ARIZONA
MEDICAL BOARD
9545
East Doubletree Ranch Road, Scottsdale,
Arizona 85258
EXPLANATION OF BOARD ACTIONS AND OVERVIEW
OF COMPLAINT CATEGORIES (SPS 9)
TThe
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
B)
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.(a)
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.(b)
Toll:
To suspend or stop temporarily.(c)
COMPLAINT
CATEGORIES
Complaints
to the Board fall roughly into the following
categories:
1.
Moral and Ethical (including prescribing
and dispensing issues)
2.
Legal Errors
3.
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.
(a)
City
Court of Tucson v. Lee, 16 Ariz.
App. 449, 452 (1972). Arizona courts
have held that kidnapping, sexual assault,
theft, fraud, embezzlement and forgery
involve moral turpitude. They have also
held that reckless driving, simple assault
and disorderly conduct and possession
of marijuana do not. Solicitation of
prostitution can also be classified
as an act of moral turpitude because
it involves an offense that is significantly
offensive to community moral standards.
State ex rel. Dean v. Dolny, 161 Ariz.
361, 363 (App. 1984).
(b)
Black’s Law Dictionary with Pronunciations,
Abridged Fifth Edition, 1983
(c)
Black’s
Law Dictionary with Pronunciations,
Abridged Fifth Edition, 1983