NBME Board Meeting transcript June 4 & 5 2004

1 CODE: 4185

LISA A. YOUNG, CCR #353

2 Peggy Hoogs & Associates

345 Marsh Avenue

3 Reno, Nevada

COURT REPORTER

10 NEVADA STATE BOARD OF MEDICAL EXAMINERS

11 BOARD MEETING

12 TRANSCRIPT OF PROCEEDINGS

13 FRIDAY, JUNE 4, 2004

14 8:30 A.M. - 3:30 P.M.

15 RENO, NEVADA

25 REPORTED BY: LISA A. YOUNG, CCR #353

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 APPEARANCES:

2 MEMBERS OF THE BOARD:

3 CHERYL A. HUG-ENGLISH, M.D., PRESIDENT

JACULINE C. JONES, Ed.D., VICE PRESIDENT

4 DONALD H. BAEPLER, Ph.D., SECRETARY-TREASURER

JOEL N. LUBRITZ, M.D., CHAIRPERSON

5 STEPHEN K. MONTOYA, M.D.

SOHAIL U. ANJUM, M.D.

6 JAVAID ANWAR, M.D.

MARLENE J. KIRCH

7 STEPHEN D. QUINN, J.D., GENERAL COUNSEL

CHAROLOTTE M. BIBLE, CHIEF DEPUTY ATTORNEY GENERAL

DRENNAN A. CLARK, J.D., SPECIAL COUNSEL

9 EDWARD O. COUSINEAU, J.D., DEPUTY GENERAL COUNSEL

LAURIE L. MUNSON, DEPUTY EXECUTIVE SECRETARY

PRESENT IN LAS VEGAS:

11 DON HAVINS, CLARK COUNTY MEDICAL SOCIETY

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 RENO, NEVADA; FRIDAY, JUNE 4, 2004; 8:30 A.M.

2 -o0o-

4 MADAM PRESIDENT: Okay. I'd like to call this

5 meeting of the Nevada State Board of Medical Examiners

6 to order.

7 Welcome to everybody. I think before we get

8 started we do have some introductions of some new staff

9 that I would like Tony to take care of for us.

10 MR. CLARK: Good morning. I'd like to

11 introduce first the newest medical examiner who is

12 assisting Dr. Barnett, Dr. Jerry Calvanese who is on the

13 staff of the Washoe Medical Center in the emergency

14 room.

15 Jerry, would you like to stand up and say a

16 word?

17 DR. CALVANESE: I am now at Northern Nevada,

18 but I was chief of emergency medicine at Triple Army

19 Center. And I was chief of emergency medicine at Washoe

20 for 10 years. And chief of emergency medicine at

21 Northern Nevada for 10 years. So I'm still a working

22 E.R. doc and I'm kind of slowing down a little. This is

23 great because I answered complaints for the last 20

24 years so it kind of falls right into my domain. And

25 it's nice to work for you.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: We certainly appreciate you

2 taking this on. It's a huge help and a real service to

3 the board so we appreciate it.

4 DR. CALVANESE: Thank you.

5 MR. CLARK: I think most of you have already

6 met but let me introduce him officially, Ed Cousineau,

7 who is deputy general counsel who came to us from the

8 attorney general's office.

9 MR. COUSINEAU: Nice to see you all again.

10 You want me to say any words here? The less a lawyer

11 says, the better.

12 MR. CLARK: I never give a lawyer an

13 opportunity to speak. It's always 75 cents a word.

14 And, Lynnette, if you would like to

15 introduce --

16 MS. KROTKE: Good morning. I would like to

17 introduce Jennifer Ross. She is our newest license

18 specialist. And she is doing a great job. So far she

19 is very excited to be here.

20 MADAM PRESIDENT: Welcome, Jennifer.

21 MR. CLARK: And Doug?

22 MR. COOPER: Thanks for allowing us to

23 increase the staff. We greatly appreciate that. You

24 have allowed us to hire three people. We have hired one

25 immediately, and two will start in July.

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1 We hired Angela Hoffman. She has a degree in

2 psychology with an emphasis on criminal justice and

3 comes to us from Cochise County, Arizona where she was a

4 juvenile probation officer.

5 She moved up here because she is getting

6 married in August. And she lives in Carson City. So

7 now we have three people -- four. One guy in Dayton and

8 three in Carson City so we are spreading out.

9 MADAM PRESIDENT: Let's start a car pool here.

10 MR. COOPER: We are very glad to have her.

11 And she is very quick. And I think she is going to be a

12 great asset.

13 MADAM PRESIDENT: Welcome.

14 MR. CLARK: That takes care of it, Madam

15 President.

16 MADAM PRESIDENT: Again, welcome to all our

17 new staff. I think that as we have said on more than

18 one occasion, the workload of this board has increased

19 tremendously and we appreciate all of your efforts.

20 And, people on the board, we certainly welcome you, and

21 I think you will find it quite interesting.

22 So we are glad to have you.

23 Has everyone had a chance to read through the

24 minutes? And, if so, if there is a motion for approval?

25 We actually have three separate minutes from our

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1 March 12th and 13th board meeting. And then we had an

2 emergency telephone conference meeting on March 30th as

3 well as a follow-up emergency conference call on May

4 17th. So are there any additions or changes to the

5 minutes?

6 DR. LUBRITZ: Yes, ma'am.

7 On page -- I don't see a page.

8 DR. BAEPLER: Upper left corner there is page

9 numbers.

10 DR. LUBRITZ: Page seven of 23. And this is

11 on March 12th and 13th of 2004. I was wondering if we

12 might add at the bottom to the last paragraph it says,

13 "Discussion ensued concerning how and which physicians

14 were polled by the Clark County Medical Society in

15 preparation of its physician paper."

16 At this time if the board feels it's

17 appropriate, I would like to specifically put that

18 Dr. Lubritz challenged the names of the physician paper

19 of the Clark County Medical Society and he has discussed

20 the physician paper with many of the previous officers

21 and current members of the board of trustees, and they

22 had not even had an opportunity to read the federation

23 of state medical board's audit, much less have an

24 opinion on it.

25 Therefore, it was an opinion letter of Dr. Don

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1 Havins and Dr. Kingsley and not that of the Clark County

2 Medical Society.

3 MADAM PRESIDENT: Joel, I have a little bit of

4 a problem in that I don't think those were actually

5 stated during that conversation.

6 DR. LUBRITZ: It was.

7 MADAM PRESIDENT: I don't know if we can add

8 those specific comments.

9 DR. LUBRITZ: I asked those specific comments

10 of Dr. Havins. And Dr. Havins was not allowed to speak,

11 and Dr. Kingsley spoke for him. And, yes, I did say all

12 of those things.

13 DR. BAEPLER: That was a conversation that

14 lasted approximately five minutes. I remember that

15 discussion.

16 MS. MUNSON: I do have the data base

17 information handwritten -- I shortened them up so I

18 definitely recall it as well.

19 MADAM PRESIDENT: So if that was stated and

20 just not your concern, it just wasn't completed in the

21 minutes?

22 DR. LUBRITZ: That is correct.

23 MADAM PRESIDENT: All right. So we can add

24 that addendum too.

25 DR. ANWAR: Joel, I do remember that

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 conversation pretty clearly. And do we need to just

2 clarify what discussion took place as far as our minutes

3 are concerned? Or do we need to go beyond that as if

4 there were speaking on behalf of the society rather than

5 themselves?

6 MADAM PRESIDENT: One suggestion that I might

7 have if people are uncomfortable with the fact that this

8 is not as complete as the minutes were or a summarative

9 comment of what happened, but if you wanted to amend

10 them based on the transcript of that, we could certainly

11 do that.

12 DR. LUBRITZ: I would have no problem with

13 that at all.

14 DR. BAEPLER: It's certainly --

15 MS. MUNSON: I can get a copy of that and put

16 it in the --

17 DR. BAEPLER: The statement that Dr. Lubritz

18 read certainly captures the essence of it.

19 MADAM PRESIDENT: Is that a motion in the form

20 of an amendment to amend the minutes based on what you

21 said?

22 DR. LUBRITZ: Yes.

23 DR. BAEPLER: Second.

24 MADAM PRESIDENT: So there is a motion and a

25 second to amend the minutes as read by Dr. Lubritz with

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1 respect to the consideration of that physician paper

2 presented by the Clark County Medical Society.

3 Any further discussion on the minutes or that

4 particular motion? We need to do this one first at this

5 point.

6 All in favor of amending the minutes as so

7 stated?

8 THE BOARD: Aye.

9 MADAM PRESIDENT: Opposed?

10 Chair votes in favor of the motion. Motion

11 carries. And those amendments will be included. Is

12 there another thing?

13 DR. LUBRITZ: This is on page nine of 23, one,

14 two, three, fourth, paragraph. Said Dr. Baepler moved

15 to approve recertification by subspecialty boards. And

16 I think it was the subspecialty boards approved by the

17 American Board of Medical Specialties.

18 MADAM PRESIDENT: That's correct.

19 DR. BAEPLER: That is correct.

20 MADAM PRESIDENT: So that is a motion to amend

21 those?

22 DR. LUBRITZ: Yes, ma'am.

23 DR. BAEPLER: Second.

24 MADAM PRESIDENT: Any further discussion on

25 that?

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1 All in favor?

2 THE BOARD: Aye.

3 MADAM PRESIDENT: Opposed?

4 Chair votes in favor of the motion, and that

5 will be amended as well.

6 MS. KIRCH: I have a question regarding the

7 May 17th meeting. I thought the final action that we

8 took was that we would update our records to reflect the

9 status, but I thought that we were not going to assist

10 her in regaining her recertification.

11 MADAM PRESIDENT: Marlene, help direct me as

12 to where you are reading.

13 MS. KIRCH: It's on 2003 of May 17.

14 MADAM PRESIDENT: Which paragraph?

15 MS. KIRCH: Three. It begins with "Board

16 staff will update the board records to accurately

17 reflect" and ends with "will assist in her" -- I didn't

18 think we had gone to reassist because I don't know that

19 that's our --

20 DR. BAEPLER: I think we discussed that we

21 can't advocate. That we can report our action. That we

22 can't advocate to this, but we are obligated to report

23 our actions concerning a settlement to any party that

24 was interested.

25 MR. QUINN: Board Member Kirch, the word

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1 assist is, in fact, used there and it is not intended to

2 be misunderstood to mean that the board will go out and

3 do something affirmatively on behalf of Dr. Giarrusso

4 but there is an inherent requirement to respond to

5 credentialing entities.

6 And in that it is meant in that respect when

7 credentialing entities look to our licensing or any

8 other facility of the board staff to confirm the status

9 that we will assist in that respect. We will respond in

10 that respect. So that is the language that was actually

11 incorporated in the document.

12 MS. KIRCH: And I never saw the document.

13 That was to be sent to us also before you submitted it.

14 That was one of the things, and I don't believe any of

15 us saw it.

16 MADAM PRESIDENT: I think, actually, it's

17 coming up for discussion in the settlement. We have a

18 copy of it.

19 MS. KIRCH: It looks like it's already been

20 filed. So, I mean --

21 DR. BAEPLER: I think the question would be

22 what you are referring to here is a process that we do

23 in every case for everyone. It's automatic, and it's

24 our obligation to report.

25 MS. KIRCH: I was just concerned with the

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 assist. Because we will -- obviously we are going to

2 report our actions. But as you recall in the file I was

3 very concerned about the assist part because, yes, we

4 have to report our actions. But going above and beyond

5 trying to go to actually help her in some ways we

6 wouldn't help anyone also concerned me. And the word

7 assist in my mind adds something there. So that's my

8 comment, an expression of concern.

9 MR. QUINN: It is not my understanding nor my

10 intention that the obligation of the board with respect

11 to Dr. Giarrusso's re-credentialing is anything above

12 and beyond what we do for any other person as an

13 obligation of the agreement.

14 And that's my understanding of what I believe

15 Dr. Giarrusso's side understood as well that she has to

16 reestablish her credentials. And we just can't -- I

17 think we can't refuse to participate.

18 MS. KIRCH: The other thing is even remove the

19 derogatory information, and we can't do that either. We

20 can update the information, but we can't remove stuff

21 that we have reported.

22 We can provide updates that we have taken

23 different action. So we have assisted here. And to

24 remove, you know -- help her remove this information --

25 we will remove it, and we can't do this.

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1 MR. QUINN: No. This removal was -- that

2 removal refers to the national practitioners data bank,

3 and it is removed if possible.

4 And my understanding and I expressed it to

5 them, and they understand it as well, my understanding

6 is we cannot affect a removal from the data bank. But

7 the data bank is out of our control. And they wanted

8 that language in there, and I said if you want -- if you

9 can remove it from the data bank, go ahead and remove it

10 from the data bank. I don't have a problem with that.

11 That's beyond our control.

12 DR. BAEPLER: You are not going to write the

13 data bank and ask that to be removed?

14 MADAM PRESIDENT: This is misleading to

15 suggest that we are going to do that.

16 MS. KIRCH: We went through that at the

17 meeting. Since we can't do that, that was not part of

18 our motion that we could -- we would disclose what

19 action we have taken. But our concern was having any of

20 this language in our minutes and/or in our agreement

21 because we can't do this stuff.

22 And I thought that that's what had transpired.

23 Maybe not. But that was my understanding at the

24 conclusion of the call that that language was not going

25 to be in the motion or in the agreement.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MR. QUINN: It's very clear we are not going

2 to change any of our records. And that's very clear.

3 That's understood. As far as the data bank, that's

4 somebody else.

5 MS. KIRCH: I don't think -- That was not

6 part of our motion, and I don't think it should be

7 included in this.

8 MR. QUINN: Okay.

9 MS. KIRCH: So I don't think the minutes

10 accurately reflect what our conclusion was at the

11 meeting. And maybe someone else can confirm that. But

12 as I recall, we didn't want the assist and we didn't

13 want the remove.

14 DR. BAEPLER: I remember specifically we said

15 you can't assume what happened never happened and that

16 once it's a matter of record, either in our records or

17 on any national data base or whatever, you can't erase

18 it.

19 You know, all we can do is report that there

20 has been a settlement.

21 MADAM PRESIDENT: You know, I have the same

22 concerns in that I think that part of the reason that we

23 sent the language back to be changed on what was read

24 over the phone was that we had concerns over these

25 specific issues being included in that they were

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1 misleading to Dr. Giarrusso, sort of leading her to

2 believe that we were the ones going to help get this

3 accomplished. And I think this language still does

4 that, that we are going to assist her in her efforts to

5 even remove, if possible, derogatory information

6 reported to the national practitioners' data base.

7 And I don't think we can do that. I don't

8 think we should do that to try and assist that to be

9 removed.

10 I don't think it's possible anyway, but I do

11 think it sort of leads you down that path to think it is

12 possible.

13 MS. KIRCH: I don't think that is what we

14 approved at the conclusion of that meeting because that

15 was our concern, the assist and removal of information.

16 MADAM PRESIDENT: Perhaps what we can do is

17 since this is going to be discussed further in -- when

18 Steve goes over some of the settlement offers that are

19 here, is we could move for approval of all of the

20 minutes but the May 17th. I think that's the one we are

21 talking about. And then when we have a more detailed

22 discussion of what the actual settlement says, we can go

23 back. Would that meet with everybody's approval?

24 DR. MONTOYA: I have one more problem.

25 MADAM PRESIDENT: Okay.

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1 DR. MONTOYA: It's March 30th, page two of

2 three, the fifth paragraph down, starts with the list.

3 Because Dr. Giarrusso contacted me about the

4 investigative committee's order, court observed urine

5 samples. That was not my discussion with her. It was

6 the diversion committee's request. I never discussed an

7 order -- an investigative committee's order.

8 DR. BAEPLER: Which paragraph?

9 DR. MONTOYA: Fifth one down. It starts with

10 my name.

11 I was advising her about the order from the

12 investigative committee and I didn't. I only talked to

13 her about the diversion committee request.

14 MR. QUINN: Okay. And on that assist part,

15 would you feel better if instead of saying assist, would

16 you feel better if it said the board will not --

17 MS. KIRCH: Just take it out.

18 MR. CLARK: Just take that phrase out.

19 DR. BAEPLER: It's strange to have in a

20 settlement agreement a specific point where we agree to

21 do something that we automatically do. We do it for

22 everybody.

23 By including it, by inference, we are

24 suggesting you are going to do more, otherwise, you

25 wouldn't have included it.

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1 We automatically, without having it in the

2 settlement, will inform the appropriate entities that

3 the case has been settled. We do that for everyone.

4 MS. KIRCH: And we do that. And so from the

5 word assist on, that whole last part, is the stuff we

6 were concerned about.

7 MR. CLARK: Perhaps you could just strike that

8 whole last phrase.

9 DR. BAEPLER: To include it's recommended

10 would be on our part because we are suggesting something

11 that can't be done.

12 MS. KIRCH: Right. Showing the status is

13 lifted and disciplinary action is dismissed, period.

14 And the rest of that I don't think is what we agreed to.

15 DR. LUBRITZ: If that were deleted, that

16 would --

17 MS. KIRCH: That would.

18 DR. JONES: If it's already been filed --

19 MADAM PRESIDENT: My concern is that. I'm

20 being advised by our attorneys that we really should

21 wait until we review the settlement per se and then the

22 language in that should be consistent in what is

23 reflected in here.

24 DR. ANWAR: Why don't we do that? Why don't

25 we wait?

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1 MADAM PRESIDENT: That will be coming up soon.

2 We can certainly make a motion to approve the rest of

3 the minutes, come back to this one specifically again.

4 Thank you, Marlene, for bringing that to our attention.

5 That's my recollection as well.

6 DR. LUBRITZ: So moved.

7 DR. ANWAR: Second.

8 MADAM PRESIDENT: There is a motion to approve

9 the minutes with the exception of May 17th, the

10 emergency telephone conference.

11 DR. ANWAR: Second.

12 MADAM PRESIDENT: Any further discussion?

13 DR. LUBRITZ: How about the second --

14 MADAM PRESIDENT: Wait. I'm sorry. We didn't

15 vote on that. Can we have a motion to amend that

16 specific --

17 DR. MONTOYA: I would like to make a motion to

18 amend.

19 DR. LUBRITZ: Second.

20 MADAM PRESIDENT: All in favor?

21 THE BOARD: Aye.

22 MADAM PRESIDENT: Opposed?

23 Chair votes in favor and that amendment will

24 be made as well.

25 Now can I have a motion again to approve all

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1 of the minutes but that?

2 DR. LUBRITZ: So moved.

3 MADAM PRESIDENT: All in favor?

4 THE BOARD: Aye.

5 MADAM PRESIDENT: Opposed?

6 Chair votes in favor, and the motion carries.

7 So we will come back to that one specific part

8 of those minutes.

9 Our next agenda item is our personnel session.

10 I do need a motion to go into closed session. We won't

11 be terribly long. But is there a motion?

12 DR. JONES: So moved.

13 MADAM PRESIDENT: Second?

14 (Whereupon the proceedings were

15 held in closed session.)

16 MADAM PRESIDENT: We are back in open session.

17 There is a recommendation for salary changes.

18 DR. BAEPLER: I would move we grant the two

19 and a half percent living expense to employees across

20 the board that merit increases, recommended by our

21 executive secretary, be approved and that our chief

22 counsel and executive director, I guess it is, not

23 executive director each, receive a ten percent merit

24 increase which will include the two and a half percent

25 cost of living.

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1 MS. KIRCH: I would in both the counsel and

2 the director, they have been promoted from their

3 initial --

4 DR. BAEPLER: Yes. The reason for that is

5 both of them have had a change in jobs, essentially

6 coming in as an assistant when hired and now functioning

7 as the head of each of their respective areas. So

8 that's the reason for that.

9 DR. ANWAR: Second.

10 MADAM PRESIDENT: There is a motion and a

11 second to change the salaries as stated.

12 All in favor?

13 THE BOARD: Aye.

14 MADAM PRESIDENT: Opposed?

15 Chair votes in favor of the motion. Motion

16 carries.

17 Again, I'd like to publically thank all of our

18 staff members, both our new executive secretary and

19 counsel, for their efforts this past year. I think that

20 certainly the board appreciates the efforts that you

21 have made in your jobs.

22 I know that there has been a steep learning

23 curve and these are both very difficult jobs. And we

24 appreciate you as well as the rest of the staff that I

25 think has left us. But we do appreciate all of the

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1 efforts of our various staff members.

2 All right. Moving on to agenda item number

3 four. This is consideration of the audit that was

4 performed by the federation. And we, at the last

5 meeting, had Tony go through, in a very detailed manner,

6 each sort of item that had been reviewed or recommended

7 by the federation, and at this meeting, really, you all

8 have received -- and Tony did a nice job of itemizing

9 those -- each item that had already been approved and

10 implemented.

11 Some of those, remember, the reason that those

12 were able to be implemented was that they had been

13 actually started before the federation had came to do

14 the audit. We had talked as a board and tried to

15 discuss some changes in our website and so forth.

16 And then the second category are

17 recommendations that the board can take action on today

18 and implement, if the board desires.

19 And then the third category are items that

20 were recommended that actually would take legislative

21 action. And so we need to do some feedback from the

22 board as to whether or not that's something you wish to

23 pursue legislatively.

24 I will say just in commenting that Tony and I,

25 we made a trip to Carson last week and appeared before

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1 the legislative counsel bureau to discuss the follow-up

2 of our recommendation of the recommendations from the

3 federation. And certainly I went through the sheet that

4 you have before you as to the things we have already

5 changed and the things we will be discussing at this

6 meeting.

7 That session went very well. There were very

8 few questions or concerns. I think that the commission

9 certainly feels that the board is being responsive to

10 the concerns that have been raised.

11 So that having been said, my hope is that we

12 can rather efficiently go through these and get input as

13 to what kind of action does the board want to take.

14 I guess, I would -- Before we actually vote

15 on that, I would ask for discussion among the board

16 members and I do think that before we vote on this we

17 may have some public comment, people that might want to

18 give their input as well.

19 Let's take section one. Any discussion on

20 some of the things that have already been implemented or

21 concerns about that?

22 Basically, it's the way that we are reviewing

23 cases. It talks about the fact that we have established

24 two investigative committees, that we are doing a better

25 job in communicating with the complainant, and then

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1 every 45 days, no longer than every 60 days, we give

2 status of that complaint to the complainant.

3 And that we now are notifying the complainant

4 of the fact of whether the complaint goes to hearing and

5 invite them if they wish to be there.

6 We also have contacted the hospitals and

7 developed a more positive relationship with them and a

8 better line of communication.

9 I think that certainly the board members all

10 know that we are reviewing every malpractice case that

11 comes across the board and proceeding to investigate it

12 if needed.

13 So any concerns on any items under subsection

14 one that the board has?

15 Joel?

16 DR. LUBRITZ: Just a question. On A, audit

17 report recommends that the board implement a system for

18 assigning and tracking high, medium, and low priority

19 investigations. And I assume that's done by Mr. Quinn

20 and the investigators.

21 MR. CLARK: And Dr. Barnett.

22 DR. LUBRITZ: And Dr. Barnett. Thank you.

23 MR. CLARK: And it's put into the computer

24 system as each case as a high priority, medium priority,

25 or low priority.

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1 DR. LUBRITZ: Thank you. May I go on? In C,

2 down toward the bottom, it says, "Thereafter, every 45

3 days, and no longer than every 60 days, the complainant

4 is sent a status letter on the investigation."

5 And my question is what would be contained in

6 a status letter, just that it's continuing to go on? On

7 the status letter that is sent, my question is what goes

8 into a status letter if you could be a little more

9 specific.

10 MR. QUINN: The status letter will inform the

11 complainant at the stage of the investigation. If the

12 investigation has gone to an investigative committee, if

13 the investigation is at the stage where it is still

14 gathering information, if the investigation has been

15 approved by the investigative committee for formal

16 action.

17 We have to be careful what we don't do is

18 breach the prohibition of disclosure against

19 confidential information. So it is a status only. It's

20 not really comment. It's just to keep them in the loop

21 so that they know that we are acting.

22 DR. LUBRITZ: Sure. And in a typical closure

23 letter, could you tell me what goes in that? That is a

24 closure of the investigation and the reason are hearings

25 scheduled before the investigative committee. That's

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1 the last sentence of C.

2 MR. QUINN: Well, it depends on the reason for

3 closure. Sometimes cases are closed because they, upon

4 initial review, there is no reason -- there is a finding

5 that there is no reasonable basis to determine that a

6 violation of the statute has occurred.

7 Sometimes a case is closed because the board

8 has no jurisdiction over the issue. That would be --

9 those two are examples of closures that would occur at

10 the very outset.

11 Then there might be a closure letter that goes

12 after an investigation has been conducted and medical

13 review has been determined that based on the information

14 there does not appear to be any issue. Any reasonable

15 basis to determine.

16 There are no facts to establish a reasonable

17 basis. So a case may be closed after medical review.

18 And, likewise, that letter would inform the complainant

19 that the medical records or the facts do not indicate

20 that there is a reasonable basis.

