State of Nevada Board of Medical Examiners Newsletter

NEVADA STATE BOARD OF MEDICAL EXAMINERS NEWSLETTER

PRESIDENT'S MESSAGE

By: Rex T. Baggett, M.D., President

The Nevada State Board of Medical Examiners has a statutory responsibility to communicate information about licensees to the public. The material released should be accurate and fully respond to the request. The source of the information the board provides is the license application, proceedings and adjudications of the board, and information forwarded to the board by malpractice carriers, physicians, courts, hospitals and other medical facilities. This database is public record.

When the Nevada State Board of Medical Examiners is queried by a citizen about a licensee of the board, the public record is open; however, most information requests are specific, i.e., biographical data, malpractice history, educational background, or disciplinary action. The information regarding board investigations of complaints is confidential by statute and not given to members of the public. The board receives in excess of 750 complaints each year. Each is investigated, but only those complaints resulting in a board disciplinary action will result in a public record.

The board's Diversion Program participants who have an unrestricted license are not a matter of public record. A licensee with board imposed license restrictions, including required participation in the Diversion Program does have a public record.

The board is a resource of information concerning Nevada law as it relates to medical practice. The staff of the board can point out law as it relates to specific questions, but neither the board nor its staff can act as a lawyer regarding a specific circumstance or provide you with legal advice. If you have specific questions regarding your practice under NRS Chapter 630, you should contact your own attorney; however, the board can point out the applicable law in NRS Chapter 630 and tell you how the board applies that law in general.

The purpose of providing information to the public about a licensee is not to harm a licensee. If inaccurate information is released, the board will promptly correct such error; however, it is unlawful for the board to withhold all information in its possession that is public record.

NEW REGULATION FOR PHYSICIAN COLLABORATION WITH ADVANCED PRACTITIONERS OF NURSING

Effective March 30, 1998, new regulations of the Nevada State Board of Medical Examiners regulate the advanced practitioner of nursing's collaborating physician's relationship to the advanced practitioner of nursing. The relationship is no longer designated as one of "supervision," but is now one of "collaboration." Please refer to the new regulations, NAC 630.490 and 630.495, for complete details.

The board will be providing instructions to collaborating physicians with respect to approval and payment of the required fee between now and July 1, 1998. Effective July 1, 1998, all collaborating physicians must have obtained approval from the board and paid the required fee. The fee to be charged by the board will be $200 for a biennium, or $100 per year. If a physician is already approved by the board as a supervising physician for a physician assistant and has paid the fee, no further fee will be required. All other physicians who wish to collaborate with an advanced practitioner of nursing must, by July 1, 1998, be approved by the board and pay the fee of $100 for the balance of this biennial registration period. This means that the protocol between the physician and the advanced practitioner of nursing must be submitted to the board as a part of the approval process prior to July 1, 1998. As indicated above, further written instructions and information will be forthcoming from the board.

LICENSURE STATISTICS - M.D.'S

For year 1997 there were 4610 physicians holding licensure in Nevada. Of these, 2760 were actively practicing within the state, an additional 676 doctors held active licenses but did not reside in Nevada, and the remaining 1174 physicians registered their licenses in inactive and/or retired status. 442 physicians were licensed for the first time by the BME during 1997. The chart below reflects a breakdown of the number of licensed physicians practicing in Nevada, by county from 1987 through 1997.

LICENSURE / POPULATION STATISTICS - M.D.'S

1980 - 1997 (18 YEARS):

PHYSICIAN ASSISTANT STATISTICS

As of year end 1997, there were 113 physician assistants licensed to practice within the state. The counties in which the P.A.'s practiced were:

PHYSICIANS LICENSED TO PRACTICE IN MEDICALLY UNDERSERVED AREAS OF NEVADA FROM JULY 1987 THROUGH DECEMBER 1997

1) 30 restricted licenses issued under NRS 630.164 (rural exemption)

2) 56 temporary licenses issued to physicians in medically underserved rural areas

3) 80 unrestricted licenses issued to physicians in medically underserved rural areas

4) 37 temporary licenses issued to physicians in medically underserved urban areas

5) 21 unrestricted licenses issued to physicians in medically underserved urban areas

DISCIPLINARY ACTIONS TAKEN AGAINST M.D.'S AS REPORTED TO THE FEDERATION OF STATE MEDICAL BOARDS

* MISCELLANEOUS actions include:

• License Restriction
• Public Reprimand
• Licensure Denied
• CME Ordered
• Drug or Alcohol Treatment Program Ordered
• Voluntary Surrender or Retirement of License Ordered
• Competency Exams (Medical, Physical, Mental) Ordered

NEVADA STATE BOARD OF MEDICAL EXAMINERS DIVERSION PROGRAM

By: F. Victor Rueckl, M.D., Director, Nevada Health Professionals Assistance Foundation

Why intervene on physicians?

