NOTICE OF AGENCY
SUBSTANTIVE POLICY STATEMENT #9
The Arizona Medical Board
9545 East Doubletree Ranch Road, Scottsdale, Arizona 85258
1. Title of the guidance document or subject of the substantive policy
statement and the guidance document number or substantive policy statement
number by which the document or policy statement is referenced:
Explanation of Board Actions and Overview of Complaint Categories
(SPS #9)
2. Date of the application of the guidance documents or the date
the substantive policy statement was issued and the effective date
of the document or policy statement if different from the publication
or issuance date:
Adopted on May 14, 2003; awaiting publication.
3. Summary of the contents of the guidance document or the substantive
policy statement:
The Board adopted disciplinary rules to inform the public
and licensees of possible sanctions for acts of unprofessional conduct.
See A.A.C. R4-16-501 et seq. The Board has prepared this guideline
as an explanation of Board actions and an overview of complaint categories
to further assist the public and licensees by explaining the actions
the Board may take, defining what those actions are and presenting
an overview of the complaint categories the Board adjudicates.
4. A statement as to whether the guidance document or substantive
policy statement is a new document or statement, or a revision:
New Statement
5. The name, address and telephone number of the person to whom questions
and comments about the guidance document or substantive policy statement
may be directed:
Legislative Liaison
Arizona Medical Board
9545 East Doubletree Ranch Roach
Scottsdale, Arizona 85258
(480) 551-2700
6. Information about where a person may obtain a copy of the guidance
document or the substantive policy statement and the costs for obtaining
the document or policy statement:
Copies of all guidance documents and substantive policy
statements referenced are available from the Arizona Medical Board
through its web site at www.azmdboard.org, or by phoning, writing
or visiting the Arizona Medical Board at the address given above.
A nominal fee may be charged for photocopies.
This substantive policy statement is advisory
only. A substantive policy statement does not include internal procedural
documents that only affect the internal procedures of the agency and
does not impose additional requirements or penalties on regulated
parties or include confidential information or rules made in accordance
with the Arizona administrative procedure act. If you believe that
this substantive policy statement does impose additional requirements
or penalties on regulated parties you may petition the agency under
Arizona Revised Statutes section 41-1033 for a review of the statement.
ARIZONA MEDICAL BOARD
SUBSTANTIVE POLICY STATEMENT #9
Explanation Of Board Actions
And Overview Of Complaint Categories
The Board has adopted disciplinary rules to inform the public and
licensees of possible sanctions for acts of unprofessional conduct.
The Board has prepared this explanation of Board actions and overview
of complaint categories to further assist the public and licensees
by explaining the actions the Board may take, defining what those
actions are and presenting an overview of the complaint categories
the Board adjudicates.
The actions of the Board may be broadly defined as follows:
a. Mandating remedial measures and/or limiting or restricting the
practice of physicians who are or may be unable to safely practice
medicine.
b. Permanently removing from practice physicians who cannot be,
or refuse to be remediated, and/or those who demonstrate a repetitive
pattern of errors that endanger the public and/or those who engage
in egregious violations of the Medical Practice Act.
c. Taking appropriate remedial or disciplinary action against physicians
who have made an isolated technical or judgment error.
d. Taking appropriate disciplinary or non-disciplinary measures
against physicians who violate statutes not involving quality of
care.
e. Remediating or removing from practice physicians who lack the
moral and ethical standards appropriate for the practice of medicine.
DEFINITIONS
Board Action Definitions
Advisory Letter: a non-disciplinary letter to
notify a physician that either:
a. While there is insufficient evidence to support disciplinary
action, the Board believes that continuation of the activities
that led to the investigation may result in further Board action
against a physician.
b. The violation is a minor or technical violation that is not
of sufficient merit to warrant disciplinary action.
c. While a physician has demonstrated substantial compliance
through rehabilitation or remediation that has mitigated the need
for disciplinary action, the Board believes that repetition of
the activities that led to the investigation may result in further
Board action against a physician.
The issuance of an advisory letter is not an appealable action.
However, a physician may file a written response to the advisory
letter. The response becomes a part of the physician’s file.
Probation: a disciplinary action designed to assist
a physician in remediating violations of the Medical Practice Act,
and/or to provide the Board and the public with a mechanism for
monitoring a physician's continuing practice to assure that the
issues of concern are rectified and are not repetitive. Probation
may be ordered as an independent disciplinary action or:
a. in combination with additional continuing medical education;
or
b. in combination with another disciplinary action.
Letter of Reprimand: a disciplinary action issued
for violations of the standard of care and/or other violations of
the Medical Practice Act, including violations of a technical nature
and isolated violations. The violations may or may not involve patient
harm and generally do not involve issues of serious moral or ethical
lapses in conduct or repetitive issues.
Decree of Censure: a disciplinary action issued
for serious or repetitive deviations from the standard of care and/or
the Medical Practice Act on the part of a physician that may, or
did, cause serious harm to a patient or to the public. A Decree
of Censure may also be issued when there have been serious moral
and ethical lapses in conduct.