21 DR. LUBRITZ: Thank you.

22 MR. QUINN: And then there could be a closure

23 after an IC which would basically say the same type of

24 thing. Following a full hearing, the closure letter

25 would inform -- would depend upon what happens at the

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 hearing.

2 DR. LUBRITZ: Okay. And on D, if a

3 complainant is advised of the date, are dates set for

4 the hearing and they are invited to attend the hearing.

5 Does that mean they would also be invited into the

6 closed session if there is a closed session? Are they

7 only there for the open session? Because if it's only

8 for the open session, my thought is that probably should

9 be -- then basically they are going to come in, a

10 complaint is going to be filed, they go into closed

11 session and when you go back into open session, it's

12 just --

13 MADAM PRESIDENT: The hearing is scheduled

14 before a hearing officer.

15 DR. LUBRITZ: Okay.

16 MADAM PRESIDENT: That's what I think they are

17 talking about. If this goes to -- it's not coming --

18 it's not the state coming before the board. It's where

19 it goes to the hearing officer and the evidence is

20 collected and that's where they are invited to the

21 hearing.

22 DR. LUBRITZ: Okay.

23 MR. QUINN: The purpose of this is to be sure

24 that a person who files a complaint, if that complaint

25 is then acted upon, continues to be informed so they

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 know what we are doing and specifically when it goes to

2 hearing that they know that that is the trial of the

3 issues that they raised by their complaint. So they can

4 show up and they can watch the testimony. They can see

5 the evidence. And there are no closed sessions at those

6 things.

7 DR. LUBRITZ: Okay. And then on E, it says,

8 "General counsel will make a determination whether the

9 complainant is to be called as a witness to testify at

10 the hearing."

11 So that's in the open session hearing that was

12 just discussed in D?

13 MR. QUINN: Yes.

14 DR. LUBRITZ: Not in the investigative

15 committee or that kind of thing?

16 MR. QUINN: That is correct.

17 DR. LUBRITZ: Thank you. Thank you.

18 MADAM PRESIDENT: Okay. Let's move on to

19 discuss under subsection two the recommendations that we

20 could adopt today and implement if the board chooses.

21 The number A would be the recommendation is

22 that the board should pursue failure to report

23 malpractice complaints and award assessments by some

24 licensees in that an aggressive enforcement effort to

25 discipline those licensees who failed to report.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 The B sort of addresses the same issue with

2 the Division of Insurance and their failure to report to

3 the board that we would, you know, follow that up with

4 penalties.

5 Under C each case reported by the clerk of the

6 court or of an insurance company should be checking to

7 see if the licensee involved self reported.

8 Again, it is a double-check system. If we are

9 not getting the reports by the licensee or by the

10 insurance companies, that we have the ability to take

11 actions and the recommendation is that we should do so.

12 D, I think I feel extremely strongly about

13 this one that we should periodically ask the entire in

14 state licensee population to help us with peer review.

15 This system will not work if we do not get help from our

16 licensees with pure reviews. And I think the

17 willingness of physicians to step up and help with that

18 process is really crucial and will become even more so

19 with the numbers we have coming into this state.

20 So I think reminders in our newsletters and

21 perhaps in other venues to include our licensees in this

22 process is incredibly important.

23 Under E the recommendation from the auditors

24 is that we should create an audit committee. If you see

25 underneath that, the staff disagrees with this

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 recommendation.

2 Actually, we already do get the report of the

3 audit. It's presented to the secretary-treasurer and

4 then the secretary-treasurer presents it to the board.

5 And I think we need to discuss this, but

6 perhaps creating another committee might just be another

7 layer of that and may not make a lot of sense.

8 DR. MONTOYA: We are a small board, and I

9 agree the last thing we need is another committee.

10 Since we are spread across a 400 mile state, it just

11 doesn't make sense to make another committee, when the

12 secretary-treasurer can look at the audit that is

13 presented to him by professionals and present it to us.

14 DR. BAEPLER: It doesn't delay anything. The

15 typical procedure would be like a week before the board

16 meeting the audit is presented to the

17 secretary-treasurer and discussed with them and then

18 immediately to the full board, you know. So it's not a

19 -- it makes a presentation to the board perhaps briefer

20 and saves a little time just saving that intermediate

21 step, but you get the full audit report.

22 MS. KIRCH: I disagree. I feel that it's

23 important that there are people available to ask those

24 auditors questions.

25 DR. BAEPLER: They are here when you get it.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 Say it's presented to the secretary-treasurer one week,

2 it's discussed a little bit, the secretary-treasurer at

3 the board meeting the next week explains the discussions

4 and any problems and the auditors are sitting right

5 there to answer any questions that the board has.

6 MS. KIRCH: I don't recall them being here

7 before, were they?

8 MR. CLARK: One of the members was here.

9 MADAM PRESIDENT: I don't think there has been

10 specific questions that we addressed.

11 MS. KIRCH: I think that's one of the things

12 we need to look at.

13 DR. BAEPLER: They should be here.

14 MS. KIRCH: If they are here, so that we can

15 ask questions --

16 DR. BAEPLER: The critical thing --

17 MS. KIRCH: -- if they have a management

18 letter that needs to be disclosed and all that, and I

19 don't know if they have been in the past.

20 DR. BAEPLER: No. Last year we had the audit,

21 and we got the management letter two or three months

22 after the audit. And that has to occur simultaneously.

23 MR. CLARK: And the management letter was sent

24 to every member of the board.

25 DR. BAEPLER: It was not timely. We should

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 receive that with the audit.

2 MADAM PRESIDENT: I'm sorry. If we can go

3 back to A, B and C, does anybody have strong feelings

4 they wanted to discuss whether or not we should be --

5 DR. ANWAR: I have a question on B that the

6 board has jurisdiction on insurance companies?

7 DR. BAEPLER: They have to go through the

8 Division of Insurance.

9 DR. ANWAR: And it says, under B, "in all

10 cases in which an insurance company fails to report to

11 the board." So we have to go to the Division of

12 Insurance department?

13 DR. BAEPLER: Yeah. We don't have

14 jurisdiction over that.

15 DR. ANWAR: Right.

16 DR. BAEPLER: Let me ask one question, too,

17 then. Do you think the medical community is well enough

18 informed that they have to self report these things?

19 Have we really been effective in communicating

20 this to them? It's hard to start penalizing them if

21 they are not adequately informed.

22 DR. ANWAR: I don't think they are.

23 DR. MONTOYA: It's better. I don't think it's

24 where it should be.

25 MADAM PRESIDENT: I think that's my feeling,

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 too. I guess we have taken steps within the newsletter

2 when this changed and we did send out a special letter

3 that addressed it.

4 But I think that it is really our

5 responsibility to send out more frequent notification of

6 this as well as perhaps meeting with the medical

7 societies, or certainly with representatives of them, to

8 make sure that people understand that it is their

9 responsibility to report.

10 I don't -- and my personal feeling is that I

11 really don't want to aggressively pursue penalizing

12 physicians.

13 I think the idea is to aggressively pursue

14 educating physicians about their responsibility. And

15 the fact is that we can impose penalties if they don't

16 do it.

17 But I think that the emphasis should be on the

18 front end that we really try to communicate the fact

19 that it is their responsibility to report. And if we

20 are still continuing not to get those reports, then I

21 think we do need to take the next step.

22 MS. KIRCH: Is something sent to them when

23 they receive their license about -- something like this

24 or do we put a license in an envelope and say you are

25 licensed? Wouldn't that be an appropriate time to bring

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 to their attention certain responsibilities they have

2 now that they are licensees in the state of Nevada?

3 MADAM PRESIDENT: They all get the statute

4 book and all of that would be in there. But you make a

5 good point in that this is new. And I think to most

6 physicians who have been in the state for a while, it is

7 cumbersome, and I don't think many of them really look

8 at that book that is sent out at renewal time. I think,

9 yes, that would be a good suggestion.

10 DR. LUBRITZ: Would it be appropriate in every

11 newsletter that goes out that you have perhaps in a

12 different color, in red or in some other color, that be

13 mentioned in each and every letter that goes out?

14 MADAM PRESIDENT: That could easily be done.

15 DR. ANWAR: Is this the way I understand this

16 in number 2A that modifications of that first paragraph

17 that that be recommended?

18 DR. BAEPLER: Two-A?

19 DR. ANWAR: Right. Is there a modification in

20 that that we need?

21 MADAM PRESIDENT: I think we certainly need to

22 add in there an aggressive approach to educate

23 physicians on their responsibility to report claims and

24 to notify them of any possible implementation of

25 discipline on failing to report or something like that.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 And then I think we talked -- we got feedback

2 on C as far as the insurance companies.

3 We don't have authority, but I think entering

4 into a better communication with that and making sure we

5 are getting reports is a good thing.

6 Anybody have a problem with the peer review?

7 I think we all feel pretty strongly that that is

8 important.

9 DR. LUBRITZ: Only one question. What would

10 you do with someone who says, Yes. I would like to do

11 peer review. And for whatever reason we feel that he is

12 not an acceptable person to do that review?

13 DR. BAEPLER: Probably just never use him.

14 MADAM PRESIDENT: Right. I think ultimately

15 the board has the discretion in who they use for pure

16 reviews, and that certainly should continue to be the

17 case.

18 DR. LUBRITZ: Thank you.

19 MADAM PRESIDENT: And now I think that we have

20 come to a consensus about the audit committee with

21 Marlene making those changes as far as making sure that

22 the management letter is sent with the audit as well as

23 having the auditors present.

24 Under F the audit recommends that the board

25 make public the board orders and statements of charges

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 which would be complaints available to the public at no

2 cost.

3 This would make public records immediately

4 available to the customer.

5 I have, I guess, a concern or question about

6 that. Are we talking here about complaints that have

7 been filed? Are we talking before that?

8 MR. CLARK: It would be the complaints that

9 are filed before a hearing examiner for hearing. This

10 is after an investigative committee has determined that

11 a complaint should be filed against a licensee. Then

12 the complaint is prepared and filed and served. It

13 would be those complaints only. And those are subject

14 to public meeting. It's a public hearing.

15 DR. ANWAR: I think it should be clarified to

16 reflect that.

17 DR. BAEPLER: The wording here does not

18 reflect that.

19 MADAM PRESIDENT: That's my concern. It isn't

20 clearly stated in this. It's a statement of charges I

21 see as certainly different. That means that there has

22 been a complaint that has been brought forward, but it

23 doesn't indicate that it has gone through an

24 investigative process and the investigative committee

25 has determined that the complaint should be filed.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. BAEPLER: When I first read this, I was

2 very much opposed to it because I thought it was the

3 complaints brought before the investigative committee,

4 and, my goodness, we are not going to list all of those.

5 MR. CLARK: No. It's after the investigative

6 committee has determined that a complaint should be

7 filed. Then a formal complaint is filed, and that's the

8 thing they are recommending be put on the website so it

9 can be downloaded by Adobe Acrobat.

10 DR. ANWAR: What is the basis of this

11 recommendation?

12 MR. CLARK: Just to make public information --

13 make the information more available to the public so

14 that they don't have to pay for copies of things that

15 they call us for.

16 They can download it themselves.

17 DR. ANJUM: It shouldn't be brought before the

18 board if it has been acted on it. So you are going to

19 have to remove it or add to it that it has been

20 dismissed. Just increase the record part so maybe we

21 should rectify and say we will put it on the website, or

22 whatever it's supposed to be, after the board has acted

23 upon it.

24 MADAM PRESIDENT: Which I think we are already

25 doing.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MR. CLARK: That's the discipline part.

2 MADAM PRESIDENT: Right. The disciplines are

3 already on the --

4 MR. CLARK: Once a complaint is filed, it's a

5 public document.

6 DR. ANJUM: So we do keep putting on that site

7 before that, you know. Once the board has acted, it is

8 in the record and the public has the access to it. That

9 should be enough really. Before the board has acted

10 upon it, you know, I don't think --

11 MS. KIRCH: In other words, the complaint is

12 filed and then the board takes action. They are

13 recommending as soon as that complaint is filed that it

14 be made available. And I don't have a problem with

15 that.

16 They can call and ask for it. They are just

17 saying go ahead and put it on the website so they can

18 download it and have it available.

19 DR. ANJUM: What part of the complaint filed,

20 the complaint --

21 MS. KIRCH: The complaint we see --

22 DR. ANJUM: When the complaint comes to the

23 reviewer or investigative committee or --

24 MS. KIRCH: No. The actual legal complaint

25 that Steve prepares.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MR. CLARK: The investigative committee has

2 made a determination that there is a violation of a

3 medical malpractice act and authorizes general counsel

4 to file a complaint to go to a hearing examiner. That

5 complaint becomes a public document. And that's what we

6 are talking about.

7 DR. LUBRITZ: If it becomes a public document,

8 could we amend what we are currently doing and let them

9 -- if someone wants to know specifically, then I think

10 it's reasonable for them to call the board and at no

11 expense the board sends to them that specific

12 information. I think that there is no reason to put

13 that on the internet when it is perfectly available by

14 merely calling the board and making it available to them

15 at no charge.

16 MADAM PRESIDENT: Steve, you want to comment?

17 MR. QUINN: It is available to the public

18 presently at a charge for the copying because that's

19 what is involved.

20 The public can presently call investigations.

21 Investigations will then have to divide manpower to pull

22 the file, take those public papers out, make Xerox

23 copies and we'll do that and do it. And there is a

24 charge. Is there a charge?

25 DR. CLARK: Sixty cents a page.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MR. QUINN: Sixty cents we are currently

2 charging.

3 DR. LUBRITZ: My thought is it's worth the 60

4 cents and time and effort rather than have it on the

5 internet. That's my personal opinion.

6 DR. ANWAR: I agree with that. I think there

7 is no reason that everything that is in public demand as

8 far as information is concerned and the public has

9 access to it, if they want to have access to it, doesn't

10 need to be put up on the internet. That's not true of

11 every governmental agency either.

12 DR. BAEPLER: My sense is that the current

13 system where we post it on the net after the action is

14 concluded and results in discipline for the doctor, you

15 can look that up now.

16 As a person out there searching a doctor, I

17 don't really care to know complaints that were dismissed

18 and then not resolved and so on. I want to see if there

19 has been any disciplinary actions taken, and that's now

20 available to people.

21 MR. COOPER: That's available to people in a

22 synopsis form. It's in a synopsis.

23 DR. ANJUM: You couldn't put every word on the

24 website either. You have to put the synopsis on the

25 website.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. LUBRITZ: I would personally like to make

2 a recommendation if they call the board specifically and

3 ask for that information, you make it available to them

4 at no charge as opposed to being put on the website.

5 DR. JONES: What are we talking about? How

6 often does that happen?

7 DR. ANJUM: It is --

8 DR. JONES: How often does someone call in and

9 ask for that?

10 MR. COOPER: Someone is getting copies on a

11 daily basis in each legal file. We know who has asked

12 for copies of the file, who we sent it to, and what we

13 charge them. But it's a daily event. I would guess

14 minimum seven a week if it's a daily event, maybe more.

15 MADAM PRESIDENT: So from your perspective it

16 would be easier if it were available electronically. It

17 would take less manpower hours for you if this were

18 available electronically?

19 MR. COOPER: That's true. We would have the

20 website synopsis. And if they wanted the actual

21 documents that the synopsis was written out, they could

22 click on that and print it instead of mailing to us --

23 they would have to send us a check. And we have to send

24 that to financial support and do a receipt for the

25 check. And when we have that money, we copy the

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 documents and send them off.

2 MADAM PRESIDENT: What I'm hearing from the

3 board members is the concern that at the complaint level

4 it puts information out there that may mislead the

5 public to think that there are actual real problems with

6 this doctor when three months from now, when the board

7 meets, that complaint may be dismissed.

8 So it is a little misleading to put complaints

9 that have been filed before action is taken by the

10 board, and I think that's the consensus I'm getting.

11 But it is public record once that complaint is

12 filed. So I think we do need to make that accessible as

13 we have been doing. And I guess the question is do we

14 continue to charge for it?

15 Personally, I don't have a problem with

16 charging the 60 cents. I do feel that when records are

17 requested from physicians' offices, from any number of

18 places they have access to it, but there is some minimal

19 compensation for the copying cost. I don't think that's

20 unreasonable.

21 DR. LUBRITZ: I have no problem with that

22 part.

23 DR. ANJUM: It is a determining factor if you

24 can pick up the phone and I need this and/or that.

25 DR. BAEPLER: Yeah.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Okay.

2 MS. MUNSON: I thought I would ask something

3 because of website involvement, and it was something I

4 read. One other option can be -- do as you say during

5 the complaint process -- we can add the complaint and

6 the order of the board at the conclusion of the

7 proceedings so then a person could access the documents

8 that way if they wanted to.

9 It would have the entire picture, not

10 misleading them into when they see a complaint. They

11 would have that. So that's another possibility.

12 DR. BAEPLER: That's confusing just to record

13 the matter at the end of the process if it has resulted

14 in a negative action for the doctor.

15 DR. LUBRITZ: And have them call in and charge

16 60 cents a page. It's still available.

17 DR. BAEPLER: It's on the website already.

18 MR. QUINN: I would like to ask a question for

19 clarification, Laurie. I'm reading this to understand

20 what is essentially intended here is for us to start to

21 adopt a procedure -- adopt an electronic filing.

22 That's what it looks like to me. We are going

23 to have to scan the documents in so that one can access

24 the entire document on Adobe Acrobat. Am I missing

25 something?

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MS. MUNSON: No. That is true. So we would

2 have the manpower for that.

3 MR. QUINN: So we will have manpower and

4 resource expenditures to get that. So we will have to

5 have that hardware and that ability as an additional

6 resource to our facilities here in order to input that

7 material.

8 This is the first step in, basically,

9 electronic paperless conduct of this activity. That's

10 what it is.

11 MADAM PRESIDENT: So what I'm hearing is a

12 recommendation from the board at this point that we not

13 do this, that we not proceed forward with F in putting

14 the complaints on the website at this time.

15 DR. LUBRITZ: That's my recommendation.

16 DR. ANWAR: My understanding, and if that's

17 different I need to know that right now, it's not just a

18 paperless information. It would be available to the

19 public.

20 MR. QUINN: That is correct, yes.

21 DR. ANWAR: Right now it isn't unless someone

22 especially is interested in it.

23 MR. QUINN: That is correct, yes. It is

24 effectively putting our public file on -- available and

25 making the public file available to the internet. So

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 the complaint, any motions that are filed in the case,

2 any intermediate orders in the case, anything that is

3 filed in the disciplinary action case would then be on

4 that record.

5 DR. ANWAR: And my personal position would be

6 against that.

7 MS. KIRCH: I disagree. I think the public is

8 entitled to that information. And I am a public member.

9 But I feel strongly that our charge is to let the public

10 know what is going on, and they have availability to the

11 information.

12 DR. ANJUM: What is the conclusion of the

13 other boards on that?

14 DR. LUBRITZ: That's my concern. What do the

15 attorneys do, what do architects do, everyone who needs

16 a license in the state? Are they making that

17 information available to the public?

18 DR. ANJUM: Right.

19 MR. QUINN: I can answer it from this

20 standpoint: All of this information, the public has a

21 right to all of this information. And they can get all

22 of this information. They can get it by coming and

23 reviewing our file. This is a step that makes that

24 easier for the public. But they have a right to it, and

25 they can get it today. And we can't make a rule that we

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 would prohibit that.

2 DR. ANJUM: So the question that Marlene has

3 is already covered?

4 DR. BAEPLER: It is.

5 MR. QUINN: It is covered. I understand what

6 she is saying. She is saying she supports facilitating

7 it easier.

8 DR. ANJUM: Where do you put the line

9 facilitating making them available? Put them on the

10 internet? Send them in the mail? Put it in the

11 newspaper?

12 MR. QUINN: Again, another state -- Laurie

13 went to Arizona. They have it completely on the

14 internet, don't they?

15 MS. MUNSON: I can't verify that they have the

16 complaint and those records available on the internet.

17 I didn't look for that. I haven't been on their website

18 for that specific purpose. I can find out what other

19 boards do if you would like me to do a comparison.

20 MR. QUINN: If we make the transition and we

21 are going to put the public file -- we are going to scan

22 it in electronically and put it on the computer and make

23 it readable by Adobe Acrobat. If we do that, then it

24 can be made available to the public and the public

25 should have the right to access it that way.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. ANJUM: Or put the synopsis on because the

2 case is not decided yet. Just make the public informed

3 there is a complaint filed and this is where we stand.

4 We don't have to scan every page and make a big file.

5 Put the synopsis on. This will go to the

6 board, and it is undecided.

7 MR. QUINN: That is being done. That is

8 available today.

9 MS. KIRCH: I don't object to it -- having it

10 after the board action. I think that should be

11 available.

12 DR. ANJUM: It is available to the public now.

13 MS. KIRCH: If we are going to start putting

14 pamphlets in physicians' offices and you can get

15 information from the medical board, a lot of people are

16 going to want to go on line. We are telling them we

17 have a website. You can go on line and find out

18 anything you want to know.

19 DR. ANJUM: Or we can add "for further

20 information call for more details."

21 MADAM PRESIDENT: I'm going to clarify

22 something that was not clear to me until just now. And

23 the synopsis of the complaint is filed before the board

24 has taken action is already on our website?

25 DR. BAEPLER: Yeah.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: What we are talking about

2 here is just making every word of the complaint

3 available on the website which is --

4 DR. BAEPLER: But we are currently meeting our

5 statutory obligations.

6 MADAM PRESIDENT: Absolutely.

7 DR. ANJUM: Through more than that.

8 MR. COUSINEAU: Can I make a point that may or

9 may not be an issue?

10 I understand that the mass majority of the

11 public does have computer internet access but there may

12 be those out there that don't. And it may be equitable

13 to --

14 DR. HAVINS: Excuse me. Las Vegas cannot hear

15 the speaker.

16 MR. COUSINEAU: Just to reiterate, it may or

17 may not be a problem that there may be certain members

18 of the public who do not have computer access.

19 Would it be inequitable then to allow

20 individuals who are available to download the materials

21 for free? Those who obviously don't have computer

22 access have to solicit it from the board. Do we want to

23 take the position that it would be no cost for those

24 materials? I think we should clarify that as well.

25 There may be a rare exception for someone who doesn't

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 have that ability.

2 MADAM PRESIDENT: Okay.

3 DR. ANJUM: I believe that -- I would suggest

4 that whatever information from the board be given to the

5 public at no cost, and if it requires faxing, copying,

6 something, that should stay the way it is.

7 MADAM PRESIDENT: Okay. We really need to

8 move on with these. We have a lot of recommendations.

9 Joel, did you have another comment?

10 DR. LUBRITZ: No, but if that was a motion, I

11 was going to second it.

12 MADAM PRESIDENT: We can do that. Maybe this

13 one is complicated enough that we want to vote on it

14 individually. So if someone wants to make a formal

15 motion with respect to F, then go ahead.

16 Joel, did you want to do that?

17 DR. LUBRITZ: No. I think --

18 DR. ANJUM: I will make a motion whatever

19 information we have in the board regarding the

20 complaints that are being discussed in synopsis form

21 should remain as it is.

22 If somebody requires more detail, we should be

23 able to provide it to them at a certain cost.

24 If just information on the internet is

25 available and asked by a person who does not have

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 internet access, we should give that information without

2 cost.

3 MADAM PRESIDENT: Is there a second?

4 DR. LUBRITZ: I'll second.

5 MADAM PRESIDENT: Any further discussion?

6 Everybody understand the motion?

7 DR. JONES: Let me ask something. So you are

8 charging some people and some people you are not?

9 DR. ANJUM: Whatever information is on the

10 internet, if somebody doesn't have the net and wants to

11 get to that, they should get it free because if they had

12 the internet --

13 DR. JONES: I understand that.

14 DR. ANJUM: If they need additional

15 information that is not on the internet, that we provide

16 at a certain cost. That should remain as it is.

17 MADAM PRESIDENT: Right. Now the synopsis is

18 just available on the synopsis. That is what would be

19 sent free. And if they wanted full details of the

20 complaint, there would be a charge?

21 MR. QUINN: I would like to point out to the

22 board that an issue has been raised that if the board

23 lifts the -- what is a reasonable charge? That is a

24 statutory charge, up to 60 cents a page. If we lift

25 that, we may get flooded with unnecessary calls.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. ANJUM: Absolutely.

2 MR. QUINN: What goes on the internet is the

3 fact that a complaint has been filed, a synopsis of the

4 statement of the basis for the complaint. If there is

5 more than one charge in the complaint, those charges are

6 enumerated.

7 And so where a complaint may be five pages,

8 what goes on the internet is that a complaint has been

9 filed against the doctor for malpractice in the failure

10 to diagnose cancer in a patient or something like that.

11 And then the doctor's charged in Count I with a

12 violation of this section, malpractice, in Count II with

13 a violation of another section, failure to do something

14 else, in Count III another section.

15 So a significant amount of detail is contained

16 in that synopsis. More than just a statement that a

17 complaint has been filed against a doctor for commission

18 of malpractice.