What stops physicians from voluntarily entering addiction treatment?

For anyone associated with medicine, the above are two frequently asked questions. The answer lies in complex, interrelated denial systems at work in the lives of physicians, which set up tremendous resistance to entering treatment for chemical dependency.

Even though physicians are taught in medical school that alcoholism and drug addiction are diseases, they still don't believe it until they have it and receive treatment. Physicians are no different than other members of our society who believe addiction is a weakness, a moral issue, or just plain stupidity.

Physicians are by training, controllers. They are taught to take control of situations, to diagnose and treat, and to be infallible. They believe they certainly know too much about medicine to become addicts, and even if it did happen, they can handle it anyway. Physicians frequently have problems with arrogance and entitlement leading to a state of "M.D.ity." Physicians believe they are different than other drug addicts and alcoholics because of their socioeconomic status. After all, their drugs are legal. Self prescribing is rampant and accepted in the medical profession. It is not uncommon to find pharmacies filling prescriptions for M.D.s even though the acts of writing the script and filling the script are both against the law. Physicians have easy access to drugs and enabling systems around them which cover up their problems.

The family is often the first to be affected by the physician's addiction and the last to stop enabling the behavior. Family members can be the most difficult ones to break through their denial, often carrying their denial long after the physician himself has been through treatment and accepts his disease and recovery. Family members fight interventions in similar ways as the physician himself. When confronted with the physician's problem, family members often respond: "He can't be an addict, he's a great doctor or husband or father or provider." "He's just stressed." "He works too hard." "He never misses work." "He is so concerned with others that he forgets himself." "He's too smart." "Isn't he entitled to a few drinks every night?" "He's earned it."

Office staff and partners fall into the same patterns as family members, often enabling the behavior long after they know the physician is using drugs. They cover up for him when he is unable to perform and when he is performing while impaired.

Why is this denial so prevalent? It's really very obvious: ego and fear. No one wants to suffer the embarrassment, humiliation, or to bear the social stigmas of alcoholism and drug addiction. Everyone involved is afraid. M.D.s' families fear losing their father or husband or financial provider, their community status, and/or their family name. Office staff fear losing their jobs. Partners fear loss of patients and income, losing a partner, and an increased daily work load, including night and weekend calls.

What can be done to overcome fear and denial? Medical staffs, families of physicians and, most importantly, physicians themselves need to be educated about physician assistance and diversion. Nevada has a tremendous support system established for physicians with addictions. The Nevada State Board of Medical Examiners "diverts" chemically dependent physicians away from formal board disciplinary action toward rehabilitation. Only two physicians have ever lost their licenses from chemical dependency in Nevada. One continues to use drugs despite four treatments, and one refused treatment. Nine physicians have graduated from five year contracts with diversion in the last 2 years. Forty-four physicians are currently under 5 year monitoring contracts and are doing well. Five physicians are currently in treatment. The Nevada State Board of Medical Examiners does not know who they are or care who they are, just that they are in recovery and being monitored.

In November 1997, one of our Nevada physicians died from an overdose of narcotics. Intervention was attempted six or seven years ago, but it was unsuccessful due to all the denial systems discussed above. By the time his denial systems were finally overcome and he entered treatment, his mind was too far gone to recover. I had known him for thirty-seven years. He was a friend of mine. I hope his death helps others to recover.

Do you know a colleague who needs help?
Call the Diversion Program for confidential, expert assistance:

In Reno: Vic Rueckl at 775/742-1171
In Las Vegas: Jim Tracy at 702/257-9005 or 702/595-7777

ATTENTION PHYSICIAN ASSISTANTS AND SUPERVISING PHYSICIANS

By: Elizabeth J. Pawlikowski, Investigator

The Nevada State Board of Medical Examiners currently has 124 licensed physician assistants and 298 approved supervising physicians.

Investigators for the board have recently completed their annual routine visits with physician assistants in the state. These visits occur to ensure that the physician assistants are properly identifying themselves to their patients, practicing within the same scope of practice as their supervising physician, and that the supervising physician is signing off on the records of the patients.

