licenses on grounds solely related to inadequate patient care: Each advocated offbeat practices looked upon as quackery by the medical establishment -- one doctor prescribed "sleep therapy" and the other relied on diagnostic "hair analysis."

On some occasions, doctors found to have knowingly acted in ways that the commission judged to be against the best interests of patients have not been strongly disciplined.

Dr. Ahmad Shamim of Laurel, for example, was found incompetent in 1984 in the treatment of four patients, and he was found to have violated the law by knowingly filing a false medical report.

Among the findings was that Shamim removed a breast and ovaries from a woman identified in commission documents as "Patient D" without testing to see if a tumor the woman had was actually cancerous. Shamim later admitted to a peer review panel that he placed a sworn affidavit in Patient D's file stating that she was a "terminally ill cancer patient," according to commission documents. He told the panel that he knew Patient D was not terminally ill, that he had said she was so he could treat her with the otherwise prohibited drug Laetrile. Patient D died.

Shamim was allowed to keep his medical license. He was suspended from practice for six months for training in oncology and subsequently placed on probation for three years. He is still in practice in Laurel.

At the time of the disciplinary action, according to news accounts of his case, Shamim said he was being harassed by the medical establishment for his unconventional treatments. He did not return phone calls for this article.

In another case, the commission has allowed a Baltimore obstetrician to continue practicing despite two disciplinary findings since 1980 -- one of incompetence and one of providing inadequate medical care. The commission concluded that the doctor performed excessively radical surgery, unnecessary cesarean sections and inadequate fetal monitoring.

The physician, Dr. Richard Buyalos, was placed on probation in 1980, with a requirement that he obtain a hospital supervisor's approval for all elective operations, according to commission documents. In 1984, the commission found that Buyalos had failed to meet the terms of his probation. It was extended for three years, until February 1987. Buyalos' probationary status still has not been lifted; the commission will not comment on why not.

In the meantime, the Board of Medical Examiners, which has the power to deny licenses to doctors, refused in 1986 to grant renewal of Buyalos' medical license. But Buyalos has been allowed to continue practicing with his old medical license until he has a hearing before the board to challenge its ruling. Buyalos could not be reached for comment.

"We grapple with the issue of education versus punishment; that's at the heart of what we do," said Margaret McKean, a consumer member of the commission. She and other commissioners said they try to be humane in their treatment of physicians while protecting the public.

"There are huge implications in taking a {doctor's} license away," said McKean. "I don't believe the quality of medicine in Maryland would be improved if we became Number One in the country" in disciplining doctors.

"We're a state agency that's there to protect the public. Our secondary role is to be rehabilitative," said Dr. Hilary O'Herlihy, commission chairman.

Another commissioner, Dr. Rose M. Bonsack, said the commission is punitive "to a certain degree, if absolutely necessary."

State Assistant Attorney General Barbara Hull Foster, who brings disciplinary charges against doctors, was selected by the commission in October as its first full-time lawyer. She, too, strongly endorses the view that the commission's job is to rehabilitate, not punish.

That opinion, however, is not shared by her boss, Attorney General J. Joseph Curran Jr., who is urging the governor to try to strengthen the disciplinary system. Curran said, for example, that he thinks doctors convicted of serious crimes ought to lose their licenses automatically.

Lawyers who specialize in medical malpractice cases are critical as well. Marvin Ellin, the leading malpractice lawyer in the state, said the commission's overriding philosophy is that "anybody can make a mistake."

While the commission's philosophy explains why many doctors found to have engaged in illegal or unethical activities have not been severely disciplined, there are other reasons why few doctors found to be incompetent lose their licenses.

Commission and state medical society officials say incompetence charges are brought relatively infrequently because of the subjective nature of what constitutes minimally acceptable medical care.