19 And, yet, my concern is, you know, we could

20 have a flood of meaningless requests for paper burdening

21 the investigative staff to pull the files and make the

22 copies and send them out if we don't make a charge for

23 the information that is substantially there.

24 MADAM PRESIDENT: I have that same concern,

25 actually. And although I understand the comment about

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 no computer access, there are so many computers that are

2 available in public libraries, you know. You can go in

3 and access it if you don't have a home computer that I

4 feel that it may really be burdensome to our staff to

5 provide --

6 I don't think 60 cents a page is a lot. And

7 it is certainly allowed by statute to do that for

8 copying. I think that's a reasonable thing. I don't

9 think that we really have to provide everything on paper

10 for free. I don't know.

11 DR. ANWAR: I agree with that. And computers

12 are accessible all over. You can go to your friend's

13 house, your mom's house, your daughter's house. You can

14 go to the library and/or several public places,

15 colleges, universities. And so I think not having

16 access is not a good enough excuse to deluge this office

17 with requests.

18 MADAM PRESIDENT: You want to modify? Was

19 there a second to the motion?

20 DR. ANJUM: I make an amendment to the motion

21 that whatever information is available on the internet

22 regarding the complaint filed upon a person should stay

23 as it is, and any additional information required by

24 anybody should be charged as it is.

25 DR. LUBRITZ: I'll second that.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Okay. There is a motion and

2 an amendment to the motion that was seconded. We have

3 to vote on the amendment. All in favor?

4 THE BOARD: Aye.

5 MADAM PRESIDENT: Opposed?

6 Chair votes in favor. The amendment carries.

7 That full motion can then have a motion to approve as

8 completely stated? There is a motion. A second to the

9 approval of that original motion.

10 DR. LUBRITZ: I'm not sure I understand.

11 MADAM PRESIDENT: We voted on approval of your

12 amendment to your motion. Now we have to vote to

13 approve the motion.

14 DR. JONES: Second.

15 DR. ANJUM: Second.

16 MADAM PRESIDENT: All in favor?

17 THE BOARD: Aye.

18 MADAM PRESIDENT: Chair votes in favor of the

19 motion, and the motion carries.

20 I know we still have a lot to do here. No one

21 has had a break, and I would like to take a five-minute

22 break and we'll come back.

23 (A recess was taken.)

24 MADAM PRESIDENT: Okay. We are going to

25 continue on.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 We have perhaps one of the most ambitious

2 agendas I have ever seen. I will say we do need to move

3 this ahead based on the fact that we have a lot to cover

4 today and tomorrow.

5 This is incredibly important, however, because

6 these are recommendations that the legislative

7 commission, as well as our medical societies and

8 physician licensees, are waiting on us to decide how to

9 go forward. And so I'm going to try and move this

10 along.

11 I do think that if there are issues that we

12 really can't resolve, then perhaps we can put those off

13 to the next meeting. But the ones we can, I would

14 really like recommendations from the board so that we

15 can move forward on this audit.

16 We had completed our discussion on F, but G

17 was just using our newsletter as a tool and doing a

18 better job with that and have a yea or nay on that.

19 THE BOARD: Yea.

20 MADAM PRESIDENT: Okay. H is recommending

21 that we hire a full-time public information media

22 specialist. I think that -- do you see the staff

23 recommendation? I certainly at this time think that

24 probably we don't have enough work to truly hire

25 someone.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 I do think that we need to have at certain

2 times the availability to do PR work. I think that

3 there are other ways to do it other than hiring a

4 full-time media consultant, but I would like input on

5 that.

6 DR. LUBRITZ: If I may, my thought was that it

7 is perhaps reasonable to try that on a part-time basis

8 as opposed to the television ads which we currently have

9 and have run for quite some time, as an alternative,

10 that might be reasonable on a part-time basis.

11 MADAM PRESIDENT: I think we are going to have

12 a presentation on our public service announcements later

13 and make a decision on that. So that is one of the

14 things we have to decide too.

15 But what about the hiring of someone sort of

16 as a per diem basis rather than a part-time basis at

17 times during legislative sessions or when particular

18 issues come up? Does the staff have the capability or

19 approval to hire somebody as needed?

20 DR. LUBRITZ: Yes, ma'am.

21 MADAM PRESIDENT: Would that work?

22 MS. KIRCH: Yes, ma'am.

23 DR. MONTOYA: What about using Tony and our

24 legislative assistant that we use to handle most of

25 this?

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Okay. I think on most of it

2 that is do-able, and I certainly would support using

3 both Kingsley and Tony as spokes people for the board.

4 I think that both are very qualified to do so.

5 And although I think the president needs to be

6 included in that loop and be the spokes person, the

7 official spokes person, I think in relating to the media

8 and relating to the public that more is better. And

9 that as long as we have sort of a unified message that

10 we are putting out there that has been approved by the

11 board, that that makes some sense.

12 DR. ANJUM: I would amend that we leave that

13 option that whenever in case we need somebody on a per

14 diem basis, we hire them. And not totally let it out

15 completely. And increase to half time to full time if

16 the need comes.

17 DR. BAEPLER: I would agree. How many

18 regulatory boards have such a position?

19 DR. ANJUM: If and when we need, we can hire

20 someone on a per diem basis.

21 DR. MONTOYA: I think our image is improving

22 daily as it is.

23 MADAM PRESIDENT: Okay. So the feeling that

24 I'm getting is that the board does not want to take

25 action on hiring someone at this time.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. ANWAR: This is a typographical error. It

2 says 115,000, actually was it supposed to be 150,000?

3 MADAM PRESIDENT: Yes.

4 I'm going to defer that to later on because we

5 have another agenda item that will address whether or

6 not we do our public service announcement.

7 And, again, J just talks about doing more PR

8 kinds of activities with speaking engagements with

9 medical and specialty groups and hospital staffs and so

10 forth and I certainly think that that's a good idea.

11 DR. MONTOYA: We started that, president.

12 MADAM PRESIDENT: Yep. And, again, K is

13 talking a little bit about not just newsletters but

14 perhaps consider some brochures that could be developed

15 that could be put in physicians' offices that tell

16 people about us.

17 MR. CLARK: We had one in the past, and what

18 we are doing now is trying to amend or modify and bring

19 it up to date.

20 MADAM PRESIDENT: So you could bring some

21 prototypes back to the board for the board to look at in

22 the future?

23 MR. CLARK: Yes, ma'am.

24 DR. LUBRITZ: My only question with that was

25 if you are going to make it a requirement -- if you have

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 a requirement, you have to have a penalty if it's not

2 done. And my question is who's going to go through all

3 the doctors' offices and make sure that they have

4 pamphlets, that they are readily available, that they

5 get them and that kind of thing? So to have a

6 regulation without a penalty is -- I think, it would be

7 good to have a pamphlet for those who want to use it.

8 But I think to make it a requirement, which will then

9 require someone to check and make sure the requirement

10 is being done, would be somewhat burdensome.

11 MADAM PRESIDENT: I think -- and perhaps none

12 of us have seen a copy of the brochure to see what it

13 looks like, so probably the first step is to see the

14 development of those brochures and then decide how they

15 should be utilized.

16 I agree with you, Joel, that the availability

17 should be there. I think it should be a positive thing,

18 actually. And that hopefully if it's done correctly,

19 that physicians would want to have it available in their

20 offices.

21 DR. BAEPLER: Several states do this. The

22 state of Texas I'm familiar with and it is a requirement

23 and it's very well received. And it's more than simply

24 a pamphlet that says if you want to file a complaint,

25 here is the address and how to do it.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 It's an informative brochure that, to a

2 degree, takes the place of our public service

3 announcements because it's available to the people who

4 come to the doctor's office.

5 DR. ANWAR: Yeah. That's a good place.

6 DR. JONES: Also, just like other things, you

7 ask during licensing, are you displaying brochures and

8 it's something that, you know, if they are answering

9 incorrectly, then it's not that we would go specifically

10 after the brochure.

11 DR. BAEPLER: It's hard to go after the doctor

12 too because often these have to be displayed in an

13 office where there is 15, 20 more doctors involved.

14 Your operation, for example. If you have -- if you

15 didn't have a brochure, who do you penalize? The group?

16 I don't know.

17 MADAM PRESIDENT: Okay. I think the

18 recommendation that I'm hearing is that we work on

19 development and continuing developing the brochure and

20 bring it back to the board to look at.

21 And then under L, is that more reliable

22 information about the physician work force in Nevada is

23 needed and is suggesting that the board can provide more

24 data within the state needed by the legislature and

25 others to make work force decisions.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 And it is suggesting that we may include some

2 simple questions on our re-licensure application that

3 would address questions such as do you accept new

4 patients? Do you accept Medicare? Et cetera, and make

5 that information available.

6 Anybody have strong feelings about that?

7 DR. LUBRITZ: I do. Suppose you make the

8 statement, yes, I accept Medicare. Yes, I take new

9 patients, or whatever. And then you make a decision a

10 month or two down the line that, no, we are not going to

11 do that?

12 Now, I think that that has nothing to do with

13 licensure. I think whether or not you accept the

14 Medicare patient or this insurance or that insurance and

15 what time your office sees patients are so changeable in

16 today's profession that that is not an appropriate thing

17 to have as questions on your licensure.

18 DR. ANJUM: This is information. It's not

19 mandated. It's only information.

20 MADAM PRESIDENT: I have the same concern,

21 though, that Joel does. And I like the idea of this,

22 but I'm wondering maybe it should be done in a survey

23 form rather than -- obviously you won't necessarily get

24 every response back as you would on a license renewal.

25 But if you are going to ask questions that

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 reflect certainly Medicare or Medicaid patients or those

2 sort of things that really reflect what kind of practice

3 you have, that does change over a two-year period of

4 time and may not be as accurate.

5 I don't know. I think that we could look at

6 some questions that maybe didn't reflect those kind of

7 things and include them on the license form.

8 I think the problem has been, and I think

9 Larry Matheis is here today and would feel the same way,

10 that it's been difficult to get data that is consistent

11 and try to come up with summative comments that we can

12 use for the governor's office for work-force issues and

13 so forth.

14 So I think that we need the answers to some of

15 these questions.

16 MR. MATHEIS: Larry Matheis with the Nevada

17 State Medical Association. I think that's right, and I

18 think the auditors misunderstood what the discussion

19 about that data was.

20 And I think that was one of the problems,

21 frankly, with the auditors. They didn't consult widely

22 outside of the board itself on some of these things.

23 And I think here it's information that I think this

24 board actually does collect.

25 It's more about what specialist, how much time

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 are they full-time, part-time, that sort of thing. It's

2 been a matter of the difficulty of accumulating that or

3 reporting that in a timely way or in a base line way. I

4 think that's more of what the legislature was talking

5 about when they were talking about helping them make

6 work-force decisions.

7 What is the supply of obstetrical care givers?

8 And how does that fluctuate? They all fluctuate with

9 time. But to have a database that starts with the

10 information that you do collect and that being reported

11 on an annual basis, then you have a base line over time.

12 And it's easier then to make for the legislature or for

13 others to start there and then be able to gather

14 additional information that is needed.

15 I think that's what the purpose of that is.

16 So I don't think it's necessarily collecting a lot of

17 new information but finding a better way to actually use

18 some of the information that you gather already.

19 MADAM PRESIDENT: I think some of that will be

20 improved because our computer system is being sort of

21 upgraded too, and it will be easier to access.

22 I'm going to make a recommendation on this

23 that perhaps we not make any great changes on our

24 license applications but that if there is input, Larry,

25 from the medical societies or some other groups, a

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 specific question, that are felt to be in addition to

2 what we are already collecting, then maybe that can be

3 presented to the board at a later date. And we can take

4 a look at that as to whether or not the board feels that

5 is indicated.

6 But I think right now, you know, it's just

7 perhaps being able to tweak the data we already gathered

8 and present it in a form that is more accessible.

9 MS. KIRCH: One of the things you consider is

10 if we do get the information, we can include that survey

11 when the licensing applications go out, request response

12 at that time. They wouldn't be penalized in any way

13 for, you know, failure to respond or whatever. If there

14 is additional information, that would be useful for

15 these other purposes. Do some professional survey at

16 that time and conclude --

17 MADAM PRESIDENT: And under M, you know, again

18 this is just a continuation of the previous one that

19 making presentations, talking about what we do. And I

20 think we have tried to do more of that. I think

21 hopefully the communications are improving. I think the

22 feedback I have gotten has been that we are doing a

23 better job with that. And I think to carry that forward

24 and to continue to do more, I don't think anybody

25 objects to that.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. ANWAR: I don't understand the language of

2 this that the board undertake a continuance and

3 ambitious program present and describe what the board

4 does and why and how it operates to every local and

5 county medical association, large hospital, and medical

6 staff. These are open meetings. They are welcome to

7 attend. They should be encouraged to attend. Go

8 outside of these meetings and make presentations to

9 every possible associations, societies. Everybody

10 should be encouraged to attend these meetings. These

11 are open meetings.

12 MADAM PRESIDENT: I think the issue -- And

13 you raise a good point. I think the issue is more

14 communication of change of things like some of the

15 issues we talked about earlier. For example, all

16 physicians should be notified that they are required to

17 report if they have a malpractice claim.

18 If there are changes about some of the changes

19 the board is doing, I think communication is a good

20 thing.

21 I don't think this language is too strong. I

22 don't think you certainly have to go to every county,

23 every small hospital. But I think to get the word out

24 about the board and what we are doing and the services

25 that the board provides, both for its licensees as well

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 as for the public, is important.

2 And I think that Tony, again, can be helpful

3 in that respect in communicating. I think some of it

4 can be done in letter form. I think we have done some

5 of that, written to societies and written to hospitals,

6 informing them of things that the board is doing.

7 DR. BAEPLER: This sounds good, but it's

8 difficult to implement.

9 It's easy to go to these groups and focus on a

10 particular issue. I would hate to have the assignment,

11 go to one of these groups and tell them what the board

12 does. My goodness. I don't know how we would focus

13 that. However, if we are considering certain issues,

14 those we can focus on. Obviously we respond to any

15 invitation we are given, that's no problem, but you have

16 to have a focus on here as to what the board does.

17 MADAM PRESIDENT: Steve?

18 DR. MONTOYA: I have spoken to a total of

19 three medical staffs and two medical societies. It's

20 not that hard. The first question you ask, do you

21 understand what the board does? And we tell them, "We

22 are there to protect the public." You get this look.

23 People don't know we are there to protect the public.

24 They think we are there to advocate for doctors come

25 hell or high water.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 Once you get across -- the big message, that's

2 what we do and then a lot of the things, when they see,

3 come down to these things in the paper or whatever they

4 see is taken in a lot better context.

5 It's not that we are going after a doctor

6 particularly. It's that we are protecting the public.

7 And that's the message that I have gotten across to

8 those medical staffs and the medical societies.

9 DR. BAEPLER: That's a good message.

10 MADAM PRESIDENT: Can you still hear us?

11 Okay. Because the monitor is still frozen.

12 In light of the fact that it's now almost

13 11:30, what I would like to do is to put off the

14 recommendations that are going to require statutory

15 changes to the next board meeting for discussion because

16 I think these are things that are not going to be able

17 to happen until the legislature meets and we have time.

18 DR. BAEPLER: Do we know the deadline for

19 getting those in for bill drafting before the

20 legislature meets?

21 MR. CLARK: We would be utilizing the

22 individual legislators so we don't have to meet the

23 governor's time frame.

24 DR. BAEPLER: I understand that, but there is

25 a timely way to get them in to get them pre-drafted.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MR. CLARK: I'm not sure. I will find out.

2 DR. BAEPLER: I would assume September will

3 still give us time?

4 MR. CLARK: Yes, I believe so.

5 DR. MONTOYA: That is largely under agenda

6 eleven also?

7 MR. CLARK: Yes.

8 MADAM PRESIDENT: So what I would like to do

9 at this point is to have a motion to approve the

10 recommendations as discussed on all the items up to this

11 point.

12 DR. ANJUM: So moved.

13 DR. LUBRITZ: Second.

14 MADAM PRESIDENT: There is a motion, and a

15 second to approve the recommendations as discussed.

16 All in favor?

17 THE BOARD: Aye.

18 MADAM PRESIDENT: Opposed?

19 Chair votes in favor, and the motion carries.

20 DR. LUBRITZ: You will look over that draft to

21 make sure?

22 MADAM PRESIDENT: Yes, Joel. Thanks.

23 I apologize. Is there any brief public

24 comments about these issues that would like to be made

25 at this point?

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. ANWAR: Can they hear us?

2 MS. MUNSON: I'm having trouble with the

3 camera so I'm trying to fix it. Can you hear us? Can

4 you see us?

5 MADAM PRESIDENT: Okay. Hearing no public

6 comment, then I'm going to move on.

7 Actually, I am going to take an item out of

8 sequence on the agenda.

9 I'm sorry. But I'm going to need your help.

10 We have Brad Thompson is here to talk about the

11 diversion program, and I'm not sure. I can't find what

12 agenda item it is under.

13 MR. CLARK: It's under 15, Madam President.

14 MADAM PRESIDENT: Okay. So, Dr. Thompson, are

15 you there?

16 DR. THOMPSON: Yes. Can you hear me?

17 MADAM PRESIDENT: Yes.

18 DR. THOMPSON: Okay. Thank you very much for

19 taking me out of order, Ms. President.

20 I naively scheduled office patients for noon,

21 so I didn't realize. Good afternoon or good morning,

22 board members.

23 I'm from the diversion committee. The Nevada

24 Health Professionals Assistance Foundation. This is my

25 interim report.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 We are very pleased to report that we are

2 still on track to get Dr. Peter Manski as our executive

3 director and medical director.

4 He unfortunately was due to start this month,

5 but due to some of -- some personal problems and some

6 other problems that we have been having, it's probably

7 going to be another month or two before he comes on

8 board.

9 Although we are negotiating his contract at

10 the moment, part of the problem is that because he is

11 such a prominent person and has a salary commensurate

12 with a senior member of the diversion program -- As you

13 recall he is from New York state and runs the diversion

14 program there. We are having a little bit of trouble

15 with making sure that we have enough funds. We don't

16 want to promise him something we can't give him, of

17 course.

18 And we are trying to be a little careful. On

19 the other hand, we very much want him to come because he

20 can make our diversion program as good as any in the

21 United States.

22 MADAM PRESIDENT: Excuse me, Dr. Thompson. Am

23 I hearing what you are saying that really we are not

24 sure he is coming?

25 DR. THOMPSON: We are committed to having him

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 come. Unfortunately, we are still dealing with some

2 financial issues such as benefits and things like that,

3 you know. Of course, we don't want to give him

4 something that we can't promise -- I mean, we can't

5 deliver on.

6 So right now he is very committed. I spoke

7 with him multiple times this week. We had a foundation

8 meeting this week of the board members, and we are

9 unanimously committed to having him come. We are just

10 having a little problem with money.

11 MADAM PRESIDENT: I'm sorry to interrupt you.

12 But, you know, this is a little bit disturbing to me

13 because the report that was given to this board months

14 ago was that he -- this was a done deal, that he was

15 contracted to come. And he was going to start May 1st

16 and that this was a go.

17 And, you know, I'm hearing a very different

18 story now that maybe he is coming but maybe it's going

19 to be several months and we may not have the money to

20 pay him.

21 DR. THOMPSON: It is still -- If you got the

22 impression last meeting that it was already a done deal,

23 and contracted, I apologize because he is still -- was

24 not under contract. It was all on a handshake at that

25 point.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 We are very committed to having him come, and

2 he is committed to coming. But it's still not a done

3 deal yet, no.

4 And he was supposed to start this month but

5 that's not going to happen. The new tentative start

6 date is going to be August the 9th.

7 He has some personal commitments too. His son

8 is getting married in July. He has another personal

9 commitment in July also. So we decided having him come

10 at the end of June and start up again and leave and then

11 come back in August that we would just start it in

12 August.

13 Yes, we are still negotiating the contract.

14 However, all parties remain committed to seeing this

15 through. And he is very excited about coming. We are

16 going to have him come out and make a personal visit and

17 look for homes in the week of -- beginning, I believe,

18 June 21st. So he is committed.

19 But, no, it's not a done deal yet. In any

20 event, we are still negotiating and that's still in the

21 works. Did you have any further questions?

22 MADAM PRESIDENT: I just want to recognize

23 that Dr. Coughlin is here also and wanted to know if you

24 had any comments.

25 DR. COUGHLIN: No, that's essentially

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 accurate. We are in the process of negotiating. We are

2 very hopeful that we will be able to retain him, but

3 it's not a done deal.

4 DR. LUBRITZ: Might I ask a question? How

5 close are you to a deal? Is it all the above: No home,

6 no benefits decided upon, no salary decided upon? Do

7 you have money? Very specifically, rather than

8 generally, could you give us an idea?

9 DR. COUGHLIN: We agreed --

10 DR. THOMPSON: Go ahead, Tim.

11 DR. COUGHLIN: We agreed on the salary. We

12 are negotiating --

13 DR. LUBRITZ: Can I interrupt? And can you

14 meet that salary? Dr. Thompson had said that there was

15 an issue of money. So if you have agreed upon it, do

16 you have the resources to pay?

17 MR. COUGHLIN: Yes, we do. One of the

18 problems is he has requested that there be a yearly

19 increase in salary as he feels he is coming in at

20 something less than what he is worth. And we are trying

21 to make sure that we get value for what we are spending.

22 And the benefits package is being, frankly,

23 pared down a little bit at this point. And we are

24 trying to spend the money we have wisely and make sure

25 that we have -- and make sure that it's equitable for

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 both sides.

2 I think it will be done. And what I'm

3 understanding from him is he is willing to compromise a

4 little bit too, but it is a negotiation.

5 DR. LUBRITZ: When do you think you can get

6 his name in ink?

7 DR. COUGHLIN: We will either have a deal

8 within the month or we won't.

9 DR. LUBRITZ: Thank you.

10 DR. BAEPLER: Is he going to be permitted to

11 carry on private practice part time?

12 DR. COUGHLIN: Yes. That will be at the

13 discretion of the foundation board and as long as he is

14 able to fulfill his responsibilities to the board.

15 DR. BAEPLER: That can be a critical part of

16 the compensation package.

17 DR. COUGHLIN: We are hoping he will get a

18 commitment with the medical school of Las Vegas.

19 DR. BAEPLER: Which medical school?

20 MADAM PRESIDENT: There is only one medical

21 school, Don.

22 So from both your perspectives, Tim, and

23 yours, Brad, are things going well with the diversion

24 program?

25 Has this caused some difficulties for you at

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1 all?

2 DR. COUGHLIN: No. We seem to be carrying on

3 fairly well. We have sent one physician back to

4 Springbrooke in the last month.

5 Brad is intervening on a number of people in

6 Las Vegas.

7 We are not seeing a whole lot of problems in

8 the north at this point. I will have to defer to what

9 Brad says on what is going on in the south.

10 DR. THOMPSON: We are having no major problems

11 in our diversion program right now. It seems to be

12 running very smoothly.

13 And I might add that I'm very happy and

14 pleased with the cooperation that your staff is giving

15 us that they have been open to questions and very

16 responsive, and I do appreciate that very much.

17 It seems to be working smoothly at the moment.

18 No, we are not having any major problems. And to answer

19 some of Joel's questions a little bit, I think we are

20 going to have Dr. Manski out in person in June.

21 I hope to have the contract mailed by, I

22 believe, it's June 26, we'll have it inked in. That's

23 my target date. That's my goal. I'm working on it, you

24 know, on all sides.

25 We are financially right now even a little bit

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 better off than we were at the last report. We are, you

2 know, approximately four to five months prudent reserve

3 operating costs so we are not in trouble at the moment.

4 The clients are -- the participants are

5 cooperating and, of course, with your support.

6 So we are still looking for other sources of

7 funding of course.

8 Unfortunately, one of your big contributors,

9 Sunrise Hospital, has recently undergone a change in

10 leadership. And, unfortunately, the new leader is not

11 as friendly as the old leader to our particular program.

12 He is familiar with the Florida PRN program, but I don't

13 think he is going to be quite as responsive to our

14 request for funding.

15 I have currently letters pending to both the

16 hospital association and to the medical society to ask

17 for funding as well. I was waiting until we had a

18 little bit better security with Dr. Manski. But I think

19 I'm pretty secure about it right now, and I will send

20 off those formal requests.

21 Dr. Manski is also very aware that funding is

22 critical to his package. And, in fact, at the recent

23 federation meeting the diversion program throughout the

24 50 states, which met right after your federation

25 meeting, that they had a lot of fund-raising ideas and

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 Manski and I both attended those.

2 The board and diversion committee has changed

3 a little bit since our last report. Dr. Jackson from

4 the north is now our treasurer. And we have added

5 Dr. John Chapel to the board. Tim Coughlin, Roger

6 Belcourt and Jerry Kate remain the president and vice

7 president and secretary.