A change to NAC 630.370(2) was effective March 30, 1998. Supervising physicians will no longer be required to sign off on all patient records. The new regulation provides:

Except as otherwise required in subsections 3 and 4, the supervising physician shall review and initial selected charts of the patients of the physician's assistant. He shall be available at all times that his physician's assistant is providing medical services, to consult with his assistant. Those consultations may be indirect, including , without limitation, by telephone.

Disciplinary action can be taken against a physician assistant if, after notice and a hearing, the board determines that any of the provisions of NAC Chapter 630 have been violated by the physician assistant. If you have any questions regarding the current regulations and/or wish to obtain a copy, you may do so by writing the board office at PO Box 7238, Reno, NV 89510 or by calling 775/688-2559 or 702/486-6244 from the Las Vegas area.

LICENSURE ELIGIBILITY AND THE APPLICATION PROCESS

By: Rebecca A. Gaul-Richard, License Specialist; Betty L. Tonner, License Specialist; and Elizabeth A. Zarubi, License Specialist

Since the 1985 legislative session, Nevada's three years of postgraduate training requirement has been the most stringent postgraduate requirement for licensure in the nation. Since 1990, board regulation has required that licensure applicants have shown competency in the form of either licensure examination or board certification, within 10 years of their licensure application. In addition, the board performs an in-depth licensing investigation and inquiry on every applicant for licensure in this state.

At this time of the year, many of you will look to hiring graduating residents and fellows of the United Sates and Canadian postgraduate programs, plus the hiring of additional experienced physicians for your practices. Too often we find that physicians calling for an application for medical licensure have previously received incorrect information regarding Nevada requirements.

As you begin your interview and hiring process, please read below the current licensure requirements. The person you may desire to interview and/or hire may not even be eligible for a medical license or may need to pass a competency examination in order to meet eligibility requirements. Reading this information will save time for you and the prospects involved, and may even expedite the application process itself.

Please refer to Nevada Revised Statutes 630.160, 630.195 and 630.164, and Nevada Administrative Code 630.080 for an outline of licensure requirements for the State of Nevada:

You may contact the board office at 775/688-2559 in Reno or from Las Vegas at 702/486-6244. Also, the licensure requirements can be obtained through the board web site at www.state.nv.us/medical/.

Please feel free to contact the following license specialists for information on obtaining medical licensure in Nevada:

• Rebecca A. Gaul-Richard - if the applicant's last name begins with A-G
• Elizabeth A. Zarubi - if the applicant's last name begins with H-O
• Betty L. Tonner - if the applicant's last name begins with P-Z

Special licensing rules also apply to licensed out-of-state physicians who wish to come into Nevada to provide medical training or patient consultations. If you have questions regarding these types of licensing situations, contact the board office for specific information.

NEW ETHICS AND PRACTICE-ORIENTED CME REQUIREMENTS

By: Elizabeth A. Zarubi, License Specialist

Physicians are currently required to provide the board with proof of 40 hours CME, Category I AMA approved, for each biennial registration period. Effective March 30, 1998, of the 40 hour requirement, physicians will be required to provide 2 of the 40 hours in medical ethics and 20 of the 40 hours in the physician's scope of practice or specialty. Physicians will be required to comply with this new CME requirement when re-registering for the biennial registration period beginning July 1, 1999 through June 30, 2001. Physicians must, therefore, complete this required CME prior to June 30, 1999.

APPEAL OF BOARD DISCIPLINARY ACTIONS

By: Leslie A. Nielsen, J.D. Senior Deputy Attorney General

Although the courts have never recognized a constitutional right to appeal a professional licensing board's disciplinary order, such a right exists by statute in Nevada and in most other states. Our Administrative Procedures Act allows for an appeal of the board's disciplinary actions first to Nevada's District Courts and then to the Nevada Supreme Court. The board as well as a physician or physician assistant disciplined may appeal any decision of the district Court to the Nevada Supreme Court.

The procedure is known as "judicial review" and is instituted by filing a petition in District Court within 30 days after service of the board's decision. Neither court may order a stay of the board's decision pending judicial review, and petitions for judicial review are entitled to priority over other civil matters.

The board is responsible for preparing a transcript of the hearing and submitting it along with the other evidence to District Court. Both the District Court and the Supreme Court are confined to this "administrative record" on judicial review. The parties prepare and submit written briefs, and the courts often allow oral argument. The courts may remand the matter to the board to consider additional evidence, however, no new evidence is taken by the courts.