Disciplinary bodies in other states have shied away from tackling incompetence cases for similar reasons, according to a 1986 report on medical discipline by the inspector general's office at the U.S. Department of Health and Human Services. The report found that boards nationwide take "strikingly few" disciplinary actions for physician incompetence or medical malpractice, despite the risk to patients and escalating cost of malpractice insurance as a result of rising damage awards.

A study on medical malpractice, released in 1987 by the U.S. General Accounting Office, seriously questioned the adequacy of the profession's ability to regulate itself. The study found that 71,930 doctors nationwide were involved in malpractice claims closed in 1984 but that only 1,540 doctors were disciplined that year.

O'Herlihy said the commission finds it difficult to separate the incompetent physicians from those who are average or marginal. "What is the dividing line? We've wrestled with this and find it very difficult," he said.

Dr. Emidio A. Bianco is chairman of the peer review committee of the Medical and Chirurgical Faculty of Maryland, or Med-Chi, which, along with its local chapters, serves as the investigative arm of the Commission on Medical Discipline. He said his committee comes across one or two incompetent doctors a year.

"In our minds, incompetence means a serious problem, it means a doctor isn't worth a nickel," said Bianco. "It's not very easy to make that determination. Physicians have a hard time dealing with that."

Critics of the disciplinary system, particularly those in the legal community, say the commission should be able to make judgments about a physician's level of competence. They note that whether a physican breached the prevailing "standard of care" in the field is a key element of most malpractice lawsuits.

They blame infrequency of serious disciplinary actions against incompetent doctors in part on a system that relies on doctors to investigate and judge their peers. Seven of the 11 commissioners are nominated or chosen by Med-Chi, the state medical society.

Del. William Horne (D-Talbot), chairman of the House Judiciary Committee, said he wants investigations conducted by paid, impartial investigators, not by other doctors who may "go to the same cocktail parties and play golf at the same country club."

Proving incompetence requires in-depth investigations that can stand up in court, particularly in the face of a vigorous legal defense mounted by a doctor fearful of losing his or her livelihood, according to lawyers and commission members.

Dr. Michael R. Dobridge, a commissioner and president-elect of Med-Chi, said that he generally favors strong sanctions against errant doctors but that practical considerations sometimes get in the way. "As soon as you go for revocation or suspension, you run into big legal problems," he said. "Then you really need to have a courtroom-level investigation and prosecution."

Officials in the state attorney general's office say the investigative work done by physician members of Med-Chi is often inadequate for use in full-blown commission hearings that can be appealed to a circuit court. Assistant attorneys general often return investigative reports to Med-Chi for more work, adding to delays in resolving cases.

"As long as the investigations are being done basically by volunteer investigators, that's going to present a problem," said Deputy Attorney General Dennis Sweeney. The commission, he said, "seems to be severely handicapped to do hearings."

Commission hearings can be enormously time-consuming: Shamim's incompetency hearing, for example, spanned 14 commission meetings over 15 months. In fiscal 1987, the commission held only four hearings.

The majority of the commission's disciplinary actions, records show, come in the form of a "consent agreement" with a doctor, in which the doctor admits to certain acts in exchange for less severe disciplinary action.

Angelo Troisi, executive director of Med-Chi, said he thinks that the commission feels pressure to enter into consent agreements because of its huge case backlog and the large number of complaints coming in. He blames the attorney general's office for being unwilling to bring some cases to hearings and says that, as a result, the commission sometimes lets doctors off lightly when strong sanctions are warranted.

Findings of incompetence often mean a physician is placed on probation and required to take a refresher course in his or her specialty -- a solution that commissioners said helps salvage a doctor's career while ensuring that the public is protected.

But critics remain unconvinced. "That's not going to do it," said Dr. William Finney, a leading legislative proponent of tort reform and self-described "rabble-rouser" who sits on Med-Chi's peer review committee. In most cases, he said, incompetent doctors are not "significantly rehabilitable."

The commission shouldn't be hesitant about putting bad doctors out of business, said Finney. If they are not going to do it, he said, "who in the hell is? That's where the buck stops."