8 As I said, to add to Tim's comments, the

9 southern Nevada diversion committee is meeting monthly.

10 It's a strong committee.

11 And, unfortunately, we just lost Lex Hopper.

12 He has a reoccurance of his tumor and, unfortunately, he

13 has had to drop out of our committee. That's about

14 where we are.

15 Thank you for taking me again out of order. I

16 appreciate it.

17 MADAM PRESIDENT: Thank you. Any questions or

18 comments from board members as far as the diversion

19 program?

20 Thank you for coming too, Dr. Coughlin.

21 MR. COUGHLIN: Thank you.

22 MADAM PRESIDENT: Okay.

23 DR. COUGHLIN: Ms. Hug-English, we have a

24 comment down here from the public.

25 MADAM PRESIDENT: Okay.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MEMBER OF PUBLIC: What's the salary you are

2 going with the diversion program director?

3 DR. COUGHLIN: Currently the salary is

4 $138,000 approximately. Is that right, Tim?

5 MADAM PRESIDENT: He left.

6 DR. COUGHLIN: Yes, that is correct.

7 DR. THOMPSON: That was fast. Yes, it's

8 within a couple of thousand of that number.

9 MADAM PRESIDENT: Any other questions?

10 All right thank you once again.

11 We are going to move on to agenda number five,

12 actually five and six kind of go together. And that is

13 consideration of the public service announcements.

14 And, Dr. Montoya, you want to tell us what

15 your committee report --

16 DR. MONTOYA: We had one more meeting this

17 last week down in Las Vegas. It's Ms. Kirch, Tony and

18 I, and we were presented with about ten different

19 scenarios both for TV and for radio which we limited to

20 about four or five --

21 We met down in Las Vegas, and we had about ten

22 things submitted to us of which we went over. We

23 eliminated the ones that the committee absolutely did

24 not like.

25 And right now in front of us we have the new

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1 ideas for scripts coming up for your consideration.

2 I imagine we have to make a decision right

3 now, but this is so far what we have been able to come

4 up with. Our message is to be positive, to let the

5 public know that we are there for them, and also let the

6 doctors know that we are not necessarily against them.

7 DR. BAEPLER: Have we added to the website,

8 when you look up doctors, where they went to school and

9 that type of thing? Or are we in the process of doing

10 that?

11 MS. MUNSON: We are in the process of

12 completing our review of all of that information. We

13 will probably need another couple months, and we will be

14 ready to do that. Currently it is not on there.

15 DR. BAEPLER: But it will be?

16 MS. MUNSON: Yes.

17 DR. MONTOYA: That's the end of my report.

18 MADAM PRESIDENT: Thank you. I think that the

19 bigger issue or the bigger thing that we need to

20 consider is under agenda item number six and whether or

21 not we want to continue the contract.

22 Now, is Mr. Fisher here?

23 MR. CLARK: No. He is unavailable for this

24 meeting. That is in his letter.

25 But we have a form of contract, if we want to

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1 go for a year. If we want to continue on with a

2 quarterly, we can do that as we have been in the past.

3 I thought that the Nevada Broadcasters

4 presented our sub-committee with some good scripts from

5 the standpoint of short TV spots. And if we can start

6 getting some more of them on, I think it will be helpful

7 to us.

8 DR. BAEPLER: Will they produce those if we

9 sign a contract only for a quarter?

10 MR. CLARK: I believe they will. I believe

11 they will.

12 And it's going -- It would take probably a

13 renewal of the quarterly contract in order to get us on

14 the board of examiners' agenda for approval of an annual

15 contract if we decided to go that way.

16 DR. BAEPLER: Yeah. I myself would like to

17 see the brochure that you are working on that would be

18 distributed in doctors' offices. In some degree, this

19 doesn't take the place of the public service

20 announcements.

21 Certainly, it would address the audience most

22 interested in the information in the public service

23 announcements.

24 MR. CLARK: We will have that for the board's

25 review at the September meeting.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. MONTOYA: What I personally would like to

2 see is get the contract to go for a year because I'm

3 tired of revisiting this every quarter and probably

4 every board meeting we revisit the same thing.

5 Get the contract going for a year, and then we

6 very rarely make any changes for a year. And I would

7 rather commit ourselves for a year, get on the horse and

8 ride it.

9 DR. BAEPLER: I think we have gone with the

10 quarter by quarter basis because we always felt

11 comfortable. The question is, Do we want to continue it

12 or not?

13 DR. MONTOYA: I think we ought to make the

14 commitment to get on and let's go. And if that horse

15 doesn't run, we can change horses in a year.

16 MADAM PRESIDENT: I think, as I recall, they

17 made the presentation at the last meeting, there was a

18 definite advantage with going with a year's contract

19 based on the fact that you could -- you know, they would

20 have more flexibility in how they do it and how they run

21 the spots and so forth.

22 MR. CLARK: They would be changing spots every

23 quarter.

24 MADAM PRESIDENT: Exactly. I am with you,

25 Steve, on the fact that I think if we are going to do

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 this, we should really commit to it for a year,

2 reevaluate it in an year and say if it isn't working or

3 at that time develop things that we think takes the

4 place of it, then we can stop it.

5 I have a feeling it's going to take probably

6 three to six months to get brochures and things

7 developed and going, so that we really won't lose much

8 by doing this.

9 DR. BAEPLER: Do we have a price for this?

10 MADAM PRESIDENT: I think it's in --

11 DR. BAEPLER: Is it on 15?

12 MADAM PRESIDENT: Under six.

13 MR. CLARK: It still would be -- wasn't it

14 5,000 a quarter? Five thousand dollars a quarter plus

15 $7500 to produce spots?

16 DR. LUBRITZ: Each spot?

17 DR. MONTOYA: Yes.

18 MR. CLARK: No, all spots.

19 DR. MONTOYA: I thought that was each?

20 MR. CLARK: No, I don't think it was each.

21 That was for development.

22 DR. BAEPLER: You are suggesting $20,000 for

23 the year plus seven and a half thousand?

24 MR. CLARK: No, it's 5,000 a month. It's

25 $60,000 plus 7,500.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. BAEPLER: Okay.

2 MS. KIRCH: And that meets the board of

3 examiner's approval, correct?

4 MR. CLARK: Yes.

5 DR. BAEPLER: Because of the length of it.

6 MS. KIRCH: I thought we were going to pursue

7 that approval?

8 MR. CLARK: We had to get the authority of the

9 board to go for a year before we sought the approval of

10 the board of examiners.

11 MS. KIRCH: Now we are in a position that we

12 can go for the full.

13 MADAM PRESIDENT: Why can't we make a motion

14 to approve it for a year pending approval?

15 MR. CLARK: That's the action you should take.

16 DR. MONTOYA: I make that motion.

17 DR. JONES: I second.

18 MADAM PRESIDENT: There is a motion and a

19 second to extend a year-long contract with the renewal

20 script ideas that have been presented.

21 Is there any further discussion about that?

22 DR. LUBRITZ: Yes.

23 MADAM PRESIDENT: Dr. Lubritz?

24 DR. LUBRITZ: We have to discuss the

25 additional cost for the production.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Yes.

2 DR. LUBRITZ: It is 60,000 for that plus --

3 MADAM PRESIDENT: Seventy-five hundred.

4 DR. LUBRITZ: Seventy-five hundred total for

5 the productions of new spots?

6 MR. CLARK: That's my understanding.

7 MS. KIRCH: We need to confirm that but --

8 MADAM PRESIDENT: Okay. So, again, there is a

9 motion and a second to approve the contract for a year

10 and at the amounts that have been presented.

11 If that amount substantially is different than

12 what we think it is, I think that needs to come back to

13 the board at the next meeting.

14 But, again, this is all pending approval by

15 the board of examiners.

16 All in favor?

17 THE BOARD: Aye.

18 MADAM PRESIDENT: Opposed?

19 Chair votes in favor of the motion. Motion

20 carries.

21 DR. LUBRITZ: May I make a comment that we

22 actively pursue not the production but the development

23 of -- with a time scale of the new -- possible new

24 method that is with the pamphlets that has been

25 suggested.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Thank you. I think that's a

2 good suggestion.

3 DR. BAEPLER: My own personal opinion is that

4 we are not getting the kind of exposure we need nor

5 necessarily the appropriate message through the current

6 public service announcements.

7 A lot of people have never seem to have seen

8 them. I'm one of them. I rarely ever see one.

9 MADAM PRESIDENT: I think that certainly with

10 a year-long contract if that's not happening after a

11 quarter, I think we have -- we certainly could bring

12 them back and say we expect to see better time slots.

13 And I think we would have more authority to do that than

14 when we have a quarter contract and each time it's sort

15 of playing catch up.

16 DR. BAEPLER: Fewer but better --

17 MADAM PRESIDENT: Better time slots.

18 I'm going to skip to agenda item number eight

19 with Dr. Rosin here today.

20 You can come up to the table, Dr. Rosin. This

21 is a consideration of a request by the Nevada Division

22 of Mental Health to allow family practice residents to

23 perform screening services at Southern Nevada Mental

24 Health Services.

25 So, Dr. Rosin, do you want to explain a little

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1 bit about what this involves?

2 DR. ROSIN: Thank you, Dr. Hug-English, and

3 members of the board.

4 For the record, I'm Dr. David Rosin.

5 As probably everyone here has some awareness,

6 there is and will be in the future a mental health

7 crisis providing care in Las Vegas.

8 We currently operate now in our emergency

9 rooms with people -- our average is 30 people a day that

10 wait two to three days in the emergency rooms waiting

11 for services. We had as many as, last September, 72

12 waiting in the Valley's emergency rooms.

13 All of these people have been certified as

14 dangerous to themselves and are awaiting services in our

15 facility.

16 The legislature has given us this last session

17 -- allowed us to increase our psychiatric emergency room

18 to 26 beds. And we have received funding to build a new

19 hospital which will increase our in-patient beds from 78

20 to 150.

21 In addition, we operate at this time the only

22 joint commission approved emergency psychiatric

23 emergency service in the state. Although, we have

24 similar services here in Reno. They will serve the

25 certified emergency department.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 The southern hospital has never been

2 certified. We received that in January. One of the

3 issues with the joint commission was since we are now

4 joint certified to perform emergency services, they are

5 now requiring us to provide emergency physicals on all

6 of our admissions into the emergency services

7 department.

8 We have always provided under the standard of

9 emergency joint commission certified -- we have always

10 gone to the standard of the physical examination between

11 24 hours of admission to the facility.

12 We have already considered our outpatient

13 function. Joint commission said no. Even though people

14 who are admitted into that service have been screened

15 medically and cleared medically by physicians in the

16 local emergency rooms, we have to be able to provide

17 that service, history and physical examination within

18 the first 24 hours.

19 We turn our 26 emergency room beds more than

20 once a day. In addition, we have an average of 40

21 people walk into our emergency services.

22 We are looking for assistance and would ask

23 consideration by the medical board to allow us to use

24 second or third year family practice residents to

25 practice -- at least, have the practice ability to do

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 histories and physicals for our state agency under the

2 supervision of our full-time licensed internist.

3 Our staff are being overwhelmed at this point.

4 We have gone to the dean of the medical school and

5 received permission pending medical board consideration.

6 We have gone to the family practice residency

7 program and received permission pending medical board

8 recognition and the ability to have these people

9 practice.

10 There is somewhat of a misnomer in the -- on

11 the agenda. Whether or not these people would be

12 contractually hired or whether they would be sharing a

13 funded position by the state and actually be state

14 employees are both under consideration.

15 If these second year family practice residents

16 would be allowed to do histories and physicals, they

17 would not have primary care of the clients, they would

18 not have prescriptive privileges.

19 We are looking to ask them to moonlight in the

20 second, third year, not generally, but with the state in

21 this facility so that we have the ability to provide the

22 services and maintain our joint commission

23 accreditation.

24 Thank you for the opportunity in presenting

25 this and would be open to consider any questions.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. BAEPLER: How much time does a second or

2 third year resident have to do this kind of work?

3 DR. ROSIN: We would be asking that they

4 provide roughly five hours a week. So we are not using

5 -- we would not use them as our primary source.

6 We cannot judge the number of folks coming in.

7 So with the number of family practice residents, we

8 believe we can get coverage with four or five hours of

9 support which was within the framework of that residency

10 program.

11 We will be -- we are part of the psychiatric

12 training program that is starting in the south. This is

13 actually service work. It's not part of the education

14 program.

15 DR. MONTOYA: It's service work. This is

16 going to be -- So they are not going to get

17 moonlighting pay.

18 DR. ROSIN: When I say service, I mean

19 educational. They will be practicing -- whether we

20 establish we are paying them contractually or as

21 employees of state has yet to be decided. They will be

22 paid for their services, for the services they provide.

23 The state, one way or another, will be paying

24 them for approximately five hours a week worth of work.

25 DR. MONTOYA: They will only work at that one

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 facility, is that right? Are they going off to the

2 other emergency rooms?

3 DR. ROSIN: No. This is psychiatric

4 emergency. So we can maintain at the Southern Nevada

5 Adult Mental Health service hospital we can maybe --

6 DR. MONTOYA: My concern was, well, we have a

7 patient coming over from Sunrise Hospital coming over

8 here. Go do his physical over --

9 DR. ROSIN: No. This is people admitted in

10 our facility. They will have been medically screened

11 from the emergency rooms before they come. But the

12 joint commission will not allow us to use that as a

13 facility to maintain our joint commission.

14 DR. MONTOYA: One last comment was in your

15 letter that you wrote to us you stated only third year

16 residents.

17 DR. HAVENS: Excuse me. We cannot hear you in

18 Las Vegas.

19 DR. MONTOYA: All right. So in your thing you

20 said that you can only have third year practice

21 residents.

22 DR. ROSIN: I apologize for that

23 missinformation that I gave you today.

24 We are asking for third year medical

25 residents. We have also gone to the DO board and asked

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 for second or third year DO residents. I apologize. My

2 letter I wrote is inaccurate. We are asking for third

3 year.

4 DR. MONTOYA: Third year program family

5 practice residents.

6 MADAM PRESIDENT: Dr. Rosin and I have had

7 several conversations about this and have actually

8 worked with -- I have also talked with the director of

9 the family practice residency program in Las Vegas to

10 try and see the best way to make this workable.

11 I think it's clear you have a need. And I

12 also think it's clear that certainly it makes some sense

13 that the residents, with the agreement of the residency

14 director as well as the dean, this is a very limited

15 scope of practice.

16 It is not moonlighting in the emergency rooms.

17 It's not doing a lot of extra time.

18 It is basically offering to help out sort of a

19 mental institution that has a need. I think that it

20 is --

21 I'm glad you clarified the third year. That

22 was our discussion as well, just the third year

23 residents.

24 The simplest way to do it, and you and I have

25 spoken about this, is contract with the residency

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 program so that it's just part of their training so that

2 you don't have to pay them extra.

3 But I think this board needs to approve it

4 with the understanding that what we have asked in the

5 past is for people who are going to be moonlighting. We

6 have asked for specific names each time. And we have

7 one later today that is going to come and ask us if he

8 can moonlight.

9 This would be approving this in concept so

10 that the third year residents who the residency director

11 of that program feels, again, it's only with that

12 director's approval, that they are okay to go and do

13 this as part of their training.

14 DR. MONTOYA: I am very familiar with

15 something like this. We did it during my residency back

16 in Arkansas where we went and manned a health clinic for

17 pap smears -- I'm an OB-GYN -- in outlying areas.

18 It's still going on in Las Vegas now through

19 the OB-GYN residents that they have there. They send

20 their people out. Some of their senior residents go out

21 to the health clinic and do the pap smears.

22 It works very well for them as part of kind of

23 a moonlighting situation. It is approved by the

24 chairman and the chairman has to approve of the time

25 spent out of there, and it's only for the upper

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 residents.

2 DR. ANWAR: I just had a side comment on your

3 opening comments that there is a mental health service

4 crisis. And I think we are trying to play catch up and

5 we are not able to catch up.

6 The addition of the additional beds going from

7 78 to 150 just barely even starts to address catching up

8 the current situation and with the population expanding

9 and growing in the southern part of the state in the Las

10 Vegas area, I don't think it even begins to address the

11 needs of that growing population. Do you have comments

12 on that?

13 DR. ROSIN: Thank you very much. Yes, I would

14 comment to that.

15 This last legislative session we were funded

16 to send a crisis team into the emergency rooms and as of

17 January this year we are sending a triage group out to

18 all emergency rooms except Sunrise Hospital who has not

19 allowed us into their emergency room to date. We are

20 still negotiating with them. Although, the sister

21 hospitals have. We are in each emergency room triaging

22 people in the emergency room not medically. These are

23 social workers. Although, I hope to get a psychiatrist

24 funded to go with that team.

25 We are able, with that triage team, to deflect

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 a large number of people.

2 I agree with you with the population growth

3 that there is a major problem.

4 We are looking at the possibility of

5 constructing a fourth pod which will give us 90 beds out

6 of the use of the state funds we have available at least

7 in getting the structure framed up. It is designed for

8 a fourth pod of 40 beds that we don't have the money to

9 finish and that will be up on the legislature for

10 approval.

11 We think we may be able to have the funds to

12 put, at least, the fourth pod up.

13 The issue we have, because we are able to

14 deflect roughly fifty percent of the people who get to

15 us back into the community into our outpatient services,

16 which are 70 percent of our budget, the issue is the 50

17 percent we can't -- they sit and occupy our beds just

18 like other people occupy the emergency room beds because

19 we don't have in-patient beds.

20 With the addition of roughly doubling the size

21 of our in-patient beds with that number of in-patient

22 beds, we will have the back up to more effectively use

23 our out-patient services and with the crisis team that

24 is going out, we believe we have a fair shot of trying

25 to manage some of the issues.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 Although, we will have to wait and see. We

2 are more optimistic than pessimistic. We know we will

3 have to be adding psychiatrists on the staff both in the

4 out-patient clinic as well as the in-patient service for

5 these additional beds up to 150.

6 We will be adding nursing staff. And we have

7 been able to extend and get the nursing staff. And we

8 will be going to the legislature for much more

9 additional funds -- for more medical funds as well as to

10 manage the people we have to hospitalize.

11 It's an ongoing situation. I think we have so

12 far received the support in terms of trying to do some

13 catch up.

14 And we are more optimistic with our ability to

15 go to thirty beds and use those beds more efficiently as

16 well as our crisis team or the triage team that is going

17 out to the hospitals. And hopefully, Sunrise will allow

18 us into their emergency room because they do a rather

19 high volume of business there.

20 DR. LUBRITZ: What will you be paying the --

21 assuming that there are residents that come, what would

22 you be paying them?

23 DR. ROSIN: The standard has not been set yet.

24 We had looked at two possibilities using the state

25 standards for what the physicians coming out of

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 residency would get paid and using that as a guideline

2 that the state were to hire again right out of

3 residency. Divide that up and getting it, at least, as

4 a bench mark. And we looked at what residents were

5 making when they were allowed to moonlight.

6 What we would like to, of course, from the

7 state's perspective pay them an adequate salary but

8 within our budget.

9 So if I were to say $40 an hour, $50 an hour I

10 would not want to have someone quote me or at least

11 that's a good ball park. It might be something similar

12 to that.

13 DR. LUBRITZ: My question is, have you

14 advertised in the medical community for physicians who

15 want to do additional work in general practice, family

16 medicine, or in other primary care areas for physicians

17 who specifically would want to come in and do history

18 and physicals?

19 DR. ROSIN: We have hired a PA through that

20 method.

21 We have not gone to the medical society or

22 advertised at this point for that. Right now we don't

23 have the budgetary money to do that.

24 DR. LUBRITZ: Since you are dealing with

25 relatively -- in my terms, relatively ill patients

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 albeit mentally ill, if you haven't looked for

2 physicians who might want to do additional work in the

3 general community rather than going to a resident in

4 third year, you are looking for M.D.s, second year

5 residency, you are looking at DOs, would it not be more

6 prudent to look significantly in your current

7 marketplace than in someone who's not quote yet a

8 qualified physician?

9 DR. ROSIN: I don't know that I have an

10 adequate answer for that. Again, we are looking for

11 very limited services.

12 DR. LUBRITZ: But very -- a history and

13 physical to me is very important. I don't know how

14 anyone can refute the fact that a history and physical

15 is perhaps one of the most important things that could

16 be going on with a patient.

17 DR. ROSIN: I agree with you, sir. What I

18 meant was in terms of primary care responsibility

19 describing the issues of that sort.

20 DR. LUBRITZ: You are basing your information

21 on a history and physical that is done -- I won't

22 belabor the point. I don't mean to be confrontational.

23 But when you say just a history and physical, to me

24 that's one of the most important things we do.

25 MADAM PRESIDENT: I think the issue is and,

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 quite frankly, I think that the residents are quite

2 qualified to do a history and physical on any patient.

3 That's certainly something they start training for from

4 day one in medical school.

5 And the reality is that I think if you went

6 into the community, you would have difficulty finding

7 people willing to provide those services whereas a

8 resident at the time of residency might see that as an

9 opportunity to make a few extra dollars in addition to

10 what their training is.

11 Now, having said that, I think that obviously

12 this board has always felt that when residents are

13 residency that's their primary focus. And this is

14 clearly not a lot of time. This is five hours a week

15 that they might do in addition to their training. So it

16 isn't going to be something that over burdens them. It

17 isn't something that is going to be required of them,

18 but it is going to be an opportunity that they can

19 participate in.

20 So I think it's a win-win for both, actually.

21 I think it's a way to provide some additional services

22 that are very clearly needed in a way that is safe and

23 makes sense and also allows opportunity for those who

24 won't to get additional experience.

25 MS. KROTKE: I have a concern on the licensing

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1 side. So these third-year residents at the end of

2 June of say 2005 they need to make sure that they still

3 have a license because limited licenses are only good

4 for a certain amount of time.

5 MADAM PRESIDENT: Right.

6 MS. KROTKE: So it's something that we are

7 definitely going to want to track who they are or do

8 they need a different license.

9 MADAM PRESIDENT: Obviously they would not be

10 allowed to do this at the conclusion of their residency

11 and they are fully licensed. And if they want to

12 continue to do that after that, if they want to continue

13 to do that in the state which they are licensed to

14 practice they would have to do it on the --

15 JOHN LANCELOTT: Excuse me. I'm John

16 Lancelott, physician assistant with the use of the

17 physician assistant pool in Las Vegas to help in this

18 situation as far as supplementing with the residents or

19 maybe getting more PAs on there to do that because a lot

20 of PAs do that work now in the area.

21 MADAM PRESIDENT: So that might be another

22 resource to pursue.

23 DR. ROSIN: In our current budget that is now

24 going, we are in the process of producing a current

25 budget for the current legislature. In that budget

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1 included in our mix of providers we have asked for funds

2 for PAs as well as advanced nurses and advanced

3 psychiatric nurses. So we are cognizant of that. When

4 we are talking about doubling the size of our facility

5 and operating efficiently, we are talking about -- we

6 are --

7 MADAM PRESIDENT: You need lots of resources.

8 DR. ROSIN: Yeah.

9 MADAM PRESIDENT: Well, is there is a feeling

10 by the board? Is there a motion as to what we want to

11 do with this?

12 DR. MONTOYA: I would like to have a motion.

13 I would like to make a motion to preapprove the use of

14 the third-year residents to go do histories and

15 physicals in the psychiatric facility.

16 DR. ANWAR: Second that.

17 DR. HAVENS: Excuse me. Las Vegas has some

18 public comments.

19 MEMBER OF THE PUBLIC: My question for

20 Dr. Rosin is would it be more economical to allow the

21 students to focus on the education or nurse

22 practitioners to do that job, get them out of the

23 emergency rooms and into the beds where they are

24 available?

25 DR. ROSIN: I'm sorry. I'm not understanding.

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1 We do have in our new budget slots for both physicians

2 assistants and advanced practice nurses to provide the

3 care we need in expanding our internal services.

4 We do have a -- we go into the hospital

5 emergency rooms. We are going with the social workers

6 who have now been privileged into the hospital.

7 If you are asking would we hire state

8 employees to perform histories and physicals in the

9 emergency room, that is not our current intent nor would

10 I be able to comment on that.

11 MEMBER OF THE PUBLIC: That's not what I was

12 asking, doctor. You were talking about your in-patient

13 emergency room at your facility. I'm just wondering if

14 it would not be more efficient to use part of your

15 full-time slots as you've requested from the legislature

16 for non-physicians to provide or perform histories and

17 physicals, get the patients out of your emergency

18 facility and into the beds and prescribe whatever meds

19 are necessary.

20 DR. ROSIN: We are currently using a PA. We

21 have included them in our mix.

22 However, our problem is this: That we -- in

23 the last year 57,000 folks came into Las Vegas. That's

24 a net increase. And of that we can predict the number

25 of people who are severely mentally ill and will come

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1 through and be screened.

2 We are looking at -- we don't have a single

3 solution. We are looking at all of these as solutions

4 with this particular request being one piece of a large

5 mix.

6 MADAM PRESIDENT: Thank you. Any other public

7 comments?

