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The Arizona Medical Board and the Medical Practice Act

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The Arizona Medical Board and the Medical Practice Act Powered By Docstoc
					The Arizona Medical Board and the
       Medical Practice Act




             William Wolf, MD, FACS
            Chief Medical Consultant
             Arizona Medical Board
        Arizona Medical Board
• Established by legislature in 1903 as BOMEX
• Tasked to medically protect the health and
  safety of Arizona citizens
• 8 MDs and 4 public members of which one is a
  nurse
• Appointed by the Governor and approved by
  the legislature
Medical Practice Act
          Medical Practice Act
• Governs Licensure of MD’s (not DO’s in AZ)
• Somewhat different in different states
           Medical Practice Act
• Most useful part to you is list of definitions of
  “unprofessional conduct”
• 47 of them from (a) to (uu)
• www.azmd.gov
      Medical Practice Act
              (z)


(z) deals with sexual conduct with patients
                    Case 1
• Megan Fox calls you for a date 3 weeks after
  you treat her for a sprained ankle.

• What do you do?
          Medical Practice Act
• (z) = sexual misconduct
• Unprofessional conduct to engage in sexual
  conduct with a current or former patient until
  6 months after physician-patient relationship
  was terminated unless you were already
  married, engaged or in a dating relationship
• Rules are different in other states
           Medical Practice Act
                   (z)
How do you (and the Board) know when the
physician-patient relationship has terminated?

• Date of last visit?
• Not necessarily!
• Better get it documented on the chart to avoid
  “He said-She said”
    “z”: What is sexual conduct?
• Engaging in or soliciting sexual relationships
• Making sexual advances (even if consensual)
• Viewing a completely or partially disrobed
  patient if the viewing is not related to
  diagnosis or treatment
                       (z)


• How can I get into trouble if everything is
  consensual and discreet?
(z) : Buyer’s Remorse
  What’s the Standard of Evidence in
  Physician unprofessional conduct?
• Reasonable doubt?
  What’s the Standard of Evidence in
  Physician unprofessional conduct?
• Reasonable doubt?
• Clear and convincing?
  What’s the Standard of Evidence in
  Physician unprofessional conduct?
• Reasonable doubt?
• Clear and convincing?
• Preponderance of evidence?
What’s the Standard of Evidence in
Physician unprofessional conduct?



Preponderance of evidence!
             (more than 50%)
         Medical Practice Act:
         Common Violations

             Enough about (z)!



• (e)
• (q)
• (ll)
(e): Failing or refusing to maintain
  adequate records on a patient



       What the heck are adequate records?
                      (e)
• According to the MPA, "Adequate records"
  means legible medical records containing, at a
  minimum, sufficient information to identify
  the patient, support the diagnosis, justify the
  treatment, accurately document the results,
  indicate advice and cautionary warnings
  provided to the patient and provide sufficient
  information for another practitioner to
  assume continuity of the patient's care at any
  point in the course of treatment.
                     (e)

• Could another doc take over?
        Most Common Violations
     (e) : Adequate medical records



• Not just important for the patient
• Important to you and your career as well
     (e) : Adequate medical records
           Common allegations
• The doctor didn’t tell me this was a possible
  complication of that drug
• The doctor didn’t tell me this was a possible
  complication of that surgery
• The doctor didn’t tell me that I had to come
  back (or when to come back)

              Write it down!
         “e”: adequate records
• Document phone calls
• If you and the patient agree to add an
  additional procedure to a surgery case, get a
  new consent form signed
• Be detailed in your discussion and
  documentation of risks and complications
                    Case 2
• You are in the hospital making rounds
• A nurse that is your friend has a sore throat
  and wants an antibiotic.

What do you do?
                   Case 2
• Writing the prescription establishes a
  physician—patient relationship
• Have to generate a record—(e)
• Also note (ss)—Unprofessional conduct to
  prescribe a prescription medication unless you
  conduct physical examination (or have
  previously established a doctor-patient
  relationship)
      What if your mom wanted an
               antibiotic?
    Still need:
• Physical exam
• Adequate records
  What if your mom wanted codeine
            cough syrup?


• “h” says: Prescribing or dispensing controlled
  substances to member of the physician’s
  immediate family is unprofessional conduct
   Who’s “immediate family”?
– Spouse
– Natural or adopted children of either the doctor
  or his/her spouse
– Father, mother, brothers, or sisters of either the
  doctor or his/her spouse
        Most Common Violations
• (q): Quality of care. Any practice that might be
  harmful or dangerous is a violation
• (ll): Gross or repeated negligence resulting in
  harm or death



  These are what you went to med school and residency to avoid
       Some avoidable (q) issues
• Failed to follow up on a test
• Failed to tell a patient about the results of a
  test
• Failed to follow a patient often enough
       (q)—Management of Chronic
           Nonmalignant Pain
•   Overdose
•   Underdose
•   Potentiate Addiction
•   Diversion
        (q)—Management of Chronic
            Nonmalignant Pain
•   Evaluation (H & P, Imaging)
•   Old records
•   Early refills
•   Pain Contracts
•   Urine testing
•   Long acting vs. short acting vs. both
        Other Common Violations
                 (f)
• (f) = habitual substance abuse or habitual
  intemperance in the use of alcohol
        Other Common Violations
                 (f)
• (f) = habitual substance abuse or habitual
  intemperance in the use of alcohol
• Must report DUI within ten days