Summary Restriction: (“Cease and Desist”):
a disciplinary action that immediately suspends an aspect of a physician’s
practice pending a formal hearing.
Suspension: a disciplinary action that prohibits
a physician from practicing for a defined period of time that may
be imposed when a physician has not remediated prior unprofessional
conduct or when a specific act is particularly egregious. Suspension
may also be used when a physician commits an act of medical fraud
and/or derives monetary benefit from the unprofessional conduct.
Suspension is also used when there is a serious quality of care
or behavioral issue requiring remediation prior to the resumption
of active practice. A suspension can be imposed for up to 12 months
without a formal hearing.
Inactive With Cause: A disciplinary action for
a physician who is impaired by drug or alcohol abuse and who was
under a Board Stipulation or Probationary Order that is no longer
in effect. The Board may reactivate the license upon the physician’s
successful completion of a diversion program.
Surrender: a disciplinary action entered into
voluntarily by a physician and voted upon by the Board that immediately
surrenders a physician’s license. A physician must admit to
being unable to safely engage in the practice of medicine, to having
committed an act of unprofessional conduct, or to having violated
the Medical Practice Act or a Board rule. In order to again practice
medicine in Arizona, a physician must wait 5 years and reapply for
a license. Surrender is an alternative to Revocation.
Summary Suspension: a disciplinary action that
immediately removes a physician from practice pending a formal hearing
when there is evidence of an imminent danger to the public health
and safety if a physician were to remain in practice during the
normal complaint resolution or formal hearing process.
Revocation: a disciplinary action that rescinds
a physician’s license when a violation of the Medical Practice
Act involves severe moral turpitude or ethical misconduct, or the
physician is unable to safely practice medicine and other remedial
actions have either failed or are unlikely to be successful. The
Board also revokes a license in instances of gross or repetitive
incompetence and/or gross or repetitive negligence.
Other Definitions
Disciplinary Action: An action taken by the Board
against a physician when there is evidence that the physician violated
the Medical Practice Act.
Standard of Care: The care and treatment of patients
that demonstrates a level of skill, judgment, knowledge, and documentation
ordinarily exercised by a physician with similar background, training,
and experience in a similar practice setting. Standard of care does
not require perfection.
Moral turpitude: Conduct on the part of a physician
that is contrary to justice, honesty, modesty or good morals. Moral
Turpitude is described as "an act of depravity and baseness".
It usually connotes a fraudulent or dishonest intent.
Negligence: Failure to exercise that degree of
care, skill and learning expected of a reasonably prudent physician
or specialist in Arizona acting in the same or similar circumstances.
See A.R.S. § 12-563.
Gross Negligence: Is an extreme departure from
the standard of care; or conduct the physician knows or should know
involves a high degree of probability that substantial harm will
result; or is the product of reckless indifference to the results
of an act.
Incompetence: Lacking sufficient knowledge or
skills, or both, to a degree likely to endanger the health of patients.
It is also the inability to perform physically or mentally.
Remediation: A program or probationary term requiring
physician retraining in current standards of care in the practice
of medicine. Typically, the remediation period reflects the level
of retraining necessary in order to protect the public’s health
and safety.
Consent Agreement: A written agreement between
a physician and the Board closing an open investigation prior to
or following a formal interview or formal hearing. A consent agreement
contains language waiving a physician’s right of appeal. A
consent agreement may be non-disciplinary if it is entered to resolve
issues involving physical or mental disabilities of a physician.
Preponderance of Evidence: Evidence of greater
weight or more convincing than evidence offered in opposition to
it; evidence that as a whole shows that the fact sought to be proved
is more probable than not.
Toll: To suspend or stop temporarily.
COMPLAINT CATEGORIES
Complaints to the Board fall roughly into the following categories:
- Moral and Ethical (including prescribing and dispensing issues)
- Legal Errors
- Standard of Care
a. Technical Errors
b. System and Documentation Issues
c. Cognitive Errors or Performance Issues
4. Behavioral and Health
a. Substance Abuse/Chemical Dependency
b. Psychiatric Impairment/ Behavioral Disorders
c. Physical and Mental Impairment
Board complaints may fall into more than one category and involve
the violation of more than one category of unprofessional conduct.
1. Moral and Ethical
If an investigation sustains a moral or ethical violation, the
Board may consider the egregiousness of the offense and whether
or not it is likely to reoccur. The following are examples of moral
and ethical violations not involving prescribing and dispensing
violations. They include, but are not limited to:
a. Sexual misconduct with a patient
b. Commission of a felony, or of a misdemeanor involving moral
turpitude
c. Fraudulent billing
d. False or fraudulent statement in connection with the practice
of medicine
e. False or fraudulent statement to the Board or in a credentialing
application or during the course of an investigation.