8 Is there a motion on the table to approve the

9 third-year residents working in this capacity?

10 All in favor?

11 DR. LUBRITZ: May we discuss?

12 MADAM PRESIDENT: Yeah, I asked for

13 discussion. Nobody had any. Go ahead.

14 DR. LUBRITZ: I missed that. I'm sorry.

15 MADAM PRESIDENT: Go ahead.

16 DR. LUBRITZ: Could we go into closed session

17 or could we delay this until we have had time to think

18 about it?

19 MADAM PRESIDENT: I don't think we can delay

20 it because this is clearly something that is needing to

21 be started if we are going to do it fairly soon.

22 I have a lot of sympathy for the position

23 Dr. Rosin finds himself in as far as shortage of

24 manpower with the change in the regulations.

25 And I think we need to take action at this

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1 meeting to let him know whether this is a possible

2 partial solution. I don't think it's going to fill the

3 need that he has. I think all of these other things

4 that have been brought up are equally important, but I

5 think this is one means for him to get some additional

6 help. I'm not sure. We can go into closed session if

7 you want.

8 DR. LUBRITZ: I would make that request.

9 DR. BAEPLER: No.

10 MADAM PRESIDENT: No, we can't.

11 DR. BAEPLER: It's not a type of matter that

12 constitutes closed session.

13 DR. LUBRITZ: I have some questions that are

14 germane that I need to ask before the board -- before we

15 make this deliberation. I don't feel comfortable in

16 doing it. I will, but I don't think I should.

17 DR. BAEPLER: How does this relate to agenda

18 item number nine?

19 MADAM PRESIDENT: Agenda item nine is a

20 particular resident from the north --

21 DR. BAEPLER: So we are taking it on a

22 case-by-case basis.

23 MADAM PRESIDENT: We are saying with this that

24 you are giving approval for this very limited scope of

25 practice similar to what Steve has said that the OB

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1 program is going to go out and do histories and

2 physicals.

3 DR. LUBRITZ: The differences in the programs

4 as to the caliber of person they have in that program.

5 And that's what I wanted to address. OB-GYN is a great

6 program.

7 MADAM PRESIDENT: I don't think you want to

8 make this decision based on the family practice program

9 is run by a very qualified director who I feel is very

10 capable to make the decision whether or not the

11 residents can work in this capacity. Is that your

12 concern that the residents or the director --

13 DR. LUBRITZ: No, ma'am. We have 39 people to

14 look at -- to look at. And I would tell you that some

15 of those people, I think, are looking for a position for

16 limited licenses. And I have great concern about some

17 of those who have been offered positions. And that

18 makes me very leery about releasing them on the citizens

19 of Nevada to do the work that I just heard needs to be

20 done and that's why I would like to go into closed

21 session.

22 DR. ANJUM: These people would be coming in as

23 third-year residents.

24 MADAM PRESIDENT: These are residents. And

25 let me be clear on this that the residency director has

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1 to feel comfortable with their level of practice to send

2 them out to moonlight. And I don't feel that any

3 residency director is going to do that.

4 Now, if what you need to feel comfortable --

5 and I think we had talked about this is -- clearly it's

6 important that we have the names of those residents so

7 we know who's functioning in that regard.

8 DR. ANJUM: That should come from the

9 residency director and saying he is comfortable issuing

10 that.

11 DR. LUBRITZ: My question is if that residency

12 director is the same residency director who has offered

13 positions to some of these people, then my thought is he

14 may not have the decision.

15 The proper -- that he may not make a proper

16 decision if it's the first level. He is sure not going

17 to have it to make it different than on a third level.

18 MADAM PRESIDENT: Let's make it --

19 Understand, Joel, to share their concerns on this, some

20 of them are coming to this board to see if they can

21 get --

22 DR. LUBRITZ: He has already offered them a

23 position knowing that.

24 MADAM PRESIDENT: I understand.

25 DR. ANJUM: Position for -- training position

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1 for training and improve and to get to the point, and

2 not everybody who gets into the training program. Some

3 don't qualify. They drop out. They are taken down.

4 That's a different scale than the --

5 If you had reason to come in and this is one

6 of his -- is specialized not even a second-year

7 resident. He is a third-year resident. And he has two

8 years. If this person is well enough trained to do

9 that --

10 DR. LUBRITZ: I will withdraw my request for

11 closed.

12 DR. BAEPLER: I have one question for the

13 doctor. Will you have a chance to review the

14 qualifications of the people that will be involved in

15 your operation or will they simply be assigned to you

16 without your having an opportunity to review them?

17 DR. ROSIN: No. I have been working with

18 Dr. Lenhart. That will continue. Our discussions have

19 been with him in terms of how these people get picked.

20 And, no, we would be able to, in any event, whether

21 contract or state employees, they will go through our

22 screening process. They also will have to demonstrate

23 competency because we have to demonstrate competency for

24 the joint commission.

25 DR. ANWAR: If the people in the third year of

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1 family practice training program cannot do a history and

2 physical of a patient, then I would have very serious

3 concerns with that whole program starting from the get

4 go, from the first year.

5 And if these people have been already approved

6 limited licenses to go into those training programs by

7 this board and they have met that basic standard and

8 after that they have spent, at least, two years to get

9 up to the third-year level and they still don't know how

10 to do a history and physical, leaving the decision

11 making as to how to start out the problems of a patient

12 and how to address them as far as treatment is

13 concerned, which is not going to be done at this level,

14 I would have very serious concerns about that whole

15 program.

16 MADAM PRESIDENT: Well, I think that the

17 representative on the board that is involved with the

18 medical school -- I can tell you I think that program

19 is a good one. And I think the people that are in the

20 program currently are doing a good job and are certainly

21 capable of filling this role.

22 I think that the issue before us and the issue

23 on the table is whether we are approving this in

24 concept.

25 The actual decisions as to who those

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1 physicians are will be decided by Dr. Lenhart, who is

2 extremely qualified and knows those residents well. And

3 by Dr. Rosin who, on the other end, has the authority,

4 if we don't feel this person is ready and don't want

5 them to fulfill this responsibility.

6 I think it has very good checks and balances

7 in it. I don't think there is a huge concern here. We

8 are talking about a skill that every medical student at

9 the time of graduation -- somebody very comfortable with

10 doing a history and physicals. So I think -- so I'm

11 going to call the question at this point.

12 And is there a motion and a second on the

13 table?

14 All in favor of the current motion?

15 THE BOARD: Aye.

16 MADAM PRESIDENT: All in favor?

17 THE BOARD: Aye.

18 MADAM PRESIDENT: Opposed?

19 Chair votes in favor of the motion, and motion

20 carries.

21 I thank you, Dr. Rosin, for coming in and

22 talking with us.

23 We are running about two hours behind our

24 agenda, and I noticed agenda number seven is a

25 presentation by the National Commission on Certification

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1 of Physician Assistants. I don't know. Is the person

2 doing that in Las Vegas?

3 LT. COL. ADAMSON: Yes, ma'am, I am.

4 MADAM PRESIDENT: How long a presentation is

5 this?

6 LT. COL. ADAMSON: I can do this in 30

7 minutes, ma'am.

8 MADAM PRESIDENT: We can't take 30 minutes.

9 DR. BAEPLER: Can we have it during lunch?

10 MADAM PRESIDENT: There is a possibility.

11 LT. COL. ADAMSON: I'm fast. I can talk very

12 fast if needed.

13 MADAM PRESIDENT: I'm going to ask you to be

14 extremely brief with the understanding that we really

15 have an incredibly full agenda. We would like the basis

16 of what you can give us in a very short time.

17 DR. ANWAR: Can we have the details of the

18 presentation given to the -- passed out to the board?

19 MADAM PRESIDENT: It's in here.

20 DR. ANWAR: And they are going to read that,

21 or can they go over one, two, three, four, five, six?

22 MADAM PRESIDENT: That's what I'm going to ask

23 you. I would like to limit this to a maximum of 10

24 minutes. We have received all of your slide

25 presentations and have copies of those.

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1 LT. COL. ADAMSON: Okay. By way of

2 introduction, my name is Katherine Adamson. My day job,

3 I'm a Lieutenant colonel with the United States Air

4 Force and academic coordinator of the inner-service

5 physician assistance program.

6 I'm here because of my status with the

7 National Commission on Certification of Physician

8 Assistants this past year.

9 My purpose here today was just to give you a

10 brief overview of the PA practice. I will eliminate

11 that as you requested and get into a little of the nuts

12 and bolts of what PS certification is.

13 We at NCCP feel that is relatively important,

14 as many of the medical boards make their decisions based

15 upon our certification.

16 I would like to review the high points on some

17 of that process. If I can turn you to --

18 Anyway, talking about initial certification

19 what is required and eligibility for that certification

20 is that the PA be a graduate of a program that is

21 approved by the accrediting review commission on

22 education for the physician assistants.

23 That individual who sits for our exam must be

24 a graduate of an ARCPA-approved program. We do not

25 grant status to anyone other than graduates of such

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1 programs.

2 The individual would then sit for and

3 hopefully be successful on completing a physician

4 assistant certifying exam.

5 Now, we offered this exam some years ago. We

6 went to a computer-based testing. And we offer that

7 exam 50 weeks out of 52 for the initial certification.

8 Our goal is to have graduates be able to become

9 certified and licensed by the various states within

10 eight weeks of graduation.

11 The exam is -- the vendor for our examination

12 as far as giving it is Sylvan Centers. There are more

13 than 300 of these across the nation. The vendor for

14 putting our exam together is the National Board of

15 Medical Examiners.

16 The initial certification exam is a

17 360-question, multiple choice questions, assessing basic

18 medical and surgical knowledge. It's a very

19 broad-based, generalistic exam.

20 One new thing we have to offer the state

21 licensing board is a website -- and I do not know if

22 Nevada has availed itself of this opportunity. But this

23 will provide electronic scores directly to the state

24 boards within 24 hours of their availability to the

25 national commission.

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110

1 Again, this is an enhanced security mechanism

2 for transferring the scores and also is there to enable

3 the states to get PAs licensed in a minimum period of

4 time.

5 We do have the service available if Nevada is

6 not using it. It is a free service and hopefully you

7 may explore this with the commission.

8 After initial certification, PAs are required

9 to maintain their certification in a number of

10 instances. Approximately 17 states, and I believe

11 Nevada is one that does require maintenance of

12 certification, as well as the Department of Defense, et

13 cetera.

14 We do that in a series of two steps. One is

15 the requirement of continuing medical education. And

16 the second requirement is to test on an every-six-year

17 basis.

18 So PAs are required to earn 100 hours of CMA

19 every two years. And then in their fifth or six year

20 they will sit for a recertifying examination, one of two

21 products. Either the physician assistant national

22 recertifying exam which is, again, another computerized

23 test or Pathway Two which is a more interesting process

24 in which the candidate may take a take-home exam which

25 is written. It is an open book, open colleague. We

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1 encourage them, these PAs, to collaborate with their

2 supervising physicians and other health-care providers.

3 They have six weeks to complete this exam.

4 And you might ask why wouldn't everyone do it? And they

5 wouldn't do it because it is a tougher exam. It is more

6 onerous as far as the cut score for being successful.

7 And there is an elective component required which may be

8 anything from earning additional degrees to learning to

9 do additional, more involved medical procedures, et

10 cetera.

11 Just a little bit about our exam development.

12 Our exams are not created in a vacuum. We do hold a

13 practice analysis every five to seven years. I was

14 privileged to chair the most recent practice analysis in

15 ensuring that our exams are underpinned with what the

16 current state of PA practice is.

17 We have many, many test committees. All our

18 questions were written by PAs. We have M.D.s -- at

19 least a single M.D. on each of our committees.

20 The questions are subjected to a fair amount

21 of scrutiny.

22 Our scoring is not normative. We have gone to

23 content-based scoring where we have an elite group of

24 PAs from across the country who take our exams and

25 decide what the quote minimally competent PA needs to

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1 know, et cetera, to help us in setting a score.

2 Some new things that we have done, is we have

3 placed a cap on the number of times the PA may sit for

4 our exams. That cap is six times in six years. The PA

5 may only sit for the initial certifying exam three times

6 in a single year. And we don't have any remediation

7 process following that.

8 It is on our feeling that PA education is now

9 on average 27 months long. The vast majority of

10 programs are granting masters degrees, and if PAs are

11 unsuccessful with six times, they need to return to

12 school.

13 We do CMA auditing as many states do. We do

14 have an appeals process which is somewhat akin to what

15 many of the medical boards do. I will say that our

16 appeals process right now is a very active process

17 because of all the PAs, approximately 600, who are now

18 deployed over in the desert and other places are having

19 difficulty with pharmaceutical-type funding to get their

20 category one CMA. So we do have a process where we can

21 automatically extend a PA certification if they are in

22 such a situation.

23 One other new thing that NCCPA has done is

24 institute a disciplinary policy. In no way do we wish

25 to supplant the role of the medical boards in this

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1 regard. We do have an active relationship with the

2 federation of state medical boards who provides us with

3 support funds on PAs who have gotten into difficulty.

4 Our intent here is that we are most

5 uncomfortable in granting our credential, our

6 certification, to PAs who have been involved in any of

7 the felonious things that are present in the

8 presentation before you.

9 In closing, there are some resources that I

10 hope many of you may explore. We have a very active

11 user-friendly website which can go into greater detail

12 should there be any further questions.

13 Thank you, Madam Chair. Was that quick

14 enough?

15 MADAM PRESIDENT: You did an excellent job.

16 Thank you for your willingness to abbreviate it. I

17 think the information is excellent. I think all of us

18 have looked through all of the information that you

19 provided in our board books.

20 And I certainly want to emphasize too that the

21 structure that the PA organization has really is in many

22 ways a model of how to follow through and maintain

23 certification and the steps that are needed. And I

24 think that it's really good to clarify for us what those

25 steps are.

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1 So I appreciate you taking the time to come,

2 and I, again, thank you for your abbreviating your

3 presentation and apologize for the fact that we are a

4 little bit off schedule today.

5 LT. COL. ADAMSON: Understood. Thank you for

6 the opportunity.

7 MADAM PRESIDENT: Okay. Anybody have any

8 comments or questions on her presentation?

9 DR. ANWAR: It was very good.

10 MADAM PRESIDENT: Let's move on and try and

11 get --

12 I know we have another agenda item that was

13 scheduled for 11:00 and that is number nine, request for

14 approval for the family practice residency program. And

15 that is Dr. Davis. And he is here with Dr. Williams

16 who's the resident who can direct us. If we can bring

17 them in. Are they out in the hall?

18 DR. MONTOYA: Which number?

19 MADAM PRESIDENT: Nine.

20 Dr. Williams and Dr. Davis, please have a

21 seat. Welcome.

22 Dr. Williams, I would like to have you just

23 describe for the board what is being requested, because

24 we didn't receive an actual letter from you. And so we

25 are a little bit unclear as to what the specifics are

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1 about.

2 DR. WILLIAMS: I'm Richard Williams. I'm

3 Dr. Davis's program director. He is going to be a

4 third-year resident in July. He is in the process of

5 obtaining a California medical license and would like to

6 moonlight during his third year in California. We

7 wanted to ask permission from the Nevada board for him

8 to do that as he has a limited license in Nevada now.

9 MADAM PRESIDENT: What we were specific --

10 Dr. Davis, do you want to address what the specific

11 moonlighting activities you want to engage in and why

12 you think this is important at this time?

13 DR. DAVIS: I would be engaging in covering a

14 smaller ER in California, Quincy, Portola, basically on

15 my off time.

16 DR. HAVINS: Excuse me. Las Vegas is having

17 trouble hearing the speaker.

18 MADAM PRESIDENT: Just summarize.

19 DR. DAVIS: Engage in activities covering

20 local ERs in Portola, Quincy and Chester. And I think

21 this would be to apply what I have learned over the

22 years and give me some valuable working experience in a

23 professional climate where I'm actually responsible for

24 myself.

25 DR. BAEPLER: How long would you intend to

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1 spend in this?

2 DR. DAVIS: Not more than a weekend, maybe

3 every couple of months. They usually have -- usually

4 weekend shifts. And it would be depending on what the

5 schedules were. But I don't plan on doing it

6 excessively.

7 MADAM PRESIDENT: One of the things that this

8 board has struggled with a little bit is that obviously

9 when you are in residency, that is your priority. And

10 that should be your priority because you are there to

11 learn.

12 I think that in certain instances, and I think

13 what you are trying to tell us, is that you feel that as

14 a third-year resident this would benefit your education

15 by allowing you maybe some different experiences than

16 those you are getting in your residency. And that you

17 feel prepared skill-wise -- and I'm sure Dr. Williams

18 what you are saying is that you feel he is capable and

19 has the skills necessary to do this. And that's what

20 this board needs to hear is that you both feel

21 comfortable to be at a level to do this safely.

22 DR. WILLIAMS: Dr. Davis has been an

23 outstanding resident throughout his two years of

24 residency so far. And as all residents could still use

25 more work experience, he has displayed strength in the

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1 field of emergency medicine which is where he is

2 planning on moonlighting. He has been a very strong

3 resident throughout his two-year residency with us so

4 far.

5 MADAM PRESIDENT: Any questions from board

6 members?

7 Is there a motion?

8 DR. ANJUM: You already have the California

9 license?

10 DR. DAVIS: No, sir. I'm in the process of

11 application. I should be granted my California license

12 at the end of June.

13 DR. ANJUM: You were doing this moonlighting

14 in California?

15 DR. DAVIS: Yes, sir, in the state of

16 California.

17 DR. ANJUM: Before you finish your three years

18 of residency here?

19 DR. DAVIS: Correct, sir.

20 DR. BAEPLER: The only concern is we

21 considered a similar type of request for people doing

22 some outside work for the Nevada Division of Mental

23 Health. And there we had a reason to allow this because

24 of the need of the state agency which is in critical

25 condition.

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1 Here, of course, there is no element of any of

2 the things that we approved the other one for, you see.

3 And to what degree granting one of these are we going to

4 be in a position where we establish a norm? In other

5 words, I'm looking for a hook to hang my hat on as to

6 why we would let one third-year resident do this and say

7 no to the next one.

8 DR. MONTOYA: We were looking after the

9 protection of the people in Nevada in the previous

10 incident over Dr. Lubritz's objection.

11 In this particular case, we are allowing him

12 to go to California. And California has their own

13 mechanism of protection. And if they don't want a

14 second year, I hope they won't give him a license.

15 MADAM PRESIDENT: Well, the reality is that

16 lots of residents in other places in other states

17 moonlight because most states allow you to have a

18 license after one year.

19 We are an exception to that. And, therefore,

20 the residents really -- they are really precluded from

21 moonlighting in Nevada.

22 Some of them ought to try and get moonlighting

23 situations in California. But I think that the position

24 we have taken in the one that we had a couple meetings

25 back which was from this same program is that it's done

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1 on an individual-case basis with residents that the

2 residency director feels very comfortable with

3 skill-wise.

4 And that the resident has reasons and goals

5 that fit in with your own ultimate practice plans that

6 you feel this would be of further benefit to you.

7 And I think that's the key for me is that

8 educationally if you feel this is going to provide you

9 some additional training and additional experiences, I

10 guess I should say, that would benefit you in the long

11 run, then maybe it's worth it.

12 I think it's really clear to this board in the

13 past has been very careful not to approve situations of

14 moonlighting that will detract from your residency

15 training because that's your primary goal and that's

16 your focus.

17 But if you can do it on a very limited scale

18 such as you have described and it would provide you with

19 some opportunities to get some additional experience,

20 then I think it's reasonable.

21 DR. ANWAR: My comment would be on similar

22 lines that when I was in training in internal medicine,

23 I did moonlight in the emergency room a little bit here

24 and there. And that was an experience that was very

25 good to have and did provide some financial benefit

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1 along with the experience that I had as a third-year

2 resident. But second-year residents were allowed to do

3 that in our program where I was.

4 But the most important thing from our

5 perspective as a board is that if they have approved you

6 for a training program and you are going through a

7 training program it's something that will enhance your

8 educational experience rather than detract from that

9 training program, that's my concern. Thank you.

10 DR. BAEPLER: I'm not against you doing this,

11 don't get me wrong. And I agree with the arguments that

12 both of you make. It can be a valuable learning

13 experience, and it is done a lot in other states.

14 So you have to go back and examine our

15 fundamental rule. Again, the arguments both of you make

16 would be applicable to most third-year residents.

17 Everything that you say I agree with, but it

18 means that we ought to be possibly examining our rule

19 about moonlighting.

20 MADAM PRESIDENT: I think that's a bigger

21 question.

22 DR. BAEPLER: Not today.

23 MADAM PRESIDENT: Not for today. But I think,

24 you know, down the road it may be with a residency

25 director and the dean's approval that this board looks

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1 at it and decides.

2 I think that we have not in the past just

3 automatically allowed residents to moonlight. And I

4 think there are reasons for that because I think some

5 moonlighting situations are detrimental to the training

6 program and the residents are tired and they are

7 fatigued and maybe not be doing as good of a job in

8 their own training program.

9 I don't see this situation in that light. I

10 think this is something that is a well-controlled-type

11 of time line that you have set out. It's reasonable.

12 It's not every weekend. It's not going 15 different

13 places in a month. And I think you have described a

14 pretty reasonable situation.

15 So I think today that what we need to decide

16 is whether this particular instance makes sense.

17 And then, Don, I would agree with you that a

18 bigger issue is do we want to look at, you know, making

19 some global changes that would affect the ability of

20 moonlighting in general. I think there's a bigger

21 question, but I think today's issue is whether or not

22 you want to approve Dr. Davis.

23 DR. ANJUM: I'm not against the idea. I think

24 he is qualified for that. How do we keep it controlled

25 that this person -- he said he is only going to do five

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1 days or five hours a week and then goes on a rampage and

2 does the moonlighting --

3 MADAM PRESIDENT: I think that's where the

4 residency director comes in and they have control of

5 that. And they can say to the resident, you can't do

6 this anymore. And they have authority over the

7 residents when they are in their training program. And

8 if it's interfering with their program, absolutely it

9 needs to stop.

10 DR. WILLIAMS: Absolutely. I'm required to by

11 the ACGMA to keep track of any resident that moonlights,

12 and it must not affect their residency and if it does

13 they are not allowed to moonlight.

14 DR. BAEPLER: To get your California license,

15 are you going to ask for an exception or does California

16 allow this?

17 DR. DAVIS: California allows this under their

18 current law after one year of post-graduate training.

19 MS. KIRCH: My concern was what supervision

20 was he going to have?

21 MADAM PRESIDENT: Any further discussion? If

22 not, is there a motion?

23 DR. MONTOYA: I make a motion we grant him the

24 ability to moonlight in California.

25 MADAM PRESIDENT: Is there a second?

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1 DR. ANWAR: Second.

2 DR. ANJUM: I'd like to make an amendment,

3 under the supervision of the program director.

4 MADAM PRESIDENT: That's correct. Yes. So

5 the motion is to allow Dr. Davis to moonlight as

6 described under the supervision of his residency

7 director.

8 DR. ANWAR: Have you accepted that motion?

9 DR. ANJUM: Yes.

10 DR. ANWAR: I second that.

11 MADAM PRESIDENT: All in favor?

12 THE BOARD: Aye.

13 MADAM PRESIDENT: Opposed?

14 Chair votes in favor of the motion. Motion

15 carries.

16 So your request for moonlighting privileges

17 has been granted.

18 DR. DAVIS: Thank you.

19 MADAM PRESIDENT: Okay. All right. Agenda

20 item number ten is our legal reports from Mr. Quinn as

21 far as some stipulated settlements.

22 MR. QUINN: I would like to --

23 I'm going to present these in an order that

24 hopefully will enable us to get through what we can as

25 expeditiously as possible.

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1 The first one I would like to deal with is

2 item number five in the booklet that I handed out.

3 This is a case that was initiated on the basis

4 of certain conduct by the subject respondent. The

5 initiation involved filing of a complaint against the

6 respondent. At the time the complaint was filed -- at

7 the time the case was presented to the investigative

8 committee for consideration, it was -- it was presented

9 by me. I did not know that the respondent had enrolled

10 in the diversion program.

11 The respondent enrolled in the diversion

12 program kind of in a backwards way. He went around

13 Carol Bower and entered into it with Dr. Rukel.

14 He signed a contract with Dr. Rukel. I was in

15 touch with Carol Bower and so I believed -- I was under

16 the impression that he had not enter into the diversion

17 program.

18 The bottom line is -- my understanding is the

19 policy is that where a physician may be subject to

20 disciplinary action based on certain conduct and he

21 enters into the diversion program, the idea of the

22 diversion program is we divert that physician to the

23 diversion program and we don't proceed with the

24 discipline on the basis of the conduct.

25 So I'm asking for approval of a voluntary

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1 dismissal of the disciplinary action.

2 DR. BAEPLER: Well, normally we have another

3 step in here someplace. We have something that in

4 essence says we will -- he can continue to practice as

5 long as we get a report that he is in good standing with

6 the diversion program.