The board's decision may be reversed if "substantial rights of the [licensee] have been prejudiced" because the board's decision is violative of constitutional or statutory law, "clearly erroneous" in view of substantial evidence, "arbitrary or capricious," or is characterized by an "abuse of discretion." This has been interpreted to mean that a court must show a degree of deference to the board's decision, and the court may not substitute its judgment for the board's judgment, particularly on issues of credibility of witnesses and what weight to give to witness testimony. This rather narrow scope of review recognizes the value of the board's specialized knowledge, yet provides for limited judicial inquiry into board action.

DOMESTIC VIOLENCE AND HEALTH CARE: A NEW ERA

By: Attorney General Frankie Sue Del Papa, Office of the Attorney General

Nevada has been chosen as one of only 10 states in the nation to develop a more comprehensive model program to respond to domestic violence within the health care system. As Chair of Nevada's 25 member Domestic Violence Prevention Council, I see this as both great news for victims, and an excellent opportunity for the health care community to collectively work toward an integrated, coordinated response.

Nevada was selected by the Family Violence Prevention Fund, (the FUND), a national non-profit organization whose mission is to help reduce family violence in America. The FUND, which has been in existence over 15 years, created the National Health Initiative on Domestic Violence with a long term goal that the health care system in 10 selected states, including Nevada, will have a comprehensive and integrated response to domestic violence by the end of March in the year 2000. The project is being supported by a grant from the Conrad N. Hilton Foundation.

The National Health Initiative places a heavy emphasis on training. The FUND has developed and tested a rigorous training regimen which is built around the participation of multi-disciplinary terms representing administrators, physicians, nurses, social workers and advocates. The goal of the training is to teach health care providers about domestic violence and to institutionalize protocols throughout the institution which require broad-based screening, intervention and referral for victims of domestic violence.

A major effort is being undertaken immediately to reach out to Nevada's health care professionals, advocates and others to see how we can best collaborate and cooperate to inventory the programming underway, to assess the unmet needs, to rank Nevada's priorities and determine what we can individually and collectively bring to the table to be involved in this project.

At the end of March 2000, the expectation is that in each of the 10 states the following would have occurred:

• Establishment of a Health Care and Domestic Violence Leadership Team committed to achieving a comprehensive response to domestic violence within the state's health care system.
• Establishment of interdisciplinary model programs in 15 health care systems/facilities that includes training and follow-up technical assistance.
• Development of a long range plan for expanding this work throughout the state.
• Development of a long range plan for addressing public policy issues related to health care and domestic violence.
• Establishment of increased media coverage around health care response to domestic violence and the state's organizing activities.
• Development of an evaluation plan for the project with the Family Violence Prevention Fund.

Research conducted by the FUND demonstrates that if domestic violence prevention activities are to become institutionalized across the health care system, active and viable leadership from key opinion leaders at all levels and across many disciplines - is vital.

The Office of the Attorney General has reviewed the previous efforts undertaken including the Emergency Room Protocols developed in response to the significant numbers of battered women who seek hospital emergency room care. Additionally, Drs. Ralph Mayer and Kitty Glantz, members of Nevada's Domestic Violence Prevention Council, have developed an informational card known as the "RADAR card," 30,000 of which are in the process of distribution to Nevada's health care community.

The Attorney General's office will work closely with Sue Meuschke, Executive Director of the Nevada Network Against Domestic Violence and Yvonne Sylva, Administrator of Nevada's Health Division, among others, to make Nevada's plan both comprehensive and inclusive. Too many families and individuals suffer needlessly from the often tragic effects of domestic violence. Unfortunately, if the cycle is not broken, the violence is likely to continue in generation after generation. But, with an enhanced and coordinated effort, we can make more of a difference in the lives of victims, in neighborhoods, communities and ultimately, in our state.

Sue Meuschke said, "this is a great opportunity for the Nevada health care community to provide important intervention in this crisis of domestic violence."

Yvonne Sylva said, "Domestic violence has become a recognized public health concern contributing to Nevada's high injury and death rates. The Health Division looks forward to the opportunity to work with all of the partners in this project to provide early identification and intervention to stop the epidemic of violence in our society."

We will be working with the FUND over the next 2 months to formalize a leadership team and outline a preliminary plan for the state. In the meantime, the office is mailing a letter and information to dozens of health organizations, associations and practitioners as well as victims' advocates and and other community leaders to seek ideas and recruit participation on the Domestic Violence and Health Care Leadership Team and for the Action Plan.

This is an opportunity to have a direct impact on this important societal issue, and we encourage and welcome suggestions, comments and participation from any interested party.