• You are far better off if you report substance
  abuse or dependence yourself than if
  someone else reports you
       Complaint Process

What do you do if someone files a complaint?
             Complaint Process:
             Sources of complaints
•   Patients
•   Patients’ families
•   Malpractice settlements or judgments
•   Other physicians
•   Other providers (nurses, etc.)
•   Hospitals
•   Insurance providers
           Complaint Process:
    Do we even open an investigation?
        Not Always, for example,
• Doctor was rude
• Wrong agency (e.g. DOs, chiropractors, etc.)
• No physician-patient relationship established
• No clear allegation in the complaint
• Claims of abandonment when it is clear that
  physician properly terminated the relationship
• Etc.
          Complaint Process:
• Malpractice settlements and judgments must
  be investigated by law (most dismissed)
              Complaint Process:

So a complaint is filed and an investigation is opened. Now what?

• Investigator formally notifies the physician
  and requests medical records and a response
  (hurry—you are only given two weeks!)
• Investigator gathers other records (hospital,
  other physicians, legal documents, interviews
  of relevant witnesses, etc.)
             Complaint Process
           Medical Consultant’s job
•   State what the standard of care is
•   Tell whether the doc deviated
•   What was the actual harm
•   What was the potential harm
•   Aggravating factors (make “crime” worse)
•   Mitigating factors (make “crime” less bad, or
    more understandable)
                      Harm
• Physician can be deemed to have deviated
  from the standard of care even if there was no
  actual harm but only potential harm

• Different than a malpractice case in which
  plaintiff must prove actual harm

               “Ask a bridge inspector”
                          --Lisa Wynn
            Complaint process
• If the Medical Consultant finds no deviation
  from the Standard of Care, the case is (usually)
  dismissed
• If the Medical Consultant finds a deviation,
  then the whole file is sent to the doc to give
  the doc a chance to respond to the MC’s
  report
           Complaint Process
• Supplemental response (optional, from doc)
• Supplemental report from MC
• SIRC (Staff Investigation Review Committee)
  then reviewed the case and prepares a
  recommendation to the Board
            Complaint process:
      Possible SIRC recommendations
•   Dismiss
•   Advisory Letter (nondisciplinary action)
•   Specific CME (nondisciplinary action)
•   Letter of Reprimand (disciplinary)
•   Practice restriction
•   Revocation (bypasses the Board, goes directly
    to hearing in front of an Administrative Law
    Judge)
          Complaint process:
    Possible SIRC recommendations



• Dismiss (Executive Director)
          Complaint process:
    Possible SIRC recommendations
           (Non-disciplinary)
• Advisory letter
• CME


           Reviewed by the Board
            Complaint process:
      Possible SIRC recommendations
                 (Discipline)
•   Letter of Reprimand
•   Decree of Censure
•   Practice restriction
•   Probation or fine

                 Doc has 3 choices
           Complaint process:
     Possible SIRC recommendations
                (Discipline)
3 choices:

• Accept SIRC’s recommendation (Consent
  Agreement)
• Formal Interview (before the Board)
• Formal Hearing (before an Administrative Law
  Judge)
       Attend a Board Meeting

• Open to the public
• See agendas and schedules at www.azmd.gov
• Eye opening experience
           Complaint process:
    Possible SIRC recommendations:
               Revocation

• Formal Hearing (before ALJ)
• Consent for license surrender
Complaint process:




       So What?
        Complaint Process

Back to the question:

What do you do if someone files a complaint?
                 Remember
• Board’s mission is to protect the public
• The Board is not out to get you
• About 80% of cases are dismissed
 Steps to Respond to a Complaint
• Review the complaint and allegations
• Decide whether to get an attorney
• Gather your records (make sure you send all
  your records)
• Prepare your response
• If you need more time, call the investigator
  (you’ll almost always get it)
Important!
          Filling out Applications
•   Licensure
•   Hospital privileges
•   Outpatient facility privileges
•   Participation in insurance programs
        Filling out Applications
• Fill them out personally, or at least check
  them very carefully for accuracy
• Make sure all questions and checkboxes have
  been answered truthfully and completely,
  with full disclosure
• Relevant items in the Medical Practice Act are
  (t) and (aa)
• “My nurse filled it out” cuts no ice with the
  Board or the courts
         Filling out Applications
         If you have questions:


Board staff (including me) can’t provide legal
  advice, but can help advise you about whether
  something from your past should be disclosed
  on an application.
“Their r no stoopid kweschuns.”



        Latin translation:
        “Ten points from Gryffindor”

				
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Description: Established by legislature in 1903 as BOMEX Tasked to medically protect the health and safety of Arizona citizens 8 MDs and 4 public members of which one is a nurse Appointed by the Governor and approved by the legislature