7 DR. HAVINS: I'm sorry. We cannot hear the

8 speaker.

9 DR. BAEPLER: I'm sorry. It seems to me that

10 we typically have another step here where we do give a

11 person a license to continue practicing subject to

12 participation in all of the things associated with it,

13 random urines and so on and favorable reports from the

14 diversion so that we are actively monitoring it.

15 MADAM PRESIDENT: Right. This just looks like

16 nothing happened.

17 DR. MONTOYA: Yeah.

18 DR. ANJUM: You can dismiss the complaint.

19 MADAM PRESIDENT: Yeah. That the complaint is

20 there, and that the board action may not be discipline

21 as far as reprimand or probation or whatever, but the

22 action is that this person is subject to contract with

23 the diversion program with the stipulations that go

24 along with it.

25 And I don't see any of that. So then what

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1 authority do we have if he doesn't comply.

2 DR. BAEPLER: And can we hold him to it?

3 DR. ANWAR: So we have to address two

4 concerns: One is what do we do with the investigation

5 that we were supposed to have since he is already

6 enrolled in the program? And, number two, now that he

7 has enrolled in the program, how is he going to be

8 monitored?

9 The board is concerned that the board receives

10 that he is following through with the program in an

11 appropriate manner. And he is complying with the

12 program 100 percent. And he is making progress.

13 MR. QUINN: I was -- I'm learning this

14 diversion program is a learning experience because he

15 was enrolled. Apparently some of our staff knew he was

16 enrolled and didn't tell me, actually, or they knew.

17 But they didn't tell me. I had this case going, and I

18 didn't know.

19 I understood -- it was my understanding and

20 perhaps a misunderstanding -- I understood if a doctor

21 gets in trouble we don't file a complaint on him in the

22 diversion program, therefore, we don't have any of that

23 structure if a doctor goes into the diversion program.

24 MADAM PRESIDENT: Here is our IC chairs. Tell

25 us what is --

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1 DR. BAEPLER: The IC recommended that we file

2 for disciplinary action. Now disciplinary action can

3 cover a broad spectrum of options.

4 I'm not sure that the board would be satisfied

5 given the circumstances of this case that simply

6 enrolling in a diversion program through an avenue that

7 most people don't use and without the IC committee or

8 the board agreeing that this would be sufficient

9 discipline, quite meets our needs.

10 And if it does, we should have this

11 understanding in writing. What's the length of contract

12 we are going to have? You know, I would like it spelled

13 out which we normally do before we get a notice like

14 that to act on.

15 We don't know in this case just what enrolling

16 in a diversion program means. Does he have a five-year

17 contract? Does he have a six-month contract? I don't

18 know.

19 MADAM PRESIDENT: I guess as an -- aside to

20 that, I'd also like to know what being in compliance

21 with a diversion program truly means. I got concerned

22 on one of these that we will be dealing with later that

23 indicates, yes, they are fully compliant with the

24 diversion program. However, unfortunately, they have

25 had two positive urine results. To me if that is

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1 happening, I want that person back before us and I want

2 to know that.

3 I don't want that to be assuming that's

4 compliance with diversion and that they are doing

5 everything that they should be doing. I think that is a

6 problem, and that then generates coming back before the

7 board.

8 So I think we need to clarify that with our

9 current, I guess, head of the diversion program. And

10 that we need to clarify to them that I have always been

11 under maybe the mistaken impression that compliance with

12 diversion means no evidence of continued substance

13 abuse.

14 DR. BAEPLER: Right. It's almost a one strike

15 and you are out.

16 MS. BIBLE: I can share an experience with

17 diversion. When Carol Bowers was in charge, she has

18 reported people that have had, you know, bad drug tests.

19 And so she has informed another medical board that uses

20 the diversion program. Now, she has her successor. I

21 don't know how she handles it. But she was pretty --

22 with my experience with her, she was very diligent about

23 letting us know about people that were not compliant,

24 and in that respect.

25 One of the things she didn't let us know is

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1 when they weren't paying and that's another complaint.

2 MR. QUINN: May I just -- I would like to ask

3 that we kind of separate a couple issues here.

4 This case -- the issue of compliance with the

5 diversion program is an issue that I would like to

6 discuss and everything that Ms. Bible just said still is

7 my understanding of what the diversion program does.

8 Compliance with the diversion program is a

9 different issue.

10 My question here and this is my -- I do not

11 understand what the board policy is, but what I

12 misunderstand, perhaps -- my understanding was that when

13 a doctor goes into the diversion program that we do not

14 -- if he is in the program, we do not proceed against

15 him. So I need that clarification.

16 DR. BAEPLER: No, we have an option there. We

17 could even go so far as restrict a person's license to

18 certain activities subject to his being in good standing

19 with diversion and consider reinstating a full license

20 when the contract for five years or whatever is

21 completed.

22 We have options available to us. It's not

23 just that any time we catch a doctor that has a problem

24 with substance abuse the doctor can just run and join

25 the diversion program and say, Fine. Now you don't have

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1 to do anything more. I'm okay.

2 It doesn't quite work that way.

3 MR. KIRCH: Yeah. I think we need to act on

4 the complaint and determine what's acceptable and just

5 agree with Don. Just because you go to the diversion

6 program you get to skate out of the complaint. I don't

7 think that's right.

8 MR. QUINN: I do not know. I was under the

9 impression, and the time it arose I was alone here. I

10 didn't have anyone to turn to.

11 I was under the impression if a doctor went

12 into the program, signed up with the program, that was

13 the idea. He was diverted to the program, and we don't

14 move forward on disciplinary action.

15 So the status is that disciplinary action is

16 pending. What I would like to have then is a resolution

17 of what to impose upon this person.

18 MADAM PRESIDENT: We can't make that decision

19 because none of us have seen the complaint. We don't

20 know what even the situation is of this discipline was.

21 DR. BAEPLER: Let me give you an extreme. It

22 could be that we are dealing with a case here and this

23 does not relate to this case. You might get a case that

24 is so egregious that we need to suspend this license or

25 even revoke it. Under those kind of circumstances that

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1 any precedent we set where somebody enrolls in a

2 diversion program, obviously doesn't get them off the

3 hook.

4 The IC wanted to file for disciplinary action.

5 Normally the disciplinary action would be the result of

6 a hearing, and the board will determine what the

7 outcome will be.

8 I suspect the board can reach that without a

9 hearing and you can negotiate on what the board wants.

10 MR. QUINN: I need to know --

11 I'm getting jammed up trying to resolve cases

12 because the board meets quarterly. I can't -- I can

13 enter into agreements to resolve cases subject to board

14 approval. That's not difficult. Except to figure out

15 what the criterion are.

16 And this one I'm obviously clearly mistaken in

17 my understanding that you don't file against this guy.

18 I did not know he was in diversion when I

19 brought it to IC for consideration. And I brought it to

20 IC for consideration, and I suppose the IC would

21 evaluate that situation. But I didn't know that's what

22 you did.

23 Just to dispose of this because the issue of

24 diversion is going to come up, what is the next step on

25 this? Do I --

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1 DR. ANJUM: You need to go back to the IC

2 committee and then, if necessary, act upon it.

3 MR. QUINN: Ask the IC to consider what terms

4 they want to impose?

5 DR. ANJUM: No, IC to look at the case as a

6 whole.

7 DR. BAEPLER: Present the case to us again but

8 this time as part --

9 MS. BIBLE: Can I just make --

10 MR. QUINN: Yeah.

11 MS. BIBLE: I think what you have here is that

12 they are saying this is not the proper procedure and

13 either they need to work out a settlement through your

14 IC members, making a recommendation or something that

15 they think the board would just -- and it's probably

16 just like your other matters. Or if your respondent is

17 not agreeable to what this board thinks is going to pass

18 mustard with this board, then you go forward with your

19 claim.

20 But I think you need to take it up with the IC

21 so that they can, you know, decide what's the

22 appropriate penalty that they think that the board would

23 agree with and just present it in a proposed settlement.

24 At that point the board can decide. They can't respond

25 with --

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1 MR. QUINN: I understand. The reason I

2 presented it this way was because I thought the filing

3 policy-wise the filing was something we did not do when

4 the guy goes into diversion.

5 DR. LUBRITZ: May I make a suggestion on this

6 particular case that Mr. Quinn send it to the IC and let

7 the IC take it up from there in the usual manner?

8 MS. KIRCH: I would second that.

9 MR. QUINN: That's what I will do. Yeah, I

10 will bring it back to the IC for consideration under the

11 circumstances.

12 DR. BAEPLER: I appreciate the time

13 constraints. And if you ever -- the meeting four times

14 a year is obviously awkward. However, IC for a single

15 item particularly if a committee has three members at

16 one end of the state you we can always find an hour to

17 meet for something like that and expedite it.

18 MADAM PRESIDENT: Also, we have done that on

19 conference calls for stipulations of settlement, too.

20 But it's, I think, important that -- you know, we did

21 that for this one in May. So there are options in

22 between meetings that you can use if needed.

23 DR. ANWAR: Unless it's a very urgent or

24 emergency situation where the whole board needs to meet

25 on an emergency basis, it can always go through the IC

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1 even before the IC is scheduled to meet.

2 DR. BAEPLER: We can expedite that.

3 MR. QUINN: I have done that with both ICs I

4 believe. I had meetings by phone and that works very

5 fine. And it's quite accommodating.

6 Okay. So let's move to the second item which

7 is --

8 MS. KIRCH: Should we vote on this?

9 MADAM PRESIDENT: We need to vote. I believe

10 that was the motion.

11 MR. QUINN: Okay. I'm sorry.

12 DR. MONTOYA: I second it.

13 MS. KIRCH: I second it.

14 MADAM PRESIDENT: All in favor?

15 THE BOARD: Aye.

16 MADAM PRESIDENT: It will go back to the IC

17 and then go from there.

18 MR. QUINN: I would like to go to item two in

19 the pamphlet that I handed out.

20 Now, I hope I followed the proper procedure in

21 this case. This is a complaint that was authorized by

22 ICB or ICA. It was authorized by ICA. We filed a

23 complaint. Then I had discussions with --

24 This is a doctor that did wrong-patient

25 surgery, wrong-patient surgery. Did no damage to the

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1 patient. Patient was not the complainant. It was the

2 patient's relative.

3 The wrong-patient surgery was done because of

4 a mix up in office procedure. Basically a staff person

5 presented the wrong patient for the laser procedure.

6 And the staff person essentially called for Mrs. Smith.

7 And Mrs. Jones stood up, and that person was not the

8 same person who checked in as Mrs. Smith. So Mrs. Jones

9 was brought in for the procedure.

10 DR. BAEPLER: Geriatric?

11 MR. QUINN: And it was done. The doctor has

12 no other disciplinary actions. He appears to be a good

13 doctor. He has changed the procedure in his office. He

14 is now utilizing the same individual who checks in

15 patients.

16 DR. ANJUM: More important here is the doctor

17 admitted his fault.

18 MR. QUINN: The doctor admitted his fault. He

19 now changed the procedure.

20 DR. BAEPLER: This Shepard group has put in

21 quality control to make sure it doesn't happen because

22 they do have so many geriatric patients. It's a busy

23 place. This was a failure of a process, not a failure

24 of a medical type.

25 MR. QUINN: So now this settlement agreement

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1 was presented for consideration by ICA. And ICA did

2 approve it in a telephonic meeting.

3 So now it's presented to the board for final

4 approval and then disposition.

5 DR. BAEPLER: The patient, by the way, they

6 pointed out was not the complainant. It was a no-harm

7 procedure. The patient continues to see this doctor as

8 her regular physician.

9 MADAM PRESIDENT: I guess the only problem

10 that I have is that in other situations where we have

11 had physicians who have recognized that they have made a

12 mistake and acknowledged it that we, at least, issued a

13 public reprimand that says, you know, basically it

14 happened and you have taken steps to correct it. And we

15 recognize that. I mean, this is as if nothing ever

16 happened.

17 DR. BAEPLER: Well, what you have here is a

18 system failure. A person in their 80s prepped for this

19 surgery that is about a three-minute surgery, sedated

20 but not out of it and draped and the doctor spent the

21 three, four minutes. Comes in and goes on to the next

22 patient.

23 It was a system failure. But the doctor is

24 always responsible, of course, for the -- you can't deny

25 that the surgeon is responsible for doing the right

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1 thing and that they have the right person. So that's a

2 problem. But it's a system failure that was totally

3 corrected. And my --

4 MR. QUINN: And my feeling -- the reason I

5 think that this type of disposition is -- I would

6 advocate acceptance of it by the board is that the job

7 that we are doing to protect the public in this case is

8 accomplished from the standpoint that the procedure that

9 led to the defect has been remedied.

10 There have been remedial measures taken so

11 that the procedure -- that the defect is not likely to

12 be repeated.

13 Secondly, the public will know that this

14 doctor was involved in a situation where he made a

15 mistake. To go further is to sanction the doctor for

16 the mistake.

17 The sanctions run the gamut from revocation to

18 probation and all matters in between that seek to

19 accomplish the same thing that I think we have

20 accomplished here, which is the sanctions are not aimed

21 at being necessarily punitive. Sometimes they are. I

22 mean, secondarily it's punitive to take a doctor, or to

23 take a doctor's license, to suspend a license. But

24 primarily it's protective of the public. That's the

25 grounds to do it. For the doctor, it's punitive.

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1 DR. BAEPLER: It even goes beyond that, you

2 know. As is pointed out, this doctor came in and he was

3 horribly embarrassed and admitted everything. There was

4 no problem with that. His demeanor was remarkable.

5 It's one of those cases where there are

6 multiple doctors in this office doing similar types of

7 surgery. It just happened to be him. It could have

8 been any one of them, you know, under the kind of

9 circumstances that their old procedures had.

10 By remedying the procedure we have actually

11 done quite a service to the public because it involves a

12 half a dozen doctors that are now using a new procedure

13 that makes sure this doesn't happen.

14 DR. ANWAR: Am I correct in this case after

15 the patient -- the wrong patient was brought in because

16 the person -- the wrong patient was brought in because

17 somebody else other than the person who checked the

18 patient asked for Mrs. Smith and Mrs. Jones stood up and

19 walked in; and after the patient was in the room

20 somebody else, a nurse or someone, came into the room

21 when the doctor was in the room and pronounced her name

22 and she answered to that name, Smith. And she said

23 Mrs. Smith and she said yes.

24 DR. BAEPLER: That's exactly what happened.

25 MS. KIRCH: Did you actually file a complaint?

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1 DR. ANJUM: The doctor was before the IC

2 committee and he knew there was some fault.

3 MS. KIRCH: You didn't just have a hearing on

4 the IC committee? You have the right to have them come

5 in and have a hearing.

6 MR. QUINN: No. Let me clarify so you don't

7 misunderstand. This particular situation was an IC

8 meeting where the doctor appeared at a request for

9 appearance. You understand?

10 MS. KIRCH: Yes, I'm on the IC committee. I'm

11 one of them.

12 MR. QUINN: Sorry. This is very similar to

13 what we just did. And this is the other case that I was

14 explaining to you in our last meeting where I wanted to

15 simply file the complaint because it notifies the public

16 that a complaint has -- a valid issue has occurred.

17 MS. KIRCH: That's what I'm asking because --

18 MADAM PRESIDENT: We don't see that.

19 MS. KIRCH: We don't see the complaint. And

20 you say it's a matter of the charging complaint against

21 -- my concern is we have actually filed a complaint and

22 now we have not seen the complaint and now we are asked

23 to do the settlement agreement.

24 MR. QUINN: Okay. Okay.

25 MR. KIRCH: I was confused because you are

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1 talking about he went before the IC committee, fine.

2 But, you know, we see people in the IC committee all the

3 time and say, fine, nothing is wrong. We tell them --

4 MR. QUINN: No. This is the identical

5 situation we were presented with the other day.

6 MS. KIRCH: We don't see that. So I'm trying

7 to find out what really happened.

8 DR. ANJUM: I think you need to be more

9 detailed in your explanation of how the process started

10 and how we handled it in the different steps. Where are

11 we now.

12 MADAM PRESIDENT: We need to see the complaint

13 and then this is your response to that, that you want

14 that complaint now dismissed with prejudice, right.

15 MR. QUINN: That's right.

16 MADAM PRESIDENT: Okay.

17 DR. ANJUM: That was the condition of the IC

18 committee.

19 DR. BAEPLER: Yes. Now just for the record

20 also the IC committee almost did not file on this. And

21 Dr. Titus and I felt when explained that the Q-A

22 procedures that the whole clinic had put in to prevent

23 this from happening again to any of the doctors working

24 there, et cetera, et cetera, we felt we reached the

25 desired end point. Dr. Titus was a person on the board

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1 that felt very strongly no we ought to file a complaint.

2 MR. QUINN: I would like to offer for the

3 board's consideration those who are not on IC committees

4 that this case and another case involves doctors who are

5 clearly involved in a medical misadventure that legally

6 constituted some malpractice.

7 However, the doctor's behavior is -- it's to

8 some -- to one degree or another some significant excuse

9 or mitigation of their responsibility. So it can be

10 passive responsibility in the sense that it's a nurse

11 who brought in the wrong patient or something like that.

12 Or a staff member buries a report. And the doctor

13 doesn't know that the report exists and finds out about

14 it.

15 There is significant reluctance to bring

16 disciplinary action against those doctors. But I have

17 advocated to both IC committees a position that I feel

18 is the responsibility of the board.

19 So this is what I have assumed is your

20 responsibility and if I'm wrong on this, I need

21 clarification. But the responsibility of the board in

22 these cases is to take action so that the fact that a

23 valid complaint exists is now on record. Because we get

24 hundreds of complaints that never get published because

25 they are confidential.

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1 But when you get a complaint that rises to the

2 level where it actually -- it indisputably appears to

3 constitute a violation of the medical practice act, then

4 I feel that that's a situation that the public is

5 entitled to know when they call up and ask about a

6 doctor's record, whether or not any complaints have been

7 filed against him, that there has been one.

8 And that's why I urged and advocated for the

9 filing of a complaint in this case and the filing of a

10 complaint in another case that we haven't heard yet that

11 were very, very similar.

12 MS. KIRCH: That's all I wanted to make sure

13 is that we are setting something that has been filed.

14 We don't know that.

15 MR. QUINN: I apologize. An assumption I

16 made.

17 If the board doesn't want to do -- take that

18 kind of action against physicians in that basis, then I

19 think that I need to ask that.

20 MADAM PRESIDENT: The only thing I would say

21 is that I think when we go to the point of filing a

22 complaint, it should not be with the attitude that, yes,

23 it reaches the level to file the compliant and then we

24 will dismiss it because the doctor really felt bad about

25 it.

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1 I think if it rises to the level of what an IC

2 feels is malpractice, then the board has a

3 responsibility to, at least, make a decision on some

4 sort of discipline even if it's a public reprimand or

5 acknowledging there were system failures and those have

6 been corrected.

7 But I think we need to be careful to go

8 forward here with the attitude that, yes, I'm going to

9 encourage the IC to file a formal complaint and then

10 recommend they dismiss that complaint because the

11 situation has been resolved.

12 DR. BAEPLER: As soon as we get into that we

13 are building statistics.

14 MR. QUINN: This settlement agreement and the

15 recitation in here is part of the permanent record as

16 well.

17 If, for example, this settlement -- the case

18 is resolved by a public reprimand, the settlement

19 agreement would be very similar. It would simply have

20 as an another provision that there would be a public

21 reprimand and then we would have to do it.

22 The facts that -- the circumstances are laid

23 out here and it's public. And then a dismissal is

24 something that comes out of any settlement in any event.

25 I mean --

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1 DR. BAEPLER: We have gotten to where we want

2 him to be. It is public knowledge.

3 DR. ANJUM: Steve, as an attorney of the

4 investigative committee of the board, not as a board.

5 So if the board wants to take different action, we still

6 have the power to do that. We can bring him for an

7 appearance. We can review the whole file. He has not

8 signed it on behalf of the board itself.

9 MADAM PRESIDENT: Right. No, I understand it.

10 DR. ANWAR: My comment on this is that if

11 there is a problem that is not directly related to a

12 cause by a physician himself, but is an indirect

13 responsibility, in which this case is, of whatever

14 happens in the rounds with his patients in his office, I

15 think it would be the direct responsibility of the

16 physician if it has been brought to the physician's

17 knowledge that a problem has occurred and he or she has

18 not taken any corrective action to correct that measure

19 and the public remains at risk in that office, that's

20 where the physician response, in my opinion, comes in.

21 But until a physician finds out and knows that

22 a problem has occurred, how can a physician even begin

23 to address that problem when he doesn't even know that a

24 problem has occurred?

25 So the physician's responsibility in this case

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1 is an indirect responsibility. And I think that should

2 be considered in our deliberation when we decide as to

3 what should be the punitive measure that we need to

4 take, if any at all, in this case.

5 MADAM PRESIDENT: Well, I think that clearly

6 this has gone through a process. And the recommendation

7 is based on coming before the IC who reviewed the entire

8 complaint that there is a resolution, and the

9 recommendation that we have before us and the only thing

10 we can take action on today is whether we want to

11 approve this settlement which is an order of dismissal

12 with prejudice.

13 DR. BAEPLER: And unlike the previous case,

14 this recommendation comes from the IC committee.

15 MADAM PRESIDENT: Right and has been fully

16 reviewed. So I think that's what we need to decide

17 today. And obviously if the board does not approve

18 this, then it goes back to square one and starts over

19 with the IC.

20 MR. QUINN: Or it could actually, I believe,

21 propose to go forward and go forward and propose what

22 you would approve and what you would like to see.

23 DR. MONTOYA: I would like to make a motion

24 that we approve this stipulation and agreement right

25 here in front of us.

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1 MADAM PRESIDENT: There is a motion to approve

2 the stipulation for settlement agreement.

3 DR. ANJUM: I second.

4 DR. JONES: I second it.

5 MS. BIBLE: The CI members cannot participate

6 in the motion vote.

7 MADAM PRESIDENT: Okay. I'm sorry. It's a

8 little confusing on who is on the IC.

9 DR. BAEPLER: There are only two remaining

10 members -- no, three because you were involved in the

11 final telephone conversation. Dr. Anjum and myself

12 participated in this recommendation.

13 MADAM PRESIDENT: I'm sorry. Can I have a

14 show of hands who is not on the IC and so I can do a

15 role call on the record?

16 Dr. Lubritz in favor of the motion?

17 DR. LUBRITZ: Yes.

18 MADAM PRESIDENT: Dr. Montoya?

19 DR. MONTOYA: Yes.

20 MADAM PRESIDENT: Ms. Kirch?

21 MS. KIRCH: Yes.

22 MADAM PRESIDENT: Dr. Jones?

23 DR. JONES: Yes.

24 MADAM PRESIDENT: And the chair votes in favor

25 of the motion. The motion carries.

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1 All right. Next?

2 MR. QUINN: The next one is item number four

3 in the pamphlet. Okay.

4 This is a case of a complaint authorized by --

5 DR. LUBRITZ: It wasn't me.

6 MR. QUINN: Okay. This was authorized by ICA.

7 A complaint has been filed. The complaint charged this

8 respondent with performing unnecessary surgery

9 consisting of --

10 DR. LUBRITZ: Unnecessary biopsy?

11 MR. QUINN: Yeah. Unnecessary biopsy and also

12 for falsifying the records, the medical records. The

13 allegation is of falsification.

14 I think I will give you a little bit of facts

15 on that because they are somewhat mitigating.

16 The records that are in question consist of a

17 consent form. Consent form is very detailed and it

18 covers all the issues that were related to the surgery

19 in small print. I mean, great detail.

20 The physician presented a consent form which

21 had some interlineations and handwriting on it and it

22 also had the subject -- also had an underlining for the

23 particular risk that actually occurred to the patient as

24 a result of the open-incision biopsy. It was a

25 stretched nerve.

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1 The patient's copy did not contain the

2 interlineations or the underlying area of concern.

3 The physician's explanation is that he met

4 with the patient, had the patient sign the consent form

5 -- no, met with the patient, duplicated the consent

6 form. Gave the patient a copy of the duplicate, told

7 the patient to go home and read it and discuss it with

8 her husband and return.

9 When the patient returned to finalize the

10 consent form and discuss it with the doctor, the

11 physician had his copy, the patient had her copy. The

12 doctor made the -- says he made the interlineations on

13 his copy and he didn't do it on the patient's copy

14 because he was only referring to his own copy. The

15 biopsy was of a --

16 DR. BAEPLER: Let me interrupt at that point.

17 The committee felt that he had done this after the

18 event. It seems highly improbable to us that prior to

19 doing the surgery he would go through a long list of

20 possible things that could go wrong. And he had to be

21 clairvoyant before the surgery to identify the two or

22 three things that really did go wrong and claim that he

23 pointed those two or three things out to the patient

24 before the surgery. Almost impossible to do that.

25 MR. QUINN: The unnecessary surgery involved

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1 biopsy of a small lump on the neck that had been there

2 for three weeks.