Prescribing and Dispensing violations are generally considered
moral and ethical violations. A physician who violates prescribing,
dispensing, or other statutes to procure substances for abuse may
be subject to discipline.
2. Legal Errors
Legal Errors refer to violations of law that do not implicate the
quality of care rendered to a patient. They include, but are not
limited to:
a. Failure to transfer records in a timely fashion
b. Failure to notify the Board of an address change
c. False advertising
d. Violations of statutes regarding fees
e. Violations of Board orders.
3. Standard Of Care
Complaints involving the standard of care encompass the bulk of
the Board's complaints and may arise from cognitive/performance
issues involving a physician, system and documentation issues, and
technical errors.
a. Technical Errors
Technical errors arise when performing procedures or surgery.
b. System and Documentation Issues
System and documentation issues include, but are not limited
to:
a. Record keeping failures or deficiencies
b. Failure to follow-up lab and X-ray reports
c. Failure to institute procedures to appropriately triage patients
for timely appointments and treatment.
The Board frequently reviews charts with documentation that is
inadequate to define and evaluate the patient's complaint. Sparse
history of present illness and absent or extremely abbreviated
physical exams are also grounds for Board action.
c. Cognitive Errors or Performance Issues
Cognitive Errors or Performance Issues involve judgment, medical
decision-making, a physician's fund of knowledge, and the application
of each to individual patients. Almost all complaints involve
some element of medical decision-making and the quality of a physician's
judgment.
The major elements that the Board may consider in dealing with
cognitive errors are whether the incident is isolated or repetitive,
and the degree to which it departs from the standard of care.
The Board may also consider whether there are issues of overall
competence involved and whether or not these are likely to be
remediable.
If the complaint involves cognitive or performance issues, the
Board may consider ordering a physician to undergo any of the
following assessments before determining whether disciplinary
action is appropriate:
- Special Purpose Examination (SPEX): SPEX
is a computer-administered examination of approximately 420
multiple-choice questions that assess knowledge required of
all physicians, regardless of specialty. It is used by the Board
to determine basic competency issues.
- Post-Licensure Assessment System (PLAS):
PLAS is a comprehensive system used to profile a physician’s
clinical performance and competency. The PLAS system utilizes
computer based multiple-choice questions, computer based patient
simulations, standardized patients, structured oral examinations,
chart simulated recall interviews and other established methods
of evaluation.
- Physician Assessment and Clinical Education Program
(PACE): PACE is a two-day program that assesses mental
health; neuropsychological performance; basic clinical and communication
skills common to all physicians; and medical knowledge, skill
and judgment pertaining to the specialty or subspecialty of
the individual physician.
4. Behavioral and Health
Behavioral and health problems involve substance abuse and chemical
dependency, psychiatric impairment, and physical and/or mental impairment.
a. Substance Abuse and Chemical Dependency
A physician who departs from the standard of care because of
chemical dependency or abuse is subject to discipline.
- A physician who relapses after successfully completing
a voluntary confidential diversion program must request
his/her license be Inactivated with Cause. Before the license
is reactivated, a physician must successfully complete long-term
inpatient treatment for substance abuse. The Board considers
requests for reactivation and may place a physician on Probation
that provides that a third offense results in Revocation or
Surrender of License.
- A physician who relapses while currently being monitored
in a voluntary program must enter a Consent Agreement
to not practice medicine until successful completion of long-term
treatment and receiving Board approval to return to the practice.
The Board may then place a physician on Probation that provides
that a third offense results in Revocation or Surrender of
License. If a license is revoked or surrendered a physician
cannot reapply for licensure for 5 years. If a physician refuses
to consent to not practice, the Board may suspend a physician
after notice and an opportunity to be heard.
- If a physician is reported to the Board as a result
of a third party complaint for illegal activities related
to chemical dependency: a physician may be ordered
to undergo further evaluation. Upon completion of the investigation,
a physician may be placed on Probation.
b. Psychiatric Impairment/Behavioral Disorders
Some Board complaints involve the behavioral and/or psychiatric
impairment of a physician. A complaint of alleged psychiatric
impairment requires psychiatric, psychometric, and/or physical
examination of the physician. Probation may be appropriate if
the evaluation determines there is a psychiatric impairment
and the physician refuses to voluntary enter a rehabilitation
agreement or a non-disciplinary practice limitation agreement.
Some physicians demonstrate behavioral problems that may not
be psychiatric impairments but may require Probation if the
physician refuses to voluntary enter a rehabilitation agreement.
For example, Probation mandating anger-management therapy, or
a restriction of work hours.
c. Physical and/or Mental Impairment
Allegation of physical and/or mental impairment may require
physical or psychometric evaluations. Board action to restrict
or remove a physician from practice may be appropriate if the
evaluation determines there is impairment and/or that the physician
is a threat to public health and safety and the physician refuses
to voluntary enter a rehabilitation agreement or a non-disciplinary
practice limitation agreement.