I encourage all of you to obtain a laminated "RADAR card" from my office by calling 775/687-3510. The card will help with screening, identifying and documenting these cases and, ultimately, may help to cure the problem through referrals and criminal prosecution. If well documented, live medical testimony may not be necessary in court. Not only are these patients victims of crime, but their children warrant protection as well.

BOARD DISCIPLINARY ACTIONS OCTOBER, 1997 THROUGH MARCH, 1998

LIM, Ranulfo Y., M.D.

Complaint Filed: 8/29/97 - Charged with 1 count of violation of NRS 630.301(3) modification and/or limitation of license to practice medicine in the state of California; 1 count of violation of NRS 630.306(11) failure to notify the board of the action taken against his license to practice medicine in the state of California; 1 count of violation of NRS 630.304(1)attempting to renew a license to practice medicine by fraud or misrepresentation or false, misleading, inaccurate or incomplete statement; and 1 count of violation of NRS 630.306(2)(a) engaging in conduct intended to deceive the board.

Board Action: 12/6/97 - The board found Dr. Lim guilty of all counts of the Complaint and revoked his license to practice medicine in the state of Nevada.

MCQUILLAN, Bernard P., M.D.

Complaint Filed: 8/29/97 - Charged with 1 count of violation of NRS 630.305(5) aiding, assisting, employing or advising, directly or indirectly, any unlicensed person to engage in the practice of medicine contrary to the provisions of chapter 630 of the Nevada Revised Statutes or the regulations of the board; 1 count of violation of NRS 630.306(2)(b) engaging in any conduct which the board has determined is a violation of the standards of practice established by regulation of the board, namely, NAC 630.230(1)(f) writing a prescription for controlled substances for any person without an appropriate examination which confirms the medical necessity for the controlled substance; and 1 count of violation of NRS 630.306(2)(a) engaging in conduct intended to deceive the board.

Board Action: 12/6/97 -The board found Dr. McQuillan guilty only of 1 count of violation of NRS 630.305(5), and ordered that he receive a written public reprimand.

ROBERTSON, MacArthur M., M.D.

Complaint Filed: 9/26/97 - Charged with 1 count of violation of NRS 630.301(3) surrender of license to practice medicine in the state of California while under investigation by the licensing authority of the state of California.

Board Action: 12/6/97 - The board found Dr. Robertson guilty and ordered that he receive a written public reprimand; that he pay the costs of the investigation and presentation of the case incurred by the board in the amount of $1,440.00, payment in full due 30 days from the date of the order; and that he be given and be required to pass a competency examination in the field of practice within which he is currently engaged.

SCHIEVE, Donald R., M.D.

Complaint Filed: 8/29/97 - Charged with 1 count of violation of NRS 630.3065(2)(a) willful failure to comply with an order of the board.

Board Action: 12/6/97 - The board found Dr. Schieve guilty and revoked his license to practice medicine in the state of Nevada.

PUBLIC REPRIMANDS ORDERED BY THE BOARD

MACARTHUR M. ROBERTSON, M.D.

Dear Dr. Robertson:

On December 6, 1997, the Nevada State Board of Medical Examiners found you guilty of surrendering your license to practice medicine in the state of California while under investigation.

The board ordered that you pay the costs of the investigation and presentation of the case incurred by the board in the amount of ONE THOUSAND FOUR HUNDRED FORTY DOLLARS ($1,440.00), that you be required to pass a competency examination in the field of practice within which you are currently engaged, and that you be issued a public reprimand.

Accordingly, it is my unpleasant duty as President of the Nevada State Board of Medical Examiners to formally and publicly reprimand you for your conduct which has brought personal and professional discredit upon you, and which reflects unfavorably upon the medical profession as a whole.

Rex T. Baggett, M.D.

President

BERNARD P. MCQUILLAN, M.D.

Dear Dr. McQuillan:

On December 6, 1997, the Nevada State Board of Medical Examiners found you guilty of aiding, assisting, employing, or advising, directly or indirectly, Rosa Bascon Loyola, a person who did not have a license to practice medicine in the state of Nevada, to practice medicine.

The board ordered that you be issued a public reprimand as a result of the finding of the board that you were guilty as set out above.

Accordingly, it is my unpleasant duty as President of the Nevada State Board of Medical Examiners to formally and publicly reprimand you for your conduct which has brought personal and professional discredit upon you, and which reflects unfavorably upon the medical profession as a whole.

Rex T. Baggett, M.D.

President

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