3 The lump had -- The referring physician to

4 the surgeon had ordered, a CAT scan. The CAT scan was

5 negative for -- the CAT scan report indicated it was

6 just some sort of fatty lymphoid tissue.

7 And the surgeon was then going to do a needle

8 biopsy, but the patient had a needle phobia. So with

9 the patient's consent, he did an incision biopsy.

10 And, of course, in the incision biopsy he

11 stretched whatever the particular nerve is on the side

12 of the neck. The patient complained subsequent to the

13 surgery of pain and weakness in the shoulder and the

14 arm. And it was later determined by a subsequent

15 physician that the cause of the patient's complaint was

16 a stretched nerve.

17 It is that particular risk that is underlined

18 in the consent form and handwritten in so. Dr. Baepler

19 is correct. The doctor was magnificently clairvoyant.

20 The peer reviewer said the surgery -- the

21 incision biopsy was unnecessary because of a negative

22 CAT scan.

23 I have discussed this with I don't know who,

24 but came to the impression that a CAT scan doesn't rule

25 out the presence of malignancy of cells. And that if

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1 one were to rely on the CAT scan and the cells turned

2 out to be malignant, that the doctor would be in really

3 huge trouble. So I -- in discussion with the doctor's

4 attorney, as part of the proposal for settlement

5 which I --

6 DR. ANJUM: Let me interrupt you a second to

7 follow-up. There are two doctors? One recommending a

8 needle biopsy and the second one recommending that you

9 can have the open incision done?

10 MR. QUINN: Right. This proposal, the

11 essential elements of it have been reviewed by the

12 investigative committee. The specific language they

13 have not seen yet. The substance is that the claim of

14 the unnecessary surgery will be dismissed and the

15 falsification of records is going to be resolved on the

16 basis that it is a record-keeping violation.

17 And the doctor will receive a public reprimand

18 and pay the cost of the investigation in the amount of

19 1,800 -- 1,089.75.

20 DR. BAEPLER: How will the public reprimand be

21 worded? Simply that it was a mistake in record keeping?

22 Something like that?

23 MR. QUINN: Yes. Yes. This is a -- Yes.

24 DR. BAEPLER: I'd like to find a little --

25 When we are convinced a person in essence falsified

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1 something that was presented to us, it seems like that's

2 more than a mistake on record keeping. Is there

3 stronger language that we could put in there?

4 I'm sorry. I was just attempting to adjust

5 the wording on the settlement to show in a possible

6 letter of public reprimand that we have a situation here

7 that was more than simply a record-keeping problem, you

8 know, just something a bit more serious, and that if we

9 can find the appropriate language.

10 MADAM PRESIDENT: The problem is at this point

11 again as with the others, that this is a settlement

12 agreement that is being proposed. We either have to

13 accept it as is or go back and renegotiate the whole

14 thing.

15 MR. QUINN: We can do another thing, too.

16 And, that is, we can establish what the terms are that

17 need to be modified that would be acceptable. Because

18 otherwise what's really happening, to me, is that I'm

19 getting an outline of what is -- what are acceptable

20 terms and then flushing it out. And then things are

21 happening to me when I put the language together. I

22 don't like the language. And so it may be that I'm

23 learning that that actual agreement has to be seen

24 first.

25 MADAM PRESIDENT: I think it is important that

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1 the board gets these when we get our agenda.

2 MR. QUINN: Yeah.

3 MADAM PRESIDENT: We usually get the

4 stipulation for settlement so that we have an

5 opportunity to look at it beforehand and some of this

6 may be -- could be done ahead of time.

7 But, at least, in the past what Dick has

8 always said is that if we don't accept it as stated, you

9 then have to go back to the other party and it has to be

10 renegotiated and it has to be brought forward again.

11 Because we can only stipulate or we can only go to

12 approve what has been authorized and, you know, and

13 worked out by both sides.

14 DR. ANJUM: What about a counter offer? We

15 can't counter?

16 MADAM PRESIDENT: This one is easy because

17 it's just an IC. It's not an attorney from the other

18 side.

19 DR. LUBRITZ: They can go back at lunch and

20 make a decision?

21 DR. BAEPLER: If we can come up with the

22 wording --

23 DR. ANJUM: As to the IC --

24 DR. LUBRITZ: Right. If they will accept

25 this, yes, this is acceptable.

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1 MR. QUINN: The reason they came in so late is

2 they came in at the last minute.

3 MS. BIBLE: Is not something that has to be --

4 he is not suspended. He is not. There is a complaint

5 and if the --

6 MADAM PRESIDENT: If it hasn't been signed by

7 the other side, then I would say if the IC agrees to the

8 change in that language and then you bring it back to us

9 after lunch. We can take care of it I think -- No?

10 MS. BIBLE: It's not a settlement agreement

11 until the other party does sign it. It hasn't been

12 signed by them, you really don't have an enforcible

13 settlement agreement. They know the terms. They agreed

14 to these terms.

15 MR. QUINN: They have approved this language.

16 The attorney has approved this language.

17 DR. ANJUM: Not in writing, but informally.

18 MR. QUINN: No. In this specific document,

19 but the respondent has not yet seen it. Sometimes

20 respondents will object to the language just as you are.

21 DR. LUBRITZ: Could they not come up, the IC

22 in lunch, and make some decisions that here is what we

23 want to see and given that new language we could say if

24 you can get them to agree with this then, yes, we

25 approve it and then we can move on?

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1 DR. BAEPLER: The problem I see there is the

2 IC doesn't really know the legal language.

3 DR. LUBRITZ: He would help you put that in.

4 DR. ANJUM: We need to go to IC first and then

5 bring it back to the board.

6 DR. ANWAR: There is still a problem and the

7 board still has to act. And the board may still

8 disagree with the language that the CI has approved.

9 So if you are going to modify something that

10 has to have some sort of an understanding unless it's

11 not possible to do on a legal basis, that is something

12 that would be acceptable to the board and not just the

13 IC.

14 DR. BAEPLER: Yeah. I feel we need some

15 stronger language than is here in terms of it's more

16 than record keeping. But I can't suggest the language.

17 I don't know what is appropriate in a legal setting to

18 make it stronger or what our options are.

19 DR. ANWAR: Sure.

20 DR. ANJUM: Before I vote for that language, I

21 need to look at the whole file again. To be honest, I

22 need to review all the biopsy reports and what the peer

23 reviews were before I can say this language is okay now.

24 MS. KIRCH: Should we just refer this back to

25 IC for further action?

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1 DR. LUBRITZ: I second.

2 DR. BAEPLER: There is no urgency here. It

3 could easily be worked through.

4 MS. KIRCH: The further action can actually be

5 the full complaint to the board or whatever, just say

6 for further action and let the IC committee determine.

7 MADAM PRESIDENT: Okay.

8 DR. LUBRITZ: Is that a motion?

9 MADAM PRESIDENT: That was a motion and was a

10 second and the motion is to refer this back to the IC.

11 And, again, these just have to be adjudicating members.

12 I don't know who those are for that.

13 DR. BAEPLER: Same group.

14 MADAM PRESIDENT: Dr. Lubritz?

15 DR. LUBRITZ: Yes, ma'am.

16 MADAM PRESIDENT: Dr. Montoya?

17 DR. MONTOYA: Yes.

18 MADAM PRESIDENT: Marlene Kirch?

19 MS. KIRCH: Yes.

20 MADAM PRESIDENT: Dr. Jones?

21 DR. JONES: Yes.

22 MADAM PRESIDENT: So this matter will be

23 referred back to the IC.

24 MR. QUINN: All right. Well, let's take up

25 Karen Giarrusso then. She is item number one in my

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1 packet.

2 MS. BIBLE: Is she on the agenda? She is on

3 another one.

4 DR. ANWAR: She is not on the agenda.

5 DR. LUBRITZ: Madam Chairman, may I step out

6 for a moment?

7 MADAM PRESIDENT: You bet.

8 We can't take action if she is not on the

9 agenda.

10 MR. QUINN: Does the case have to be on the

11 agenda for settlement?

12 MS. BIBLE: Yes.

13 MADAM PRESIDENT: Okay. So we cannot take

14 action on Dr. Giarrusso's settlement agreement.

15 DR. ANWAR: What about emergency meetings? Do

16 those have to be public?

17 MADAM PRESIDENT: We can do it in a conference

18 call and do a notice. I think we can do it over the

19 phone as long as --

20 MS. BIBLE: Right.

21 MADAM PRESIDENT: -- long as we have noticed

22 it.

23 MS. BIBLE: You can do it over the phone. It

24 wouldn't be an emergency.

25 MS. KIRCH: This puts us back because we have

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1 to approve or disapprove the minutes also.

2 MADAM PRESIDENT: That's correct. You know,

3 I'm going to make a suggestion that we not approve those

4 minutes at this time. That we just leave it as is and

5 not act on those minutes because there were some changes

6 in the language that we needed to look at that also

7 reflects this settlement.

8 This is basically a result of that conference

9 call. So there is some issues with both. We can't act

10 on those issues because it's not noticed in the meeting.

11 So I think we can address those minutes in our next

12 conference call.

13 MS. KIRCH: Can we start all over again?

14 MADAM PRESIDENT: So how about with

15 Dr. Rutledge?

16 MR. QUINN: The final is Dr. Rutledge, and I

17 know that Dr. Lubritz is going to want to --

18 DR. ANWAR: He is back.

19 MADAM PRESIDENT: We can't talk about

20 Dr. Giarrusso. She is not listed on the agenda. So we

21 are moving on to Dr. Rutledge.

22 MR. QUINN: The history of Dr. Rutledge is

23 that he applied for a license in 2002 and in answer to

24 question 31 or 14 whether he has ever been under

25 investigation for a violation of any laws, statute, or

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1 regulation. He answered no.

2 And our licensing specialist uncovered some

3 information that suggests that he was, in fact -- that

4 his answer was incorrect.

5 Rather than take action on Dr. Rutledge's

6 license application at that time, the board allowed

7 Dr. Rutledge to withdraw his application.

8 Subsequently in 2003, about five months later,

9 he applied again. And this time he answered the same

10 question with an affirmative answer that he had been

11 under investigation. And upon consideration, the board

12 denied his 2003 application on the basis of the

13 incorrect answer given in his 2002 application.

14 Dr. Rutledge appealed the board's action to

15 the district court, and the district court ruled, among

16 other things, but significantly, in my judgment, that

17 the board's action was unlawful and erroneous on the

18 basis that the board acted improperly, took the action

19 on the 2003 application on the basis of the 2002

20 application which the board allowed him to withdraw

21 without taking action.

22 I have -- on behalf of the board I filed an

23 appeal of that decision by the district court to the

24 supreme court, and the case is pending in the supreme

25 court.

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1 In the meantime, I have been in touch with the

2 attorneys for Dr. Rutledge. And we've hammered out an

3 agreement that provides for the issuance essentially of

4 a license to Dr. Rutledge in exchange for his agreement

5 to release the board and all of its members from any

6 liability.

7 My concern is two fold, one, the grounds that

8 the court relied upon, the legal ground of estoppel,

9 may, in fact, have some merit.

10 The board arguably, at least, in the view

11 favorable to Dr. Rutledge, when the board said that

12 Dr. Rutledge could withdraw his 2002 application, the

13 board allowed Dr. Rutledge -- the board did not take any

14 punitive action or negative action on the basis of it

15 and allowed him to go on as if he had not filed that

16 application.

17 When he came back and answered correctly the

18 next time, at least, correctly in the view of the board,

19 the board under the estoppel theory -- the board

20 unlawfully then relied on the information that the board

21 permitted him to withdraw in deciding the 2003

22 application.

23 I think that in all respects and other

24 respects Dr. Rutledge's application was complete and

25 indicated that he is a qualified and a competent

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1 physician.

2 I have a secondary concern, and so on that

3 issue I think there is a significant possibility that

4 Dr. Rutledge will prevail on appeal.

5 On a secondary issue and realistically I'm

6 concerned that Dr. Rutledge may file a lawsuit against

7 the board. The board's action at the time and the board

8 members when they -- when the board considers

9 applications, they are not acting in a capacity that

10 would entitle them to any special absolute immunity, but

11 they would be protected by good-faith immunity.

12 Dr. Rutledge could only prevail if he

13 demonstrated some bad faith. In the course of the

14 board's actions, there was some bristling interaction

15 between Dr. Rutledge and members of the board that could

16 preclude, and the circumstances themselves, could

17 preclude resolving any disputes in a summarily

18 adjudicated fashion leading to potentially years of

19 litigation.

20 And although there are lots of arguments on

21 both sides and in defense of it, the litigation, if it

22 were filed, could be protracted. He would assert, I

23 would see, as damages the loss of revenues suffered from

24 what he would project would be the income of his

25 practice here in Nevada and he has practices in other

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1 states.

2 He answered a question in a way that our

3 licensing staff felt was incorrect on the basis of

4 information that the licensing specialist obtained from

5 North Carolina where he was otherwise licensed.

6 The information specifically refers to

7 interviews being conducted by the North Carolina board.

8 The district court judge who resolved the

9 case, in addition to finding that estoppel rendered the

10 board's decision unlawful -- the district court judge

11 also found that his answer in 2002 was correct, was a

12 true answer.

13 So there are sort of double barrels against us

14 on that. The agreement that is at tab three of the

15 packet is what was hammered out between counsel. It

16 would simply provide --

17 Excuse me. I should add that the district

18 court order was to remand the case for consideration by

19 the board of its 2003 application in accordance with the

20 district court's findings, one, that the other answer

21 was correct and, two, that the board is estopped from

22 relying on the answer in the 2002 application as grounds

23 to deny the 2003 application.

24 So my understanding of this intent and

25 understanding of this compromising settlement agreement

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1 is to provide that the board would today act favorably

2 to grant Dr. Rutledge a medical license, that

3 Dr. Rutledge has updated his application and that

4 Dr. Rutledge, in exchange, would release and discharge

5 the board and its members and representatives from any

6 possible liability and exposure from a lawsuit.

7 DR. BAEPLER: The risk of not accepting this

8 would be that filing an appeal which --

9 MR. QUINN: Has been done.

10 DR. BAEPLER: You appealed to the supreme

11 court?

12 MR. QUINN: Yes.

13 DR. BAEPLER: During which time we could be

14 exposed to additional liability loss. He can -- does

15 this kind of a case come under that $50,000 maximum

16 liability for the state of Nevada?

17 MR. QUINN: It depends.

18 MS. BIBLE: It depends on where he files.

19 MR. QUINN: If it were me, I would file a

20 federal court action.

21 DR. BAEPLER: Then we are dead. I think we

22 are probably strapped by this decision or the liability

23 can be horrendous --

24 MADAM PRESIDENT: The reality is if I can take

25 us back to the initial discussions with Dr. Rutledge,

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1 and I think that one of the concerns that I have with

2 this is -- And I actually think this is a good

3 resolution. But I think we, the board, became angry

4 with Dr. Rutledge over attitudinal issues.

5 And I think that we need to really be careful

6 to separate that. Because in essence what we did was

7 allow him to resubmit another application the second

8 time around, but then took action on him based on the

9 first application where we felt that he had falsified

10 information.

11 And I think what the court is saying has some

12 merit that if, indeed, we were going to allow him to

13 withdraw the first time and resubmit a new one, we had

14 to take action based on that new application.

15 When he came the second time, he was not very

16 humble and I think that bothered some of the board and

17 some of the discussions ensued because of it.

18 But the reality is that as far as a licensure

19 issue, I think his new application was correct, had

20 correct information on it, and that ultimately that's

21 the decision we have to base it on.

22 DR. BAEPLER: Also, on many of these cases

23 there are two elements that you need to be aware of.

24 One is substance. The second is procedure.

25 And I have a feeling on this case we probably

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1 could have sustained the substance part of it but not

2 the procedure part. And both are equally important in a

3 court. So we really have to pay meticulous detail to

4 procedure.

5 MADAM PRESIDENT: Charlotte?

6 DR. ANJUM: What's the problem with procedure?

7 DR. BAEPLER: Procedure was the way in which

8 we enhanced him, to over simplify, let him withdraw an

9 application, and then use that application against him

10 in a second go around when from a legal perspective

11 investigation let him withdraw. It can't exist in our

12 files, you see.

13 DR. ANJUM: Yeah.

14 MS. BIBLE: That's what I was going to add is

15 that I think when this board was considering an

16 application, there was some consideration and doubt as

17 to what the affect of that was. You did have the

18 information.

19 He did take that particular action. He did

20 answer that question incorrectly. You did know of that.

21 And now the court has reviewed that and has made that

22 determination that we should not have relied on that

23 application. And yet, as you said, we did know of that

24 information and the board did act --

25 DR. BAEPLER: It's like double jeopardy.

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1 MS. BIBLE: The court had made a determination

2 that I don't think this board acted in any improper --

3 you know, acted really improperly with the information

4 that was available at that time.

5 But the court didn't make the determination

6 that we didn't have a legal consideration on that

7 matter.

8 But the board was acting on substantive facts

9 that it was aware of when it did act. And now a court

10 has made a ruling. So now it's your opportunity to

11 decide what to do with that decision of the court.

12 MR. QUINN: I would comment while it is fresh

13 for consideration that I don't believe that this case

14 precludes the board from extending it, you know, I want

15 to say it's generosity in the future to permit an

16 applicant to withdraw. But if it does so, and if the

17 reason for -- that led up to the desire to permit

18 withdraw is sufficiently meaningful that the board would

19 like to, it should say that we are going to allow you to

20 withdraw, but if you withdraw, we are going to reserve

21 the right to consider the reasons should you apply in

22 the future.

23 If the board desires, I will permit withdrawal

24 instead of denial for the obvious reasons.

25 DR. BAEPLER: And the option for part of the

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1 record.

2 DR. ANJUM: I think you do that, and the

3 applicant frequently asks can we apply again. So this

4 problem will happen again, and we will fall into the

5 same problem again.

6 MR. QUINN: When an applicant says that, you

7 can say, if you apply again, we will consider this and

8 we will consider this reason that we are proffering to

9 you right now. And we will conclude that in

10 consideration when we rule on your application in the

11 future.

12 DR. ANJUM: How would the court look at it

13 that way?

14 MR. QUINN: Well, I think that that satisfies

15 the estoppel consideration. Would you agree with that?

16 It would seem you are telling them outright you can't

17 rely --

18 See, estoppel comes from -- it's a notion that

19 the person can rely upon your action as saying we are

20 going to just let you bury that one. And we are not

21 going to deny it.

22 We don't want to deny it on that basis. So

23 you come back and answer it right, and then we will give

24 you the license. You know, one could reasonably be led

25 down that path. But if you tell another person, Look,

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1 don't come back because we will remember this answer,

2 then that person can't rely on it anymore.

3 DR. BAEPLER: Let's recall too the person

4 withdrew rather than turning him down because if we turn

5 him down, it's a reportable offense.

6 DR. ANJUM: Can't the person come back? He

7 can apply any time.

8 MADAM PRESIDENT: Dr. Montoya?

9 DR. MONTOYA: I would like to make a motion

10 that we go ahead and grant the license to practice here

11 in Nevada.

12 DR. LUBRITZ: Second it.

13 MADAM PRESIDENT: Do we need to have the

14 motion approved in this settlement?

15 DR. MONTOYA: And approve the settlement

16 agreement.

17 MADAM PRESIDENT: Which includes granting him

18 a license?

19 DR. MONTOYA: Yes.

20 MADAM PRESIDENT: So the motion, again, is to

21 approve the compromised settlement agreement that

22 includes granting Dr. Rutledge his license. Was there a

23 second to that?

24 DR. LUBRITZ: Second.

25 MS. KROTKE: Can we not grant him his license

PEGGY HOOGS & ASSOCIATES (775) 327-4460

168

1 until we have the material that makes his application

2 current, because the application you are talking about

3 is now over six months old?

4 MR. QUINN: No. No. This proposal, I think,

5 it's in here --

6 MADAM PRESIDENT: If we don't grant it today,

7 it will become null and void and the appeal will

8 proceed.

9 DR. MONTOYA: I stick by my motion.

10 MADAM PRESIDENT: All right. All in favor?

11 THE BOARD: Aye.

12 MADAM PRESIDENT: Opposed?

13 Chair votes in favor of the motion. Motion is

14 granted.

15 I think on that note we need to break for

16 lunch.

17 (A recess was taken for lunch.)

18 (Whereupon the remaining proceedings were held

19 in closed session.)

20 -o0o-

PEGGY HOOGS & ASSOCIATES (775) 327-4460

169

1 STATE OF NEVADA, )

) ss.

2 COUNTY OF WASHOE. )

4 I, LISA A. YOUNG, a Certified Court

5 Reporter in and for the state of Nevada, do hereby

6 certify:

7 That the foregoing proceedings were taken by

8 me at the time and place therein set forth; that the

9 proceedings were recorded stenographically by me and

10 thereafter transcribed via computer under my

11 supervision; that the foregoing is a full, true and

12 correct transcription of the proceedings to the best of

13 my knowledge, skill and ability.

14 I further certify that I am not a relative nor

15 an employee of any attorney or any of the parties, nor

16 am I financially or otherwise interested in this action.

17 I declare under penalty of perjury under the

18 laws of the state of Nevada that the foregoing

19 statements are true and correct.

20 Dated in Reno, Nevada this 17th day of June,

21 2004.

22 ___________________________

LISA A. YOUNG, CCR #353

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 CODE: 4185

LISA A. YOUNG, CCR #353

2 Peggy Hoogs & Associates

345 Marsh Avenue

3 Reno, Nevada

COURT REPORTER

10 NEVADA STATE BOARD OF MEDICAL EXAMINERS

11 BOARD MEETING

12 SATURDAY, JUNE 5, 2004; 8:00 A.M.

13 RENO, NEVADA

25 Reported by: LISA A. YOUNG, CCR #353

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 APPEARANCES:

2 CHERYL A. HUG-ENGLISH, M.D. PRESIDENT

JACULINE C. JONES, Ed.D., VICE PRESIDENT

3 DONALD H. BAEPLER, Ph.D., SECRETARY-TREASURER

JOEL N. LUBRITZ, M.D., CHAIRPERSON

4 STEPHEN K. MONTOYA, M.D.

SOHAIL U. ANJUM, M.D.

5 JAVAID ANWAR, M.D.

MARLENE J. KIRCH

STEPHEN D. QUINN, J.D., GENERAL COUNSEL

7 CHAROLOTTE M. BIBLE, CHIEF DEPUTY ATTORNEY GENERAL

EDWARD O. COUSINEAU, J.D., DEPUTY GENERAL COUNSEL

8 DRENNAN A. CLARK, J.D., SPECIAL COUNSEL

LAURIE L. MUNSON, DEPUTY EXECUTIVE SECRETARY

PRESENT IN LAS VEGAS:

DON HAVINS, M.D. CLARK COUNTY MEDICAL SOCIETY

MIKE GARCIA

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 RENO, NEVADA; SATURDAY, JUNE 5, 2004; 8:00 A.M.

2 -o0o-

3 MADAM PRESIDENT: I'd like to call this

4 continuation of the Nevada State Board of Medical

5 Examiners meeting to order.

6 Hope everybody slept well. It was a long day

7 yesterday, and we still have quite a bit to get through

8 this morning. However, it isn't quite so daunting than

9 yesterday's agenda did.

10 I think since we have still quite a few

11 appearances to get through I would like to start with

12 those. Let's get through the appearances and go back to

13 our agenda and hopefully finish up what we need to.

14 So let's begin our first appearance, and we'll

15 go to closed session.

16 (Whereupon the proceedings were held

17 in closed session.)

18 MADAM PRESIDENT: We're back from closed

19 session.

20 DR. LUBRITZ: Can we go back to 11? Under the

21 legislative -- Well, I guess it wouldn't be there.

22 I'll wait until you are finished. I was going to see if

23 we could somehow get the board to give --

24 DR. HAVINS: Excuse me. We cannot hear the

25 speaker.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. LUBRITZ: I was wondering if there was

2 some way we can get the board to show support for KODN

3 which is keep our doctors in Nevada. It is going to

4 probably be the only time we will ever be able to have

5 an initiative that people will vote on that is

6 attempting to keep our doctors in Nevada that has

7 certain things in it limiting malpractice, whatever.

8 So I don't think it's ever going to be on

9 again. And if the board feels it's appropriate, then I

10 would like to be able to --

11 I'm not even on that board or that committee,

12 but as sitting here, it might be helpful for the

13 citizens of Nevada to know that the board --

14 MADAM PRESIDENT: I think you would want to

15 find out more specifics about what they are presenting

16 and what the initiative is before you actually support

17 it going into the legislative session. I think it would

18 be really important to find out what the specifics are.

19 I passed out to Tony and to Steve today -- and

20 you need to be aware that there is a letter that has

21 been circulated by the Nevada Trial Lawyers' Association

22 that is sort of getting all their ducks in a row for the

23 next legislative session to fight any kind of tort

24 reform. And there is a response back from the medical

25 society saying that, you know, we need to be aware of

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 this and be a little proactive on our own.

2 So I think that there is going to be a battle

3 ground, and I think it is important that everybody is

4 very informed about what the issues are. And I expect

5 that they are asking -- the attorneys are asking for a

6 contribution of 15 to $20,000 per person to support

7 fighting this.

8 MR. CLARK: I will send a copy of both of

9 these letters from the Washoe Medical Society and Nevada

10 Trial Lawyers to every board member on Monday morning so

11 every board member will be able to review these.

12 DR. BAEPLER: I personally supported it. I

13 would like the attorneys' opinion later as to whether a

14 regulatory board can support or advocate that. I don't

15 know that.

16 MADAM PRESIDENT: That's my concern is that I

17 think that it should be clearly laid out. I'm sure that

18 the board will be involved in aspects of the legislation

19 that comes up that is related to this because there will

20 be issues there I'm sure.

21 So it bears watching, and I think -- so,

22 again, they are really -- you know, there is a lot of

23 information going out and a lot of preparation, I think,

24 preparing for the next legislative session. So we will

25 keep an eye on that. Okay.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 Our investigative committee reports.

2 DR. BAEPLER: Do we have the handouts for

3 that? The statistics and the list. Let me see. Maybe

4 I have it here. Okay.

5 Here is B. We considered in committee A, 112

6 cases. We filed on three of them, requested two

7 appearances at the next meeting, followed up with more

8 information required on four, and listed 103 cases

9 closed on this sheet in case you want to look at names.

10 DR. LUBRITZ: On ICB we had a total of cases

11 considered were 78.

12 The total cases authorized for filing formal

13 complaint was two.

14 Total cases authorized for peer review were

15 five.

16 Total cases requested for appearance were two.

17 Total cases authorized for further follow-up

18 investigation was one.

19 And total cases authorized for closure were

20 68.

21 MADAM PRESIDENT: Don, does that include yours

22 as well, your totals? You're passing it around.

23 DR. BAEPLER: The numbers that I read

24 represents committee A.

25 MADAM PRESIDENT: As soon as that's had a

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 chance to circulate around, I will ask for approval and

2 closure of those cases.

3 Anything else you want --

4 DR. LUBRITZ: I would like to see A.

5 MADAM PRESIDENT: Yeah, it will circulate

6 around. Anything else either of you would like to

7 report?

8 DR. BAEPLER: No.

9 MADAM PRESIDENT: How about, Don, you want to

10 give us the secretary-treasurer's report as to the

11 budget?

12 DR. BAEPLER: I can be very brief on that.

13 The budget is in your agenda. We call it a budget.

14 It's a best guess. We are not locked into it. We make

15 adjustments throughout the year as needed. Some of them

16 may be budgeted a little high or low, but the important

17 thing is the bottom line is well within our revenue

18 projections.

19 And significant changes are always brought to

20 the board for approval. So this is our best guess that

21 it has to be flexible because we never know what is

22 going to happen during the course of the year.

23 MR. CLARK: We will be receiving the audit in

24 July. And that audit, from our outside financial

25 auditors, will then be presented to the board at the

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 September meeting.

2 MADAM PRESIDENT: And so I think we do -- we

3 need a motion to approve the budget as presented.

4 MS. KIRCH: I so move.

5 DR. BAEPLER: Dr. Lubritz is asking if the

6 interest figure is a little bit high. It could be.

7 Don't forget the ten-year note went up one and a quarter

8 points in the last six weeks. The commercial market is

9 driving rates, not the feds. Basically, that's a low

10 rate.

11 But when you see that ten-year note moving up

12 as rapidly as it is, it is almost five percent, four

13 point seven which is the last time I looked which is

14 this week. We are capable of projecting slightly higher

15 return.

16 DR. LUBRITZ: And roughly what percentage of

17 our moneys do we have are in notes?

18 DR. BAEPLER: I don't know what in ten-year

19 notes. There is a statement here, for example, on this

20 year's figures where we had projected 69,000 -- no, we

21 had budgeted -- I've got to get to the right line with

22 this small print.

23 We had budgeted 70,000 and with a little over

24 a month to go when this was printed, we had collected

25 55. So we will be somewhere in the 60s. So we

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 projected a little bit optimistically because no one

2 thought that the rates would stay low as long as they

3 have.

4 We reflect an anticipated increase, and I

5 think we will see the ten-year note closer to six

6 percent by the end of the year, if not actually above

7 it.

8 MADAM PRESIDENT: Okay. Any other questions

9 on the budget?

10 I think there was a motion and a second to

11 approve it as stated.

12 All in favor?

13 THE BOARD: Aye.

14 MADAM PRESIDENT: Opposed?

15 Chair votes in favor. Motion carries.

16 Jackie, did you want to give a report on the

17 federation meeting or can you wait?

18 DR. JONES: Very briefly. We were very well

19 represented at the meeting. Dick and Larry gave very

20 nice presentations. It was well attended.

21 We got to go on the hill. None of our

22 representatives were there. However, we got to talk to

23 aids and talk to them about helping pass the internet

24 prescription bill that is before them.

25 It was very interesting to see Tom Ridge. He

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 was a luncheon speaker. The lights went out or went

2 very low when he was speaking. It was very dramatic.

3 Secret service people running around. It was very

4 interesting.

5 It was a very good meeting.

6 MADAM PRESIDENT: Good. Thank you.

7 And, Steve, did you want to comment about the

8 Nevada State Medical Association?

9 DR. MONTOYA: I was very well received when I

10 went up to the Clark County Medical Society.

11 I haven't been to the state medical

12 association yet.

13 They are hungry for knowledge as to what we

14 are doing.

15 From a person actually on the board, I'm kind

16 of happy to fill this position. And they are not

17 necessarily fighting us. They are trying to work with

18 us a little more.

19 MADAM PRESIDENT: That's my sense as well.

20 And I think that, again, the more communication we can

21 have that the better that will become. So I thank you

22 for doing that.

23 Tony, do you have anything you want to say

24 about the executive reports?

25 MR. CLARK: We have entered into a lease for

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 the additional space in the building here for housing

2 all our investigators together. That will be being

3 modified with some drywall by the 15th of the month.

4 And we will then start putting in the computer

5 capability ports for them to be hooked up.

6 Doug is on line and has identified two new

7 investigators who will come on board on July 1st.

8 Really, that's about it for the time being.

9 Oh, a couple things --

10 DR. HAVINS: Excuse me, Tony. Is your

11 microphone turned on?

12 MR. CLARK: It is now.

13 There is a two-day course in June here in Reno

14 that teaches you how to put together better newsletters

15 and bulletins, and I would like the board's authority to

16 send Laurie to that course.

17 And Doug wants to send five of his

18 investigators to a course in Kansas City that is upgrade

19 training for investigators, and that would be in

20 September. We could consider that at the September

21 board meeting. If the board wants to approve it now, I

22 would appreciate it.

23 DR. BAEPLER: You get better airfares if you

24 have more time.

25 MR. CLARK: That will cost about $5000 for the

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 five to attend a four-day training session.

2 MADAM PRESIDENT: So we need a motion to

3 approve that.

4 DR. BAEPLER: I move we approve it.

5 DR. LUBRITZ: Second.

6 MADAM PRESIDENT: There is a motion to approve

7 the meetings.

8 All in favor?

9 THE BOARD: Aye.

10 MADAM PRESIDENT: Opposed?

11 Chair votes in favor. Motion carries.

12 MS. MUNSON: We have provided a new policy

13 procedure manual, organizational chart manual. I forgot

14 where we put it.

15 MR. CLARK: As a result of the discussions

16 yesterday on compensation for employees, we are going to

17 have to put some new policies together to present to the

18 board for its consideration in September.

19 But this is up to date as of Tuesday.

20 MS. MUNSON: It's in here somewhere. Some of

21 the titles have been changed to better reflect the

22 nature of the people in those positions, the work that

23 they are doing.

24 In most of the policies there were not many

25 changes, with the exception of minor grammatical things

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 that were found.

2 We did add a dress policy.

3 And we added a job description for the license

4 application review -- malpractice review committee as

5 the board had requested at the December meeting. That's

6 been added.

7 And the only additional job description in

8 there is for lead investigator as per the discussion

9 yesterday for Pamela Castagnola for her promotion.

10 MADAM PRESIDENT: Okay. And do you need a

11 motion to approve this new organizational chart?

12 MS. MUNSON: Yes, please.

13 MS. KIRCH: So moved.

14 DR. JONES: Second.

15 MADAM PRESIDENT: There is a motion and a

16 second to approve the new organizational chart as

17 presented.

18 All in favor?

19 THE BOARD: Aye.

20 MADAM PRESIDENT: Opposed?

21 Chair votes in favor, and the motion carries.

22 Tony, anything else?

23 MR. CLARK: No. That's it, Madam President.

24 MADAM PRESIDENT: That brings us to -- Sorry?

25 Do you have anything else, Laurie?

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MR. CLARK: There is an annual report, and I

2 don't know where it is.

3 MS. MUNSON: Under 15. That one I knew where

4 it was.

5 I prepared the annual report for the year 2003

6 for the board.

7 MR. CLARK: It's under item 15.

8 MS. MUNSON: Last thing under number 15.

9 DR. BAEPLER: Last blue sheet.

10 MS. MUNSON: We have prepared it.

11 MR. CLARK: I believe this just needs the

12 board's approval.

13 MADAM PRESIDENT: Is there a motion to approve

14 the annual report?

15 DR. JONES: So moved.

16 MS. KIRCH: Second.

17 MADAM PRESIDENT: All in favor?

18 THE BOARD: Aye.

19 MADAM PRESIDENT: Opposed?

20 Chair votes in favor. Motion carries.

21 Okay. That brings us to our legal reports.

22 Steve and Charolette?

23 MR. QUINN: Legal reports as far as board

24 prosecution, we have nine in works and five will be in

25 the works soon following the recent IC meetings

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 authorized by cases. Seven cases involved in

2 litigation.

3 We have 14 open-board cases for prosecution,

4 and seven litigation cases outstanding including

5 judicial review of -- judicial review cases, petition to

6 compel the board to investigate, and a lawsuit which is

7 unfortunately not totally expired.

8 There is a petition which was filed early --

9 well, we received it in the early part of April that

10 requires an order from the court, if a response is due.

11 No order has been received, but no denial has been

12 received yet either.

13 There were no good grounds for the petition.

14 So I'm very hopeful, and I expect it will not be

15 granted.

16 And that's all I have.

17 MADAM PRESIDENT: Okay. Charlotte, you have

18 anything?

19 MS. BIBLE: I do not because Steve is handling

20 everything so well.

21 MS. KIRCH: We can probably approve the IC

22 stuff.

23 DR. BAEPLER: Do we have the ICA for Joel?

24 Where is the IC reports?

25 MADAM PRESIDENT: All right. Anything else on

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 the legal reports then?

2 MR. QUINN: No.

3 MADAM PRESIDENT: No. Okay.

4 Just as a point of clarification, we did issue

5 an administrative license yesterday. And can you remind

6 me of the physician's name? Do you remember?

7 MS. MUNSON: Kenneth Beckman.

8 MADAM PRESIDENT: On Dr. Beckman, we need to

9 clarify that that be a limited license as stated earlier

10 today that it is in no way a derogatory or disciplinary

11 action on his license but it will be a limited license

12 limited to administrative practice.

13 DR. ANJUM: How is that different from the

14 radiology license?

15 MADAM PRESIDENT: The radiology is a

16 special-purpose license that clearly is stated -- is

17 limited to reading of films electronically. So it's

18 very narrowly tailored.

19 Now, it's possible that there could be another

20 category added to that, and I think that's what we had

21 asked, that we look at where we can fit an

22 administrative category that doesn't really then put a

23 limitation on the license.

24 DR. ANJUM: Sure.

25 MR. CLARK: I'll have that in the legislative

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 proposal report for September for the board's

2 consideration.

3 DR. ANJUM: Correct.

4 MADAM PRESIDENT: Okay. I think everybody has

5 had an opportunity to see the IC reports, and if so, I

6 need approval for --

7 MS. KIRCH: Motion for approval.

8 DR. MONTOYA: Second.

9 MADAM PRESIDENT: There is a motion and a

10 second for approval on both ICA and ICB reports. All in

11 favor?

12 THE BOARD: Aye.

13 MADAM PRESIDENT: Opposed?

14 Chair votes in favor. The motion carries.

15 Thank you for all the IC committee members for

16 your help. That is a tremendous effort in addition to

17 these meetings.

18 We need to approve the licensure ratifications

19 that were under agenda number 19.

20 DR. BAEPLER: So moved.

21 MADAM PRESIDENT: Is there a second?

22 DR. MONTOYA: Second.

23 MADAM PRESIDENT: There is a motion and a

24 second to approve licensure ratification. All in favor?

25 THE BOARD: Aye.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Opposed?

2 Chair votes in favor of the motion, and the

3 motion carries.

4 Unless I am missing something, that takes us

5 down to the election of officers. Anybody else have

6 anything?

7 MR. CLARK: Just the future agenda, those

8 matters that have been postponed and a proposal on a new

9 policy concerning compensation for employees for our

10 manual.

11 MADAM PRESIDENT: As well as some of the

12 additional things that we added for the --

13 MR. CLARK: Yes, for the legislative agenda.

14 MS. KIRCH: And not as long.

15 MR. CLARK: And not as long.

16 MADAM PRESIDENT: I think that, too, that I

17 was thinking the way that yesterday was and the way

18 today is, perhaps if the appearances stay the way they

19 have been at this meeting, that we really need to look

20 at Saturday as a longer day which it used to be.

21 MR. CLARK: And in order to get the board

22 books out to the board members earlier, we're going to

23 be instituting an earlier cut-off date so that the board

24 members will have a little over two weeks prior to a

25 board meeting to review all of these materials.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 DR. ANJUM: Great.

2 MR. CLARK: That may result in fewer people

3 coming before each board meeting.

4 DR. BAEPLER: For the first one, and for the

5 second one there will be a backlog.

6 MR. CLARK: It's going to keep staying about

7 the same.

8 MADAM PRESIDENT: I do think if it's like

9 this, we really need to think about putting some into

10 Saturday and having a longer day on Saturday. I think

11 we just have to. We can't certainly do what we did

12 yesterday very often.

13 MR. CLARK: One other thing we can do is if it

14 appears that we have this many appearances, we can do

15 fewer administrative items the first morning.

16 MADAM PRESIDENT: Okay. And I'm just going to

17 take a second since this is really my last meeting both

18 as a board member and as president to say how much I

19 have enjoyed this. And, honestly, it has been a

20 privilege to serve with each of you.

21 I don't think that, certainly, the community

22 at large or people really understand how difficult this

23 job really is and how much work goes into it, how much

24 effort each of you put into this process.

25 And I just want to acknowledge each of you and

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 thank you for all of your efforts and to tell you how

2 much I have enjoyed it.

3 It has been eight years. It's gone by really

4 fast. And I know this board will carry on to do great

5 things.

6 Again, thank you for the opportunity. And,

7 truly, it's been an honor to serve as president for the

8 last few years. And thank you.

9 DR. MONTOYA: It's been an honor to serve

10 under you. This is my second time to serve with you. I

11 just can't believe what a magnificent woman you are.

12 MADAM PRESIDENT: I appreciate that. I really

13 wasn't searching for that, but thank you so much. I

14 truly appreciate that.

15 But now we need to have our election of

16 officers. So I would accept nominations for president.

17 And, actually, I would like to make a

18 nomination. And I would like to nominate Dr. Montoya

19 for our next president.

20 DR. BAEPLER: I'll second.

21 DR. LUBRITZ: I'll second.

22 DR. MONTOYA: I will accept.

23 MADAM PRESIDENT: Any further nominations?

24 All in favor?

25 THE BOARD: Aye.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 MADAM PRESIDENT: Opposed?

2 Chair votes in favor, and congratulations.

3 DR. ANJUM: What is your shoe size, Cheryl,

4 that he has to fill? Seems like pretty large, huh?

5 MADAM PRESIDENT: He'll do terrific.

6 Nominees for vice president?

7 DR. BAEPLER: I would like to nominate Joel

8 Lubritz.

9 MS. KIRCH: Second.

10 MADAM PRESIDENT: Any further nominations? If

11 not, all in favor?

12 THE BOARD: Aye.

13 MADAM PRESIDENT: Opposed?

14 Chair votes in favor. Motion carries. And

15 congratulations.

16 DR. ANJUM: Do you accept it?

17 DR. LUBRITZ: Thank you.

18 MADAM PRESIDENT: And nominations for

19 secretary-treasurer?

20 DR. MONTOYA: I would like to nominate

21 Dr. Baepler.

22 DR. LUBRITZ: Second.

23 MADAM PRESIDENT: Okay. There is a nomination

24 for Dr. Baepler for secretary-treasurer. Any further

25 nominations? Okay.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 All in favor?

2 THE BOARD: Aye.

3 MADAM PRESIDENT: Opposed?

4 Chair votes in favor. Motion carries. And

5 congratulations.

6 DR. BAEPLER: Thank you. And I do enjoy the

7 involvement that this position brings.

8 And I would just like to add a comment, too,

9 that we all appreciate your efforts. And I think given

10 her remarkable efforts at this last legislative session,

11 we ought to hire you as an assistant to keep you and

12 Jackie, with your remarkable letter of having attended

13 almost every national meeting and federation meeting.

14 We will probably bring you back to send you to some

15 meetings.

16 DR. JONES: Thank you, Don.

17 MADAM PRESIDENT: Let's see.

18 I think that as far as committee appointments,

19 the IC committees will stay as is. But I'm going to say

20 to our now current president that I would suggest for

21 the internal affairs committee that you wait until the

22 new appointments are made for both Jackie and my

23 position which will hopefully be within the next month

24 or two.

25 And that will -- I think those people will be

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 able to serve on the internal affairs committee.

2 DR. BAEPLER: Let's see. The IC committee,

3 the president, will serve on one?

4 MADAM PRESIDENT: No, he can't.

5 MS. KIRCH: So you are going to have to do

6 some juggling.

7 MADAM PRESIDENT: I think you want to have

8 some opportunity to think about that. So I would

9 suggest that those appointments -- you will have to make

10 it soon, but you will have the authority to do that

11 before the next meeting.

12 DR. MONTOYA: It will be soon.

13 MR. CLARK: I will put the word out as to his

14 election.

15 MADAM PRESIDENT: Lastly, I just want to say,

16 too, that I do think that this board has come a

17 tremendously long way within the last couple years as

18 far as establishing communication.

19 And I hope, Larry, you would agree with that.

20 I think the addition of our staff certainly has made a

21 tremendous difference. I think going forward and

22 working closely with the medical societies as well as

23 with communications with our legislature is going to be

24 really critically important over the next couple of

25 years. And so I think that will continue to grow and

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 develop.

2 And I think certainly this board not only

3 serves the public, but I think that we do have a

4 responsibility to communicate effectively with our

5 licensees as well. So thank you.

6 DR. MONTOYA: We have one more thing.

7 I have a proclamation here from the governor.

8 First, to Jackie Jones who was appointed

9 July 1st, 1996 and served as a member of the Nevada

10 State Board of Medical Examiners and served for eight

11 years.

12 She has served the board with distinction as

13 the vice president for three years, distinction as a

14 member and chairperson of internal affairs, license

15 application, malpractice review, investigative

16 committees and with conflicts and disciplinary charges

17 and whereas Jackie C. Jones, educational doctor, has

18 been a board representative of the Federation of the

19 United States Delegate and Reference Committee member

20 and, there is more, serves for the state and community

21 as a civic and cultural leader, now, therefore, I, Kenny

22 Guinn, Governor of the state of Nevada, do hereby

23 proclaim June 3rd, 2004 a day of honor of Jackie Jones,

24 Ed.D., for eight years of outstanding service. I have

25 here a plaque for her exemplary services as a member of

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 the board.

2 DR. JONES: This truly has been a great

3 experience. It's been a great learning experience for

4 me. I met very -- many, many new friends. And I am

5 going to miss being here.

6 I'm not going to miss reading all of the

7 stuff, but I'm certainly going to miss being here.

8 And thank you very much. It's been a pleasure

9 dealing with all of you.

10 DR. MONTOYA: To the magnificent woman seated

11 next to me, another proclamation from the governor.

12 Whereas Cheryl Hug-English, M.D., was

13 appointed September 1st, 1996 and served as a member of

14 the Nevada State Board of Medical Examiners and served

15 on the board eight years since her appointment. She has

16 served the board with distinction as its president for

17 the last three years.

18 Cheryl Hug-English has served as a distinctive

19 chairperson as a license application, malpractice

20 review, investigative committee dealing with conflicts

21 with serious disciplinary charges. And, further,

22 Dr. Hug-English has served her state and community as a

23 board member, distinguished physician, and as a civic

24 and cultural leader.

25 Now, therefore, I, Kenny Guinn, Governor of

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 the state of Nevada, do proclaim this day, September

2 30th, 2004, a day in honor of Cheryl Hug-English eight

3 years of outstanding service for the Nevada Board of

4 Medical Examiners.

5 And with the plaque for exemplary service as a

6 member and officer of the board.

7 MADAM PRESIDENT: That's beautiful. Thank

8 you. I really appreciate it.

9 I'm sure the governor is going to be quick in

10 doing this.

11 Do we have any matters for future agenda or

12 anything else?

13 MR. CLARK: Public comment.

14 MADAM PRESIDENT: Public comment?

15 DR. MATHEIS: Larry Matheis, Nevada State

16 Medical Association.

17 I do want to thank both Dr. Jones and

18 Dr. Hug-English for their contributions. And

19 Dr. Hug-English especially for this very trying period

20 of transition with a lot of political heat. I think you

21 have been professional. You have been fair and very

22 classy all through it. I thank you for that.

23 MADAM PRESIDENT: Thank you very much.

24 DR. MATHEIS: I know the pressure that was put

25 on you maybe better than others.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 I would also like to join with Dr. Montoya's

2 comment. I think having a physician speak to physicians

3 at the medical associations and society meetings, I

4 think, helps the communication. And I provided him with

5 some background. And I will do that as much as he needs

6 as this moves along.

7 And I know Michael Fischer is now the

8 president now as well as with Dr. John Williamson, past

9 president, are really committed to making the

10 relationship between the Nevada State Medical

11 Association and board as professional as possible and

12 cordial as possible.

13 We don't have to agree on how to do

14 everything, but we have to have communication that is

15 working effectively for the practice of medicine is what

16 our concern is.

17 I have one item that may go on the future

18 agenda that is from the federation meeting that is about

19 the pain management consensus guidelines because we do

20 have those adopted by regulation --

21 MR. CLARK: We do have to adopt a new

22 regulation.

23 DR. MATHEIS: I haven't sent out to all of our

24 members a summary of changes. What I have heard is the

25 changes only improved it. I do think that's an item you

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 might want to address.

2 MADAM PRESIDENT: Let's add that.

3 And thank you, Larry, for your comments.

4 DR. MONTOYA: Sometimes when those guys have

5 gotten in trouble, it is when they don't follow those

6 guidelines.

7 MADAM PRESIDENT: Any public comments down

8 south?

9 DR. HAVINS: Yes, I have two things. One, for

10 the Clark County Medical Society, we would like to thank

11 and congratulate Dr. Jones and Dr. Hug-English on their

12 eight years of service and particularly Dr. Hug-English

13 for a magnificent job as president of the board.

14 On the KODN initiative, the KODN initiative is

15 a copy of the provision of micro-legislation in

16 California passed in 1975, word for word, with two

17 exceptions. One, there is 350,000 doctor cap on

18 non-economic damages on KODN whereas there is $250,000

19 cap on micro.

20 There also is in KODN an elimination of joint

21 liability so that there would be no more deep pockets.

22 Other than that, it's California's micro.

23 Thank you.

24 MADAM PRESIDENT: Thank you, Don.

25 With that, this meeting is adjourned.

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 (Whereupon the proceedings were concluded at 12:45 p.m.)

2 -o0o-

PEGGY HOOGS & ASSOCIATES (775) 327-4460

1 STATE OF NEVADA, )

) ss.

2 COUNTY OF WASHOE. )

4 I, LISA A. YOUNG, a Certified Court

5 Reporter in and for the state of Nevada, do hereby

6 certify:

7 That the foregoing proceedings were taken by

8 me at the time and place therein set forth; that the

9 proceedings were recorded stenographically by me and

10 thereafter transcribed via computer under my

11 supervision; that the foregoing is a full, true and

12 correct transcription of the proceedings to the best of

13 my knowledge, skill and ability.

14 I further certify that I am not a relative nor

15 an employee of any attorney or any of the parties, nor

16 am I financially or otherwise interested in this action.

17 I declare under penalty of perjury under the

18 laws of the state of Nevada that the foregoing

19 statements are true and correct.

20 Dated in Reno, Nevada this 17th day of June,

21 2004.

22 ___________________________

LISA A. YOUNG, CCR #353

PEGGY HOOGS & ASSOCIATES (775) 327-4460